lam (3 mg), ketamine HCI (25 mg) and ondansetron (2 mg). The
"melts" are placed under the patient's tongue before surgery and take
effect within minutes.
"Every facility has some form of oral sedation available for patients
who refuse to have IVs started," says T. Hunter Newsom, MD, a
cataract and refractive surgeon and the founder of the Newsom Eye &
Laser Center in Sebring and Tampa, Fla.
Not having to place an IV is only one of the reasons to use oral seda-
tion for cataract patients. "Anesthesia approaches vary so widely, and
sublingual sedation brings a greater consistency to the process
because we can avoid first pass metabolism. It also has rapid onset,"
says Dr. Berdahl.
The "sublingual troche" Dr. Berdahl uses generally is given in one-,
one-and-a-half or two-tablet dosages. He estimates 40% of his cataract
patients get one tablet, 30% get one and a half and the other 30% get
two tablets before surgery. The dosage is driven primarily by age. "The
older the patient, the less sedation they receive," says Dr. Berdahl.
The final and, according to Dr. Berdahl, potentially greatest big-pic-
ture benefit of oral sedation options is that they're opioid-free. "The
ability to avoid fentanyl in cataract procedures is important," says Dr.
Berdahl. "The literature shows patients who receive opioids only once
can face problems of dependency."
Obstacles to overcome
With all the reported benefits, you'd think oral sedation would be a
standard form of anesthesia for cataract surgeries. That's not the case.
"There are some real barriers to adoption," says Dr. Berdahl.
For one, the current form of the midazolam-ketamine-ondansetron
tablet isn't an FDA-approved product. "Even though it's compounded
at a 503(b) outsourcing facility that undergoes the same scrutiny as
5 0 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • J U L Y 2 0 2 0
