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Review
. 2025 May 2:19:1475-1487.
doi: 10.2147/OPTH.S512750. eCollection 2025.

Sub-Tenon's versus Topical Anesthesia for Effectiveness of Analgesia During Cataract Surgery: A Systematic Review with Meta-Analysis

Ghazal Valizadeh  1   2 , Elliot Duong  3 , Christopher Thang  2   3   4 , Leigh D White  3   4
Affiliations
Review

Sub-Tenon's versus Topical Anesthesia for Effectiveness of Analgesia During Cataract Surgery: A Systematic Review with Meta-Analysis

Ghazal Valizadeh et al. Clin Ophthalmol. .

Abstract

Background: Sub-Tenon's and topical anesthesia are the most common anesthetic techniques employed for cataract surgery. The objectives were to compare the effectiveness of intraoperative analgesia between the two techniques.

Methods: A systematic review was performed of three databases (MEDLINE, EMBASE, CENTRAL) from inception until August 2023. Included were adult patients undergoing routine cataract surgery with sub-Tenon's or topical anesthesia. Excluded were studies using systemic medications and complicated surgeries. The primary outcome was intraoperative analgesia assessed by patient reported pain scores. Secondary outcomes were post-operative pain at 30 minutes and 24 hours, patient satisfaction, surgeon satisfaction and complications. Risk of bias was evaluated using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). Outcomes were statistically assessed with meta-analyses where able.

Results: Twelve studies with 1370 patients were included in the meta-analysis. Sub-Tenon's block provided better intraoperative analgesia with lower pain scores (SMD -0.53, 95% CI -0.70 to -0.36; p < 0.001) which remained significant on subgroup analysis of six studies with uniform pain scales (MD -0.84, 95% CI -1.22 to -0.47; p < 0.001). Instances of severe intraoperative discomfort requiring rescue regional anesthesia were reported with topical anesthesia. While there was no difference in pain scores at 30 minutes or 24 hours post-operatively, higher patient and surgeon satisfaction was found with sub-Tenon's anesthesia. Serious complications were rare, with a higher reported rate of posterior capsule rupture with topical anesthesia. Only two of fourteen studies were considered an overall low risk-of-bias.

Conclusion: Sub-Tenon's block provides marginally better intraoperative analgesia during cataract surgery over topical anesthesia. Both can be considered effective for uncomplicated cataract surgery.

Keywords: cataract surgery; regional anesthesia; sub-Tenon’s; topical anesthesia.

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Conflict of interest statement

The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
PRISMA flow diagram.
Figure 2
Figure 2
Forest plot of sub-Tenon’s versus topical anesthesia in providing intraoperative analgesia for all included studies using SMD.
Figure 3
Figure 3
Forest plot of sub-Tenon’s versus topical anesthesia in providing intraoperative analgesia for all studies using a 0–10 pain scale.
Figure 4
Figure 4
Forest plot of pain during administration of sub-Tenon’s versus topical anesthesia in cataract surgery.
Figure 5
Figure 5
Forest plot of post-operative pain at 30 minutes for sub-Tenon’s versus topical anesthesia in cataract surgery.
Figure 6
Figure 6
Summary of risk of bias domains presented as percentages across all included studies.
Figure 7
Figure 7
Summary of each risk of bias item for all included studies.
See this image and copyright information in PMC

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