Fear and Anxiety Associated with Cataract Surgery Under Local Anaesthesia in Adults: A Systematic Review

Authors: Obuchowska I, Konopinska J.

Geographical coverage: Not reported

Sector: Impact Evaluation

Sub-sector: Quality of life

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background:

Cataract is the leading cause of blindness worldwide. Cataract surgery, typically performed under local anaesthesia, is one of the most frequently performed procedures to treat this condition. Although the procedure is generally safe and effective, many patients experience significant fear and anxiety related to the surgery. These emotions are driven by concerns about pain, potential vision loss, and the intraoperative experience. Visual sensations during surgery, such as lights, movements, and colours, often intensify anxiety, especially when patients are not informed about these sensations in advance. Other contributing factors include the unfamiliar surgical environment, the need for pre-surgical fasting, and fear of poor surgical outcomes.

Objective:

To determine the causes and frequency of fear and anxiety in patients undergoing cataract surgery under local anaesthesia, and to identify methods for improving the intraoperative experience and supporting the patient prior to surgery.

Main Findings:

The review included 72 full-text articles related to fear and anxiety during cataract surgery under local anaesthesia. The findings revealed that fear and anxiety are prevalent among patients undergoing cataract surgery under local anaesthesia, primarily due to concerns about pain, loss of vision, and the surgical procedure itself. Women, patients with hypochondriacal tendencies, and individuals with higher preoperative visual acuity exhibited greater levels of anxiety. The intensity of these emotions peaked on the day of surgery, with patients reporting the highest stress during the immediate preoperative period. Visual sensations experienced during the procedure – such as light flashes or the perception of instrument movements – further exacerbated fear, particularly when only topical anaesthesia was used.

Preoperative education and counselling were identified as highly effective in alleviating anxiety, with patients benefiting from detailed explanations about the procedure and the use of multimedia aids to set expectations. Non-pharmacological interventions, such as hand massage and listening to music before and during surgery, significantly reduced anxiety and improved physiological markers like heart rate and blood pressure. Pharmacological sedation, though useful for some patients, was limited by its unpredictable effects on patient cooperation, especially in older individuals. Patients undergoing second-eye cataract surgery generally reported lower anxiety levels compared to their first-eye surgery, which was attributed to their prior positive surgical experience; however, any significant differences in the second procedure (e.g. a different technique or complication) could reintroduce stress. Overall, a combination of patient education, non-invasive relaxation techniques, and personalised care was found to enhance patient satisfaction and improve surgical outcomes.

Methodology:

The literature search was conducted in PubMed and Scopus to identify studies on the emotional states experienced during cataract surgery under local anaesthesia. No language restrictions were applied, and full-text translations were performed for articles not published in English. Two reviewers independently extracted relevant data and assessed the methodological quality of the included studies. The findings from the studies were then synthesised narratively.

Applicability/External Validity:

The review did not explicitly discuss limitations to its external validity, such as cultural differences in how anxiety is expressed or differences in healthcare systems that might affect patient experience. However, it did note variations in sedation practices and patient preferences across countries (for example, routine sedation is common in the USA, whereas minimal sedation is more typical in the UK). The review emphasised that non-pharmacological interventions (such as patient education, hand massage, and music therapy) were broadly effective in reducing anxiety. It also acknowledged that individual patient factors (such as age and inherent anxiety traits) could influence anxiety levels and the effectiveness of these interventions.

Geographical Focus:

No geographical limits were applied to the searches. The review did not fully report the geographical distribution of the included studies; while some study locations were mentioned in tables, the information was not comprehensive.

Summary of Quality Assessment:

Overall, there is low confidence in the review’s conclusions due to several limitations in its methodology. On the positive side, the review conducted searches in multiple databases (PubMed and Scopus) without language restrictions, and it clearly defined its inclusion criteria. Data extraction and quality appraisal were performed independently by two reviewers, and the findings were synthesised narratively. However, the review did not specify how many reviewers participated in the initial screening of studies, nor did it mention whether the reference lists of included studies were checked for additional relevant publications. It also did not provide lists of included or excluded studies, nor detailed characteristics of each included study. Furthermore, the review did not report the results of any risk of bias assessment for the included studies. These omissions mean that the strength of the evidence and the reliability of the conclusions are uncertain, and the findings should be interpreted with caution.