Awake-and-aware: the new norm?

Other medical specialties are learning
what ophthalmology has known for decades.

The New York Times ran a story two months ago about a growing trend among some medical specialties of performing awake-and-aware surgery.

When asked about the Times’ story Paul Koch, MD’s, reaction was essentially, “Really? That’s news?” That’s because Dr. Koch has been operating on awake-and-aware patients since 1981 — and he’s not alone.

Awake-and-aware surgery has been the standard of care for ophthalmologists since Ronald Reagan was sworn in as the 40th president, IBM released the first PCs and Pac-Man began digesting pellets.

If ophthalmologists could give their colleagues outside of ophthalmology one bit of advice, it’s to expect the unexpected from your patients — like when they ask you through the haze of sedation, what color underwear you’re sporting or how they’d like to hook up with you later and, well, you know.

“I have had the very occasional patient make romantic suggestions, and even make romantic maneuvers while under the drape,” says Marguerite McDonald, MD, FACS, a corneal, cataract and refractive surgeon with the Ophthalmic Consultants of Long Island, N.Y., and a clinical professor of ophthalmology at New York University and Tulane.


General anesthesia is still used in these operations, but it is usually reserved for longer, more complicated procedures.

“If I’m doing a big operation, I can see putting [a patient] to sleep,” says Dr. Koch, chief medical officer at Claris Vision in Raynham, Mass. “I’m not sure that I would want to be awake for a 90-minute operation.”

As ophthalmologists have long known, and their peers in other medical specialties are now learning, the benefits of operating on sedated-but-awake patients are many. Foremost among them is patient safety. General anesthesia presents risks for every patient and is especially worrisome for older adults, many of whom take a laundry list of medications.

Sedating patients but keeping them awake minimizes the risk of complications.

“You don’t die from eye surgery,” says Jorge Calzada, MD, a retinal surgeon at the Charles Retinal Institute in Memphis, Tenn. “You don’t bleed out from eye surgery. Any patient who has a real systemic problem during eye surgery, it’s nearly always related to complications from anesthesia.”

Sedated patients also recover faster and, in some cases, can be on their way home as soon as 15 minutes after leaving the operating room. A fast recovery sans nausea, vomiting or other postsurgical concerns is great for the patient and also allows for a quick turnover of the operating room and better use of the practice’s resources.

“The advantage of having a patient pop up, have a little juice and crackers and head straight home within minutes of surgery, you can’t beat that,” says Dr. McDonald.


Ophthalmologists began performing sedated but awake surgery in the early 1980s. When Dr. Koch was a first-year resident at the Manhattan Eye and Ear Hospital in New York in 1978, “every single patient had general anesthesia.” By his senior year general anesthesia was out, Patients instead were sedated but awake, their eyes numbed with an injectable local anesthetic.

“It was easier for the patients’ health,” Dr. Koch says. “But it reduced some of our flexibility about what we could say out loud.”

As ophthalmology moved to surgery centers in the early to mid-1990s, sedation techniques continued to evolve. Today most surgeons use a combination of numbing agent drops along with sedatives that keep the patient awake, aware and comfortable. Dr. Koch’s practice uses a short acting combination of midazolam and remifentanil. Patients are awake but “very still for six or seven minutes.”

“Some surgeons like to do surgery with topical anesthetics so they can talk to the patient and get them off the table to go right home,” Dr. Koch says. “Other doctors take the edge off the patient by giving them a little sedative and a little narcotic. I don’t know anybody routinely giving [general anesthesia.”


While most ophthalmologists perform surgeries while patients are sedated and awake, a minority of patients — Dr. Koch puts the number at one in 50 — ask to be asleep. For patients who opt to stay awake, surgeons carefully evaluate them for pain tolerance and comfort level. It’s also important to get a thorough patient history.

“People who twitch and move and squeeze a lot during the office exam, you make a note of all of that,” says Dr. McDonald. “If you put in an anesthetic drop and they scream, or if you use the slit lamp and they say the light is too bright, you might be in for a ride in the operating room.”

A surgeon can relieve a patient’s anxiety by explaining what he can expect. Sherri Rowen, MD, a cataract surgeon in Newport Beach, Calif., tells her anxious patients to relax because they are going to see “the coolest things” and have a great experience.

“Some say they like it and they start talking about all the colors and shapes,” Dr. Rowen says.

The key to successful, drama-free awake-and-aware surgery is finding the perfect blend and amount of drugs that keeps a patient happy, relaxed, noncombative and awake.

Image courtesy ECOTN staff.

Larry Patterson, MD, medical director of Eye Centers of Tennessee, with assistance from scrub tech Sarah Wilson, performs cataract surgery on an awake-and-aware patient.

“It’s really about managing your patient while you are working, to have the perfect dosing of sedation but keeping them awake to have them cooperate,” says Dr. Rowen.

Finding that sedation sweet spot can be tricky. Too little and the patient can become agitated and flail around on the table. Too much and the patient falls asleep, which is the last thing a surgeon wants. Sedation drugs, Dr. McDonald points out, “bring out the best in some people and the worst in other people.”

A surgeon doesn’t want a patient falling completely asleep because they can jolt awake, moving their head and eyes at the wrong moment. For that reason, Dr. Calzada has a strict rule in his operating room – patients are either sedated, awake and aware, or asleep. No in-between exists.

“Awake with mild sedation for anxiety is optimal,” Dr. Calzada says. “But if the patient is way too anxious where they need pretty heavy IV sedation, then in my opinion that patient goes into general anesthesia because you can control everything better. It is a situation of managing risks and managing expectations.”

Still, the sedative/numbing agent cocktail works well in an overwhelming number of cases. If it didn’t, says Dr McDonald, it would be reasonable to consider giving general anesthesia.

“If even 1% of the [sedated but awake] cases went poorly, that would be reason to consider general anesthesia on a routine basis,” says Dr. McDonald. “But this is not the case. The vast majority goes well.”

But if a patient does get a little antsy, Dr. McDonald and Dr. Rowen tape their heads to the table. The patient can move, but not sit up.

“Years ago I had a patient sit up on the table and that’s not a good thing,” Dr. Rowen says. “So taping the head gives you the latitude so that if they move or thrash the head isn’t going to move too far.”

Having a cooperative patient is another benefit of awake-and-aware surgery. Patients can look in a particular direction or stare at a light when told to by the surgeon.


As for the downside of having a patient awake: Patients can talk — a lot. How much? Just think about the last happy drunk you encountered.

Dr. Calzada says patients have sung gospel and called out for Jesus from under the drape. Dr. Koch’s patients randomly strike up conversation, asking him about his golf game (Dr. Koch doesn’t golf). Dr. McDonald and Dr. Rowen have experienced patients with greatly lowered inhibitions once sedated. One of Dr. McDonald’s patients, a woman in her 40s, described in “embarrassing detail” her interest in two male anesthesiologists.

“You could tell they were incredibly embarrassed,” Dr. McDonald says. “But they were loving it.”

To quiet patient kibitzing, Dr. McDonald says she talks throughout the surgery. And while she loves music, her operating room “is as quiet as a tomb” because, she jokes, she doesn’t want to hear a song from her prom and “wonder where Tommy is now.” The only thing she wants to hear in her operating room during surgery is the sound of her voice.

“If [patients] hear you talking they will stop talking so they can listen to what you say about their surgery,” she says. “They hear that you’re calm. They hear that you are talking about their case and not the latest football game or TV show, that you are focused on them, that staff are working well together and that their case is proceeding uneventfully. They can pick all that up from listening to the surgeon. That calms them down.”

And while “happy drunk” talk can be a bit distracting, most surgeons don’t mind as long as it’s not during a critical juncture in the procedure. The good news, say the surgeons, is that most patients will stop talking when they are told to.

“The real problem is when they talk and they move their head, which is where the microscope is,” Dr. Calzada says. “So we don’t want them to talk unless there is a problem, they have pain or whatever it is they need. We just tell the patient, please don’t talk. The rational individual will say, ‘Oh, I’m sorry,’ and stop talking.”


One last thing about performing awake-and-aware surgery: Because of the drugs’ effects, patients often don’t remember much of anything, including what they may have said.

So, if a patient asks if they said anything embarrassing while on the table, the answer is simple.

“Even if they did,” says Dr. McDonald, “I say, `Of course not.’” OM