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Global shortages and adverse effects of preservative-free lidocaine solution for off-label intracameral analgesia during phacoemulsification

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Session Details

Session Title: Corneal Endothelium & Cataract Surgery

Session Date/Time: Monday 24/09/2018 | 16:30-18:00

Paper Time: 17:39

Venue: Room A3, Podium 1

First Author: : B.Armstrong UAE

Co Author(s): :                        

Abstract Details


Routine clear corneal phacoemulsification under topical anesthesia is generally very well tolerated by patients. Combined with off-label use of intracameral injection of 1% preservative free lidocaine for added analgesia, we often do surgery under conscious sedation without an anesthesiologist. The potential of corneal toxicity due to intracameral solution is known, but overall this approach is widely accepted and deemed safe. The purpose of this paper is to raise awareness about the potential for adverse effects of intracameral instillation of some preparations of preservative free lidocaine.


Cleveland Clinic Abu Dhabi – Abu Dhabi, UAE


We routinely instill 1% preservative free lidocaine as the first intraocular step of phacoemulsification. However, we began noticing that just after instillation of lidocaine, there was reduction of the red reflex and sustained poor visualization throughout the surgery. We also noticed an unusually high incidence of postoperative day 1 corneal edema. After realizing that we may be experiencing corneal toxicity from our lidocaine solution, we asked our pharmacy to source a lidocaine solution from a different company. After changing lidocaine solutions, our issue resolved.


We retrospectively reviewed the charts of over 300 cases before and after the change in lidocaine solutions. After switching lidocaine solutions, we found postoperative day 1 rates of corneal edema reduced and visual acuity improved. However, the visual acuity difference did not reach statistical significance (P=0.13). We recorded footage showing the sudden change in the red reflex and corneal haze that occurred just after Lidocaine instillation. There were no relevant differences between the constituents of each lidocaine solution. However, the pH of our initial solution ranges between 4-6, whereas the new solution ranges between 5-7.


Corneal toxicity from off-label use of intracameral lidocaine injection is a real possibility and can result in intraoperative loss of red reflex and poor visualization during phacoemulsification. In this instance, low pH of our initial solution could have been the issue. Postoperative corneal edema can impact patient experience, and it is unknown if there are long term impacts on corneal endothelial cell health. Compounded by global lidocaine shortages, perhaps we should consider alternative methods of intracameral analgesia during phacoemulsification.

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