Journal of Pain Research Dovepress

open access to scientific and medical research

Open Access Full Text Article Original Research

Hypnosis intervention for the management of

pain perception during cataract surgery
Journal of Pain Research downloaded from https://www.dovepress.com/ by 46.148.127.118 on 07-Oct-2018

This article was published in the following Dove Press journal:

Journal of Pain Research

Xiaofan Chen 1,* Objective: To investigate the effectiveness of hypnosis in pain management during cataract
Rongdi Yuan 1,* surgery.
Xiao Chen 2 Methods: Male or female patients with bilateral age-related cataract who wished to have both
Min Sun 2 eyes subjected to phacoemulsification surgery were preliminarily admitted. Immediately after
For personal use only.

the first-eye surgery, each patient was evaluated for pain using the visual analog scale (VAS), and
Sen Lin 2
patients with a VAS score >1 were enrolled. By using block randomization, the enrolled patients
Jian Ye 2
were allocated to either the treatment group, which received a hypnosis intervention before the
Chunlin Chen 2
scheduled second-eye surgery, or the control group, which did not undergo hypnosis. The levels
1
Department of Ophthalmology, of anxiety, pain, and cooperation were evaluated independently by the patients and the surgeon.
Xinqiao Hospital, Third Military
Medical University, Chongqing, Results: During the intraoperative pain assessment, 5%, 34%, 38%, and 23% of patients in
400042, China; 2Department the control group reported experiencing no pain, mild pain, moderate pain, and severe pain,
of Ophthalmology, Institute of respectively. In contrast, in the hypnosis group, 18%, 56%, 15%, and 11% of patients reported
Surgery Research, Daping Hospital,
Third Military Medical University, experiencing no pain, mild pain, moderate pain, and severe pain, respectively, which showed
Chongqing, 400042, China significant differences between the groups (P<0.005). The evaluation of anxiety level showed
*These authors contributed equally to that the mean score in the control group and hypnosis group was 11.77±0.32 and 6.64±0.21,
this work respectively, revealing a highly significant difference between the two groups (P<0.005). The
assessment of patient cooperation showed that only 5% and 18% of patients in the control group
and 18% and 36% of patients in the hypnosis group showed excellent and good cooperation,
respectively, while 47% of patients in the control group and only 24% of patients in the hypnosis
group exhibited poor cooperation, revealing significant differences between the groups (P<0.005).
Conclusion: Hypnosis may be considered as an auxiliary measure in cataract surgery, especially
for patients who experienced obvious pain during the first-eye surgery.
Keywords: pain, patient satisfaction, cataract surgery, hypnosis

Introduction
Phacoemulsification is the most effective cataract surgery currently performed and
is characterized by a smaller wound and reduced surgery time. Given the advance-
ments in equipment and the proficiency of surgical skills, topical anesthesia is
Correspondence: Chunlin Chen the preferred method in phacoemulsification surgery to avoid the risks associated
Department of Ophthalmology, with local (retrobulbar or peribulbar) anesthesia, such as chemosis, ecchymosis,
Xinqiao Hospital, Third Military Medical
University, 83 Xinqiao Main Street, retrobulbar hemorrhage, globe penetration, or perforation; 1,2 however, phacoemul-
Chongqing 400042, China sification with topical anesthesia is not a completely painless procedure, with
Tel +86 23 6875 7765
Fax +86 23 6875 7767
patients frequently experiencing pain during the surgery.1,3–6 In a study comparing
Email chunlinc@126.com topical anesthesia and local anesthesia for phacoemulsification surgery, about

submit your manuscript | www.dovepress.com Journal of Pain Research 2018:11 1921–1926 1921
Dovepress © 2018 Chen et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
http://dx.doi.org/10.2147/JPR.S174490
php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work
you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

Powered by TCPDF (www.tcpdf.org)

 Chen et al Dovepress

30.1% of patients with topical anesthesia complained Treatment

of intraoperative pain, while only 6.7% of patients with Patients in the treatment group were managed by a hypno-
local anesthesia reported intraoperative pain.7 In another therapist half an hour before the second-eye surgery. After
study, 78.3% of patients reported experiencing pain dur- explaining the hypnosis procedure, the hypnotherapist
ing phacoemulsification surgery with topical anesthesia; initiated a 10- to 15-minute short hypnosis session using a
when the intensity of pain was evaluated, the percentage technique described by Erickson;15 after the hypnosis ses-
of patients reporting mild, moderate, and intense pain sion, the patient’s anxiety for the forthcoming surgery was
was 35.9%, 25.0%, and 17.4%, respectively.5 Although evaluated, and a standard phacoemulsification surgery under
Journal of Pain Research downloaded from https://www.dovepress.com/ by 46.148.127.118 on 07-Oct-2018

the use of topical anesthesia may help avoid the potential topical anesthesia was performed by the same surgeon. The
complications of local anesthesia, the possibility of the eye topical anesthesia used was 0.5% proparacaine hydrochloride
moving or closing due to pain may represent a significant drops (Alcaine, Alcon Pharma; Puurs, Belgium) which was
handicap; thus, preoperative administration of analgesics applied to the ocular surface twice at 2- to 3-minute inter-
or the use of an additional sedative measure may increase vals. In cases where patients experienced unbearable pain
patient comfort and cooperation. and were uncooperative, an additional dose of 2% lidocaine
Hypnosis is a method of psychotherapy that can modu- was administered by sub-Tenon’s injection. The patients in
late the phenomenological aspects of conscious experience, the control group underwent the same procedures except for
relieve pain, relax the body, and reduce anxiety.8,9 A limited the hypnosis session. Patients who had any of the following
number of studies have demonstrated the efficacy of clini- were excluded from the study: complicated surgeries, such
For personal use only.

cal hypnosis in the treatment of pain and anxiety in severe as zonular dialysis or posterior capsule rupture; a history of
diseases.10–12 In the context of anesthesia, hypnosis can be previous eye surgery; evidence of injury or inflammation;
used alone or in combination with the drugs typically used nystagmus; communication or cooperation difficulties; any
in anesthetic regimens, and increasing evidence supports the prior experience of using hypnosis; conditions of psychosis,
value of hypnosis in reducing patient stress and anxiety and such as hallucinations, delusions, or depression; or excessive
inducing relaxation.13,14 smoking and drinking habit. The surgeon was blinded to
In this study, we discuss the effectiveness of hypnosis in the group allocations until the entire study was completed.
alleviating pain associated with cataract surgery. Upon completion of the surgery, the patients received oral
instructions to guide their return to consciousness, and pain
Methods and cooperation levels were subsequently evaluated by the
Patients patients and the surgeon separately.
Male or female patients, aged 50–85 years, with bilateral age- Patient pain was evaluated after the surgery using a VAS
related cataract and who wished to have phacoemulsification ruler as follows: 0 point, no pain; 1–3 points, mild pain; and
surgery in both eyes were preliminarily admitted. Immedi- >3 points, moderate-to-severe pain (Figure 1).
ately after the first-eye surgery, each patient was evaluated for Patient cooperation was graded from 0 (no event) to 3
pain using the visual analog scale (VAS), and patients with (obvious eye and head movement and/or lid squeezing) by
a VAS score >1 were enrolled. Using block randomization, the surgeon after the surgery. The grade was classified as
the enrolled patients were allocated to either the treatment follows: 0, excellent cooperation (no events); 1, good coop-
group, which received hypnosis intervention before the eration (eyelid squeezing); 2, sufficient cooperation (globe
scheduled second-eye surgery, or the control group, which movement and eyelid squeezing); 3, poor cooperation (head
did not undergo hypnosis. movement, globe movement, and eyelid squeezing).

Figure 1 Pain score chart. 0, no pain; 1–3, mild pain; 4–6, moderate pain; 7–9, severe pain; 10, unbearable pain.

1922 submit your manuscript | www.dovepress.com Journal of Pain Research 2018:11

Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Hypnosis benefits cataract surgery

Patient anxiety was evaluated before surgery using the Table 1 Patient characteristics
Amsterdam Preoperative Anxiety and Information Scale Parameter Hypnosis Control P-value
(APAIS). The test involved a six-item questionnaire. Four Patients (n) 55 56 –
items in the questionnaire were used to measure preoperative Mean age (years) ± SD 64.11±5.74 64.66±5.07 0.59
Sex (male/female) 25/30 27/29 0.85
anxiety, and two items were used to measure the need for
information. The items were rated on a 5-point Likert scale
from “not at all” to “extremely”. Each question was scored
from 1 to 5. The total anxiety scale score ranged from 4 to pain, moderate pain, and severe pain, respectively, which
Journal of Pain Research downloaded from https://www.dovepress.com/ by 46.148.127.118 on 07-Oct-2018

20. The information demand scale score ranged from 2 to 10. showed significant differences between the groups (P<0.005)
This study was approved by the Third Affiliated Hospital (Table 2 and Figure 3).
Institutional Review Board, Third Military Medical Univer- Patient anxiety levels were evaluated using the APAIS. A
sity, Chongqing, China, and all patients provided written highly significant difference was noted between the control
informed consent. The clinical trial registration number is group and the hypnosis group (P<0.005). The mean score of
ChiCTR1800014711. the control group was 11.77 (SD 0.32), and the mean score
of the hypnosis group was 6.64 (SD 0.21). Results from the
Statistical analysis patient anxiety assessments are presented in Table 3 and
Quantitative data were compared between the two groups via Figure 4.
t-test (normal distribution) and the Wilcoxon rank sum test The cooperation assessment revealed that only 5% and
For personal use only.

(non-normal distribution). The c2 test was used to compare 18% of patients in the control group exhibited excellent and
categorical variables. The Spearman rank correlation was good cooperation, respectively, whereas 47% of patients
used for nonparametric data. Statistical analysis was per- exhibited poor cooperation. In contrast, in the hypnosis
formed using SPSS 13.0 (SPSS Inc., Chicago, IL, USA). The group, 18% and 36% of patients exhibited excellent and
sample size for the study was based on the results from an good cooperation, respectively, whereas 24% exhibited poor
earlier study; two-tailed t-tests were conducted with a=0.05 cooperation, which showed significant differences among the
and b=0.1, and it was determined that at least 50 patients four groups (P<0.005). The results of the patient cooperation
were required for each group. Taking patient discontinua- assessments are presented in Table 4 and Figure 5.
tion into consideration, as well as possible complications There was a significant positive correlation between the
in the surgery, a total of 120 patients were chosen to ensure VAS and cooperation, both in the hypnosis group and in the
sufficient enrollment. control group (r=0.414, P<0.005; r=0.596, P<0.005). How-
ever, there was no significant correlation between the VAS
Results and the anxiety analysis in either group.
A total of 120 patients were enrolled and formed the intent-
to-treat population, with 60 patients randomized to each study Discussion
group. Among the enrolled patients, three in the treatment In conventional cataract surgery, a skilled doctor can perform
group and two in the control group did not undergo their a successful phacoemulsification surgery in approximately
second-eye surgery for health or other reasons. In addition, 10 minutes, and topical anesthesia is thus often used to save
two patients from each group were excluded from the study time; however, topical anesthesia is not always completely
because complications occurred and lidocaine was used in effective for relieving pain and anxiety in phacoemulsifica-
the surgery. Hence, 111 patients (48 men and 53 women, 55 tion surgery. Most recent studies have focused on determin-
in the treatment group and 56 in the control group) between ing whether the pain experienced during the second-eye
50 and 82 years (median 64 years) were included in the surgery is greater than or equal to that experienced during
final evaluation. Baseline characteristics were well balanced the first-eye surgery,16–19 but few researchers have focused
between the two groups (Table 1 and Figure 2). on reducing patient pain during the cataract surgery under
During the intraoperative pain assessment using the VAS, topical anesthesia. In fact, if the patient experienced pain
5%, 34%, 38%, and 23% of patients in the control group during the first-eye surgery, particularly obvious pain, he/
reported having no pain, mild pain, moderate pain, and severe she will inevitably experience pain and anxiety during the
pain, respectively. In contrast, in the hypnosis group, 18%, second-eye surgery if only local anesthesia is used without
56%, 15%, and 11% of patients reported having no pain, mild any auxiliary sedative measures.

Journal of Pain Research 2018:11 submit your manuscript | www.dovepress.com

1923
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Chen et al Dovepress
Journal of Pain Research downloaded from https://www.dovepress.com/ by 46.148.127.118 on 07-Oct-2018
For personal use only.

Figure 2 Study flow chart.

Abbreviation: VAS, visual analog scale.

Table 2 Patient VAS scores

Groups n VAS during phacoemulsification surgery, n (%) c2 P-value
0 1–2 2–3 3–4
Hypnosis 55 10 (18%) 31 (56%) 8 (15%) 6 (11%) 15.557 0.001
Control 56 3 (5%) 19 (34%) 21 (38%) 13 (23%)
Abbreviation: VAS, visual analog scale.

Figure 3 Extent of patient pain with or without hypnosis.

Abbreviation: VAS, visual analog scale.

1924 submit your manuscript | www.dovepress.com Journal of Pain Research 2018:11

Dovepress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Hypnosis benefits cataract surgery

Hypnosis has been used in ophthalmic surgery for many

years, and several cases of successful hypnosis applica-
tion have been reported.20,21 However, these reports mainly
focused on the ability of hypnosis to reduce medication
use and increase patient satisfaction or described its use in
high-risk patients in unusual situations.22–24 In the present
study, we assessed whether hypnosis can assist in alleviating
cataract patient pain and anxiety and improve cooperation
Journal of Pain Research downloaded from https://www.dovepress.com/ by 46.148.127.118 on 07-Oct-2018

Figure 5 Cooperation levels in patients with or without hypnosis.

in the second-eye surgery. In total, our results showed that
patients in the hypnosis group exhibited remarkably improved
results, though hypnosis combined with topical anesthesia
data suggest that hypnosis was able to help alleviate pain,
was not able to eliminate pain for all patients, which may
especially for patients who experienced obvious pain dur-
be reasonable given individual differences in the hypnotic
ing the first-eye surgery. Second, patients VAS score was
effect and pain sensitivity. Overall, many patients in the
positively associated with cooperation score, indicating
hypnosis group presented with reduced pain, lower anxiety,
that patients who experience less pain demonstrate better
and increased cooperation.
cooperation.
Our study revealed two main conclusions. First, with
hypnosis therapy, patients with a higher VAS score in their
Conclusion
For personal use only.

first-eye surgery showed a remarkable decrease in VAS

To the best of our knowledge, this is the first study inves-
score in their second-eye surgery (data not shown). These
tigating the effects of hypnosis on the management of pain
during cataract surgery in the second eye. Although our data
Table 3 Patient anxiety evaluation
must be interpreted with caution given the high variability in
hypnosis techniques, the lack of standard scales to indicate
Groups n Anxiety before the t P-value
phacoemulsification hypnotic susceptibility, individual differences to hypnotic
surgery (mean ± SD) susceptibility, and the small number of patients included in
Hypnosis 55 6.64±0.21 13.21 <0.0001 the study, our results clearly demonstrated that hypnosis may
Control 56 11.77±0.32 be considered as an auxiliary measure for cataract surgery in
the second eye, especially for patients who experienced pain
during the first-eye surgery.

Acknowledgments
The authors would like to thank all the patients for graciously
participating in the study and the reviewers for their valuable
comments.

Author contributions
Chunlin Chen and Jian Ye designed the study and conducted
the analyses. Xiaofan Chen, Rongdi Yuan, Xiao Chen, and
Min Sun performed the experiments. Xiaofan Chen and Sen
Lin wrote the manuscript. All authors read and approved the
Figure 4 Anxiety levels in patients with or without hypnosis. final manuscript.

Table 4 Patient cooperation scores

Groups n Cooperation during phacoemulsification surgery, n (%) c2 P-value
0 1 2 3
Hypnosis 55 10 (18%) 20 (36%) 12 (22%) 13 (24%) 12.944 0.005
Control 56 3 (5%) 10 (18%) 16 (30%) 27 (47%)

Journal of Pain Research 2018:11 submit your manuscript | www.dovepress.com

1925
Dovepress

Powered by TCPDF (www.tcpdf.org)

 Chen et al Dovepress

Disclosure 11. Jafarizadeh H, Lotfi M, Ajoudani F, Kiani A, Alinejad V. Hypnosis for reduc-
tion of background pain and pain anxiety in men with burns: A blinded,
The authors report no conflicts of interest in this work. randomised, placebo-controlled study. Burns. 2018;44(1):108–117.
12. Bhatt RR, Martin SR, Evans S, et al. The effect of hypnosis on pain and
peripheral blood flow in sickle-cell disease: a pilot study. J Pain Res.
References 2017;10:1635–1644.
1. Ezra DG, Allan BD. Topical anaesthesia alone versus topical anaes- 13. Facco E. Hypnosis and anesthesia: back to the future. Minerva Aneste-
thesia with intracameral lidocaine for phacoemulsification. Cochrane siol. 2016;82(12):1343–1356.
Database Syst Rev. 2007;18(3):CD005276. 14. Wobst AH. Hypnosis and surgery: past, present, and future. Anesth
2. Nanji KC, Roberto SA, Morley MG, Bayes J. Preventing Adverse Events Analg. 2007;104(5):1199–1208.
in Cataract Surgery: Recommendations From a Massachusetts Expert 15. Erickson MH. Further clinical techniques of hypnosis: utilization
Journal of Pain Research downloaded from https://www.dovepress.com/ by 46.148.127.118 on 07-Oct-2018

Panel. Anesth Analg. 2018;126(5):1537–1547. techniques. 1959. Am J Clin Hypn. 2009;51(4):341–362.

3. Hosoda Y, Kuriyama S, Jingami Y, Hattori H, Hayashi H, Matsumoto 16. Sharma NS, Ooi JL, Figueira EC, et al. Patient perceptions of second
M. A comparison of patient pain and visual outcome using topical eye clear corneal cataract surgery using assisted topical anaesthesia.
anesthesia versus regional anesthesia during cataract surgery. Clin Eye (Lond). 2008;22(4):547–550.
Ophthalmol. 2016;10:1139–1144. 17. Ursea R, Feng MT, Zhou M, Lien V, Loeb R. Pain perception in
4. Ezra DG, Nambiar A, Allan BD. Supplementary intracameral sequential cataract surgery: comparison of first and second procedures.
lidocaine for phacoemulsification under topical anesthesia. A meta- J Cataract Refract Surg. 2011;37(6):1009–1014.
analysis of randomized controlled trials. Ophthalmology. 2008;115(3): 18. Hari-Kovacs A, Lovas P, Facsko A, Crate ID. Is second eye
455–487. phacoemulsification really more painful? Wien Klin Wochenschr.
5. Dadaı Z, Borazan M, Öncel Acır N. Pain Perception in Phacoemulsifi- 2012;124(15–16):516–519.
cation with Topical Anesthesia and Evaluation of Factors Related with 19. Akkaya S, Özkurt YB, Aksoy S, Kökçen HK. Differences in pain
Pain. Turk J Ophthalmol. 2016;46(4):151–155. experience and cooperation between consecutive surgeries in patients
6. Kongsap P, Wiriyaluppa C. A comparison of patient pain during cataract undergoing phacoemulsification. Int Ophthalmol. 2017;37(3):545–552.
surgery with topical anesthesia in Prechop Manual Phacofragmentation 20. Lewenstein LN. Hypnosis as an anesthetic in pediatric ophthalmology.
For personal use only.

versus phacoemulsification. J Med Assoc Thai. 2006;89(7):959–966. Anesthesiology. 1978;49(2):144–145.

7. Uusitalo RJ, Maunuksela EL, Paloheimo M, Kallio H, Laatikainen L. 21. John ME Jr, Parrino JP. Practical hypnotic suggestion in ophthalmic
Converting to topical anesthesia in cataract surgery. J Cataract Refract surgery. Am J Ophthalmol. 1983;96(4):540–542.
Surg. 1999;25(3):432–440. 22. Lewenstein LN, Iwamoto K, Schwartz H. Hypnosis in high risk oph-
8. Kendrick C, Sliwinski J, Yu Y, et al. Hypnosis for Acute Procedural thalmic surgery. Ophthalmic Surg. 1981;12(1):39–41.
Pain: A Critical Review. Int J Clin Exp Hypn. 2016;64(1):75–115. 23. Kiss G, Butler J. Hypnosis for cataract surgery in an American Society
9. Lynn SJ, Laurence JR, Kirsch I, Hypnosis, suggestion, and suggest- of Anesthesiologists physical status IV patient. Anaesth Intensive Care.
ibility: an integrative model. Am J Clin Hypn. 2015;57(3):314–329. 2011;39(6):1139–1141.
10. Barbero U, Ferraris F, Muro M, Budano C, Anselmino M, Gaita F. 24. Agard E, Pernod C, El Chehab H, Russo A, Haxaire M, Dot C. A role for
Hypnosis as an effective and inexpensive option to control pain in hypnosis in cataract surgery: Report of 171 procedures. J Fr Ophtalmol.
transcatheter ablation of cardiac arrhythmias. J Cardiovasc Med (Hag- 2016;39(3):287–291.
erstown). 2018;19(1):18–21.

Journal of Pain Research Dovepress

Publish your work in this journal
The Journal of Pain Research is an international, peer reviewed, open The manuscript management system is completely online and includes
access, online journal that welcomes laboratory and clinical findings a very quick and fair peer-review system, which is all easy to use. Visit
in the fields of pain research and the prevention and management http://www.dovepress.com/testimonials.php to read real quotes from
of pain. Original research, reviews, symposium reports, hypoth- published authors.
esis formation and commentaries are all considered for publication.
Submit your manuscript here: https://www.dovepress.com/journal-of-pain-research-journal

1926 submit your manuscript | www.dovepress.com Journal of Pain Research 2018:11

Dovepress

Powered by TCPDF (www.tcpdf.org)