Anaesth Crit Care Pain Med 35 (2016) 343346

Original Article

Risk factors for intraoperative hypertension in patients undergoing

cataract surgery under topical anaesthesia
Gilles Guerrier a,*, Sylvie Rondet a, Dalila Hallal a, Jacques Levy a, Hugo Bourdon b,
Antoine P. Brezin b, Charles Marc Samama a
a
Departement danesthesie-reanimation, hopital Cochin, universite Paris-Descartes, 75014 Paris, France
b
Service dophtalmologie, hopital Cochin, universite Paris-Descartes, 75014 Paris, France

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: Hypertension is the most common operative medical complication in patients undergoing
Available online 16 June 2016 cataract surgery under topical anaesthesia. Our objective was to identify risk factors for high blood
pressure requiring anaesthetic interventions.
Keywords: Methods: All patients undergoing elective cataract operations were included in an observational
Cataract surgery prospective study preceded by a medical history description and physical examination. Intraoperative
Topical anaesthesia adverse medical events and type of management were recorded.
Hypertension
Results: We studied 514 elective cataract operations. The overall rate of hypertension during surgery was
10.4% (n = 54). Independent risk factors for developing intraoperative hypertension were female sex
(OR = 3.8 [1.410.3]; P = 0.01), age > 80 years (OR = 4.5 [1.513.8]; P = 0.01) and anxiety (OR = 10.5 [4.1
27.0]; P < 0.001). The incidence of hypertension was not signicantly reduced by premedication
(OR = 0.5 [0.046.0]; P = 0.6). There was no signicant difference between patients with or without
hypertension history in the rates of hypertensive events (OR = 3.2 [0.615.5]; P = 0.15). Management of
hypertension or anxiety was similar in patients regardless of their past medical history or ASA risk class.
Conclusions: A specic at-risk population may benet from targeted preoperative interventions for
reducing intraoperative anxiety and hypertension.
2016 Societe francaise danesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All
rights reserved.

1. Introduction intraoperative medical events during cataract surgery [58]. In-

Cataract surgery is the most commonly performed operation in
elderly people in developed countries. Approximately 600,000
cataract procedures were performed in France in 2010 [1]. For over
two decades, this surgery has been performed almost exclusively
as an outpatient procedure using local anaesthesia with the option
of intravenous sedation. Cataracts are a prevalent problem
affecting the elderly. This population is specically affected by
comorbidities, including systemic hypertension [2]. Systemic
hypertension is considered as a minor risk factor that does not
affect overall perioperative management for non-cardiac surgery
[3]. Moreover, perioperative outcomes are similar in hypertensive
and in normotensive patients in most clinical situations [4]. How-
ever, hypertension and agitation remain the most common
* Corresponding author. Hopital Cochin, 27, rue du Faubourg-Saint-Jacques,
75014 Paris, France. Tel.:/fax: +33 1 58 41 41 41.
E-mail address: guerriergilles@gmail.com (G. Guerrier).
traoperative hypertension may raise intra-ocular pressure, thus
increasing the risk of surgical complications, including zonular
dialysis and posterior capsule rupture with or without vitreous
prolapse into the anterior chamber [9]. Risk factors for intraop-
erative hypertension have not been extensively studied. We have
performed a study aimed at identifying risk factors associated with
intraoperative hypertension events requiring anaesthetic inter-
vention during cataract surgery performed under topical anaes-
thesia.
2. Methods
2.1. Study design and patient selection
A prospective observational study with no therapeutic inter-
vention was performed in a single centre among patients
scheduled to undergo cataract surgery and who were recruited
between October 1st, 2014 and March 31st, 2015. The aim of the

http://dx.doi.org/10.1016/j.accpm.2016.01.005
2352-5568/ 2016 Societe francaise danesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Downloaded for Anonymous User (n/a) at University of Balamand from ClinicalKey.com by Elsevier on September 05, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
344 G. Guerrier et al. / Anaesth Crit Care Pain Med 35 (2016) 343346
study was to identify risk factors for hypertension requiring
anaesthetic intervention. Patients undergoing surgery under
general anaesthesia or in the second eye were not eligible for
the study. Patients with untreated or uncontrolled hypertension
were excluded from the study (dened by a systolic blood pressure
above 160 mmHg recorded during an anaesthetic consultation).
2.2. Procedure
The study imposed no changes in the procedures for
anaesthesia or cataract surgery that were routine for each
anaesthetist and each surgeon. Premedication by hydroxyzine
(1 mg/kg) was administrated to patients one hour before surgery.
During the preoperative consultation, all patients were told to take
their usual medications, including antihypertensive agents, with
the exception of anti-diabetic drugs. Solid foods could be given to
the patient up to 6 h before anaesthetic induction, and clear uid
was offered until 2 h before induction. Information was also
provided on the perioperative process. Topical anaesthesia
consisted in the application of lidocaine 2% gel 10 minutes before
incision.
2.3. Ethics statement
An institutional review board approved the study protocol,
which required no randomization, no intervention and implied the
simple recording of routinely monitored data (reference CPP: SC
3239). Informed non-opposition was obtained from all patients
and reported in medical records.
2.4. Data recorded and monitoring
Demographic characteristics, the American Society of Anes-
thesiologists (ASA) risk class, medical history, including coexisting
illnesses and medications were recorded by an anaesthetist at the
time of the preoperative medical examination. Intraoperative
medical events and administered treatments were recorded on a
standardized form by the anaesthetist or nurse anaesthetist. Heart
rate, non-invasive arterial pressure, and pulse oximetry were
recorded from an anaesthesia monitor during the surgical
intervention. Non-invasive arterial pressure was measured every
5 minutes and reported on a paper sheet. Anxiety was assessed
during surgery using a numeric verbal scale, from 1 (no anxiety) to
5 (extreme anxiety).
2.5. Denitions
Hypertension was dened as an increase in systolic pressure
to  160 mmHg or in diastolic pressure  100 mmHg among
patients with no pre-existing hypertension or with controlled
hypertension. Two consecutive measures were necessary for the
diagnosis of intraoperative hypertension. Tachycardia was dened
by an increase of heart rate to  100 b/min. Anxiety was dened by
a score of 3 or more on the numeric verbal scale.
2.6. Statistical analysis
To compare patients with versus without intraoperative
hypertension, quantitative and qualitative variables were analysed
by using Students t-tests and Chi2 tests, respectively. When the
frequency of events was  5 or values did not follow normal
distributions, Fishers Exact and MannWhitney tests were used.
Data were analysed using STATA (version 12, Stata Corporation,
Texas). Crude and adjusted odds ratios (OR) with 95% CI were
calculated. Multiple logistic regression models were constructed to
identify independent factors associated with intraoperative
Downloaded for Anonymous User (n/a) at University of Balamand from ClinicalKey.com by Elsevier on September 05, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
hypertension. Initial regression models were rst constructed
including all variables for which the P-value was less than 0.05. To
simplify the model, variables were removed one at a time
depending on the signicance level (P < 0.05) provided by the
likelihood ratio test. Due to their relevance for the outcome
measure, the following were forced in the nal model: premedica-
tion, past medical history of hypertension and ingestion of
hypertensive drugs.
3. Results
Over the study period, 530 patients were scheduled to undergo
elective cataract surgery for the rst time. We prospectively
studied 514 elective cataract operations (16 procedures were
cancelled for unexpected medical events requiring hospital
admission for 12 patients and for unknown reasons for 4 patients).
Patient demographic characteristics are described in
Table 1. Hypertension was recorded in 54 (10.4%) patients. The
mean systolic blood pressure was 172  15 mmHg and
130  18 mmHg among patients with and without intraoperative
hypertension, respectively (P < 0.001). A signicant difference in
mean diastolic blood pressure was also observed between the two
groups (85  32 mmHg versus 74  15 mmHg; P = 0.04). Indepen-
dent risk factors associated with hypertension were female sex
(OR = 3.8 [1.410.3]; P = 0.01), age > 80 years (OR = 4.5 [1.513.8];
P = 0.01) and anxiety (OR = 10.5 [4.127.0]). There were no signicant
differences between patients with or without hypertension history in
the occurrence of hypertensive events (13.6 and 6.7, respectively, per
100 operations; P = 0.07). Similarly, pursuing antihypertensive drugs
before surgery, ASA risk class, premedication and surgeon experience
(junior or senior) had no signicant impact on hypertensive events
(Table 2). Ten (25%) women experiencing an intraoperative hyper-
tensive event had a known hypertension. Management of hyperten-
sion [nicardipine IV titration administrated in 28 (52%) patients] or
anxiety (IV midazolam) was similar in patients regardless of their past
medical history or ASA risk class.
4. Discussion
Our results suggest that intraoperative hypertension during
cataract surgery is independently associated with age, sex and
anxiety. Although daycare surgery offers signicant advantages,
eye surgery in the elderly may induce anxiety favouring
intraoperative acute hypertensive events. According to our
experience, intraoperative awareness, fear of pain, fear of
frightening visual sensations, and fear of impairing head or eye
movements are common causes of intraoperative anxiety. Anxiety
may inuence the volume of anaesthetic required, the safe
intraoperative maintenance of the patient and the success of the
surgical procedure itself [10]. Reinforced premedication may
decrease the likelihood or the severity of intraoperative anxiety.
However, anxiety was similar regardless of the use of pharmaco-
logic premedication by hydroxyzine, thus questioning the useful-
ness of this strategy in our population. Moreover, premedication
via hydroxyzine raised concerns due to recently published
pharmacovigilance case reports of QT prolongation [11]. Selective
a2-agonists, such as clonidine or dexmedetomidine have been
proposed as potential alternatives to hydroxyzine, despite side
effects, including bradycardia and hypotension. The optimal choice
for premedication for elderly people in day-case surgery remains
to be claried.
Although the usefulness of a systematic preoperative anaes-
thesia consultation for patients undergoing cataract surgery under
topical anaesthesia has been questioned in two recent articles
[12,13], a face-to-face discussion may be useful in terms of
 G. Guerrier et al. / Anaesth Crit Care Pain Med 35 (2016) 343346 345

Table 1
Demographic characteristics of patients undergoing cataract surgery under topical anaesthesia.

Variables Total No hypertension Hypertension No anxiety Anxiety

n = 514 n = 460 (%) n = 54 (%) n = 412 (%) n = 102 (%)

Age (mean) 72  10 71  10 77  10 72  10 71  12
Sex
Female 270 (53) 230 (50) 40 (74) 214 (52) 60 (59)
Male 244 (47) 230 (50) 14 (26) 198 (48) 42 (41)
ASA
I/II 444 (86) 378 (82) 42 (78) 354 (86) 90 (88)
III 70 (14) 82 (18) 12 (22) 58 (14) 12 (12)

Table 2
Risk factors for intraoperative hypertension during cataract surgery under topical anaesthesia.

Variables Total No hypertension Hypertension Unadjusted P-value Adusted OR P-value

n = 514 n = 460 (%) n = 54 (%) OR (95% CI) (95% CI)

 80 years 110 (21) 86 (18) 24 (44) 3.5 (1.58.0) 0.003 3.8 (1.410.3) 0.008
Female 274 (53) 234 (50) 40 (74) 2.8 (1.16.9) 0.02 4.5 (1.513.8) 0.008
Premedication 506 (98) 454 (98) 52 (96) 0.6 (0.15.1) 0.6 0.5 (0.12.2) 0.4
Anxiety 106 (20) 72 (15) 34 (63) 9.2 (3.921.8) < 0.001 10.5 (4.127.0) < 0.001
Treated hypertension 280 (54) 242 (52) 38 (70) 2.2 (0.95.1) 0.08 3.1 (0.615.4) 0.15
Hypertensive drugs continued 238 (85) 208 (86) 30 (79) 1.5 (0.73.4) 0.3 0.5 (0.12.2) 0.4

relieving the anxiety induced by eye surgery. It is widely
recognized that an important relationship exists between patient
anxiety and adequacy of communication with the medical team
[14]. Innovative strategies for easing preoperative and intraoper-
ative anxiety are needed, such as listening to music, which may be
a promising non-pharmacological method in vulnerable patients,
such as the elderly [15]. There is some evidence of a positive effect
on both anxiety and blood pressure, particularly if the patient is
able to select his or her own music [16].
Interestingly, the rate of intraoperative hypertension was the
same in patients who had a past medical history of hypertension as
compared to that in patients who did not report hypertension. In
addition, no signicant differences were observed according to
type of treatment or premedication given. None of our patients had
their surgical procedure cancelled or postponed because of poorly
controlled hypertension during a medical examination.
Our ndings show a dramatic sex imbalance. This nding is
supported by studies in other surgical specialties that have
overwhelmingly found that female patients undergoing surgery
experience higher levels of anxiety [17] and intraoperative
hypertension [18]. Reasons for such differences remain unclear.
The literature suggests that female patients have a signicantly
higher need for information than men [19] and that it is
satisfaction with the information, rather than the level of
information itself, that correlates specically with perioperative
anxiety levels [20].
Our study suffers from several limitations. First, potential
factors detrimentally impacting anxiety levels were not recorded,
such as waiting time, monophtalmic patients, and pain. Although it
may be difcult to differentiate pain from anxiety, pain was less
likely to occur since lidocaine 2% gel provides satisfactory analgesic
efcacy [21]. Moreover, there were no differences between
patients with or without hypertension in the proportion of
analgesic drugs administrated during surgery (retrospective
review of anaesthetic charts). Second, the impact of hypertensive
events on the surgical procedure is unknown since there was no
surgical follow-up after surgery.
5. Conclusion
Our results reveal robust and plausible associations that may
help in identifying patients at risk of developing hypertension
during cataract surgery, including anxious patients, female
patients, and the elderly. Targeted interventions may usefully
reduce the incidence of medical adverse events by developing
relevant protocols for both surgeons and anaesthetists. Elderly
women may benet from improved communication with medical
staff. In addition, individual patient state of mind should be
routinely documented and evaluated through a standardized
procedure before surgery. This individual preoperative care can
make it possible to provide emotional support, decrease anxiety,
and give the patient a positive experience when undergoing
surgery. Further studies are needed to investigate neglected
aspects of the awake surgery experience, including patient anxiety
and adequacy of information.
Disclosure of interest
The authors declare that they have no competing interest.
References
[1] Caisse nationale dassurance maladie des travailleurs salaries. La chirurgie de
la cataracte en France; 2008 Available athttp://www.ameli.fr/leadmin/
user_upload/documents/DP_Cataracte.pdf, . Accessed May 6, 2015.
[2] Koolwijk J, Fick M, Selles C, Turgut G, Noordergraaf JI, Tukkers FS, et al.
Outpatient cataract surgery: incident and procedural risk analysis do not
support current clinical ophthalmology guidelines. Ophthalmology
2015;122:2817.
[3] Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al.
American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee to Update the 1996 Guidelines on Periopera-
tive Cardiovascular Evaluation for Noncardiac Surgery). Circulation
2002;105:125767.
[4] Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and
perioperative cardiac risk. Br J Anaesth 2004;92:57083.
[5] Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, et al. The
value of routine preoperative medical testing before cataract surgery. Study of
Medical Testing for Cataract Surgery. N Engl J Med 2000;342:16875.
[6] Zakrzewski PA, Banashkevich AV, Friel T, Braga-Mele R. Monitored anesthesia
care by registered respiratory therapists during cataract surgery: an update.
Opthalmology 2010;117:897902.
[7] Moreno-Montanes J, Sabater AL, Barrio-Barrio J, Perez-Valdivieso JR, Cacho-
Asenjo E, Garca-Granero M. Risks factors and regression model for risk
calculation of anesthesiologic intervention in topical and intracameral cataract
surgery. J Cataract Refract Surg 2012;38:214453.
[8] Basta B, Gioia L, Gemma M, Dedola E, Bianchi I, Fasce F, et al. Systemic adverse
events during 2005 phacoemulsications under monitored anesthesia care: a
prospective evaluation. Minerva Anestesiol 2011;77:87783.
[9] Jonas JB, Pakdaman B, Sauder G. Frequency and predicting factors of surgical
complications in cataract surgery performed under topical anaesthesia. Acta
Ophthalmol Scand 2006;84:1512.

Downloaded for Anonymous User (n/a) at University of Balamand from ClinicalKey.com by Elsevier on September 05, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
346 G. Guerrier et al. / Anaesth Crit Care Pain Med 35 (2016) 343346

[10] Maranets I, Kain ZN. Preoperative anxiety and intraoperative anesthetic
requirements. Anesth Analg 1999;89:134651.
[11] Comite pour levaluation des risques en matiere de pharmacovigilance PRAC/
Reevaluation des medicaments a base dhydroxyzine et des medicaments a base
de codeine. Available at http://ansm.sante.fr/S-informer/Travaux-de-l-Agence-
Europeenne-des-Medicaments-EMA [Accessed 12th November 2015].
[12] Bouvet L, Calderon AL, Augris-Mathieu C, Diot-Junique N, Benoit MP, Boselli E,
et al. Assessment of anesthesiologist intervention during cataract surgery
under topical anesthesia. J Fr Ophtalmol 2015;38:31621.
[13] de Beketch C, Boissonnot M, Bernit AF, Debaene B, Djabarouti M, Bouamama N,
et al. Simplied anesthesia protocol for cataract surgery under topical anes-
thesia: one year retrospective study. J Fr Ophtalmol 2013;36:504.
[14] Mokashi A, Leatherbarrow B, Kincey J, Slater R, Hillier V, Mayer S. Patient
communication during cataract surgery. Eye (Lond) 2004;18:14751.
[15] Leardi S, Pietroletti R, Angeloni G, Necozione S, Ranalletta G, Del Gusto B.
Randomized clinical trial examining the effect of music therapy in stress
response to day surgery. Br J Surg 2007;94:9437.
[16] Lee D, Henderson A, Shum D. The effect of music on preprocedure anxiety in
Hong Kong Chinese day patients. J Clin Nurs 2004;13:297303.
[17] Trento M, Tomelini M, Lattanzio R, Brancato R, Coggiola A, Benecchi R.
Perception of, and anxiety levels induced by, laser treatment in patients with
sight-threatening diabetic retinopathy. A multicentre study. Diabet Med
2006;23:11069.
[18] Yap YC, Woo WW, Kathirgamanathan T, Kosmin A, Faye B, Kodati S. Variation
of blood pressure during topical phacoemulsication. Eye (Lond)
2009;23:41620.
[19] Keulers BJ, Scheltinga MR, Houterman S, Van Der Wilt GJ, Spauwen PH.
Surgeons underestimate their patients desire for preoperative information.
World J Surg 2008;32:96470.
[20] Williams OA. Patient knowledge of operative care. J R Soc Med 1993;86:328
31.
[21] Amiel H, Koch PS. Tetracaine hydrochloride 0.5% versus lidocaine 2% jelly as a
topical anesthetic agent in cataract surgery: comparative clinical trial. J
Cataract Refract Surg 2007;33:98100.

Downloaded for Anonymous User (n/a) at University of Balamand from ClinicalKey.com by Elsevier on September 05, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.