Minimally invasive adrenalectomy is the standard of care for small adrenal tumours. Both the transperitoneal lateral approach and posterior retroperitoneal approach are widely used and have been proven to be safe and effective. However, the prevalence of chronic postsurgical pain has not been specifically investigated in previous studies. The primary goal of this study was to identify the prevalence of chronic postsurgical pain after minimally invasive adrenalectomy.A cross-sectional study was performed among all consecutive patients who had undergone minimally invasive adrenalectomy in a single university medical centre. The primary outcome was the prevalence of chronic postsurgical pain. Secondary outcomes were the prevalence of localized hypoesthesia, risk factors for the development of chronic postsurgical pain, and the Health-Related Quality of Life. Three questionnaires were used to measure the prevalence and severity of chronic postsurgical pain, hypoesthesia, and Health-Related Quality of Life. Logistic regression analysis was performed to determine risk factors for development of chronic postsurgical pain.Six hundred two patients underwent minimally invasive adrenalectomy between January 2007 and September 2019, of whom 328 signed informed consent. The prevalence of chronic postsurgical pain was 14.9%. In the group of patients with chronic postsurgical pain, 33% reported hypoesthesia as well. Young age was a significant predictor for developing chronic postsurgical pain. The prevalence of localized hypoesthesia was 15.2%. In patients with chronic postsurgical pain, Health-Related Quality of Life was significantly lower, compared to patients without pain.The prevalence of chronic postsurgical pain following minimally invasive adrenalectomy is considerable. Furthermore, the presence of chronic postsurgical pain was correlated with a significant and clinically relevant lower Health-Related Quality of Life. These findings should be included in the preoperative counselling of the patient. In the absence of evidence for effective treatment in established chronic pain, prevention should be the key strategy and topic of future research.The online version contains supplementary material available at 10.1186/s12871-022-01696-4. Since the introduction in 1992, minimally invasive adrenalectomy (MIA) has become the standard of care for the management of small ≤7 cm) benign adrenal tumours and, in selected cases, for the treatment of small ≤6 cm) malignant tumours . Neverth cm malig cm benigThe primary outcome of this study was the prevalence of CPSP. Secondary outcomes were the prevalence of hypoesthesia, risk factors for CPSP and the impact of CPSP on Health-Related Quality of Life (HRQoL).2 were eligible for PRA. In all other patients TLA was indicated. Two surgeons performed the procedures, both with more than 15 years of laparoscopic experience. Living patients were approached by telephone, subsequently written information was sent after which informed consent was obtained. All patients were asked to complete three questionnaires at the time of study. The study was approved by the research ethics committee of the Radboud University Nijmegen Medical Centre (2019–5500).All adult patients who underwent MIA in our hospital between February 2007 and September 2019 were included in a cross-sectional study. Patients were approached by phone between October 2019 and January 2020. PRA was introduced in our hospital in 2011. Patients with (presumably) benign tumours or pheochromocytomas ≤7 cm, and a body mass index (BMI) < 35 kg/mThere were four objectives in this study; (1) assessment of CPSP; (2) assessment of localized hypoesthesia; (3) analysis of possible risk factors for CPSP; and (4) the influence of CPSP on HRQoL. The primary outcome of this study was the prevalence of CPSP. The presence of CPSP was scored when patients replied “yes” to the question if they currently had pain which could be related back to their adrenalectomy, i.e. wound pain, pain at site of the scar, flank pain, referred shoulder pain. When patients answered “yes” to the chronic pain question, they were included in the chronic pain group, and they were asked to fill in the follow up questionnaire: the Dutch version of the McGill Pain Questionnaire (MPQ) . When thSecondary outcomes were the prevalence of localized hypoesthesia, analysis of possible risk factors for CPSP and HRQoL. When patients answered “yes” to the localized hypoesthesia question they were included in the group with localized hypoesthesia and were asked to fill in the subsequent self-designed follow up questionnaire to determine its localization, duration, and course Appendix . The ‘onAll patients were asked to fill in the questionnaire regarding HRQoL: the RAND Short Form-36 Health Status Inventory (RAND SF-36) . The RANPerioperative patient data were collected from a prospectively maintained database and included: medical history, age at the time of surgery, BMI, ASA-score, medication and indication for surgery, side of adrenalectomy, duration of surgery, operating technique, conversion to open surgery and postoperative complications, according to the Clavien-Dindo classification. The presence of preoperative pain, preoperative anxiety disorders or depression was obtained from electronic patient documents and scored “yes” if it was reported.t-test was used. Chi-square and ANOVA were used for categorical variables. Correlation between variables that were normally distributed was calculated with the Pearson correlation coefficient and with the Spearman rank correlation method for non-normally distributed variables.The data were assessed for normality using the Shapiro-Wilk Test. To compare normally distributed continuous variables Student p < .05 in the univariate model were included in the multivariate model. Statistical significance was defined as a p-value <.05. All statistical analyses were performed using Statistical Package for the Social Sciences .To identify possible predictive factors for CPSP binary logistic regression was performed. The Hosmer-Lemeshow goodness of fit test was used to describe the performance of the regression model. Variables with a significance level of A total of 602 patients underwent MIA between February 2007 and September 2019. Five hundred forty-four patients were approached by phone between October 2019 and January 2020. Fifty-eight patients were lost to follow-up because of death or missing contact information. We received response from 358 (65.8%) patients, of which 328 patients signed informed consent. Of these patients, 172 underwent TLA and 156 PRA. Patient enrolment is depicted in Fig. The mean age of patients at time of adrenalectomy was 54 years and 52% was male. The mean follow-up time was 4.6 years. The most common indications for surgery were primary aldosteronism (PA) (50%), pheochromocytoma (23%), and Cushing’s syndrome 13%). Forty-nine patients (15%) reported pain preoperatively, and 52 (16%) patients used pain medication preoperatively. In the group of patients with CPSP, 25% had reported pain preoperatively and 22% used analgesia before surgery. History or comorbidity of neurological diseases, which included for example cerebral vascular events, hernia nuclei pulposi, and peripheral neuropathy was not significantly different between patients with and without CPSP. Thirty-four patients had any postoperative complication, of which 15 (4.6%) patients had a Clavien-Dindo I complication, 11 (3.3%) patients had a Clavien-Dindo II, and 8 (2.4%) patients had a Clavien-Dindo III complication. Most Clavien-Dindo II complications were postoperative pulmonary infections or urinary tract infections (73%). The Clavien-Dindo III complications included three patients who underwent additional surgery (0.9%), two because of an incisional hernia and one because of an urinoma. Other Clavien-Dindo III complications included pulmonary embolism and postoperative abscess which required percutaneous drainage. Patient characteristics are presented in Table 3%. FortyForty-nine out of 328 patients (14.9%) reported the presence of CPSP, of which 34 received TLA (69.4%) and 15 PRA (30.6%). Onset of CPSP was acute in 18 patients (36.7%) and slow in 28 patients (57.1%). In the group of patients with CPSP, 32.7% reported hypoesthesia as well. In the group of patients with CPSP, most patients (44.9%) experienced continuous pain with fluctuating severity. In this group, the mean general pain intensity measured by VAS was 34 (± 25). The reported localizations were the ipsilateral flank (67.3%), the contralateral flank (16.3%) and other more diverse localizations such as groin, shoulders or arms (16.3%).n = 21; 42.9%) and stabbing  in the sensory class; tiring  in the affective class; and annoying  in the evaluative class. The mean pain intensity measured by the total score of the PRI  was 40.8 . Twenty patients (40.8%) were using analgesics for the reported pain, mostly acetaminophen or nonsteroidal anti-inflammatory drugs (34.7%); four patients reported the use of opioids (8.2%). Further characteristics are presented in Table The mean Number of Words Chosen (NWC) was 7.9 of 20 words. Sensory descriptors were chosen more frequently than affective or evaluative terms. The most frequently selected words were nagging (Fifty-two patients (15.8%) reported hypoesthesia, of which 19 patients received TLA (36.5%) and 33 PRA (63.5%). Onset of hypoesthesia was acute in 28 patients (53.8%) and slow in 18 patients (34.6%). Twenty-one patients (40.4%) experienced a continuous feeling of hypoesthesia. The reported localizations were the ipsilateral flank (78.8%), leg or arms (11.5%) or unknown (9.6%). Further characteristics are presented in Table p = .405).When looking at the univariate binary logistic regression, age, BMI, ASA-score, preexisting pain, surgical complications with Clavien-Dindo score III, TLA, and primary aldosteronism as indication for surgery were significant individual predictors of CPSP Table . When pep < .001) and on the scale of bodily pain between patients without pain (mean 86.1 ± SD 21.9) and patients with CPSP (mean 59.1 ± SD 20.1) (p < .001). When analyzing pain intensity, a higher mean VAS-score was significantly correlated with a lower score on the following subscales of the RAND-SF36 questionnaire: role limitations due to physical health problems , role limitations due to emotional problems , general mental health  and bodily pain . In patients with CPSP the presence of hypoesthesia as well resulted in a significantly lower score of physical functioning . On the other seven domains there was no significant difference.The HRQoL of patients with CPSP after MIA was significantly lower in all subscales compared with patients without pain Table . Major dAlthough MIA was proven to be safe and effective for a heterogeneous group of patients with adrenal disorders, the prevalence of CPSP has not been reported widely. In this cohort study the prevalence of CPSP following MIA was 14.9%. The presence of CPSP was correlated with a significantly lower HRQoL.Acosta et al. found a prevalence of 8% chronic back pain in twelve open and 6% in seventeen laparoscopic bilateral adrenalectomies for hypercortisolism [Walz et al. observed an incidence of 8.5% of temporary hypoesthesia and/or relaxation of the abdominal wall after PRA [Bruintjes et al. showed a prevalence of CPSP of 5.7% following laparoscopic donor nephrectomy in relatively healthy live kidney donors. They also showed a significantly lower HRQoL in patients with CPSP on all subscales of the RAND-SF36, except role limitations due to emotional problems [Bruintjes et al. There are some possible explanations. First, there is a certain risk of recall bias, which might indicate that patient with pain symptoms are more willing to fill in the questionnaires compared to patients without pain, causing an overestimation of CPSP in this study. Second, we used the visual analogue scale and MPQ to report and classify postoperative pain. Differences in definition, classification systems used or methodology of analysis might impede comparisons among studies [Bruintjes et al. The prevalence of nerve injury-induced neuropathic pain was high in patients with persistent pain after thoracic and breast surgeries, 66 and 68%, respectively. In patients with CPSP after groin hernia repair, the prevalence of neuropathic pain was 31%, and after total hip or knee arthroplasty it was 6% [Johansen et al., who reported a strong association between sensory abnormalities and persistent pain, increasing with higher pain intensities [tisolism . Walz etfter PRA . A studyproblems . The pre studies . Third, t was 6% . So, thet was 6% –18. We fensities . These fensities . Early pAfter multivariate regression analysis young age was a significant predictor of CPSP. This predictor has already been described for other surgical procedures than adrenalectomy, such as video-assisted thoracoscopy or thoracotomy , breast When looking at pain severity, patients with a higher VAS-score had significantly lower scores on several domains of the RAND-SF36. This means that the presence of more severe pain results in a significantly lower HRQoL. CPSP can lead to functional limitations and psychological distress in patients. Therefore, identifying the risk factors and applying a preventive strategy may help to decrease the incidence of CPSP and the resulting lower HRQoL. Possible preventive strategies include modification of the surgical technique, adequate pain control throughout the perioperative period, and preoperative psychological intervention focusing on psychosocial and cognitive risk factors .The main strength of this study is that we specifically investigated the prevalence of CPSP after MIA as a primary outcome, which was not done before. Furthermore, this study includes a large patient number from an expert centre, with a relatively high response rate compared with other small-scale phone or e-mail surveys . This alWe acknowledge a few limitations in our study. First, patients with a variety of indications for surgery, disease-related symptoms and differences in comorbidity were compared. Preoperative patient data revealed that according to the group of patients with CPSP 25% had pre-existent pain symptoms, and 22% used analgesia before surgery. This could have an influence on preoperative and postoperative HRQoL between patients, and may influence their recovery after surgery, with or without the presence of CPSP. Second, because of the delay of inclusion , loss to follow-up may have influenced the results. We received response from 66% of patients, and 54% patients signed informed consent. Bias from lack of response might cause an incomplete analysis of the data. So, we cannot ensure that the remaining 46% had similar outcomes to those patients we assessed. Third, the questionnaire regarding CPSP was specific to only answer “yes” if the pain could be related back to their adrenalectomy, i.e. in time of onset and specific localization. However, it is still possible that patients with pre-existing pain reported “yes” as well. This could have resulted in an overestimation of the prevalence of CPSP. We tried to reduce this by searching and reporting comorbidities present at time of surgery which could lead to chronic pain symptoms. Finally, no structured preoperative HRQoL data were present in our population.In conclusion, in this study we have shown a substantial prevalence of CPSP following MIA. The presence of CPSP was significantly correlated with a lower HRQoL. When present, CPSP should be identified in a timely manner, since adequate management by pharmacotherapy, appropriate pain interventions, and/or psychological management, can improve the pain and the physical and social functionality of patients. Furthermore, in the absence of evidence for the most effective treatment in established chronic pain, prevention should be the key strategy. Future trials should focus on etiology and prevention of CPSP after MIA.Additional file 1.


The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations.G) and to establish its reliability and validity.To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German  using correlations, ROC-curves and regression models.G-Tool against the OMPQ-Tool of rs = 0.74 . The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77  [OMPQ = 0.74] and 0.76  [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%.The participants’ (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75  test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKThe German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative. Subgrouping for Targeted Treatment). It allocates patients to one of three prognostic sub-groups  in which they receive a risk-matched treatment [Musculoskeletal (MSK) disorders comprising pain in the region of the lower back, the neck, or osteoarthritis affecting the joints of the upper or lower extremities are among the leading causes of disability. These complaints often have a chronic course and their burden on individuals and society is large –3. Due treatment –10. Thisreatment , 11. Intreatment , 13. Onereatment .Through a programme of research the STarT-Back-Tool has therefore been adapted and validated to produce the Keele STarT-MSK risk stratification tool (STarT-MSK) for use in a broader musculskeletal patient population . This apA translated version of the original STarT-MSK could support German physiotherapists, physicians or other health professionals to be able to provide risk-based stratified care for musculoskeletal disorders , 18. RisG). Moreover, we aimed to investigate its test-retest reliability, construct validity discriminative ability, predictive ability and floor or ceiling effects.The objective of this study was, to formally translate and cross-culturally adapt the STarT-MSK-Tool into German (German version: STarT-MSKA cohort study including a retest (t1) and a half-year follow-up (t2) in addition to the intitial assessment (t0) was conducted. Patients were recruited from physiotherapy clinics (n = 7). The inclusion criteria were patients 18 years or older with acute, subacute or chronic complaints in the region of the lumbar spine, the hip or knee, the shoulder or the neck. The exclusion criteria were those with a known or suspected tumor, an acute inflammatory condition, recent musculoskeletal-related surgery (last six months) or trauma (last 3 months). German language skills had to be sufficient to complete the study questionnaires and participants had to provide written consent and their email and telephone details for follow-up purposes.Initial data (t0) was collected electronically in the clinics via SoSci Survey . The invEthical approval was granted by the Ethics Committee of Trier University of Applied Sciences, Computer Science/Therapeutic Sciences (registration ID: 01–2019). All patients gave their written informed consent for participation before enrollment in the clinics.G. There are two versions of the STarT-MSK-Tool: (1st) a self-report version which was used in this study and (2nd) a clinical interview version. A copy of the instrument can be requested here: www.keele.ac.uk/startmsk.The instrument validated in this study is the STarT-MSKThe translation and cross-cultural adaptation was done according to internationally accepted guidelines and with permission for translation from the developers of the original version . The trawww.keele.ac.uk/startmsk.To check for acceptability and comprehension a pre-test was carried out with 10 patients from a German physiotherapy clinic. A Think-Aloud method was utilized, while the tool was completed . MoreoveDIS) [DIS) [To test for construct validity several reference instruments were added. Based on a formative model, both, the STarT-MSK like the OMPQ assess the risk for future pain and disability, using a set of items of known biopsychosocial risk factors , 35, 36.DIS) , Roland DIS)  or WesteS) [DIS) . Pain inS) [DIS) , 42.The STarT-MSK comprises of 10 items. The first item is an 11-point numeric pain rating scale. The other nine items have a dichotomous response option: yes/no. To calculate a sum-score, the items are recoded . The final score is calculated by summarizing the point for all 10 items, with a possible total score ranging from 0 to 12. Based on cut-off points established for the original version, a total score of ≤4 points indicates low risk, a total score between 5–8 points medium risk, and ≥9 points high risk for persisting pain disability .DIS-score was calculated by summarizing the item values, then divided by the number of items resulting in a range from 0 to 10 points [DIS-score was calculated by summarizing the item values, then divided by the number of valid items, with maximally one non-valid item accepted. This also resulted in a score ranging from 0 to 10 points [To determine the OMPQ score the sum of the five subscale means was computed resulting in a possible range from 0 to 50 points . The RMD0 points . The SPA0 points .Descriptive statistics were calculated to characterize the study population and each subgroup. The baseline characteristics of the study participants are provided to allow interpretability of the study sample. Moreover, numbers on recruitment rate, drop-outs and missing data were described.test-retest reliability the intraclass correlation coefficient ) was used. An ICC above 0.50 was considered acceptable [To investigate the ceptable . Additioconstruct validity the STarT-MSKG was related to the OMPQ. Spearman correlations were calculated for the time point t0. A priori a positive correlation was expected, with higher scores meaning worse prognosis on both instruments. The magnitude of the reported correlation coefficient was evaluated with a correlation of 0.1–0.3 considered to be small, >0.3–0.5 to be moderate, and greater than 0.5 to be large [At least a moderate correlation of greater than 0.4 was considered sufficient. Additionally, to visually represent the correlation of the instruments, box and whisker plot graphs were be presented using the OMPQ-score for each subgroup defined by the STarT-MSKG score. Next to the relation with the OMPQ, coefficients (Spearman) for the correlation with the reference instruments for disability were calculated across the pain sites  curves with areas under the curves (AUC) and 95% confidence interval (CI) were computed [DIS [DIS [DIS ≥ 2.1 [DIS ≥ 4.1 [To assess STarT-MSKcomputed . The curcomputed , NDI [37ted [DIS , SPADIDIDIS [DIS ). MoreovDIS [DIS , NDI ≥ 1DIS [DIS , WOMACDIIS ≥ 2.1 , SPADIDIIS ≥ 4.1 .At least acceptable discrimination for disability was expected.Adjectives that can be used to describe AUC-values have been proposed by Hosmer and Lemeshow with an AUC = 0.5 suggesting ‘no discrimination’, 0.7 to < 0.8 considered ‘acceptable discrimination’, 0.8 to 0.9 considered ‘excellent discrimination’ and >0.9 considered ‘outstanding discrimination’ . At leaspredictive ability the t0 score of the STarT-MSKGwas used as the predictor variable in univariate linear regression. It was aimed to explain a proportion of at least 30% of variance in the outcome (disability and pain). For comparison purposes the variance explained by the OMPQ was also calculated. Additionally, logistic regression analyses were performed. For dichotomization of disability the thresholds given above were used (see discriminative ability), for pain intensity the median was used (with 2.7 at t0 and 4.3 at t2 this fitted well with thresholds described in the literature [2-statistics (adjusted/ Nagelkerke) explaining the variance were evaluated. To test the calibration of the logistic prediction models, Spiegelhalter’s z test was used [To analyse the terature , 53). Thwas used , 55.G predicting dichotomised t2-outcomes (dichotomisation see discriminative ability). Moreover, to enable comparison, AUCs were calculated for OMPQ predicting dichotomised t2-outcomes.Next to regression analyses and in parallel to the procedure described for discriminative ability, areas under the curves (AUC) with 95% confidence intervals (CI) were calculated for STarT-MSKTerwee et al. suggested a sample size of 50 patients for construct validity and reliability . TherefoAs significance level alpha = 5% was set. Analyses were performed using SPSS version 27.0 and R language and environment for statistical computing, version 4.0.0 .Consent for participation was given by 287 patients. The mean age was 47 (SD 15.8) years, and 51% were female, with overall 48.8% at low, 43.6% at medium and 7.7% at high risk. . Non-conThere were 122 patients with lower back complaints, 65 with neck, 40 with shoulder and 60 with hip/knee complaints. Thirty-six patients (12.5%) previously received surgery in the region of their complaints. Additional details on the characteristics of the study population are given in The median time interval between t0 and t1 was 7 (IQR = 8) days and between t0 and t2 181 (IQR = 11) days. The follow-up questionnaires sent to the patients at t1 and t2 were returned by 261 (91%) and 246 (86%) of the participants, respectively. Non-responders at t1 on average were 6.5 years younger than responders, with a large confidence interval  and were less often female . Non-responders at t2 on average were 6.6 years younger than responders, with a confidence interval not including zero  and were less often female .G was 0.75  and therefore, is ‘good’. For individual items the median κ was 0.58 (range 0.42 (item 9) to 0.72 (item 7 and 10)) (The ICC (t0 to t1) for the STarT-MSKand 10)) .G-Tool against the OMPQ-Tool was rs = 0.74 . A visual presentation of the correlation is given in G-Tool against the disability measures consistently was lower, ranging from rs = 0.44 to rs = 0.71 , indicating ‘acceptable’ discrimination. The AUC for pain was 0.83 , indicating ‘good’ discrimination  for pain at 6 months and 20% (variance explained by OMPQ 19%) for combined disability as shown by adjusted R2. The explained variance therefore fell short of the 30% aimed for, both for predicting pain and disability.The univariate logistic regression models, comparable were statistically significant, with both p < 0.001, resulting in an amount of variance explained by the STarT-MSKG of 29% for pain at 6 months and 26% for combined disability as shown by Nagelkerke’s R2. With z = -0.01 for disability and z = 0.07 for pain, Spiegelhalter’s z was non-significant .For the univariate G ability to predict pain-cases at follow-up was 0.77 . The AUC for disability was 0.76 , indicating ‘acceptable’ prediction  was used . The goo2>30%. The number of 30% was estimated based on results from the development study, being unpublished at the time [G together with covariables could be analysed for example in multiple regression analyses. Comparably, for the German version of the STarT-Back-Tool, adding a one item-variable capturing global health status and the baseline score of the outcome (disability) successfully increased the variance explained to ≥45% [Predictive properties checked by ROC-Analyses resulted in acceptable AUCs that were higher than those of the OMPQ, although with extensively overlapping CI. The calculated, logistic and linear models with pain or disability outcomes explained from 20% to 29% of the variance in outcome, but did not exceed the pre-specified target of Rthe time . The achthe time . In futu to ≥45% . Moreove to ≥45% . In the  to ≥45% . CalculaG, it would be worthwhile to develop a study design specifically aiming at improving prediction.The treatment was not influenced by the researchers in the presented study, thus, it can be assumed that the content will have influenced the outcome at follow-up and the variance explained by the regression analyses. An alternative would have been to standardize the procedures, but such a shift from an observational to an experimental design would have led to costs exceeding the available resources for this project. On the other hand, to withhold therapy would have been unethical. Considering the other positive properties established for reliability and validity of the STarT-MSKAll predictive ROC at least resulted in acceptable AUC. The cut-offs used to differ between cases and non-cases were derived from the literature –50. NoneG is related to that of the STarT-Back-Tool. While the area of application of STarT-Back-Tool is limited to low back pain [G is its appropriability for patients with a variety of musculoskeletal complaints. In practice, such a possibility for generic use makes clinical processes easier with one instrument fitting for a broader group of patients. The administrative burden can be reduced, since often patients present with complaints at several sites simultaneously [The development of the STarT-MSKack pain , a strenaneously , 60. Moraneously , 62.G strengthens its use for this purpose. Since practitioners have mixed ideas about how to best make use of prognostic tools [Another strength of the STarT-MSK is that matched treatments were compiled and instruments assisting clinicians in decision-making are under development , 28, 63.ic tools , 67, strReference for the development of the STarT-MSK at Keele (UK) was the STarT-Back-Tool , 18. ThrNext to the German version multiple other translations were done including the Dutch, French, Hebrew and Norwegian versions which were validated. However, three of those studies were conducted with smaller sample-sizes and only one with a design enabling determination of the instrument’s predictive ability , 19, 21.The low amount of dropout in this study is an area of strength. It is substantially lower than the benchmark set by the Cochrane Back and Neck Group for long term follow-up . This inConcerning the sample size, in the literature minimal numbers of 50 to 100 participants are required for validation , 71. In The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. It fulfils the fundamental requirements for an assessment instrument having shown good test-retest-reliability, face, construct validity and predictive validity when analysing ROC-Curves. The instrument explains a considerable amount of variance in six month pain and disability scores. However, whilst the prognostic abilities are comparable to those of the existing reference standard (OMPQ), as the variance was lower than the target set a priori, it is recommended that future research should seek to raise the predictive abilities of this tool further.S1 FigG total score; RMDQ: Roland Morris Disability Questionnaire; NDI: Neck Disability Index; SPADI: Shoulder Pain and Disability Index, subscale disability; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, subscale disability; t0: initial.Disability-scores versus STarT-MSK(TIF)Click here for additional data file.S2 FigG total score; RMDQ: Roland Morris Disability Questionnaire; NDI: Neck Disability Index; SPADI: Shoulder Pain and Disability Index, subscale disability; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, subscale disability; t2: follow-up.Disability-scores versus STarT-MSK(TIF)Click here for additional data file.


Bertolotti’s syndrome (BS) is defined as the presence of low back pain (LBP), radiculopathy or both with a dysplastic transverse process (TP) of the fifth lumbar vertebra that is articulated or fused with the sacral base or iliac crest. This study aimed to investigate the prevalence and severity of BS to promote awareness of this disease.A retrospective review of anteroposterior lumbosacral plain radiographs was conducted between 1 January and 31 December 2017. Patients were recruited via systematic randomised sampling and were then interviewed and examined. The severity of BS was measured objectively using the numerical pain rating scale (NPRS) and Oswestry disability questionnaire (ODQ). Data were analysed using IBM SPSS for Windows version 22.The prevalence of BS was 9.6% (16/166). Age significantly affected the severity of BS. The older and younger groups had a mean ODQ score of 42.86% and 24.08%, respectively (P=0.006). There was no significant relationship found between the prevalence of BS and age (P=0.126). Only one patient was diagnosed with BS during medical consultation. The mean NPRS score was 5.5. The majority of the BS cases were of moderate severity (43.8%), followed by those of minimal severity (31.2%) and severe disability (25%).Early diagnosis of BS and orthopaedic referral are crucial to halt its progression. BS should be considered in patients presenting with LBP during assessments of lumbosacral radiographs. Lumbosacral transitional vertebrae (LSTV) are a congenitally morphological spinal variation that spans a spectrum from a dysplastic transverse process (TP) of the fifth (L5) lumbar vertebra to partial/complete fusion between the TP of L5 and sacral base or iliac crest.1 Specifically, reference has been made to the fact that the disc above the transitional vertebra appears to be at risk of increased degenerative changes, while the disc below appears to be protected.6 These findings are also supported by Aihara et al., who proposed that this pathophysiology is attributed to hypermobility and abnormal torque of the intervertebral disc space immediately above the transitional vertebra, which appears to be more concentrated than do other levels.6 Once disc degeneration occurs, further mechanical irritation of the nerve root by the degenerated disc or pseudo-joint may lead to radicular symptoms.7The exact cause of LBP in patients with BS remains uncertain, although a few theories mainly attributed to arthritic changes and disc degeneration have been postulated.3 Further, Castellvi et al. found a high prevalence of lumbosacral anomalies of 30%.1 Although Tini et al. suggested that LSTV was not associated with LBP, other studies indicated an association of LSTV with LBP and buttock pain.9The prevalence of BS in the general population varies in the literature. It has been reported to be between 4.6% and 7% and reach up to 11.4% in patients under the age of 30 years.10Currently, data on the prevalence, severity and underdiagnosis rate of BS in Malaysia are scarce. In the country, LBP is a common presentation in daily clinical practice and commonly being assessed initially by local medical practitioners ranging from primary care to emergency doctors who subsequently offer orthopaedic referral. However, not many medical practitioners are aware of this condition, which leads to delay in its diagnosis and treatment. In Malaysia, Manmohan et al. reported the case of a 20-year-old lady who experienced marked back pain for 8 years for which she had visited general practitioners (GPs) regularly and underwent various advanced imaging studies, including lumbosacral magnetic resonance imaging (MRI) (thrice), cervical spine MRI (once), lumbar spine computed tomography (once), plain lumbosacral spine radiography  and nerve conduction study (once) prior to the diagnosis of BS.5 Therefore, this study aimed to determine the prevalence, severity and underdiagnosis rate of BS in Malaysia.Accordingly, this study is expected to add to the existing body of literature information promoting the awareness of this disease, earlier diagnosis and orthopaedic referral if clinically indicated. This would consequently help reduce the economic burden by reducing unnecessary tests and multiple visits to GPs and emergency departments. Early diagnosis with timely management provides relief of acute pain and helps prevent chronic LBP along with its complications. Symptomatic patients whose conservative management failed may be initially treated with local steroid and anaesthetic agent injections.The study was performed in Hospital Serdang, Malaysia. Ethical approval was provided by the Medical Research and Ethics Committee, Ministry of Health Malaysia prior to the initiation of the study. Six hundred anteroposterior (AP) plain LSRs that were taken in 2017 were selected via purposive sampling from 1 January to 31 December 2017. We selected 50 LSRs of the patients for each month, which totalled up to 600 LSRs over 12 months.In purposive sampling, the LSRs of the patients were arranged according to the date from the first day of the month until the end of the month between January and December 2017. Once arranged, the LSRs were selected and reviewed to select the first 50 radiographs for each month up to a total of 600 radiographs for 12 months. Only the LSRs of the patients who fulfilled the inclusion criteria were selected. Radiographs were reviewed using the Zero Footprint medical image viewer software, which is the default radiographic viewer in Hospital Serdang.Figure 1). Meanwhile, the exclusion criteria were pregnancy, known history of any lumbosacral spine fractures and spinal disc pathology, including degenerative disc disease and prolapse intervertebral disc, and plain radiographic evidence of the following: previous lumbosacral surgery, lumbosacral spine fracture, spinal tumours, other congenital lumbosacral malformation and spinal infections.The inclusion criteria were Malaysian nationality, age between 18 and 60 years and true AP view of the LSR of the patients who visited Hospital Serdang in 2017. A true AP view of the lumbosacral radiograph was defined as the view showing all spinous processes in a straight line, in which the pedicle distance to the spinous process on each side was similar . Subsequently, Castellvi classification was used to describe the morphologic appearance of LSTV .1 The four types in this classification were then further subclassified into unilateral (a) or bilateral (b) involvement : Type I: Dysplastic TP (>19 mm); Type II: Incomplete lumbarisation/sacralisation (pseudo-articulation); Type III: Complete lumbarisation/sacralisation (bony union) between the TP and sacrum; Type IV: Mixture of types II and III on each side. In our study, we used the simplified classification by Nardo et al. where the cases were not further classified into bilateral or unilateral to minimise the number of categories.8Radiological assessment was performed using the AP-view LSRs to accurately determine the size of the TP of L5, which was measured between the uppermost and lowermost points  was performed to collect the demographic data, including age, sex and ethnicity, of the 166 patients. We identified 16 patients with LSTV, who were then interviewed and examined. Informed consent was obtained, followed by focused history-taking, clinical examination and questionnaire completion. The examinations conducted included localisation of low back tenderness and routine neurological lower limb examination. Back tenderness localisation was divided into lumbar, buttock, radiculopathy and others where specification was required. Lower limb neurological examinations followed the American Spinal Injury Association chart of key muscles and key sensory points.14The pain severity was measured using three scales, one for pain during the entire present episode, while the other two were for usual pain during the previous week and during the last episode (when there was no episode of back pain in the past week). In all cases, the pain scale used was the 11-point numerical pain rating scale (NPRS) anchored at one end by the label ‘no pain’ and at the opposite end by ‘worst pain possible’. The question asked was as follows: We realise that there have been ‘good’ and ‘bad’ days, but, on average, how would you rate the severity of your back pain: during the entire time you have had it, during the past week and during the last episode (if there was no episode of back pain in the past week)? This format of questioning has been successfully used in previous studies and is a well-validated method of measuring a patients’ pain experience.15 The scores are interpreted as follows: 0%-20%: minimal disability, 21%-40%: moderate disability, 41%-60%: severe disability, 61%-80%: crippled and 81%-100%: either bed-bound status or exaggerated symptoms.The patients were then asked to answer the Oswestry disability questionnaire (ODQ) with our guidance to specifically assess the severity of LBP. This questionnaire comprises 10 questions. Each question has a total possible score of 5. When the first statement is marked, the score is 0; when the last statement is marked, then the score is 5. The final scores are obtained by dividing the total scores with the total possible scores and multiplying them by 100. This is also well validated in the literature.2), normal (18.50-24.99 kg/m2) and overweight (≥25.00 kg/m2).16The weight and height were measured to calculate the body mass index (BMI) defined as weight in kilograms divided by height in metres squared. The BMI was measured and classified in accordance with the World Health Organization guidelines into underweight  for all qualitative variables. The chi-square test or Yates continuity correction was used for categorical data analysis and Student’s t-test for continuous data analysis. Statistical significance was set at P-values of <0.05. The IBM SPSS Statistics for Windows, Version 22.0  was used to conduct the analyses.A total of 166 patients (age: 18-60 years) who satisfied the inclusion criteria were selected on the basis of the reviewed LSRs of the 600 patients. Of them, 16 were diagnosed with BS (9.6%). Seven out of these sixteen patients had Castellvi type I (43.8%); six, type II (37.5%); and three, type III (18.7%). Fourteen patients presented with LBP one patient with radiculopathy and one patient with both LBP and radiculopathy. The mean duration of symptoms was 6.81 years (standard deviation [SD]: 5.167), with no significant association to the severity of BS measured using the ODQ (P=0.690).Table 1).Fifteen patients had previous medical consultations with primary care and emergency doctors. The common diagnoses made were mechanical back pain (n=7), prolapsed intervertebral disc (n=5) and degenerative lumbar disease (n=2). Only one patient was offered orthopaedic referral, and appropriate treatment was then initiated. One patient did not seek any medical attention; the LSR was obtained owing to other reasons. No significant differences were found between BS and age, sex and ethnicity (2. Age was significantly associated with the severity of BS (Table 2).The severity of BS was measured using the NPRS score, which ranged from 2 to 8, with a mean score of 5.5 (entire time and last episode). Based on the ODQ score, five patients had minimal back pain; seven, moderate; and four, severe. The mean BMI was 29.59  kg/m8 The variability and wide range in the prevalence may be attributed to varying factors, including narrow age span, inclusion of patients without back pain but with other diseases or biased selection of patients.5 As previously described, the prevalence of BS was higher in studies that included patients with LBP and lower in community-based studies.8 Although our patients were from a single hospital, the prevalence of BS in this study (9.6%) was within the range of previous reports. Additionally, no significant difference was observed between the male (9.3%) and female (10%) groups, which is comparable to earlier findings, although some showed a higher prevalence of BS in men.17 The prevalence of BS was not significantly associated with age (P=0.126), also similar to previous findings.3 To our knowledge, this is the first study of its kind in Malaysia; it showed similar results with the study by Nardo et al. that there was no significant relationship between BS and ethnic groups (P=0.363).8In the literature, the prevalence of BS ranges between 4.0% and 37%.12The simple NPRS used in this study could represent the severity and disability of LBP as it was significantly related to the detailed ODQ score. This indicates that this simple, more rapid and accurate method should be utilised by local medical practitioners in assessing the severity of LBP. Age was also found to be significantly associated with the severity of BS. In this study, the patients aged >30 years had a higher mean ODQ score (42.9%) than those aged <30 years (24.1%) (P=0.006). This finding is also similar with the findings by Peterson et al. that older patients reported more disability than did younger patients.3 A proper radiological assessment of plain LSRs can prevent medical practitioners from performing unwanted advanced imaging studies, which may subsequently reduce the economic burden.To the best of our knowledge, no study has shown underdiagnoses of patients with BS in Malaysia. In this study, 14 of 15 patients were not diagnosed with BS during their medical consultations. This shows the importance of early detection of BS, so that timely intervention of the condition could be provided. Early detection can also help prevent worsening of LBP which was significantly observed in the older patients in this study. It can be achieved by having a high index of suspicion upon clinical assessment of patients with LBP inclusive of clinical history, physical examination and appropriate LSR assessment to identify any radiological anomalies, including LSTV. In addition, LBP is one of the main reasons for needing medical assistance, and 80% of adults seek help at some stage in life. In the USA, approximately 15%-20% of the population is affected by LBP and an estimated USD 50 billion is the annual cost for diagnosing and treating LBP.8 One possible explanation may be the difference in the sample size used. Nevertheless, our study also has some limitations. It was conducted in a single health care centre and included a relatively small number of patients. We used systematic randomised sampling to lessen the effect of this limitation and to ascertain that this study may represent our local community.Herein, all patients with LSTV were diagnosed with BS. This finding is contradicted by a previous literature where only 57.6% of patients with LSTV were diagnosed with BS.The prevalence of BS among patients in Malaysia was 9.6%. The older patients were more likely to present moderate-to-severe symptoms than the younger patients. All patients with LSTV were diagnosed with BS. Of the 15 patients with BS, 14 were undiagnosed upon medical consultation, making it an utmost necessity to include BS as part of the differential diagnosis of LBP


Localized tibial strain is one of the hypotheses to explain residual pain after Oxford UKA. We evaluate whether the depth of the vertical cut during tibial resection correlates with medial knee pain. We aimed to investigate the association between the depth of tibial resection and medial knee pain after OUKA.This prospective cohort study enrolled 85 patients (mean age: 64.5 ± 7.7 years) who underwent cemented OUKA at our institute during October 2018–June 2019. The depth of tibial resection was measured intraoperatively as the thickness of the anterior, middle, and posterior parts. The greatest of the three thicknesses was recorded. Medial knee pain was assessed at 6 weeks and followed to 6 months. Patients were divided into the pain (P) and no pain (NP) groups. Preoperative and postoperative radiographic findings and OKS were compared between groups. We used logistic regression to analyze the independent association.p = 0.049). There was no significant difference in the depth of tibial resection between groups. Medial knee pain had resolved by 6 months in all patients, and the 6-month OKS was similar between groups.The mean preoperative Oxford Knee Score (OKS) was 27.2 ± 7.6. The incidence of medial knee pain was 23.5% at 6 weeks after OUKA. The P group had a significantly lower OKS at 6 weeks compared to the NP group ]. Mobile-bearing unicompartmental knee arthroplasty (UKA) is an effective treatment for medial compartmental osteoarthritis (OA). It provides good clinical results and long-term survivorship . HoweverMedial knee pain is a common complaint that leads to unsatisfactory outcomes after mobile-bearing UKA. The incidence of this problem was reported to widely range from 1 to 55% . SeveralConcerning bone resection depth, Berend, et al.  reportedThis prospective cohort study consecutively enrolled patients who underwent cemented OUKA at our institute from October 2018 to June 2019. All included patients were diagnosed with an anteromedial OA (Kellgren-Lawrence grade 3 or 4). The indications for OUKA were varus deformity < 15°, flexion contracture < 15°, and knee flexion at least 110°. Patients with psychological problems, previous knee surgery, significant hip or spine problem, or follow-up time < 6 months were excluded. This study was approved by our center’s institutional review board (IRB), and written informed consent was obtains from all study patients.All procedures were performed by a single experienced surgeon (PU). After inflating the tourniquet to a pressure of 300 mmHg, the mini-medial parapatellar approach was used . The finThe postoperative rehabilitation protocol was started as soon as possible, including ankle pumping, range-of-motion exercise, and out-of-bed ambulation. Cold compression was applied for at least 8 hours per day. All patients received the same postoperative pain management protocol. No intraoperative or postoperative complications were observed in this study.Demographic and clinical data were collected, including age, gender, body weight, height, body mass index (BMI), and preoperative Oxford knee score (OKS). Anteroposterior hip-knee-ankle (HKA) radiographs were evaluated preoperatively and at 4 weeks after surgery. Mechanical femorotibial angle (FTA) was measured in both radiographs. Medial proximal tibial angle (MPTA) and tibial tray inclination were measured by a similar method from preoperative and postoperative HKA radiographs, respectively Fig. . PreoperThe depth of tibial resection was measured intraoperatively using a Vernier caliper according to the following method. First, the widest part of the resected fragment perpendicular to the lateral border was identified using the medial-lateral (ML) line. The midpoint of the ML line was marked and defined as the O point. The anteroposterior (AP) line was drawn perpendicular to the ML line and then passed through the O point. Lastly, the measurement of tibial resection depth was recorded in three parts, as follows: 1) the anterior part was the maximal thickness on the AO line, 2) the middle part was the maximal thickness on the MO line, and 3) the posterior part was the maximal thickness on the OP line  sign of inflammation , 2) positive Tinel’s sign, and 3) increasing pain on knee motion or during resisted knee flexion. The anteromedial area was defined as the area within the following boundaries: the medial joint line, the medial border of the tibial tubercle, the lowest part of the tibial tubercle, and the midpoint of the most anterior and most posterior parts of the knee. Complications, including venous thromboembolism, fracture, and infection, were also recorded during the follow-up period.Our sample size for this study was calculated using data from a study by Edmonson, et al. . They ret-test, chi-square test, or Fisher’s exact test was used to compare variables between groups depending on the distribution of data. Identification of factors independently associated with medial knee pain and variables with p-value < 0.2 were entered into the logistic regression model. Univariate and multivariate analyses were then performed. A p-value < 0.05 was regarded as being statistically significant. All data analyses were performed using SPSS Statistics software .Continuous data are presented as mean ± standard deviation, and categorical data are given as numbers and percentages. According to the presence of medial knee pain at 6 weeks, the cohort was divided into the pain (P) and no pain (NP) groups. Independent A total of 95 knees were recruited. Of those, 10 knees were excluded due to anterior cruciate ligament (ACL) insufficiency (4 knees), lateral compartment damage (3 knees), and loss to follow-up (3 knees). The remaining 85 knees (mean age of patients: 64.5 ± 7.7 years) were included in the final analysis. The patient demographic and clinical characteristics of this cohort are shown in Table p = 0.037) (Table p = 1.000) or tibial inclination (p = 0.589) between groups. However, the P group had a significantly lower OKS at 6 weeks compared to the NP group (p = 0.049). Medial knee pain spontaneously resolved in all study patients by 6 months after surgery. The mean difference is 1.00 with standard error of 1.155 (95% CI: − 3.2978 to 1.2978) with a poor correlation (correlation coefficient < 0.3). There was no significant difference in 6-month OKS between groups (p = 0.326)  Table . Regardip-value < 0.2  and depths of tibial resection were included in a logistic regression model. The univariate or multivariate analysis results revealed no independent association between an evaluated factor and medial knee pain .For the analysis of factors that could significantly influence medial knee pain, variables with This study’s cohort characteristics are equivalent to the recent largest OUKA cohort study in Thailand . Our stuOur study was cautious of specific areas that defined medial knee pain and differentiated soft tissue pain from underlying bone pain. Although our method does not ensure absolute differentiation between these two types of pain, we are confident that the various criteria we used facilitated accurate medial knee pain identification. Our study’s prospective design also allowed us to exclude other possible causes, such as medial overhanging of components and cementing error.Another important finding in this study was that we could not identify any factors independently associated with medial knee pain, including depth of tibia resection. Previous finite element analysis found tibial strain to be increased by 20% after UKA . This exMoreover, we found no significant correlation between component alignment and medial knee pain. Since the spherical femoral component of the OUKA was tolerant to malalignment up to 10 degrees  and OxfoTibial component coronal alignment or tibial inclination were the essential factors most often mentioned in several studies , 23. TheThis research has limitations. First, despite including 85 knees in our final analysis and the smallest number predicted in our sample size calculation, it is possible that our study lacked the power to detect statistically significant differences and associations between groups. Second, because we only considered OA patients, it is possible that our findings do not apply to patients with osteonecrosis. Thirdly, preoperative MRI bone marrow was related to lower pain levels following UKA , althougMedial knee pain was found to be common in the early postoperative period after OUKA, but this pain spontaneously resolved by 6 months. As a range of tibial resection level, post-operative pain is not associated with tibial resection thickness in this study.


Cataract surgery pain management in light of the opioid crisis and how ophthalmologists can help make a positive impact with the use of non-opioid options is discussed. Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis. When considered collectively, the use of opioids in this cataract surgery population creates a perfect storm for potential opioid use disorder (OUD). The literature lacks a comprehensive review of opioids and their relationship to cataract surgery. This article discusses the evolution of cataract surgery and associated pain management, particularly the role and use of opioids in cataract surgery, the associated risks of opioid use in this vulnerable population, and how ophthalmologists and optometrists can help combat the opioid crisis by using nonopioid alternatives to manage pain in their cataract surgery patients.The United States is in the midst of an opioid epidemic. The use of opioids is increasing, and those most at risk are individuals over age 50 years.9 Phacoemulsification is now performed in 96% to 97% of all cataract surgeries in the United States.11 Further advances such as femtosecond lasers, premium intraocular lens, pupil expansion devices, intraoperative dyes, and options for topical anesthesia have made today's cataract surgery elegant and safe with a very high success rate  .”30 Approximately one-third of outpatient procedures in the United States, whether diagnostic or therapeutic, use MAC.32 The most common medications that comprise MAC in the United States are shown in Table Unlike general anesthesia, MAC does not require intubation or ventilation and can be titrated according to patient and surgeon needs.38 Fentanyl and remifentanil are the most commonly used opioids in MAC, and this decision is typically based on the clinicians' preference, duration of the procedure, cost, and convenience.In the United States, approximately 99% of patients who undergo any surgery receive opioid analgesics at some point perioperatively.39 Part of the reason for this prolonged recovery with fentanyl is the increased incidence of postoperative nausea and vomiting associated with the use of opioids.40Opioids such as fentanyl remain a cornerstone of MAC during cataract surgery. A Mayo Clinic  study analyzed sedation and recovery in 20 116 ophthalmologic procedures. Of these, 76.1% were cataract surgeries, with MAC being the most common (84.8%) anesthesia technique. Overall, 79.5% of ophthalmic surgery patients received fentanyl as part of their anesthesia protocol. Prolonged anesthesia recovery was linked to intraoperative fentanyl use, postoperative pain, and postoperative requirements for opioids. Of those patients with prolonged recovery, 97.2% had received fentanyl compared with 77.5% of patients who had an expected course of recovery. This study also found that perioperative opioids resulted in a prolonged duration of anesthesia.Further evidence of the common use of fentanyl during cataract surgery can be seen by reviewing the clinical research literature, looking specifically at studies in which all cataract surgery patients receive fentanyl and those that use fentanyl as a comparator. The widespread use of both of these approaches in clinical trials speaks indirectly to the pervasive use of fentanyl in cataract surgery overall. A cursory search of PubMed for “cataract surgery” AND “fentanyl” yields results from both the ophthalmology and the anesthesiology literature. A representation of the publications of the last 20 years is summarized in Table 51 Although cataract surgery is often considered a minor, relatively low pain procedure, opioids are widely administered to patients undergoing cataract surgery.To assess whether opioids are used as part of routine institutional practice or MAC protocols in cataract surgery, a group from Duke University performed a single-center retrospective study of 2659 patients (3764 cases) undergoing routine cataract surgery over a 2-year period. Patients were excluded if they required combined surgery with a glaucoma, corneal, or retina procedure. The anesthesia for each case was reviewed, and it was found that 3649 cases (96.9%) received at least 1 dose of fentanyl.52 In the 1990s, pain experts pushed for pain to be considered the fifth vital sign.53 Between then and 2010, there was a 4 fold increase in opioid pain medication use and corresponding increases in overdose death rates and hospital admissions.54 From 1999 to 2016, over 200 000 deaths in the United States were attributed to overdoses involving prescription opioids.55Opioid pain medications were used for pain management in patients with cancer starting in the 1980s, when it was believed that the risk for addiction was rare.56 Both longer duration of treatment and higher dosages of opioids can increase the risk for OUD, overdose, and death. Although the annual prescribing rate decreased by 19% from 2006 to 2017, the amount of opioid in morphine milligram equivalents—a calculation of the total amount of opioids allowing for differences in drug type and strength—prescribed per person is about 3 times higher than in 1999. Looking at it a different way, approximately 58 opioid prescriptions were written for every 100 Americans in 2017, with an average of 18 days per prescription.57Most people addicted to opioids are first exposed through prescription medications.58 In general, patients undergoing abdominal/pelvic and orthopedic procedures have fewer opioids left over than patients having nonabdominal soft tissue surgeries. In addition, open surgical procedures resulted in fewer leftover opioids than laparoscopic surgeries. The study concluded that postsurgical prescribing regulations for opioids should not be undertaken without considering the type and nature of the surgery.58 Although cataract surgery was not explicitly included in this analysis, one could surmise that phacoemulsification is a relatively low pain procedure, and opioids, if prescribed postsurgically, may go unused, thereby increasing the risk for diversion into the community.A meta-analysis of 44 studies found that 61% of opioids prescribed after surgery are not used, resulting in large quantities of opioids potentially available in the community outside the context of surgery.59The elderly cataract surgery patient population is not immune to this national crisis. Not only does opioid use pose a public health burden, but these elderly patients are also at an increased risk for OUD and for intraoperative and postoperative cataract surgery complications.61 The mean age for cataract extraction in the United States is about 68 years.62 It has been shown that opioid misuse/abuse is growing fastest in the 50–64 year age group.3 For chronic pain or medical/surgical procedures, older adults are often prescribed opioids, which can lead to OUD. In addition, the elderly may experience anxiety, a decrease in independence, or the loss of a partner, any of which could potentially lead to a dependence on these medications.3 Older age may also result in accidental misuse due to forgetfulness, confusion, or impaired judgment due to polypharmacy.2There are several intertwining risk factors for opioid abuse. Age is a factor, with studies citing patients from age 50 to 80 years as being at risk for excessive opioid use.64 Sun et al. analyzed inpatient and outpatient data from a large administrative health claims database. They assessed 11 surgical procedures between January 2001 and December 2013, identifying specific diagnosis and procedure codes as well as pharmacy claims. They included 641 941 opioid-naive surgical patients and compared them with 18 011 137 opioid-naive nonsurgical patients, looking at the incidence of chronic opioid use, defined as having filled ≥10 prescriptions or more than 120 days' supply of an opioid in the first year after surgery.60 Patients undergoing open cholecystectomy or total knee arthroplasty had the highest rates of chronic opioid use, with 1.2% and 1.4% incidence, respectively. Nonsurgical patients had a chronic opioid use rate of 0.136%. The procedures with the lowest rate of chronic opioid use after surgery were cesarean delivery (∼0.12%), cataract extraction (∼0.14%), and laparoscopic cholecystectomy (∼0.18%).60 Although the rate of chronic opioid use after cataract surgery was low, because this is the most common surgery worldwide, even a small percentage of potential patients with chronic opioid use result in a large number of patients at risk for OUD.67With over 300 million surgeries globally occurring each year, surgery is a risk factor for OUD, with postoperative pain a leading cause.1 A study analyzed 39 140 opioid-naive patients aged 66 years or older who underwent major elective surgery. It found that patients with diabetes, heart failure, and pulmonary disease had greater risk for prolonged opioid use.64 Because the cataract surgery population is older, they are more likely to have 1 or more of these comorbidities.Specific comorbidities may also increase the risk for OUD after surgery.66 Geriatric patients tend to require smaller doses, have delayed onset of action, and experience prolonged effects of a drug. In addition, both cardiac and respiratory depression are more significant in this patient population.40 Overall, elderly patients are more sensitive to the adverse effects of opioids.68 It has also been found that the required dose of fentanyl decreased significantly with age, with 1 study noting a 50% decrease from age 20 to age 89 years and another estimating that opioid dosing should decrease by 25% to 50% in elderly patients.68 Paradoxically, elderly patients are often preferentially given fentanyl because of the risks from benzodiazepines such as respiratory depression, deeper sedation, delirium, and exacerbated dementia.69Another risk factor for OUD is simply age-related physiologic changes. The pharmacokinetics and pharmacodynamics of drugs can be vastly different in the elderly compared with younger patients.71 Elderly patients are more likely to have chronic conditions and temporally adjacent procedures, resulting in greater cumulative opioid exposure potential.71,72 With the cataract surgery patient population generally being over age 65 years, long-term opioid use and OUD are risks. Given that OUD risk increases with repeated exposures or cumulative doses, preventing any individual point of opioid exposure may reduce the overall medical risk.Several studies have shown that there is increased risk for addiction and overdose with each episode of opioid use.73–75 Pain during cataract surgery is managed with MAC and other intraoperative pain management strategies; however, some patients still report moderate to severe discomfort. A 2015 study found that 35% of 106 patients undergoing first-eye cataract surgery reported intraoperative pain. This number was even higher in patients' second eyes, with 87% reporting pain during surgery.76 This may be due to increased awareness of the procedure leading to greater anxiety; thus, patients report greater pain.77It is argued that cataract surgery pain is present but poorly understood and potentially underestimated.75 Patients used the Keele verbal pain chart, grading their pain from 0 to 4 , toward the beginning, middle, and end of their cataract extraction. Analyzing scores from all surgical stages, 10.5% of patients experienced no pain throughout the procedure. Of those experiencing pain, the mean total pain score from all 3 stages combined was 3.05 (SD = 1.242) of 12. There were no statistically significant differences based on age, sex, or laterality. Reports of pain varied based on the cataract type, with patients having either corticonuclear + posterior subcapsular cataracts or white mature cataracts experiencing greater pain levels than those having posterior subcapsular cataracts alone.75Another study assessed 63 patients undergoing phacoemulsification with just topical anesthesia and had patients grade their pain at different stages during surgery.78 A study in Finland analyzed 201 cataract surgeries in which only topical anesthesia was used. Postoperative pain was assessed, and 10% of patients reported ocular pain with a median pain score of 4 to 5/10 at 24 hours after surgery. By 6 weeks after surgery, 7% of patients reported ocular pain with a median pain score of 3 to 4/10.78Postoperative pain has been assessed as well. Although most patients report no, slight, or mild discomfort after cataract extraction, there may be approximately 5% of patients who experience moderate to severe pain.73 This analysis concludes that although most recovery from cataract surgery is largely uneventful, a meaningful percentage of patients do experience significant postoperative pain that should be followed and managed.In another study, Porela-Tiihonen et al. systematically reviewed the incidence, prevalence, and management of pain after cataract surgery. Twenty-one studies were ultimately assessed, and some trends emerged. Whether assessed immediately postoperatively, within the first 72 hours, or weeks after surgery, pain was lower across the board in the groups receiving interventions to reduce inflammation and pain compared with the control groups. Having said that, the authors found that cataract surgery is associated with significant postoperative pain in some patients, with 1 study reporting the incidence of moderate or severe pain to be as high as 35%.70With the widespread adoption of small incision phacoemulsification, the pain associated with cataract surgery has been minimized but not eliminated. Nonopioid pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, can often control postoperative pain and discomfort in place of an opioid.79 In some patients, more opioids used intraoperatively lead to a greater requirement for opioids postoperatively; this has been referred to as the opioid paradox.38 One may think that opioids intraoperatively would decrease the postoperative need for opioids, but this is not always the case. Although postoperative pain control is important, there is a known link between surgery and chronic opioid use; therefore, perioperative pain management decisions should be carefully considered.64Opioids prescribed perioperatively may lead to long-term use, regardless of prior patient exposure to opioids.80 These patients were considered opioid naive, having filled no opioid prescriptions in the year before their respective procedures. For patients filling a perioperative opioid prescription, the incidence of persistent opioid use for >90 days was calculated, and the predictors of persistent opioid use after both major and minor surgical procedures were assessed. This study defined new persistent opioid use as an opioid prescription filled between 90 and 180 days after surgery. The 7109 patients undergoing major and 29 068 patients undergoing minor surgical procedures had a rate of new persistent opioid use from 5.9% to 6.5% compared with the nonsurgery control group, which had a rate of 0.4%.80 Although this study did not include cataract surgery, and the maximum patient age was 64 years, there could be some translation of these data to cataract surgery as a minor procedure.A study of U.S. adults of ages 18 to 64 years from a nationwide 2013 to 2014 insurance claims database assessed the incidence of new persistent opioid use after major or minor surgery.63 This study also assessed long-term risk for patients' dependence on opioids after low-risk surgical procedures. Patients undergoing cataract surgery who received a postoperative opioid prescription were approximately 60% more likely to be using opioids long term than those not receiving an opioid prescription. Of the low-risk surgeries assessed , cataract surgery actually had the largest odds ratio for risk for long-term opioid use. Cataract surgery patients were 1.62 times more likely to use opioids long term compared with the other procedures, which ranged from 1.33 to 1.41 times.63Another study found that approximately 5% of patients were prescribed an opioid after cataract surgery.81In a memorandum included in public comments to the Centers for Medicare and Medicaid Services' Calendar Year 2020 proposed rule for the hospital outpatient prospective payment system and the Medicare ambulatory surgical center payment system, David J. Clark, MD, PhD, Veterans Affairs Palo Alto and Stanford University Department of Anesthesiology, Perioperative Medicine, and Pain, stated, “Reducing exposure to opioids even after small surgeries may have even greater benefits in that it could reduce the cumulative risk resulting from multiple opioid exposures. Those in the elderly patient population may undergo multiple temporally related procedures , almost all of which entail opioid administration both during surgery and postoperatively.”76,79 By decreasing the overall prevalence of chronic opioid use postoperatively, the goal is also to decrease opioid-related adverse events, which are the hallmark of the current opioid crisis.79Whether patients are taking opioids prior to surgery, simply undergoing surgery is a risk factor for chronic opioid use postoperatively. Assessing the surgical population as a whole, including patients taking opioids prior to surgery, postoperative chronic opioid use ranges from 9.2% to 13%.67Ophthalmology as a whole prescribes opioids at a lower rate (4%) compared with the national average across all prescribers (6.8%). Contrast these values to the median rates for surgeons as a whole (36.5%), pain medicine (48.6%), and physical medicine and rehabilitation (35.5%).70 This study concluded that ophthalmologists are generally judicious in their prescribing patterns for opioids, but, given the opioid crisis, prescribing protocols should be reviewed as, even with a limited 5-day supply, up to 10% of patients can become chronic opioid users at 1 year.82A study analyzing the Medicare Part D Prescriber Data from 2013 to 2015 looked at opioid prescribing patterns among ophthalmologists. The study revealed that 88% to 89% of ophthalmologists wrote <10 opioid prescriptions annually. About 1% of ophthalmologists wrote 100+ opioid prescriptions per year. The average ophthalmologist wrote 7 opioid prescriptions per year with a 5-day mean supply.71 With the ongoing national opioid crisis, understanding these patterns may help ophthalmologists participate in addressing the epidemic.In another study, Kolomeyer et al. analyzed a large administrative medical claims database, identifying 2 407 962 incisional ocular surgeries from 2000 to 2016, which met strict enrollment criteria surrounding length of data available and timing of any opioid prescriptions. Of these patients, 45 776 were prescribed a postoperative opioid. The study assessed the rates of filled opioid prescriptions and found that the rate increased for all types of incisional ocular surgery over time.71 Of these patients, 77% also received topical NSAIDs and/or steroids preoperatively, postoperative, or both. This suggests that topical treatments may not adequately address postoperative pain and highlights the need for alignment and coordination of cataract surgery pain management between ophthalmologists and anesthesiologists or other MAC providers.72Among ophthalmology subspecialties, cataract surgery had the highest number of filled opioid prescriptions in this limited database, with approximately 20 000 written during this 17-year period.83 This widespread community availability of opioids ultimately stems from the large supply of opioid prescriptions, thus contributing to the public health crisis. The quantity of opioids sold to hospitals, doctors' offices, and pharmacies increased by a factor of 4 from 1999 to 2010.2 In 2012, U.S. physicians wrote nearly 260 million opioid prescriptions, a staggering 70% of the global supply of opioids.84 Therefore, it is reasonable to expect that opioids given to patients may be opioids given to the entire community.According to the Center for Behavioral Health Statistics and Quality, 50.5% of the estimated 4.3 million nonmedical users of prescription opioid drugs in 2014 obtained them for free from a prescription intended for a friend or relative, whereas 22.1% obtained them from a physician.15 Patients received 1 drop of preservative-free 0.5% tetracaine, with additional drops or a tetracaine-soaked pledget if discomfort escalated. A change in patients' vital signs was used as a surrogate for pain. Patients' blood pressure increased by 1%, whereas the heart rate and respiratory rate decreased by 2% and 1%, respectively.15 Fichman concluded that overall, patients were very comfortable during cataract surgery despite receiving no IV sedation.Pain management during cataract surgery may be approached in a stepwise fashion. Figure 36 Providing patient education about the procedure and perioperative experience and setting realistic expectations may be adequate in addressing patient anxiety, which can decrease pain during surgery and lead to a decreased need for opioid pain management.36With the refinement of cataract surgery, some surgeons use this local/regional approach to pain without sedation.79,84 Drugs or classes of drugs such as acetaminophen, NSAIDs , gabapentinoids, corticosteroids, ketamine, and local or regional anesthetics can be used perioperatively and/or postoperatively to avoid some of the side effects of opioids, especially in the elderly cataract surgery population.79 The combination of treatments likely has an additive effect on opioid-sparing.79,84 Care should be taken, however, to consider the potential side effects of these alternative medications.Although eliminating sedation during cataract surgery may not work for all patients, there are other approaches that do not include opioids. Multimodal analgesia can be an effective pain management technique for cataract extraction in which 2 or more medications or nonpharmacologic interventions  having different mechanisms of action are used to address postoperative pain.85 All patients received topical anesthetic with additional anesthetic administered intracamerally (surgeon 1) or topically (surgeon 2). Although the midazolam/ketamine/ondansetron group showed a statistically significant reduced need for IV medications (P = .013) compared with the other groups, patients across all 3 groups required additional IV medications 32.1% of the time. No significant differences were found between surgical or discharge times across patient groups, surgeon or patient satisfaction, or side-effect profile between groups.85 The authors concluded that, “when used for cataract surgery, midazolam/ketamine/ondansetron offers an opioid-sparing alternative to conscious sedation that is safe, effective, and superior to diazepam in reduction of anxiety and need for IV medications.” It is important to note that compounded midazolam/ketamine/ondansetron has not been assessed for safety or efficacy by the U.S. Food and Drug Administration (FDA) and carries the patient risks inherent in compounded products.One option found to be an effective nonopioid sedative for cataract surgery is the sublingual MKO Melt (compounded by ImprimisRx), which contains midazolam, ketamine, and ondansetron. Jeffries et al. prospectively studied 611 patients undergoing cataract surgery by 2 surgeons. Patients were randomized to receive diazepam alone, diazepam/tramadol/ondansetron, or compounded midazolam/ketamine/ondansetron.86 Added to the irrigating solution for continuous intracameral administration during cataract surgery, phenylephrine/ketorolac 1.0%/0.3% minimizes intraoperative and postoperative  opioid exposure while, at the same time, decreasing postoperative pain.An FDA-approved local nonopioid option specific to cataract surgery is Omidria [(phenylephrine and ketorolac injection) 1%/0.3% (Omeros Corporation)], a combination drug containing 1% phenylephrine, a mydriatic agent, and 0.3% ketorolac, an NSAID.P < .0001).87 There was also a significant reduction in early postoperative ocular pain measured via visual analog scale (VAS) scores. Within the first 12 hours, the VAS scores in the phenylephrine/ketorolac 1.0%/0.3% group were >50% lower than in the placebo group. In addition, the use of oral analgesics on the day of surgery was significantly lower in the treatment group compared with the placebo group (P = .001). The proportion of patients who were pain free at all measured time points was significantly higher, and concurrently, the proportion of patients experiencing moderate to severe pain at any time was significantly lower in the phenylephrine/ketorolac 1.0%/0.3% group.87In 2 phase 3 prospective, randomized, double-blind clinical trials, 808 patients were randomized to receive treatment (n = 403) or placebo (n = 405) administered intracamerally with irrigation solution during cataract surgery. Mydriasis was maintained better in patients receiving phenylephrine/ketorolac 1.0%/0.3%, with the treatment group having a mean change in area under the curve of 0.08 mm compared with the placebo group, which had a change of −0.50 mm .92Similar pain management benefits of phenylephrine/ketorolac 1.0%/0.3% have been demonstrated in children. In a randomized, double-masked, active-control phase 3 pediatric study, mean pain scores, as measured by the Alder Hey Triage Pain Scale, were significantly lower in the phenylephrine/ketorolac 1.0%/0.3% group compared with the phenylephrine 1.0% group. Although this study was not powered to detect a difference in pain scores, significantly lower mean scores were seen at both 6 hours and 24 hours postoperatively .Knowing that phenylephrine/ketorolac 1.0%/0.3% lessens patient pain, of interest is the impact it may have on decreasing perioperative opioid administration, particularly fentanyl, which is often used as part of MAC. Donnenfeld et al. compared intracameral phenylephrine/ketorolac 1.0%/0.3% to epinephrine (1 mg/mL) on pain reduction and opioid usage during cataract surgery. Sixty patients were prospectively enrolled, 41 in the phenylephrine/ketorolac 1.0%/0.3% group and 19 in the epinephrine group, all of whom received topical lidocaine gel, intracameral preservative-free lidocaine 1%, and a standardized regimen of preoperative and postoperative topical medications.P < .001). The proportion of patients with a VAS score ≤3 was greater in the phenylephrine/ketorolac 1.0%/0.3% group (85.0%) than that of the control group . Also, a significantly smaller proportion of patients in the study group  required intraoperative fentanyl. With respect to the composite endpoint, the patients receiving phenylephrine/ketorolac 1.0%/0.3% were 94% less likely to require fentanyl or to have moderate to severe pain than those in the epinephrine group.72The mean VAS pain scores were 48.9% lower in the phenylephrine/ketorolac 1.0%/0.3% study group compared with the control epinephrine group . Mean VAS pain scores intraoperatively were also significantly (56.7%) lower in the phenylephrine/ketorolac 1.0%/0.3% group than in the epinephrine group , as were the mean VAS pain scores at 10 minutes  and 1 day  postoperatively, representing pain score reductions of 57.1% and 66.7%, respectively.93Overall, the number of patients requiring intraoperative fentanyl analgesia was significantly lower in the phenylephrine/ketorolac 1.0%/0.3% group compared with the epinephrine group  filled at least 1 opioid prescription. The opioid pill count for the first prescription for patients receiving phenylephrine/ketorolac 1.0%/0.3% was significantly lower than for patients in the control group, with 20 pills and 45 pills prescribed, respectively (P = .015). The findings were similar when assessing a 7-day postoperative window. Despite demonstrating a statistically significant lower number of opioids prescribed, the phenylephrine/ketorolac 1.0%/0.3% patients, as a whole, were also significantly more likely to have 1 or more presurgical comorbidity or risk factors for complex surgery than the control group , which would be expected to have resulted in increased postoperative pain.94In addition to perioperative opioid considerations, prescribing patterns for postsurgical opioids is important, too. Jackson et al. looked at real-world opioid prescribing after cataract surgery in patients who received phenylephrine/ketorolac 1.0%/0.3%. This retrospective study assessed data from the MarketScan databases of patients undergoing cataract surgery with or without phenylephrine/ketorolac 1.0%/0.3%. A group of 218 672 patients was identified from the data between January 1, 2015, and July 15, 2019. Of these, 5145 received phenylephrine/ketorolac 1.0%/0.3% during surgery. In the 2-day postoperative period, 0.50% of the phenylephrine/ketorolac 1.0%/0.3% group and 0.68% of the 213 527 control group patients  and postoperative complications  were higher in the opioid users than the nonusers. Both visually significant and vision-threatening complications were higher in the prescription opioid user group as well. Overall, prescription opioid users were 5 times more likely to experience intraoperative complications during cataract surgery and 3 times more likely to have postoperative complications.59The overall rates of intraoperative complications (odds ratio 5.018, 95% CI, 1.250-20.140, 70 The Kolomeyer study found that the overall rate of opioid prescriptions filled after cataract surgery was increasing from 2000 to 2016. During that period, opioid prescriptions were filled following 0.95% per cataract surgery procedure.71 Ocular incisional surgeries as a group were associated with a 1.9% rate of filled opioid prescriptions; however, the greatest number of surgeries performed in this group were cataract extractions, which, when excluded, resulted in a 7.57% rate of filled opioid prescriptions across the remaining ocular incisional procedures, collectively.71As the opioid crisis continues, a number of surgical specialties have looked at their opioid prescribing patterns. As discussed, there have been just a few studies looking at prescribing trends within ophthalmology, focusing primarily on prescriptions written without looking at how many are actually filled.71Of interest, although cataract surgery techniques, equipment, and technology have advanced, resulting in less invasive procedures, both patient-perceived pain and opioid prescriptions are increasing. Kolomeyer et al. postulated several potential reasons for this paradox, including deficient physician education about opioid prescribing or pain assessment, greater focus on pain as the fifth vital sign, lack of state and/or national standardization of opioid prescribing regulations, increased awareness by physicians about patient pain/pain perception and the correlation with physician and hospital satisfaction scores, and drug company marketing strategies.The authors of the Kolomeyer study encouraged ophthalmologists to evaluate their opioid prescribing habits. Particularly in light of the national opioid crisis, it is time for ophthalmologists as a whole, including cataract surgeons, to assess the role of opioids in pain management for cataract surgery. With nonopioid pain management strategies such as multimodal anesthesia, phenylephrine/ketorolac 1.0%/0.3%, postoperative topical pain medications, and even patient education, cataract surgeons can positively influence patients away from opioids.67 One example of a systemic strategy is the Veterans Administration's approach to addressing OUD, developed in 2017, called S.T.O.P. P.A.I.N., a comprehensive, multipronged approach to prevent opioid abuse and treat those who become addicted.3The U.S. government's public health response to the opioid crisis has focused on stopping abuse, decreasing the opioids diverted into the community, and minimizing demand.S–Stepped Care ModelT–Treatment alternatives/complementary careO–Ongoing monitoring of usageP–Practice GuidelinesP–Prescription monitoringA–Academic DetailingI–Informed consent for patientsN–Naloxone distribution95 Another bill that generated strong bipartisan support in the 116th Congress in both the Senate and the House of Representatives and has been reintroduced in both chambers of the 117th Congress is the Non-Opioids Prevent Addiction In the Nation Act.96,97 If passed, the Non-Opioids Prevent Addiction In the Nation Act would amend the Social Security Act to combat the opioid crisis by promoting access to nonopioid treatments in the hospital outpatient setting. Each of these public health measures appropriately seeks to address an important aspect of the opioid epidemic.There have been several legislative approaches as well, such as the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act which, among other provisions, directed the Center for Medicare and Medicaid Services to review payment structures to remove financial incentives for practitioners to use and prescribe opioids instead of nonopioid alternatives.Although much has been learned about the opioid crisis and how cataract surgeons can respond, there are some limitations and gaps in the current data. There have been no comprehensive studies assessing pain management and analgesia at all points in the cataract surgery process, nor have there been studies assessing the prescribing patterns by provider type and the ways in which ophthalmologists and anesthesiologists could more effectively collaborate, providing patients the best possible surgical experience and outcome without exposing them, or their communities, to the risks of opioid medications.Although cataract surgeons do not prescribe opioids for postoperative pain at a high rate, the sheer volume of cataract surgeries performed both in the United States and worldwide means that there are a large number of patients who receive and fill opioid prescriptions, with which comes the risk for potential opioid misuse, abuse, and diversion. There are several ways that cataract surgeons can actively combat the opioid crisis. First, understand that there is a persistent disconnection between pain management and patient pain experience in cataract surgery despite increasingly refined surgical techniques and take the opportunity to assess, change, and improve standard care practices. Second, take a holistic approach when caring for these elderly cataract surgery patients. By doing so, cataract surgeons can not only mitigate the risk for OUD but also help prevent polypharmacy issues in this population. Third, be particularly mindful of cataract surgery patients already on an opioid regimen for another condition and take mitigating steps to decrease the potential for complications. Finally, reevaluate your standard protocols for pain management and analgesia surrounding cataract surgery and consider using FDA-approved nonopioid alternatives such as phenylephrine/ketorolac 1.0%/0.3% and, if and when approved, midazolam/ketamine/ondansetron; nonpharmacologic support; or some combination of these nonopioid strategies. The goal of ophthalmologists should be to balance patients' pain control needs with judicious use of opioids while better using newer and safer nonopioid alternatives. This is an excellent opportunity to collaborate with anesthesia colleagues to educate each other about what joint practices might best serve cataract surgery patients.71,72 Use of intraoperative opioids can increase postoperative opioid requirements, and cataract surgery patients receiving an opioid prescription are 60% more likely to use opioids long term than those who are not prescribed an opioid.63 Patients given a prescription for an opioid medication may leave all or part unused, thereby opening the potential for diversion of those pills into the community.98There are numerous potential issues arising from the use of perioperative opioids in the cataract surgery patient population. Not only these elderly individuals are more sensitive to the adverse effects of opioids but also their risk for OUD may be inherently increased by both number of exposures and total cumulative doses of opioids.72,82,87 Fewer complications, shorter surgeries, and less time in the postanesthesia care unit have positive financial implications.39,72,82 Finally, there are public health implications associated with the use of phenylephrine/ketorolac 1.0%/0.3% in that decreased need for opioid prescriptions postoperatively means potentially less risk for OUD for cataract surgery patients and fewer opioids susceptible to diversion within our communities.58 Ophthalmology can make a difference to patients individually and to society as a whole by judicious use of opioids and using newer and safer nonopioid alternatives.By minimizing the need for an opioid, whether perioperatively or postoperatively, there will be broad benefits. It has been shown that phenylephrine/ketorolac 1.0%/0.3% results in the need for fewer opioids and less pain, and fewer opioids result in fewer complications, all collectively improving patient satisfaction.