Amethocaine or ketorolac eyedrops provide inadequate analgesia in pediatric strabismus surgery

Efficacy of tetracaine eye drops in strabismus surgery: a systematic review and meta-analysis of randomized controlled trials

AIM

To comprehensively evaluate the efficacy and safety profile of tetracaine eye drops as a local anesthetic agent among pediatric patients undergoing for strabismus surgery.

METHODS

We systemically searched four electronic databases (PubMed, Scopus, Web of Science, and Cochrane Library) from inception until April 2023. We included randomized controlled trials (RCTs) comparing tetracaine and placebo or no intervention for intraoperative and postoperative outcomes in strabismus surgery patients. We used the Cochrane risk of bias-2 tool for the risk of bias assessment. Continuous variables were pooled as mean difference (MD) or standardized mean difference (SMD), and categorical variables were pooled as risk ratio (RR) with a 95% confidence interval (CI).

RESULTS

Six RCTs were included in the meta-analysis, with a total of 326 patients. There was no significant difference between the tetracaine and the control groups regarding the mean operative time (MD = -0.10 minutes, 95% CI [-3.79, 3.59], p = .96), the mean time to first analgesia (MD = -0.87 minutes, 95% CI [-11.15, 9.40], P = .87), the mean behavior score (SMD = -S0.48, 95% CI [-1.24, 0.28], p = .22), the rate of postoperative vomiting (RR = 1.27, 95% CI [0.62, 2.61], p = .52), or the number of additional analgesia (RR = 0.55, 95% CI [0.27, 1.13], p = .10).

CONCLUSION

Our systematic review and meta-analysis found no significant differences in the safety and efficacy of tetracaine eye drops for strabismus surgery when compared to placebo or no intervention. Further investigation is needed to establish the best local anesthetic for strabismus surgery.

Postoperative Behaviour after Primary Strabismus Surgery in Children: Is There an Influence of Intraoperative Topical Anaesthesia?

INTRODUCTION

The course of the recovery phase after general anaesthesia, during which consciousness and pain gradually return, is essentially determined by the choice of anaesthetic drug, and its total dose or duration of application. This phase is often complicated by more or less severe agitation, especially in children. In the present study we investigated whether the application of a topical anaesthetic to the conjunctiva at the end of a strabismus operation had a positive effect on the recovery behaviour of the child.

PATIENTS/METHODS

This prospective, randomised, blinded study was conducted with 50 healthy, ASA class I or II children, aged 3 to 8 years undergoing their first strabismus operation. Following the surgeon's randomisation two drops of a 0,5% tetracaine-HCl ophthalmic solution were applied to the operated conjunctiva three times at 30-s intervals immediately following wound closure. The postoperative evaluation encompassed heart rate, as well as COMFORT and CHEOPS scores. The first assessment was directly postoperatively with repetitions at 15, 30, 45, 60, 75, 90 and 120 min, as well as on the day after surgery.

RESULTS

The CHEOPS scores did not differ significantly between children with or without topical anaesthesia at any time during the observation period. The COMFORT scores revealed a slight, but non-significant analgesic effect at 15 and 30 min. The 60 min score showed the opposite effect, possibly indicating a slight disadvantage of the topical anaesthesia. There were no significant differences with regard to time to first request for additional systemic analgesia, to the total dose of systemic pain medication, or to when the patient was eligible for discharge to the ward.

CONCLUSION

The application of topical tetracaine-HCl immediately after wound closure had no positive effects on the course of the postoperative recovery period after strabismus surgery in children. There was no evidence of an effect on pain or emergence agitation.

Anaesthetic considerations for strabismus surgery in children and adults

Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery. Repeated surgery is common as each operation has a 60%-80% chance of successful correction. The benefits of early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaesthetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional ophthalmic block is at the discretion of the team.

Does Topical Proparacaine Improve Postoperative Comfort After Strabismus Surgery?

Background

Strabismus surgery is often performed on children and adults as a quick-turnover, outpatient procedure under general anesthesia. Ideal methods to reduce post-operative pain and nausea are not yet perfected. We postulated that a simple topical anesthetic drop after surgery might help.

Methods

In a prospective study of oculocardiac reflex (OCR) and strabismus surgery, a cohort of ongoing patients either received proparacaine immediately post-op, or none. Co-variables were Intraoperative opioid and OCR, patient age, type of surgery. Several post-operative recovery outcome variables were prospectively monitored.

Results

Sixty strabismus surgery patients (age 15±22 years) received proparacaine 1% while another 80 (16.5±22 years) received none; both received topical antibiotic-steroid ointment. Pain and nausea (Likert scale) were not impacted by covariables complexity of case, age less than 3.5, OCR >33% drop, intraoperative opioid or neuro-status. Immediate post-op heart rate was lower if OCR >33% and if opioids used. Time until discharge was shorter in younger patients. Proparacaine did not impact outcome variables, except in patients younger than 3.5 years when post-op pain was worse.

Conclusion

Post-op topical anesthetic either produced no difference, or worsened post-op pain and recovery. This prospective study does not support the use of topical anesthetic drop to reduce post-strabismus pain and nausea.

Clinical trials registration

NCT03672435, Strabismus Recovery With Proparacaine and Oculocardiac Reflex (OCRprop).

Comparison of topical oxybuprocaine and intravenous fentanyl in pediatric strabismus surgery

PURPOSE

To compare the outcomes such as postoperative nausea/vomiting, analgesic requirements, and hospital stay following the use of topical oxybuprocaine hydrochloride 0.4% or intravenous (IV) fentanyl in children undergoing strabismus surgery.

METHODS

This was a prospective cohort study. Children operated under general anesthesia for strabismus were given topical oxybuprocaine hydrochloride 0.4% (Group T) and IV fentanyl (Group F) before surgery. The episodes of nausea/vomiting, pain score, requirement of additional analgesia during postoperative period, and duration of hospital stay were compared in two groups.

RESULTS

There were 47 children in Group T and 59 children in Group F. The median pain score in two groups were 2.38 (25% quartile; 2.0) and 3.00 (25% quartile; 3.00), respectively. The difference was significant (K W P < 0.03). The episodes of nausea/vomiting in two groups were in 2 and 6 children in Group T and Group F, respectively. The median hospital stay of children of Group T and Group F were 242 and 285 min, respectively. The difference was not statistically significant (P = 0.22).

CONCLUSIONS

Using intraoperative topical oxybuprocaine drops, one can achieve better analgesic outcomes and reduce risk of nausea and vomiting compared to intravenous opioid analgesics and therefore, the hospital stay could also be marginally reduced.

A randomised comparison of lidocaine 2% gel and proparacaine 0.5% eye drops in paediatric squint surgery

We conducted a randomised trial comparing lidocaine 2% gel with proparacaine 0.5% eye drops in children having elective squint surgery. One hundred and forty children aged between 3 and 14 years were recruited. The requirement for intra-operative fentanyl and postoperative ibuprofen was significantly less in the lidocaine group compared with the proparacaine group (1 (1.7%) vs 12 (18.5%), p=0.002 and 16 (27.6%) 38 (58.5%), p=0.001, respectively). The incidence of postoperative nausea and vomiting was significantly less in the lidocaine group compared with the proparacaine group (6 (10.3%) vs 16 (24.6%), p=0.04). There were no differences between the groups in terms of incidence and severity of the oculocardiac reflex. We conclude that, compared with proparacaine 0.5% eye drops, a single application of lidocaine 2% gel improves peri-operative analgesia and reduces the incidence of postoperative nausea and vomiting in elective paediatric squint surgery.

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy

OBJECTIVE

To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy.

STUDY DESIGN

Prospective randomized double blind controlled study.

METHODS

Seventy-five children aged 3-10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9-10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24h postoperatively).

RESULTS

The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p>0.05). The mCHEOPS scores at 10 min, 30 min, 1h, 8h were significantly lower in both tramadol and ketamine group when compared with control (p<0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p<0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p<0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p>0.05).

CONCLUSIONS

Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia.

Sub-Tenon's ropivacaine block for pain relief after primary strabismus surgery

PURPOSE

Pain is the main cause of patient distress/dissatisfaction after strabismus surgery. The aim of the study was to evaluate the effect of sub-Tenon's block with ropivacaine at the end of strabismus surgery on post-operative pain.

METHODS

A prospective trial was conducted in 79 patients (age 1.0-65 years) scheduled for outpatient primary strabismus surgery with fixed sutures under general anesthesia (GA) at a major tertiary hospital. Half the patients were randomly allocated to receive sub-Tenon's block with ropivacaine 0.2% at conclusion of the operation. Primary outcome measures were visual analog scale (VAS) scores at arrival to the post-anesthesia care unit (PACU), at discharge 3 hr later, 12-16 hr post-operatively, and 24 hr post-operatively. Supplemental analgesia requirements and patient satisfaction were recorded as well. Data were presented as median (range). Mann-Whitney test, Pearson chi(2)-test or Fisher's exact test was used for statistical analysis; p <or= 0.05 was considered significant.

RESULTS

There were no between-group differences in median VAS scores at arrival to the PACU and at discharge, with a borderline difference at 24 hr post-operatively (p = 0.06). At 12-16 hr post-operatively, the median score was 0.0 (range 0-5) in the study group and 4.0 (range 0-6) in the controls (p < 0.001). The lower VAS score in the study group was associated with a lower rate of supplemental analgesia use (21.9% versus 57.9%, p = 0.001), fewer doses of supplemental analgesia (10 doses versus 35, p = 0.03), and higher patient satisfaction (p < 0.001).

CONCLUSIONS

Sub-Tenon's block with ropivacaine 0.2% at the completion of outpatient primary strabismus surgery with fixed sutures under GA reduces pain 12-16 hr post-operatively and analgesia requirements 4-23 hr post-operatively.

Anesthetic management for pediatric strabismus surgery: Continuing professional development

PURPOSE

Strabismus surgery is one of the most common pediatric ophthalmic procedures. The purpose of this continuing professional development module is to update physicians on the anesthetic considerations of pediatric patients undergoing strabismus surgery.

PRINCIPAL FINDINGS

The preoperative assessment is important, as patients undergoing strabismus surgery may have an associated neuromuscular disorder, congenital syndrome, or cardiac disease. Malignant hyperthermia is no longer considered as being an issue associated with strabismus. The laryngeal mask airway is used frequently and has been shown as being associated with a low incidence of complications in strabismus surgery. The anesthesia technique can be adapted to decrease the incidence of the oculocardiac reflex and the oculorespiratory reflex, and the use of anticholinergic prophylaxis remains debatable. Since patients are at high risk for postoperative nausea and vomiting (PONV), combination anti-emetic therapy is recommended using dexamethasone and ondansetron. Metoclopramide was not found to provide additional benefit when combined with other anti-emetics. Droperidol is effective, but there remains a black box warning for dysrhythmias. Effective analgesics in this patient population include acetaminophen, nonsteroidal anti-inflammatory drugs, peribulbar blocks, and subtenon blocks. Topical tetracaine drops have demonstrated mixed results, and topical nonsteroidal anti-inflammatory drops were found not to be effective. The use of opioids should be minimized due to the increased incidence of PONV.

CONCLUSIONS

To provide optimal care for the pediatric patient undergoing strabismus surgery, it is important to understand the unique anesthetic considerations for strabismus surgery and to appreciate how each decision regarding the anesthetic technique can alter these considerations.

Subtenon lidocaine vs topical proparacaine in adult strabismus surgery

Intraoperative subtenon 2% lidocaine and topical 0.5% proparacaine in patients undergoing strabismus surgery were compared. No additional systemic analgesics and sedatives were used. Mean and total pain scores intraoperatively and postoperatively were not different. Each anesthetic agent provides good intraoperative anesthesia and postoperative analgesia. Topical 0.5% proparacaine may be preferred because of its easy administration and fewer side effects, lack of hospital admission, and immediate and predictable alignment of the eyes.

Topical lidocaine and oral acetaminophen provide similar analgesia for myringotomy and tube placement in children

PURPOSE

Preoperative oral acetaminophen (30 mg x kg(-1)) was compared with topical 2% lidocaine ear drops for postoperative analgesia following bilateral myringotomy and tube placement (BMT) in children.

METHODS

In a randomized, prospective, double-blind trial, we studied 124 patients, six months to eight years, ASA physical status I or II, undergoing elective BMT under general anesthesia. The patients in Group I received acetaminophen 30 mg x kg(-1) orally in a grape flavoured syrup 30 to 60 min before surgery and 0.9% saline drops (placebo) in each ear upon insertion of tympanostomy tube. Patients in Group II received a placebo (grape flavoured syrup) before surgery and 2% lidocaine, 0.5 mL in each ear when ear tubes were inserted. Postoperative pain assessments were recorded every five minutes in the postanesthesia care unit, and every 15 min in the day care surgical unit (DCSU) using the modified Children's Hospital of Eastern Ontario pain scale (mCHEOPS), a ten-point scale. Pain at home was documented by parents using a 0 (no pain) to 10 (worst pain imaginable) scale.

RESULTS

The median (range) mCHEOPS scores in the DCSU at 15 and 30 min were similar, i.e., 5 (4-9) in the acetaminophen group and 4 (4-8) in the lidocaine group. The proportion of patients receiving supplemental analgesics in the 24 hr following surgery was similar in both groups (45% and 42% respectively).

CONCLUSION

Topical lidocaine and oral acetaminophen in a dose of 30 mg x kg(-1) provide similar analgesia following BMT.

Pain Relief after Pterygium Surgery with Viscous Lidocaine

PURPOSE

The aim of the current study is to investigate the efficacy of lidocaine 2% gel for the control of pain experienced after pterygium surgery.

METHODS

We conducted a prospective, randomized clinical trial on 45 eyes of 45 patients who underwent pterygium surgery. The patients were randomized into 2 groups. Group 1 was provided with topical 2% lidocaine gel and group 2 with artificial tear gel. The primary outcome of interest was the pain experienced at the 4th, 7th and 10th postoperative hours. Corneal reepithelization was evaluated by slitlamp biomicroscopy. Pain was determined using a 10-point linear visual analogue scale. No systemic analgesic or topical nonsteroidal anti-inflammatory drop was administered.

RESULTS

The groups had similar demographic data. The mean pain scores of the study and the control groups according to the visual analogue scale were: 4.13 +/- 1.86 and 6.50 +/- 1.47 (p = 0.001) at the 4th postoperative hour, 4.00 +/- 1.16 and 4.00 +/- 1.16 (p = 0.001) at the 7th , and 2.39 +/- 0.89 and 3.63 +/- 1.00 (p = 0.001) at the 10th postoperative hour, respectively. The mean area of the corneal epithelial defect in the lidocaine gel group was 4.78 +/- 1.04 mm2 and 4.68 +/- 0.89 in the artificial tear gel group (p = 0.42). The mean corneal reepithelization time was 37.56 +/- 10.42 h in the lidocaine gel group and 34.36 +/- 10.00 h in the artificial tear gel group (p = 0.26). There were no side effects related to the drugs observed in either of the 2 treatment groups.

CONCLUSION

We conclude that topical lidocaine gel is an effective and safe anesthetic agent for the control of pain experienced shortly after pterygium surgery.

Ropivacaine compared to bupivacaine for post-tonsillectomy pain relief in children: a randomized controlled study

OBJECTIVE

To compare the effects of ropivacaine and bupivacaine on post-tonsillectomy pain in children.

METHODS

Forty-six children aged 2-12 years, undergoing tonsillectomy were enrolled in the study. Group 1 (n=16) received bupivacaine, group 2 (n=15) received ropivacaine, and a group 3 (control) (n=15) received 9% NaCl (saline) infiltrated around each tonsil. Pain was evaluated using a modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) recorded 15 min and 1, 4, 12, 16, and 24h postoperatively.

RESULTS

No difference was found in the demographic data among the groups. The pain scores were similar between the bupivacaine and ropivacaine groups (p>0.05). The pain scores in both analgesia groups were significantly (p<0.05) lower 1, 4, 12, 16, and 24h postoperatively compared to the control group. Analgesic requirements and the time to first analgesia were also significantly (p<0.05) different between the analgesia and control groups.

CONCLUSION

Local ropivacaine infiltration is a safe and effective method and equivalent to bupivacaine for post-tonsillectomy pain.

Recent developments in paediatric regional anaesthesia

PURPOSE OF REVIEW

This review will focus on recently published data concerning side effects and complications of paediatric regional anaesthesia, putting into perspective the currently used techniques.

RECENT FINDINGS

Penile block is clearly a technique with a very large benefit and minimal side effects. Ilioinguinal nerve block, on the other hand, quite commonly leads to complications. Single-shot caudal anaesthesia is considered a safe and effective technique; however, even with this widely used block, complications such as sacral osteomyelitis can occur. Recent review articles have focussed on the role of additives for prolonging the duration of paediatric caudal anaesthesia. The use of ketamine or s-ketamine as an additive appears to be most promising for the future.

SUMMARY

Paediatric regional anaesthesia is now widely used for postoperative pain relief in children. However, a careful risk-benefit analysis is always mandatory before such medical interventions are undertaken.