We note with interest the article by Jawad et al. [1] demonstrating that transconjunctival local anaesthesia for lower eyelid surgery was associated with less discomfort and bruising than conventional transcutaneous local anaesthesia. Many oculoplastic surgeons now regularly perform transconjunctival local anaesthesia for some eyelid surgeries and report patients feeling less discomfort than with transcutaneous approaches. The publication of randomised controlled trial evidence of this is to be welcomed.

This trial did not include any patient reported assessment of pain during the surgical procedure itself or the need for additional administration of local anaesthesia intra-operatively. The primary aim of any local anaesthesia is to provide effective analgesia for the whole duration of surgery, minimising patient discomfort or the need for repeated injections. Many of our patients need a further transcutaneous injection of anaesthetic after the transconjunctival injection. Anecdotally, they report less discomfort from this if given after a transconjunctival injection as opposed to it being the first injection though we have not quantitatively assessed this. It would be useful to know the authors experience of patient-reported pain during surgery and need for further anaesthesia. Local anaesthesia preparations and techniques have been more extensively studied in cataract surgery than eyelid surgery but during these studies, patient reported pain during surgery and need for additional anaesthesia are common primary outcomes [2, 3].

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