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Does eyelid surgery hurt?

Many patients ask me if their eyelid surgery hurts and if they can be asleep so that they don’t feel anything. There is no need; local anaesthesia is fine for most eyelid surgeries.
This may surprise you. Eyelid surgery is ideally suited to be done under local anaesthetic. This is true for a small cyst or chalazion, larger surgery for drooping eyelids with ptosis, eyebags or hooding needing blepharoplasty. The reason local anaesthetic is so good is two-fold:Firstly, with local anaesthetic the patient feels no eye or eyelid discomfort after application of topical eyedrops and direct infiltration to numb the area.Secondly, under local anaesthetic, the surgeon can judge the result much better because the patient can cooperate by opening or closing their eyes on command.

The development of painless eyelid surgery

This was not always the case! We owe local anaesthetics to the intrepid explorers and traders of the mid 19th century. In 1850, just over three hundred years after the Francisco Pizarro Gonzalez the Spanish conquistador conquered the Inca Empire in Peru in 1532, an Austrian called von Scherzer brought coca leaves to Europe, which led to cocaine.
His friend Sigmund Freud described the properties of coca and prompted another Austrian called Koller to perform in 1884 the first clinical operation under local anaesthesia, by administration of cocaine on the eye!
The use of cocaine for local and regional anaesthesia rapidly spread throughout Europe and America. Not surprisingly, the toxic effects of cocaine were soon identified, resulting in overdose amongst patients and addicted medical staff. Local anaesthesia fell into disrepute until modern organic chemistry led to the synthesis of pure cocaine in 1891.
Newer local anaesthetics were synthesised between 1891 and 1930, including tetracaine which we still use as an anaesthetic eye drop. More local anaesthetics were prepared synthetically between 1898 and 1972 including lidocaine which we still use in eyelid surgery. These drugs were much less toxic than cocaine.
Bupivacaine is one drug with a long duration of action and history of clinical application. Synthesised in 1957, it was introduced in 1965 and changed eyelid surgery. We now use small amounts of bupivacaine for effective long-acting and painless anaesthesia of eyelids. Eyelid surgery does not hurt.

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