PRACTICAL HYPNOTIC SUGGESTION IN OPHTHALMIC SURGERY

M A U R I C E E. J O H N , J R . , M.D. , AND JEAN P. PARRINO JeffersonvilL·, Indiana

To determine the effectiveness of hypnotic suggestion in eliminating unnecessary movement by the patient during surgery and to reduce postoperative discomfort, we assigned 59 patients undergoing radial keratotomy for the first time (32 men and 27 women ranging in age from 20 to 56 years; mean age, 30 years) to one of two groups. The first group (No. = 34) listened to a four-minute script designed to relax them just before undergoing surgery; the control group (No. = 25) received the same medications but did not hear the script. The two groups did not differ significantly in their behavior during surgery, the amount of pain experienced during surgery and postoperatively, or their awareness of the procedure. They did differ significantly in their descriptions of how they felt the day after surgery; 13 of 34 patients in the hypnosis group said they felt wonderful; only one of 24 patients in the control group expressed this opinion.

A sudden movement by the patient during delicate eye surgery can negate a flawless surgical technique. Even with a general anesthetic, involuntary move­ment may alter the outcome of any proce­dure. An informed, confident, and re­laxed patient may be the key to a successful surgical conclusion.1

The patient can be relaxed before sur­gery chemically with a tranquilizing med­ication or by relaxation therapy coupled with hypnotic suggestion. Morgan2 de­scribed hypnotic suggestion as:

. . . a tranquilizer without danger of overdose, addiction and adverse reaction. Hypnosis often induces in the patient an increased confidence and trust in the physician, it sometimes creates a satisfying euphoria. It has one more advantage. Hypnosis gives you a patient who will act upon your suggestions.

Accepted for publication Aug. 9, 1983. From the John-Kenyon Eye Research Foundation,

JefTersonville, Indiana. Reprint requests to Jean P. Parrino, John-Kenyon

Eye Research Foundation, Suite 102, 1305 Wall St., JefTersonville, IN 47130.

Because hynotic suggestion is not widely used in ophthalmic surgery, re­search studies are few. Clinical observa­tions and anecdotal accounts constitute most of the published ophthalmologic material.3

To test the efficacy of hypnosis in relax­ing the patient preoperatively and reduc­ing discomfort postoperatively, we con­ducted the following clinical trial.

SUBJECTS AND M E T H O D S

Script—Our trial included the pro­duction of a single relaxation and sugges­tion script. This script was intended to provide a relaxed and confident patient during the surgical procedure and to eliminate the need for pain medication during the first 24 hours after surgery. The script was developed by a profession­al hypnotherapist and was four minutes long.

Subjects—All the patients underwent similar surgical procedures that allowed immediate feedback from the patients and the study observers. We selected

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VOL. 96, NO. 4 HYPNOSIS IN SURGERY 541

radial keratotomy for this study because it is an outpatient procedure that requires a local anesthetic. Additionally, the pa­tients vary widely in age and the amount of pain involved can be anticipated.

The study initially included 62 patients who underwent radial keratotomy be­tween March 23, 1982, and Jan. 31, 1983. Three were later excluded. One did not fill out the questionnaire, one requested general rather than local anesthesia, and one requested pain medication before surgery. Of the remaining 59 patients, 32 were men and 27 were women. They ranged in age from 20 to 56 years (mean age, 30 years; median age, 29.5 years; mode age, 30 years).

All the patients were undergoing radial keratotomy for the first time. Each pa­tient was randomly assigned to either the hypnosis (No. = 34) or the control group (No. = 25) by a research technician. The two groups were matched for age (by decade) and sex.

Methods—After the normal preopera-tive preparation, the patient was brought into the operating room and prepared for surgery. After the administration of topi­cal anesthesia, the cornea was marked. At this point the surgical assistant left the room, the lights were dimmed, and the surgeon checked a card to determine whether or not this patient had been selected to receive hypnotic suggestion.

If the patient had been assigned to the hypnosis group, the surgeon obtained the patient's permission for relaxation thera­py. The surgeon delivered the hypnotic suggestion by reading from the predeter­mined script. The same script was read to each patient to avoid any deviation in delivery or timing. At the conclusion of the hypnotic suggestion, the anesthesiol­ogist injected methohexitol sodium (a rapid, ultrashort-acting barbiturate anes­thetic agent). The patient was then given a 3-ml retrobulbar injection of bupi-

vacaine HC1 with epinephrine, 4% lido-caine, and hyaluronidase and a Nedbath block with 2% lidocaine.

If the patient had been selected as a control, no hypnotic suggestion was de­livered and the patient received the in­jection and local block immediately. After four minutes elapsed (to correspond with the hypnosis group), the surgical assistant was recalled to the operating room. When the patient became responsive, the surgery was performed. The eye was then patched and, after 30 minutes in the recovery room, the patient left the hospital.

The surgical assistant, who did not know whether or not the hypnotic sug­gestion had been delivered, evaluated the pat ients behavior on a prearranged scale: 1, relaxed; 2, asleep with move­ment; 3, awake with movement; 4, talka­tive; 5, additional medications adminis­tered; 6, general anesthesia required; and 7, procedure cancelled.

The day after surgery the patient re­turned to the clinic and was given a survey questionnaire. The patient was informed that this survey was part of a hospital study. The questions were asked and the answers recorded by the clinic receptionist who did not know whether or not the patient had received the hyp­notic suggestion. The survey form began with questions relating to the quality and quantity of food given to the patient after surgery; these were followed by ques­tions pertaining to the severity and dura­tion of pain during the surgery and the 24 hours after the operation.

R E S U L T S

The evaluation of the patients' behav­ior during surgery by the surgical assist­ant showed no significant difference be­tween the two groups; almost all the patients were relaxed whether or not they had received the specific suggestion.

542 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER, 1983

Analysis of the questions regarding pain experienced during surgery showed that none of the patients described any significant discomfort. This was expected because of the nature of the local anes­thetic.

The responses concerning pain after surgery also showed no dramatic differ­ence between the two groups. This was also true for questions regarding the onset and duration of the discomfort ex­perienced. The duration and intensity of pain reported after surgery were slightly greater in the control group but, again, the numbers were too small to be statisti­cally significant.

Further, the two groups differed little in their awareness of the surgical proce­dure.

One important difference between the two groups appeared when we analyzed the patients' responses to how they felt the day after surgery; 13 of 34 patients in the hypnosis group described the day after surgery as wonderful and an addi­tional ten felt relaxed, whereas only one of 25 patients in the control group ex­pressed this opinion (Figure). Although the hypnosis group reported discomfort when asked about pain experienced after surgery, they did not seem to be affected by it when describing their overall feel­ings.

A statistician found these data to be statistically significant: t = 3.0311 and df = 57 (two-tailed), significant at P = .005 level; x2 = 11.2854 and df = 4, significant at P < .05.

Figure (John and Parrino). Responses to the ques­tion: "How did you feel the day after surgery?"

DISCUSSION

Our initial results indicated that hyp­nosis can be a practical technique in ophthalmic practice. Because better rap­port between physician and patient at the time of surgery might have yielded simi­lar results, a second study is underway in which both groups interact with the phy­sician for four minutes at the time of surgery. The hypnosis group hears the four-minute hypnotic suggestion script and the control group carries on a conver­sation with the surgeon for the same length of time.

REFERENCES 1. Zimmerman, D.: Hypnotherapy in surgical

management. A review. J. R. Soc. Med. 73:579, 1980.

2. Morgan, G. E.: Hypnosis in Ophthalmology. Birmingham, Aesculapius Publishing Co., 1980, p. 9.

3. Lowenstein, L. N., Iwamoto, K., and Schwartz, H.: Hypnosis in high risk ophthalmic surgery. Ophthalmic Surg. 12:39, 1981.