 Yeah, so today I'll be talking about the phenomena of increased pain reported by patients after their second eye surgery in comparison to their first surgery and then wrap up with introducing a new clinical study that will be taking place here at the Moran next month to provide more insight into this phenomena. And so this increased pain during second eye surgery has really only been described or noticed since topical anesthesia has replaced nerve blocks and while it's improved a lot of patient outcomes, patients also reporting this increased awareness of their environment and specifically more pain during their second eye. So I'll be reviewing some of the literature. This is a relatively new topic so it is, there's only about four papers on that only looking at the ones that investigated looking at consecutive eyes in a single patient. Those studies I look at only the second eye or first type one patient, try to compare the second eye to the second patient, but they're unable to control for these interpatient differences. So the first study was just a couple years ago and they wanted to look at the whole patient experience that's going on during the perioperative period. And one of these factors are looking at was anxiety and they were indeed able to show that patients do have an increased level of anxiety during their first eye surgery and this anxiety is greatly decreased during their second surgery. They also wanted to measure pains that we're looking at here and the way they did this is they asked patients to remember the pain that they experienced during the interoperative period in order to get a better idea of what they're experiencing. And they did also find that indeed patients do have an increased level of pain during their second eye surgery. However when they asked them to remember this pain one day later, this effect disappeared. So bringing the question, okay how reliable is a patient's recollection of their pain during the surgery? And so further studies try to build upon this, they too looked at the pain that patients remember after their surgery. They were able to replicate this, shown indeed there is an increased pain. However they try to bring some clinical relevance to this. So okay great they're going through pain but how is this relevant for us? So they asked the surgeons to rate the cooperation of the patients during surgery and they found that there was an inverse relationship here where the more pain a patient experienced the less cooperative they were. So they started trying to close their eyes, they weren't able to fix it, weren't as able to receive direction. So now this is not just a patient comfort issue, it's also safety issue where if they're be moving around during surgery this can cause some unintended errors during surgery. So further studies again, they try to replicate this. And this study was not able to repeat this findings, nothing significant was found with the pain perception but they did note another interesting phenomenon here is that when patients were asked to score their pain on a 0-10 scale they asked them to do that first and then they asked them to okay which one was more painful, the first, the second or neither. 50% of patients said that their second eye was more painful indeed. However of those 40% actually rated their second eye less painful on a 0-10 scale. So again bring into question okay how reliable is patient recollection of pain and how are we able to improve these outcomes when we're not really able to measure this. So here's the last one we'll quickly jump through is they went to look further into okay how can we trust these patients pain so again ask them to recall their pain but they took a different approach they said okay now tell us two to three weeks later how much pain did you have and a significant decrease in the amount of pain that they're able to recall during two to three weeks later and the same effect was seen during the second eye as well. And so the idea here is patients during their second eye surgery when they're asked to you know how painful is their eye they remember a lot less pain from the first surgery. So for example if they scored a one on the pain scale during the first surgery you know during their second eye they're now they remember it as a 0.5 and so whatever pain that they experienced now they're like oh I was twice as painful they're going to give you another score of one. And so it makes it difficult to truly quantify this they see it as a lot more painful but the scoring system does not bring out any significance. So that's the totality of the literature on this phenomenon that's reported and absolutely yes they're all standardized to receive the same amount and most of these studies yeah most of these studies they do a job of reporting that afterwards and they didn't find any significant difference the amount given and one of these studies actually didn't didn't give any percent at all and that way they're able to eliminate that compounder as well and they're able to get the same result. So just to summarize what we know about second eyes surgery is it's really right now this is the the theory is that there's patient expectations going into surgery they expect a lot more pain on the first one when they don't have any pain it's seen as a lot less significant and they expect the same outcome on the second surgery and any amount of pain is seen to be greater and this is again magnified with anxiety and memory of the patient and so why does this matter Dr. Lee has done a great job here at the university health system to to really promote this idea of value driven outcomes and we all know very well that you know the equation of value we're here to bring value to our patients and and what we need to do is be able to first measure what's going on intraoperatively if we're if we're planning to increase the quality in the service of of these surgeries that we give these patients so up to now we haven't really been able to measure it and so the study will be proposing for starting here we'll be measuring intraoperative pain with a new device we've been partnered with the Department of Mechanical Engineering and Dr. Roundy has developed this device I'll show a picture here in a minute about where patients are able to report pain and discomfort during the intraoperative period we'll also be looking at anxiety and before the surgery but then also the anticipation okay what are patients expecting before surgery happens when I was interviewing patients to try to design this study some some of them would even report that they only slept two to three hours the night before because of this increased anxiety of not knowing you know what's gonna happen and so this is an area of what we can try to improve some outcomes to standardize what patients can expect them to come we'll also be looking at patient recall to find some correlation to see if this device is able to provide the intraoperative data that we're looking for and then a bigger picture analysis would be like okay overall satisfaction okay maybe they're experiencing greater pain but does this matter two or three weeks later maybe it's just a comment they make right after surgery but their overall satisfaction of the care they're receiving is remains the same so we'll be looking at as well so this is a picture of the device this is designed by Dr. Roundy and Dr. Sakata and what is this a patient communication device patients are able to hold it during the surgery and they're able to engage this button at the top of the device here if they're in any discomfort or distress during surgery and this would be recorded there's also a couple other factors here they'll be measuring including like passive squeeze so sometimes the patients have increased anxiety they tend to clench their fists and this will give us a better idea of the amount of passive force given during surgery and also acceleration of their hand if they tend to jerk or squeeze just give it a little more data what's going on interoperatively so we can actually improve what's the outcomes so yeah so we'll be starting this next month we're excited to see how this will translate to improve patient care and if anybody's interested in becoming involved in a quality improvement project then you know feel free to contact me or Dr. Chaya and we'll let you know more about it any questions so the question is that they objectively looked at the severity of the same injury in Korea, thank my lucky stars I'm out of the war Dr. Manilas absolutely the patients won't be included if they have the same surgeon for both eyes that's what we're looking at Dr. Ambati one of the studies did yes they looked at heart rate, mean arterial pressure, respiratory rate they looked at those basic vital signs and they did show us a small correlation with anxiety with that the the results were conflicting there wasn't anything really significant found from them I forgot the variables but they it wasn't consistent across what they were looking for and the effect wasn't that great but blood pressure was the one that they saw was as anxiety was higher preoperatively so was blood pressure and postoperatively blood pressure was lower after the surgery was over they didn't really find an effect between the first and second eye just pre and postoperatively that's a great question on music that that is something we should control for I haven't thought about down it's a I'll have to reflect on it I think that'd be have to be a separate study for different types of music and how that affects but yeah it's a very good point that's a potential confounder there has been studies on that though it's been difficult to conduct them because typically the surgery is done on the one with the best corrected lowest best corrective vision so it's been difficult to do a study that's been randomized but the what has been shown is that there is no difference between the two on follow-up studies but earlier on there were some studies that did suggest that these ones everything that they showed show there was no significant difference between the two so I guess their jury still out there's some people on both sides of that yeah yes the idea that they're more aware of their environment they're able to anticipate what the surgeon is going to do next so they're waiting for that incision and and maybe any type of pressure they feel that's up on their more aware to it you have a question back there and it's a good point did the only studies that looked into simultaneous work for LASIK and they in those surgeries bilateral simultaneous they do have this phenomena of increased perception of pain intraoperatively and there's one study only one study that she did that and they did show that there was that same effect and then far as far as cataract surgery and most it's difficult as most surgeons went to wait a couple days before they're doing the second one just to see the outcomes of the first so it's a little more difficult to get a cohort of simultaneous cataract surgeries that's a great question and yeah so this will be the first study of its kind I'm looking at this pain during cataract surgery and so in a way this is also the would be a validation of the device as well and that's why we're also measuring the right now with the Gold Center is is this patient recall and and and seeing how it compares to that and so this is more of a the first study of its kind to look at this phenomena and so we'll find out more once it's complete about that but there are other studies that do show that patients are willing to gauge devices interoperatively to report their experience to surgeons and that's what it has been suggested if this the authors all conclude saying tell your patients they're gonna have more pain on the second eye so get that anxiety up so they don't experience it all right thank you everyone great think thank you our medical students