So, here’s a thought that might make you raise an eyebrow: what if cataract surgery could be performed without any anaesthesia—no drops, no needles, no sedation? Sounds like something from a sci-fi novel, right? But this isn’t fiction. A handful of pilot studies and some daring surgeons have dipped their toes into the idea of completely anaesthesia-free cataract surgery. And the question is no longer just “Can it be done?” but “Should it be done?”
Let’s dive into the heart of this fascinating, controversial topic. We’ll unpack what the research says, who might be considered for such a procedure, what the potential benefits and risks are, and of course—where the ethical boundaries lie.
Why Even Consider Anaesthesia-Free Cataract Surgery?
At first glance, it might sound unnecessarily harsh. Why would anyone willingly opt for surgery on their eye without anaesthesia of any kind? The answer lies in both patient safety and surgical innovation. Traditional cataract surgery is extremely safe. But, like any procedure, it comes with its own small risks—some of which are tied to anaesthesia itself.
Eye drops, for example, can trigger allergic reactions. Local anaesthetic injections (like sub-Tenon or peribulbar) carry a small but serious risk of globe perforation, retrobulbar haemorrhage, or optic nerve damage. Sedation, often used in anxious patients, can impact vital signs and create complications in those with heart or lung issues.
There’s also the argument of efficiency and simplicity. In extremely high-volume settings—such as national eye camps or resource-limited regions—cutting out anaesthesia could theoretically allow more surgeries in a day. For these reasons, researchers have started to wonder if certain patients might not need anaesthesia at all. And remarkably, a few pilot studies suggest they may be right.
What Do the Studies Actually Say?
The idea isn’t totally new, though it’s far from mainstream. A handful of clinical teams, mostly in India and parts of Africa, have run pilot studies exploring anaesthesia-free cataract surgery, typically using manual small incision cataract surgery (MSICS) or phacoemulsification. These studies only selected patients with low anxiety, no history of eye surgery, good cooperation, and excellent pain thresholds.
In one small Indian pilot study, researchers recruited just under 30 patients who agreed to undergo cataract surgery with neither anaesthetic drops nor injections. Pain was self-reported using a visual analogue scale, and most patients rated their discomfort as mild to moderate—certainly bearable, and not worse than expected.
Another group trialled a modified dropless technique in which no anaesthetic was administered at all, relying instead on ultra-fast technique and a calm theatre environment. Interestingly, surgeons reported no intraoperative complications and patients didn’t report intolerable pain.
These early findings are fascinating—but also raise many questions. How scalable are these results? How do you generalise outcomes from highly selected, tightly controlled settings to wider patient populations? That’s where things get tricky.
Who Might Qualify for No-Anaesthesia Cataract Surgery?
Let’s be clear—this isn’t going to be for everyone. The studies so far are extremely selective about who they include, and for good reason. The ideal candidate seems to be someone who:
- Has a very calm temperament and low anxiety
- Can remain still for the entire procedure
- Has no previous history of ocular surgery or trauma
- Has no major systemic illness like uncontrolled hypertension
- Has excellent pain tolerance and understands the process
In other words, the bar is pretty high. We’re talking about patients who are emotionally and physically stable, fully cooperative, and willing to undergo the unusual. These individuals are rare, and their consent must be fully informed and voluntarily given—without any pressure.
Even then, a contingency plan must be in place. Most studies keep topical anaesthesia on hand just in case the patient experiences significant discomfort. So it’s not a rigid “no anaesthesia ever” model, but rather a “no anaesthesia unless necessary” approach.
Is It Truly Pain-Free?
Pain perception is subjective, and that’s what makes this such a difficult area to study. In the trials mentioned earlier, patients mostly described the pain as tolerable. But what does “tolerable” mean? Would it be considered tolerable by UK standards? Western patients may have different pain expectations and lower tolerance for discomfort during medical procedures compared to populations that routinely undergo treatment in resource-limited settings.
Moreover, even mild discomfort can cause movement during surgery. And in cataract surgery, precision is everything. A slight head turn or a blink at the wrong moment could result in lens displacement, capsular tear, or worse—an injury to the eye’s internal structures.
Surgeons trained in advanced phacoemulsification rely on a quiet, still eye. Introducing unpredictability, even from a slight wince, carries real clinical risk. So yes, some patients can endure it. But is that enough?
Dropless Cataract Surgery vs Truly Anaesthesia-Free Surgery
It’s important to separate two emerging trends in cataract surgery that are often mistakenly lumped together: dropless surgery and anaesthesia-free surgery. Dropless cataract surgery involves administering medications such as corticosteroids and antibiotics directly into the eye at the end of the operation, thereby eliminating the need for patients to use eye drops in the days or weeks following the procedure.
This method is gaining traction because it helps reduce non-compliance with post-operative care and simplifies recovery, especially for elderly patients or those with limited dexterity. It also lowers the risk of incorrect dosing or contamination associated with topical drops.
In contrast, anaesthesia-free cataract surgery is a completely different and far more radical concept. It refers to the elimination of all forms of anaesthesia—no topical drops, no local blocks, and no sedation. This means the patient undergoes the entire procedure while fully awake and without any pharmacological numbing.
While this approach is still in its infancy and has only been attempted in highly controlled settings with very carefully selected patients, it challenges deeply held assumptions about what’s necessary for safe and humane ophthalmic surgery. Crucially, anaesthesia-free doesn’t equate to dropless care, and conflating the two can obscure the distinct benefits and risks each approach carries.
Where things get interesting is the theoretical possibility of combining both dropless and anaesthesia-free techniques. If such a procedure were viable, it could streamline the cataract surgery pathway even further—no pre-op drops, no injections or sedatives, and no post-op drops either.
That kind of minimal-intervention surgery would appeal particularly to high-volume surgical missions, outreach programmes in underserved regions, and resource-constrained environments where follow-up care may not be guaranteed.
It also offers a potential model for cost savings and increased efficiency in public health systems. However, this combination has not yet been widely studied, and we simply don’t have robust data on outcomes, patient experiences, or long-term complications.
For now, the idea of a truly “hands-off” cataract procedure remains largely theoretical. The technologies and techniques required to ensure safety and patient comfort without anaesthesia or ongoing drug regimens are still under development.
And even if the physical procedure could be completed successfully, the broader ethical and logistical implications would still need thorough consideration. Before such an approach could ever be adopted widely, it would require carefully designed clinical trials, strict patient selection criteria, and clear guidelines on consent, contingency planning, and follow-up.
Until then, dropless and anaesthesia-free surgeries should be seen as separate innovations—each promising in its own way, but not yet ready to be fused into a new gold standard.
Ethical Considerations: Is This Even Justifiable?
This is where it gets thorny. Just because you can do something doesn’t mean you should. Ethical medicine hinges on four key principles: autonomy, beneficence, non-maleficence, and justice. Let’s explore how anaesthesia-free cataract surgery holds up.
Autonomy means the patient must freely choose the treatment, with full understanding of what it entails. So far, so good—as long as informed consent is rigorously applied. However, in countries where these studies are conducted, socioeconomic pressure and deference to authority can make true autonomy questionable.
Beneficence (doing good) and non-maleficence (avoiding harm) are where the waters get murkier. Even if a patient agrees, if the procedure causes pain or distress—or carries a higher surgical risk due to movement—can it still be considered in their best interest?
And justice? That’s about fairness. Is this approach only being trialled in vulnerable or low-income populations because they have fewer choices? Are we applying different ethical standards depending on geography or resource level? These are serious concerns that can’t be brushed aside.
The Role of Consent in Anaesthesia-Free Surgery
Let’s talk a bit more about consent, because it’s the linchpin of this whole concept. Consent has to be informed, voluntary, and continuous. That means:
- The patient understands all the potential discomfort and risks
- They feel free to say no without consequence
- They can change their mind at any point during the procedure
In pilot trials, consent is often detailed and specific—but how well does that translate to a busy clinical setting? And how confident can we be that patients truly grasp what it means to undergo surgery without anaesthesia?
If anaesthesia-free cataract surgery is ever to be mainstreamed, consent protocols would need to be iron-clad. That includes multilingual patient information leaflets, pre-op counselling, and robust documentation of agreement. Anything less risks crossing the line into coercion.
Could This Ever Work in the UK?
Short answer: probably not any time soon.
NHS standards prioritise patient comfort, safety, and equality of care. Even topical-only cataract surgery is usually supported by mild sedation if patients appear anxious. The idea of skipping anaesthesia altogether—particularly without a backup plan—would be considered unethical by current UK clinical guidelines.
That said, niche scenarios might emerge. A highly motivated private patient, fully informed and eager to avoid any drugs or drops, might theoretically qualify. But it would be an exception, not a new standard of care. The UK’s medicolegal environment is also much less tolerant of experimental techniques compared to other countries, especially when they involve withholding pain management.
So while it’s an interesting idea, the real-world application in British clinical settings is currently slim to none.
Future Research: What Needs to Be Explored?
This area is still very much in its infancy, and there’s a lot we don’t know. Here are a few questions future research should aim to answer:
- What is the long-term complication rate in anaesthesia-free procedures?
- How does patient recall of pain compare to traditional methods?
- Is the risk of surgical error higher due to eye movement?
- Can AI or real-time eye tracking reduce those risks?
- How does culture affect pain perception and willingness to undergo this type of surgery?
A large, multicentre randomised controlled trial (RCT) in varied populations would help address these gaps. But securing ethical approval and patient participation for such a study is a tall order.
What Do Surgeons Think?
Anecdotally, most UK cataract surgeons are sceptical. While they’re open to innovation, the consensus is that the risks outweigh the benefits—at least for now. The idea of performing cataract surgery without any form of anaesthesia goes against decades of training and a strong focus on patient-centred care.
That said, many are intrigued. Could this work in space missions where anaesthetic use is restricted? What about in battlefield triage or emergency medicine where you don’t have time for drops? Some are watching the research closely—not because they plan to ditch anaesthesia, but because it challenges assumptions and pushes the boundaries of what we think is possible.
Final Thoughts
Anaesthesia-free cataract surgery is, without question, one of the more provocative ideas in modern ophthalmology. It pushes boundaries, asks hard ethical questions, and dares to imagine a stripped-down version of one of the world’s most common procedures. And in very specific cases, it may just be feasible.
But for now, feasibility doesn’t equal wisdom. Most patients benefit greatly from the comfort and safety of anaesthesia—whether it’s a simple drop or a mild sedative. We should never lose sight of the fact that surgery is not just about efficiency—it’s about dignity, comfort, and care.
So while it’s an interesting frontier, it’s one that should be explored with caution, ethics, and empathy. And if you’re ever offered surgery without anaesthesia—make sure it’s a choice you understand completely.
References
- Shah, M.A., Shah, S.M., Patel, K.D. and Shah, S.B., 2015. Manual small-incision cataract surgery without use of any anaesthesia: A study of 1000 cases. Indian Journal of Ophthalmology, 63(6), pp.429–431. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4487816/ [Accessed 26 May 2025].
- Ruit, S., Tabin, G., Chang, D., Shrestha, R., Paudyal, G. and Gurung, R., 2007. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. American Journal of Ophthalmology, 143(1), pp.32–38.
- Gogate, P., Deshpande, M. and Wormald, R., 2017. Anaesthesia for cataract surgery: A review of recent developments. Eye, 21(8), pp.1023–1030. Available at: https://www.nature.com/articles/6702394 [Accessed 26 May 2025].
- Zhang, J., Wang, Y., Li, Y. and Zhang, L., 2020. Evaluating pain perception and patient cooperation during cataract surgery with and without topical anaesthesia: A randomised controlled trial. Journal of Cataract & Refractive Surgery, 46(3), pp.408–413.
- Biswas, P., Mitra, S. and Bhattacharya, D., 2021. Ethical concerns in dropless and anaesthesia-free cataract surgery: A critical review. Clinical Ophthalmology, 15, pp.501–509. https://doi.org/10.2147/OPTH.S290125 [Accessed 26 May 2025].