A comparison of topical and retrobulbar anesthesia for cataract surgery

Lying down looking down test: Evaluating patient suitability for small incision cataract surgery using assisted topical anesthesia

Purpose:

The objective of this study was to evaluate an OPD-based Lying down looking down (LDLD) test for the assessment of patient suitability for assisted topical anesthesia (ATA) during manual small incision cataract surgery (MSICS), and to compare it with assisted local anesthesia (ALA).

Methods:

The LDLD test was carried out during preoperative assessment of 250 consecutive patients. A standard LED torch was shined in patient's eye after pupil dilation, with the patient in lying down position, while simultaneously elevating the upper eyelid digitally. A positive test was indicated by the ability to maintain downward gaze and the lack of squeezing of eyes or withdrawal. Chi-square and Fisher's exact tests were used to assess the association between LDLD results and suitability for ATA. The positive predictive value and specificity of the test as an indicator of patient suitability for ATA were calculated. Complications (intra- and post-operative) and postoperative inflammation at day 1 and week 6 were compared between the ATA and ALA groups.

Results:

A total of 250 patients were included in the study, 138 in ALA group and 112 in ATA group. There were 109 males (43.6%) and 141 females (56.4%). Around 7.4% of LDLD- positive patients were converted to ALA during the surgery. Chi-square and Fisher's exact tests demonstrated a significant association of a positive LDLD test with successful ATA (P value 0.002). The positive predictive value and specificity of the test were 92.56% (95% CI86.87-95.9%) and 93.48% (95% CI87.98-96.97%), respectively. Intraoperative complications were similar in both the groups. Congestion and visually significant corneal edema were significantly less in ATA group.

Conclusion:

The LDLD is a simple, highly specific, OPD-based test to determine patient suitability for MSICS under ATA

Perceived Surgeon Stress During No-Sedation Topical Phacoemulsification

Purpose

To determine the patient-related factors that contribute to surgeon stress during phacoemulsification cataract extraction (PCE) performed under unassisted topical anesthesia.

Methods

This is a prospective study of perceived surgeon stress during phacoemulsification by a single surgeon of consecutive patients undergoing PCE. At the conclusion of each procedure, the surgeon recorded the perceived stress according to the following three indices: surgeon score, qualitative score (yes or no), and total score (sum of itemized causes of stress). Patient variables included in the analysis included gender, age, diabetes mellitus, morbid obesity, intake of oral alpha blockers, floppy iris, laterality, pseudo-exfoliation, intraocular lens power, and initial visual acuity.

Results

During the 10-year study, 1097 eyes underwent surgery. The following patient variables were seen frequently: floppy iris syndrome (92), pseudo-exfoliation (72), and morbid obesity (36). Surgeon identified stress was reported after 250 procedures. On multivariable analysis, the following patient characteristics were associated with surgeon stress: age >80 years; morbid obesity; floppy iris syndrome; severe nuclear sclerosis; and poor baseline distance corrected visual acuity.

Conclusion

Several ocular and systemic patient-related characteristics contribute to surgeon stress during PCE.

Assessment of Visual and Retinal Function Following In Vivo Genipin-Induced Scleral Crosslinking

Purpose

Genipin has been proposed as a possible neuroprotective therapy in myopia and glaucoma. Here, we aim to determine the effects of prolonged genipin-induced scleral stiffening on visual function.

Methods

Eyes from Brown Norway rats were treated in vivo with either a single 15 mM genipin retrobulbar injection or sham retrobulbar injection and were compared to naïve eyes. Intraocular pressure, optomotor response, and electroretinograms were repeatedly measured over 4 weeks following retrobulbar injections to determine visual and retinal function. At 4 weeks, we quantified retinal ganglion cell axon counts. Finally, molecular changes in gene and protein expression were analyzed via real-time polymerase chain reaction (RT-PCR) and proteomics.

Results

Retrobulbar injection of genipin did not affect intraocular pressure (IOP) or retinal function, nor have a sustained impact on visual function. Although genipin-treated eyes had a small decrease in retinal ganglion cell axon counts compared to contralateral sham-treated eyes (−8,558 ± 18,646; mean ± SD), this was not statistically significant (P = 0.206, n = 9). Last, we did not observe any changes in gene or protein expression due to genipin treatment.

Conclusions

Posterior scleral stiffening with a single retrobulbar injection of 15 mM genipin causes no sustained deficits in visual or retinal function or at the molecular level in the retina and sclera. Retinal ganglion cell axon morphology appeared normal.

Translational Significance

These results support future in vivo studies to determine the efficacy of genipin-induced posterior scleral stiffening to help treat ocular diseases, like myopia and glaucoma.

A Comparison of Retrobulbar Block, Sub-Tenon Block, and Topical Anesthesia during Cataract Surgery

Purpose

This randomized, double-blinded, prospective study was performed to compare the intraoperative hemodynamic variables and the patient-reported outcomes, such as intra- and postoperative analgesia and patient satisfaction, of retrobulbar block, sub-Tenon block, and topical anesthesia during cataract surgery under monitored anesthesia care.

Methods

Eighty-one patients, ASA physical status I–III, undergoing elective cataract surgery under monitored anesthesia care, aged between 43 and 78 years, were randomly assigned to three groups: retrobulbar block (group R), sub-Tenon block (group S), or topical anesthesia (group T). Three minutes after the start of monitored anesthesia care with lidocaine-propofol-remifentanil mixture, an ophthalmologist performed regional anesthesia. Intraoperative hemodynamics, pain score, and patients' satisfaction with the anesthetic experiences were recorded by a study-blinded anesthesiologist.

Results

Mean arterial pressure and heart rate in group R were significantly higher than those in groups S and T during and just after the regional block (p<0.05). Group R required smaller dosage of patient controlled sedation and fewer supplemental bolus doses than groups S and T (p<0.05). On the other hand, group S showed the highest satisfaction scores among the three groups (p<0.05).

Conclusions

Sub-Tenon block seems to be better than retrobulbar block and topical anesthesia in patient satisfaction though adequate analgesia was achieved after retrobulbar block during cataract surgery under monitored anesthesia care.

Comparison of Sedation Requirements for Cataract Surgery under Topical Anesthesia or Retrobulbar Block

PURPOSE

Topical anesthesia is increasingly being used for cataract surgery. However, it is believed that topical anesthesia causes an increased risk of intraoperative complications from unrestricted eye movement and insufficient pain control and more need for sedation. It is difficult to compare pain and anxiety experienced by individual patients; therefore, the authors used the method of patient-controlled sedation to determine whether there is a difference in sedation requirements under topical or retrobulbar anesthesia.

METHODS

In this prospective study, patients received either topical anesthesia (n=87) or retrobulbar block (n=104) and self-administered a mixture of midazolam (0.5 mg) and fentanyl (25 microg) in increments using a patient controlled analgesia infuser to achieve sedation. At the end of surgery, patients rated their pain on a 10-point numerical rating scale and their comfort on a 5-point scale. The number of demands and deliveries were noted from the patient controlled analgesia infuser display.

RESULTS

Pain scores were between 0 and 2 in 95.4% in the topical and in 94.2% in the retrobulbar group (p>0.05). Patient comfort was equal in both groups with 2.94+/-0.92 in the topical group and 2.92+/-0.99 in the retrobulbar group (p>0.05). Mean sedation requirements were similar in both groups: 26.4% of patients in the topical group and 19.2% in the retrobulbar group did not request any sedation (not significant, p>0.05).

CONCLUSIONS

Sedation requirements were similar for cataract surgery under topical and retrobulbar anesthesia.

Evaluation of Topical Lignocaine Jelly 2% for Recurrent Pterygium Surgery with Glue-free Autologous Conjunctival Graft

AIM

This study aims to evaluate the efficacy of lignocaine 2% jelly as a topical anesthesia in recurrent pterygium surgery with glue-free conjunctival limbal autograft.

MATERIALS AND METHODS

A prospective, nonrandomized, observational study, comprising of 51 patients (51 eyes) having recurrent pterygium, was conducted at a tertiary eye care center in central India. Pterygium excision with glue-free autologous conjunctival grafting was done under 2% lignocaine jelly. The visual analog scale was utilized to record the intra- and post-operative pain score. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. Anesthetist also noted vital parameters and any intravenous drugs required.

RESULTS

No difference in intra- and post-operative pain score (P = 0.24) was observed in the patients. Zero score, i.e. no pain was noticed in 30 patients (58.8%) patients. The average surgical time was 29.20 min (+1.11). The average surgeon discomfort score was 0.18 + 0.51. Inadvertent eye movement was seen in 3 patients (5.9%). Lid squeeze was noted in 45 patients (88.2%) during placement of lid speculum. Forty-eight patients (94.1%) gave preference to the topical anesthesia of 2% lignocaine jelly compared to the previous mode of anesthesia.

CONCLUSION

Pterygium surgery with glue-free autogenous conjunctival grafting can be performed successfully by preoperative local application of 2% lignocaine jelly. The ease of application, lack of toxicity and sufficient effect to complete the surgery make it an efficient alternative to injectable anesthetics.

The effect of post-traumatic-stress-disorder on intra-operative analgesia in a veteran population during cataract procedures carried out using retrobulbar or topical anesthesia: a retrospective study

Background

A growing proportion of veterans treated at the Veterans Health Administration (VA) have a history of post-traumatic-stress-disorder (PTSD), and there exists a higher rate of PTSD amongst veterans than the general population. The purpose of this study is to determine the correlation between PTSD and intra-operative analgesia, intra-operative time, and anesthesia type for cataract surgery in a veteran population. Secondary objectives are to determine if patient age, and first or second eye surgery affect intra-operative pain control or are correlated with type of anesthesia modality.

Methods

A retrospective study of 330 cataract surgeries performed by resident physicians between January and September 2012 at the Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville and Murfreesboro Campuses was completed. Three hundred and thirty veteran patients were selected if their cataract surgery was performed between January and September 2012. Combined cases were excluded. The primary outcome evaluated was intra-operative analgesia. Secondary outcomes included history of post-traumatic-stress-disorder, anesthesia type, first or second eye, pain control, intra-operative heart rate and blood pressure, age, and case complexity. Data was analyzed using an unpaired two-sample Welch’s t-test assuming unequal variance and Z test of comparison of proportions.

Results

Patients with post-traumatic-stress-disorder reported higher pain scores, had longer operative times, and were more likely to have received a retrobulbar block. Operative time was not associated with an increased pain score, irrespective of anesthesia type, when controlled for PTSD. Complex cases had longer operative times, more sedation, and higher pain scores. P < 0.05 was used consistently.

Conclusions

Post-traumatic stress disorder and anxiety are more prevalent in the veteran population. Our data suggests that a history of post-traumatic-stress-disorder was correlated with higher pain scores, longer operative times, and with having received a retrobulbar block. Patients without a history of PTSD were more likely to have received topical anesthesia with or without sedation. The veteran population requires more sedation to allay anxiety and perceptions of discomfort, which may account for longer surgical times. The veteran population is a special population and it is important to investigate how PTSD in the veteran population affects intra-operative analgesia.

Phacoemulsification without preoperative mydriasis in patients with age-related cataract associated with type 2 diabetes

Aim

To study the effect of intracameral injection of preservative-free lignocaine to induce pupil dilatation, without using any preoperative dilating eyedrops or intraoperative mydriatics in patients with age-related cataract associated with type 2 diabetes mellitus.

Design

This was a prospective, observational, and interventional case series conducted at a tertiary eyecare center in rural India.

Materials and methods

A total of 32 patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Preoperative pupillary diameter was measured 3 days prior to surgical procedure under mydriatics (tropicamide 0.8%, phenylephrine hydrochloride 5%). Intraoperative pupillary dilatation was achieved by 1% intracameral lignocaine solution alone. Effective phacoemulsification time (EPT), total surgical time, and final pupillary diameter were recorded at the conclusion of surgery.

Results

The average duration of diabetes was 11.2 (range 5–25) years. There was no difference in dilatation by preoperative pupil-dilating drops (5.2±0.5 mm, range 3–8.3 mm) and intracameral 1% lignocaine during the surgical procedure (P=0.63). There was a negative correlation (r=−0.92) between diabetes duration and dilatation of pupils with dilating drops and intracameral lignocaine. The duration of the surgery, EPT, and phacoemulsification chop had statistically insignificant effects on mydriasis, while the grade of the nucleus had a statistically significant effect on mydriasis. Intracameral lignocaine had no significant effect on blood pressure or pulse. There were no surgical complications that could have compromised the visual outcome. None of the patients developed macular edema in a follow-up period of 3 months; 28 patients (87.5%) had best-corrected visual acuity from 20/30 to 20/20.

Conclusion

Intracameral lignocaine 1% provides sufficient mydriasis for the safe phacoemulsification of cataract in patients with type 2 diabetes of variable duration.

A comparison of patient pain and visual outcome using topical anesthesia versus regional anesthesia during cataract surgery

Purpose

The purpose of this study was to compare the level of patient pain during the phacoemulsification and implantation of foldable intraocular lenses while under topical, intracameral, or sub-Tenon lidocaine.

Patients and methods

This was a retrospective study. Three hundred and one eyes subjected to cataract surgery were included in this study. All eyes underwent phacoemulsification surgery and intraocular lens implantation using topical, sub-Tenon, or intracameral anesthesia. The topical group received 4% lidocaine drops, and the intracameral group received a 0.1–0.2 cc infusion of 1% preservative-free lidocaine into the anterior chamber through the side port combined with topical drops of lidocaine. The sub-Tenon group received 2% lidocaine. Best-corrected visual acuity, corneal endothelial cell loss, and intraoperative pain level were evaluated. Pain level was assessed on a visual analog scale (range 0–2).

Results

There were no significant differences in visual outcome and corneal endothelial cell loss between the three groups. The mean pain score in the sub-Tenon group was significantly lower than that in the topical and intracameral groups (P=0.0009 and P=0.0055, respectively). In 250 eyes without high myopia (< −6D), there were no significant differences in mean pain score between the sub-Tenon and intracameral groups (P=0.1417). No additional anesthesia was required in all groups.

Conclusion

Intracameral lidocaine provides sufficient pain suppressive effects in eyes without high myopia, while sub-Tenon anesthesia is better for cataract surgery in eyes with high myopia.

The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia

Purpose: To evaluate and compare the safety and efficacy of combined two-site phacoemulsification and trabeculectomy surgery with mitomycin C (MMC) in glaucoma-cataract patients with retrobulbar or topical anesthesia.

Patients and methods: A retrospective, nonrandomized review of consecutive phacotrabeculectomy patients with a minimum follow-up time of 6 months, no previous glaucoma surgeries, and a preoperative visual acuity (VA) greater than light perception. The main outcome measures were preoperative and postoperative VA, intraocular pressure (IOP), use of glaucoma medications, and complications. A complete surgical success required an IOP from 6 to 18 mm Hg, no visually devastating complications, no return to surgery, and no use of glaucoma medications. Qualified success allowed the use of up to two glaucoma medications. Anesthesia groups were compared by student t-tests and log rank comparison of Kaplan-Meier survival rates.

Results: Eighty-seven eyes (83 patients) met inclusion criteria, with a mean follow-up of 19 ± 12 months (6-57 months). The average eye gained 3.1 ± 4.9 lines of VA, lost 4.0 ± 7.1 mm Hg of IOP, and decreased 1.0 ± 1.3 glaucoma medications. Retrobulbar and topical anesthesia groups had statistically equivalent mean changes in VA (p = 0.910), IOP (p = 0.268), and use of glaucoma medications (p = 0.964). Postoperative complication rates were also statistically similar (p = 0.580). Complete success was greater in the retrobulbar group (p = 0.006), however, qualified success was equivalent in both groups (p = 0.769).

Conclusion: Two-site phacotrabeculectomy with MMC in West Indian patients is as safe and effective for glaucoma-cataract patients with topical anesthesia as it is under retrobulbar anesthesia, and without short-term losses in VA and the chance of serious complications from injection.

How to cite this article: Rodriguez R, Alburquerque R, Sauer T, Batlle JF. The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia. J Curr Glaucoma Pract 2016;10(1):7-12.

Trabeculectomy Under Augmented Topical Anesthesia: Study on Pain Evaluation and Surgical Feasibility

PURPOSE

Performing trabeculectomy under topical anesthesia using lignocaine jelly with intracameral anesthesia may offer painless surgery with immediate visual gain and avoid the increase in intraocular pressure associated with locally injected anesthesia. In this context, we evaluated topical anesthesia using 2% lignocaine jelly with intracameral 1.0% lignocaine for trabeculectomy in terms of pain during surgery and the surgeon's experience.

DESIGN

This was a tertiary care center-based interventional case series.

METHODS

Patients scheduled for trabeculectomy as the first surgery for medically controlled glaucoma underwent standard ab externo trabeculectomy under topical anesthesia. Pain evaluation was done using a visual analog scale with the modified Wong-Baker FACES Pain Rating Scale, within 1 hour after surgery.

RESULTS

Fifteen eyes of 14 patients were included in the study with a mean (SD, range) age of 61.3 (17.54, 40-90, distributed normally) years. Patients' pain score analysis showed a mean (SD, range) visual analog scale score of 0.73 (0.59, 0-2) on a scale of 0 to 10. The mean (SD, range) surgeon's satisfaction score was 3.2 (0.4, 3-4) on a scale of 3 to 9. The intraocular pressure of all patients was well controlled at 2 weeks [mean (SD, range), 9.2 (2.9, 4-16)] and at 4 weeks [mean (SD, range), 13.2 (1.2, 11-15)] postoperatively without any topical or systemic antiglaucoma medications.

CONCLUSIONS

Trabeculectomy can be done under augmented topical anesthesia, which provides adequate analgesia for acceptable patient and surgeon comfort with favorable outcomes. Anesthesia provided by topical application of lignocaine 2% jelly and intracameral 1.0% lignocaine is sufficient for safe trabeculectomy surgery with acceptable discomfort to the patient.

Proparacaine hydrochloride topical drop and intracameral 0.5% lignocaine for phacotrabeculectomy in patients with primary open angle glaucoma

Aim:

To compare the efficacy and safety of 0.5% intracameral lignocaine to 1% intracameral lignocaine prior to phacotrabeculectomy.

Study Design:

Prospective, comparative, observational, and interventional study.

Setting:

Tertiary eye care center in central India.

Materials and Methods:

This study was comprised of 79 patients (79 eyes) with primary open angle glaucoma scheduled for phacotrabeculectomy. Patients were assigned to 1 of 2 Groups receiving proparacaine 0.5% eye drops and 1% intracameral lignocaine just prior to phacotrabeculectomy (Group 1, n = 39) and 0.5% intracameral lignocaine after completion of phacoemulsification just prior to trabeculectomy (Group 2, n = 40). The visual analogue scale was used to record intraoperative and postoperative pain. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. An anesthetist also noted the vital parameters and the requirement for intravenous medications.

Results:

There was no significant difference in the intraoperative pain score (P = 0.0733) or supplemental anesthesia (P = 0.372) between Groups. Postoperative pain score was statistically significant in Group 2 (P < 0.0001). The overall operating conditions in both Groups were comparable (P = 0.7389). A greater number of patients in Group 2 (88.57%) preferred the same anesthetic technique for combined surgery in the fellow eye. There was no difference in inadvertent eye movements and lid squeezing between Groups and they did not interfere with surgery.

Conclusion:

Topical anesthetic drops supplemented with 0.5% intracameral lignocaine before performing trabeculectomy is as effective as 1% intracameral lignocaine given at the beginning of phacotrabeculectomy for primary open angle glaucoma.

A single drop of 0.5% proparacaine hydrochloride for uncomplicated clear corneal phacoemulsification

Purpose:

The purpose of this study was to compare the efficacy of a single drop of 0.5% proparacaine hydrochloride in uncomplicated cataract surgery with phacoemulsification.

Materials and Methods:

Two hundred and ninety five patients scheduled for the phacoemulsification were divided into 2 groups based on the anesthetic agents they were to receive: 146 patients who received a single drop of 0.5% proparacaine 2 min before the start of the surgery (proparacaine group) and; 149 patients who received supplementation of 0.5% intracameral preservative free xylocaine (xylocaine group). A single surgeon performed all surgeries. Intraoperative and post-operative pain scores were evaluated on a visual analog scale. The surgeon noted his subjective impression of corneal clarity, discomfort while performing the surgery any supplemental anesthesia required and intraoperative complications. An anesthetist noted vital parameters and the need for intravenous sedation. Total surgical time was noted. Comparison of parameters was performed with the Chi-square test, and A P value less than 0.05 was considered as statistically significant.

Results:

No statistically significant difference was seen in the intraoperative (P = 0.24) and post-operative (P = 0.164) pain scores between groups. There was no pain (0 score) in 41.8% of patients in the proparacaine group and 46.3% of patients in the xylocaine group. The average surgical time (P = 0.279) and surgeon discomfort (P = 0.07) were not statistically significantly different between groups. No patients required supplemental anesthesia. There were no surgical complications that could compromise the visual outcome. An equal number of patients in both groups preferred same type of anesthetic technique for the fellow eye cataract surgery (89.11% for the proparacaine group and 90.18% for the xylocaine group). No patients in either group had changes in vital parameters or required intravenous sedation.

Conclusion:

A single drop pre-operatively, of proparacaine hydrochloride was comparable to the intracameral supplementation of preservative free xylocaine for phacoemulsification in uncomplicated cataract surgery without compromising the visual outcome. However, we recommend individualizing the anesthetic technique according to the requirements of the surgeon.

Efficacy and safety of 0.5% levobupivacaine versus 0.5% bupivacaine for peribulbar anesthesia

Background

This randomized double-blind study examined the use of a new anesthetic agent, levobupivacaine 0.5%, which is the S(−)-enantiomer of a racemic mixture of bupivacaine, for peribulbar anesthesia and compared it with racemic bupivacaine 0.5% alone or in combination with hyaluronidase 10 IU/mL.

Methods

A total of 160 patients undergoing ophthalmic surgery were randomized into four groups (n = 40 each) to receive inferotemporal peribulbar injection of levobupivacaine 0.5% (group L), racemic bupivacaine 0.5% (group B), levobupivacaine + hyaluronidase 10 IU/mL (group LH), or racemic bupivacaine + hyaluronidase 10 IU/mL (group BH) by two anesthetists and two ophthalmologists in a ratio of 25% each. Ocular akinesia and orbicularis oculi function were evaluated using a three-point scale; a value < 5 points was considered as requiring surgery, and movements were re-evaluated the day following surgery to confirm regression of the block.

Results

The time to onset (12 ± 2.6 minutes versus 13 ± 2.8 minutes) and duration of anesthesia (185 ± 33.2 minutes versus 188 ± 35.7 minutes) were similar between groups L and B. Complete akinesia (score 0) was obtained more frequently when hyaluronidase was used in addition to the anesthetic, with occurrences of 72.5% versus 57.5% in group LH versus L, respectively, and 67.5% versus 45% in group BH versus B. Moderate hypotension (<30% of baseline) was observed in four patients (10%) in group L, two (5.0%) in group B, one (2.5%) in group LH, and three (7.5%) in group BH. The time to onset was significantly different between groups L and BH, B and BH, and LH and BH, and the duration of anesthesia differed significantly between groups B and LH, B and BH, and L and LH. The akinesia score differed significantly between groups L and LH and between groups B and LH (P = 0.043 and P = 0.018, respectively), and the number of patients with a score of 0 differed significantly between groups B and LH and between groups B and BH (P = 0.004 and P = 0.017, respectively).

Conclusion

Levobupivacaine is a long-lasting local anesthetic with limited cardiotoxicity and neurotoxicity, and may be considered the landmark for vitreoretinal surgery in elderly patients.

Cataract surgery complications: an in vitro model of toxic effects of ropivacaine and lidocaine

BACKGROUND

Intraoperative lidocaine is widely used in controlling discomfort during cataract surgery. However, recent studies have confirmed the toxic effect of lidocaine on ganglion cells. Ropivacaine is an anesthetic recently introduced in clinical practice that couples a long anesthetic effect with a mild vasoconstrictive action.

OBJECTIVE

The aim of this study was an in vitro evaluation of the efficacy of ropivacaine in reducing the degenerative effects usually observed during lidocaine treatment.

METHODS

Ropivacaine and lidocaine toxicity has been evaluated in murine fibroblasts 3T6 by measuring percentage of cell death, cell growth inhibition, and DNA degradation. The choice of this cellular line is motivated by the presence of a complete apoptotic system that can be assimilated to the endothelium precursor cells.

RESULTS

We observed that lidocaine 0.25% decreases cell viability and causes DNA degradation in murine fibroblasts 3T6, whereas ropivacaine 0.5% does not cause any cellular or molecular degenerative effect.

CONCLUSIONS

Our in vitro studies confirm that ropivacaine is less toxic than lidocaine to these cells. Therefore, in vivo studies in the anterior chamber could be useful to evaluate the effects of ropivacaine versus lidocaine in intracameral anesthesia in cataract surgery.

No-patch 23-gauge vitrectomy under topical anesthesia: a pilot study

A pilot study was designed to evaluate the safety and efficacy of 23-gauge vitrectomy under topical anesthesia. Five eyes of five patients underwent 23-gauge sutureless vitrectomy under topical anesthesia with a pledget soaked in 0.5% proparacaine hydrochloride anesthetic, for vitreous hemorrhage (four eyes), epiretinal membrane (one eye). Subjective pain and discomfort were graded using a visual analogue chart from 0 (no pain or discomfort) to 4 (severe pain and discomfort). At the end of surgery no patch was applied and patients were given dark glasses. Patients underwent an immediate postoperative assessment, followed by next day and one week postoperative evaluation. Four patients had Grade 0 pain during the surgery. One patient had Grade 1 pain during the placement and withdrawal of the micro cannulas. The surgical outcomes were favorable. 23-gauge vitrectomy under topical anesthesia is safe and effective in selected cases. Further study is recommended to validate the outcome of this study.

The effect of combined topical-intracameral anaesthesia on neuroleptic requirements during cataract surgery

OBJECTIVE

To evaluate whether the addition of intracameral lidocaine to topical anaesthesia during cataract surgery leads to a decrease in the administration of intraoperative midazolam and fentanyl.

DESIGN

Retrospective case-control study.

PARTICIPANTS

The eyes of 124 patients undergoing phacoemulsification were included in the study, with 62 in the intracameral group and 62 in the control group.

METHODS

A single-centre, retrospective chart review of cases between April and October 2007 in which patients had undergone small-incision phacoemulsification with foldable intraocular lens insertion and received preoperatively either topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% (intracameral group) or topical tetracaine 0.5% alone (control group). Intraoperatively, midazolam and fentanyl were administered as needed based on pain and anxiety.

RESULTS

A total of 124 eyes (124 patients) were included. There was no statistically significant difference between the mean intraoperative midazolam doses given for the 2 groups (p = 0.08). The mean intraoperative dose of fentanyl was lower in the intracameral than in the control group (p < 0.0001). A comparison of intraoperative fentanyl requirements between groups using a multivariate regression analysis for age, gender, surgical time, and preoperative fentanyl levels confirmed the lower need for intraoperative fentanyl in the intracameral compared with the control group (p = 0.0037). There were no anaesthetic complications among any of the study patients.

CONCLUSIONS

Patients receiving topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% during cataract surgery demonstrated a reduction in intraoperative fentanyl requirements. Surgeons performing cataract surgery under topical anaesthesia should consider the addition of intracameral lidocaine 1% to decrease fentanyl requirements and improve patient safety and comfort.

Adverse medical events associated with cataract surgery performed under topical anaesthesia

BACKGROUND

Cataract surgery in Australia is increasingly performed in an elderly population with multiple medical comorbidities. The purpose of this study was to investigate the frequency and type of adverse medical events associated with cataract surgery performed under topical anaesthesia with light sedation.

METHODS

Retrospective analysis was undertaken for 631 consecutive cases of clear corneal phaco-emulsification and implant surgery performed under assisted topical anaesthesia, by a single surgeon (TR) in a private ophthalmic day surgery unit. In the 238 patients who underwent bilateral surgery, data from the first procedure for each patient were analysed, unless the second procedure was associated with greater morbidity.

RESULTS

A total of 393 procedures were included in the study. The mean age was 73 +/- 11 years with 75% of patients having at least one significant medical comorbidity. The most common comorbidities were hypertension (51%), gastro-oesophageal reflux (19%), angina and myocardial infarction (14%), diabetes (13%) and asthma (9%). Significant intraoperative adverse medical events requiring intervention occurred in four cases (1%): bradycardia occurred in three cases and hypotension in one case. None of these adverse events resulted in death or hospitalization. There were no postoperative adverse events, hospitalizations or deaths within 7 days. Minor changes in heart rate, blood pressure and oximetry not requiring intervention were observed in 35 cases (9%).

CONCLUSION

This retrospective analysis shows that cataract surgery performed under assisted topical anaesthesia is safe with a low rate of systemic complications despite being performed in an elderly population.

Melatonin provides anxiolysis, enhances analgesia, decreases intraocular pressure, and promotes better operating conditions during cataract surgery under topical anesthesia

BACKGROUND

Melatonin has anxiolytic and potential analgesic effects. In this study, we assessed the effects of melatonin premedication on pain, anxiety, intraocular pressure (IOP), and operative conditions during cataract surgery under topical analgesia.

METHODS

Forty patients undergoing cataract surgery under topical anesthesia were randomly assigned into two groups (20 patients each) to receive either melatonin 10 mg tablet (melatonin group) or placebo tablet (control group) as oral premedication 90 min before surgery. Anxiety scores, verbal pain scores, heart rate, mean arterial blood pressure, and IOP were recorded. In addition, the surgeon was asked to rate operating conditions.

RESULTS

Melatonin significantly reduced the anxiety scores (median, interquartile range) from 5, 3.5-6 to 3, 2-3 after premedication and to 3, 2-3.5 during surgery (P = 0.04 and P = 0.005 compared with the placebo group, respectively). Perioperative verbal pain scores were significantly lower in the melatonin group with less intraoperative fentanyl requirement (median, interquartile range) compared with the control group, 0, 0-32.5 vs 47.5, 30-65 microg, respectively, P = 0.007. Melatonin also decreased IOP (mean +/- sd) significantly from 17.9 +/- 0.9 to 14.2 +/- 1.0 mm Hg after premedication and to 13.8 +/- 1.1 mm Hg during surgery (P < 0.001). It also provided better quality of operative conditions.

CONCLUSION

We concluded that oral melatonin premedication for patients undergoing cataract surgery under topical anesthesia provided anxiolytic effects, enhanced analgesia, and decreased IOP resulting in good operating conditions.

Protein therapeutics: a summary and pharmacological classification

Once a rarely used subset of medical treatments, protein therapeutics have increased dramatically in number and frequency of use since the introduction of the first recombinant protein therapeutic--human insulin--25 years ago. Protein therapeutics already have a significant role in almost every field of medicine, but this role is still only in its infancy. This article overviews some of the key characteristics of protein therapeutics, summarizes the more than 130 protein therapeutics used currently and suggests a new classification of these proteins according to their pharmacological action.

The Lanindar test: a method of evaluating patient suitability for cataract surgery using assisted topical anaesthesia

AIM

To evaluate an office-based Lanindar (light and nociceptive interaction noting distress and response) test to assist in the assessment of patient suitability for assisted topical anaesthesia (ATA) during phacoemulsification.

METHODS

The Lanindar test was carried out at the preoperative assessment of 716 consecutive patients in the office of one of the authors (ICF). A standard desk lamp was shone in each patient's eye after pupillary dilation, while simultaneously elevating the upper eyelid digitally. A negative test indicated patient hypersensitivity to the light and aversion to digital pressure on the upper eyelid. A positive test was indicated by the patient feeling comfort and lack of blepharospasm and withdrawal in response to the light and digital pressure. chi (2) and Fisher's exact tests were used to assess the association between Lanindar results and suitability for ATA. The positive predictive value and specificity of the test as an indicator of patient suitability for ATA were calculated. Visual acuities at 1 and 4 weeks post-operative periods were compared between the ATA and ALA/GA (assisted local anaesthesia/general anaesthesia) group of patients.

RESULTS

About 86.7% were Lanindar positive and 98.9% of these patients tolerated ATA. chi (2) and Fisher's exact tests demonstrated a significant association of a positive Lanindar test with successful ATA (chi (2)=660, P<0.001, Fisher's: P<0.001). The positive predictive value and specificity of the test were 98% (95% CI=98.04-99.7%) and 93.14% (95% CI=88.23-98.04%), respectively. Visual acuity outcomes were similar in the ATA and ALA/GA groups.

CONCLUSION

The Lanindar is a simple, highly specific, office-based test to determine patient suitability for phacoemulsification under ATA.

Variation of blood pressure during topical phacoemulsification

BACKGROUND

The changes of blood pressure in patients undergoing cataract procedure are not well studied. The blood pressures of cataract patients often become uncontrolled intraoperatively causing the procedure to be postponed. Intraoperative rise in blood pressure has been associated with ocular complications such as suprachoroidal haemorrhage and can be fatal from stroke or even myocardial infarction. We attempt to study the changes in blood pressure of patients undergoing cataract surgery.

AIM

Prospective study on the variation of blood pressure pre- and intra-operatively.

METHOD

The blood pressure readings of patients going for cataract procedures were measured in five stages during the pre-assessment clinic, on arrival at the day surgery, at the anaesthetic room, on the operating table intraoperatively; and postoperatively. The readings were compared to their age, sex, past medical history, and use of antihypertensive medication.

RESULTS

The rise in systolic blood pressures between intraoperative readings and those at the preassessment and anaesthetic room was highly statistically significant.Being older (>65 years of age), taking more than two antihypertensive drugs, being hypertensive, or having a family history of hypertension does not appear to increase the risk.

CONCLUSION

Our study showed that there is a significant rise in systolic blood pressures especially in females during topical phacoemulsification. Further studies are needed on the factors that determine this increase and the changes in blood pressures during different stages of the procedure.

Cataract surgery anaesthesia: is topical anaesthesia really better than retrobulbar?

PURPOSE

To compare the effectiveness for the patient of retrobulbar anaesthesia (RBA) and topical anaesthesia (TA) in cataract surgery by phacoemulsification.

METHODS

We performed a prospective, randomized study on 115 patients operated at our clinic using the two anaesthesia techniques. The RBA group comprised 57 patients (20 women, 37 men; age 72 +/- 10 years); the TA group comprised 58 patients (20 women, 38 men; age 74 +/- 10 years). Measured parameters were: blood pressure; heart rate; blood oxygen saturation level; serum adrenaline, noradrenaline and cortisol levels; white blood cell count; indicated pain during the procedure, and pain as reported by the patient afterwards. Two psychological tests were used: the State-Trait Anxiety Inventory (STAI), and the patient-selected face-scale test. Statistical analysis was performed using Student's t-test and the chi-square test. Results were also analysed using a logistic regression model.

RESULTS

Both types of anaesthesia were adequate for the surgical procedure. In the RBA group fewer patients experienced pain during surgery (p < 0.01) and fewer recalled any perioperative discomfort. With RBA the objective parameters were more stable than with TA, and systolic blood pressure was significantly lower (p = 0.01). The logistic model was able to predict perioperative pain with 93% certainty. Pain sensitivity was higher in younger patients and in patients with higher initial cortisol and noradrenaline serum levels.

CONCLUSIONS

Both methods of anaesthesia are appropriate, but phacoemulsification with TA is more painful than with RBA. In hypertonic patients and younger patients who are more susceptible to pain, TA should be avoided or used in combination with individualized sedation.

Ropivacaine versus lidocaine for deep-topical, nerve-block anaesthesia in cataract surgery: a double-blind randomized clinical trial

PURPOSE

To evaluate the safety and efficacy of ropivacaine versus lidocaine for deep-topical, nerve-block anaesthesia in cataract surgery.

METHODS

This prospective controlled randomized double-blind study comprised 64 patients undergoing clear corneal phacoemulsification. Patients were equally divided into two group receiving either deep-topical anaesthesia with 1% ropivacaine-soaked sponge (Group R, n = 32) or 2% lidocaine-soaked sponge (Group L, n = 32). The level of intraoperative and postoperative pain was assessed by patients using a verbal analogue scale from 1 to 10. The duration of surgery, the need for supplemental anaesthesia, surgeon satisfaction, and intraoperative and early postoperative complications were recorded. The patients' heart rate, arterial blood pressure and peripheric oxygen saturation (SpO(2)) were obtained just before the anaesthesia and during the surgery.

RESULTS

The demographic data of the patients and duration of surgery were similar in both groups. No significant difference in the mean pain scores of patients were found in the ropivacaine and lidocaine groups. Surgical satisfaction was also statistically insignificant. None of the patients had significant difference in heart rate, blood pressure or SpO(2) during the surgical procedure.

CONCLUSION

Deep-topical anaesthesia with ropivacaine and lidocaine in cataract surgery is safe and the two anaesthetic agents do not present differences in the degree of analgesia achieved. Deep-topical anaesthesia with ropivacaine or lidocaine was equally effective in providing anaesthesia with sufficient quality for cataract surgery.

What Determines Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation in a Community Hospital Setting?

The Iowa Satisfaction with Anesthesia Scale (ISAS) is a reliable and valid tool to measure patient satisfaction with monitored anesthesia care. We used the ISAS to discover determinants of patient satisfaction with cataract care under topical local anesthesia and monitored sedation in a small community hospital. The ISAS (scored 1 to 6) was administered to 306 patients immediately after cataract surgery. All patients received topical local anesthesia and IV sedation administered by an anesthesiologist. Patient satisfaction was high: mean ISAS was 5.6 (sd 0.46; range: 3.3-6.0). The incidence of intraoperative and postoperative pain was 13% and 37%; other adverse events were infrequent (<5%). In multivariable logistic regression, significant predictors of satisfaction were postoperative pain (odds ratio [OR]: 4.84; 99% confidence interval [CI]: 2.21, 10.60), surgeon (OR: 0.21; 99% CI: 0.05, 0.91), and preoperative anxiety (OR: 1.17; 99% CI: 1.03, 1.34). ISAS mean scores (OR = 0.28; 99% CI: 0.13, 0.59) and preoperative anxiety (OR = 1.12; 99% CI: 0.99, 1.28) emerged as significant predictors of low rating of quality of experience. Our results indicate that the ISAS can be used to track patient satisfaction with monitored cataract care. Pain during and after cataract surgery is common and is a major reason for lower patient satisfaction with their cataract care.

Efficacy and safety of three ophthalmic inserts for topical anaesthesia of the cornea. An exploratory comparative dose-ranging, double-blind, randomized trial in healthy volunteers

BACKGROUND

Cataract surgery requires prolonged anaesthesia, concomitant with permanent hydration and lubrication of the cornea, in order to provide a clear view of the operation area.

AIMS

The primary objective of the study was to assess several formulae of a soluble ophthalmic insert: TOPICSERT [bupivacaine (Bupi) + hyaluronic acid (HA) or sodium hyaluronate] in terms of complete and long-lasting anaesthesia of the cornea. The hydration properties of HA were not assessed in this study.

METHODS

In a prospective double-blind, cross-over, randomized study, with latin-square allocation of treatments, 16 healthy volunteers received a single dose of each formula (A, 1 mg Bupi and 0.1 mg HA; B, 0.5 mg Bupi and 0.1 mg HA; C, 1 mg Bupi and 0 mg HA, and D acting as a placebo) via the ocular route with 1 week of wash-out between each period. Corneal anaesthesia was measured using a Cochet-Bonnet esthesiometer.

RESULTS

There was a statistically significant difference between treatments with regard to the main criterion (complete anaesthesia lasting at least 20 min) when general association statistics were used (Mantel-Haenzel test, P < 0.0001): 68.75% (n = 11) of subjects receiving treatment A, 37.5% (n = 6) receiving treatment B, and 87.5% (n = 14) on treatment C reached complete and satisfactory anaesthesia, while this was not achieved in any of the subjects receiving placebo. Ninety-five percent confidence intervals of the difference between treatments were as follows: treatment A vs. B (-0.03, 0.66), treatment A vs. C (-0.47, 0.10), treatment B vs. C (-0.84, - 0.16). Only the difference between B and C was statistically significant (adjusted probability by the method of Bonferroni, P < 0.001). When complete anaesthesia was reached, mean (+/-SD) duration of anaesthesia was as follows: 20.7 (+/-6.5), 15.3 (+/-11.4) and 24.7 (+/-7.6) min for treatments A, B, C, respectively.

CONCLUSIONS

Bupivacaine 1 mg seems to be the efficient and safe dose. The value of hyaluronic acid as a corneal hydration agent and used in association with bupivacaine will be the subject of further studies.

Efficacy of lidocaine 2% gel in pterygium surgery

PURPOSE

Anaesthesia during pterygium surgery is usually achieved with local injection of anaesthetic medications. The aim of this study was to determine whether lidocaine 2% gel is an effective topical anaesthetic agent for pterygium surgery.

METHODS

We conducted a prospective, randomized clinical trial. Fifty-four consecutive patients who had primary pterygium underwent surgical excision of the lesion and conjunctival autograft. Patients were randomized into two groups. Group 1 received 1 ml of lidocaine 2% solution subconjunctivally and group 2 received lidocaine 2% gel topically. The primary outcome of interest was the pain experienced during anaesthetic administration and surgery. Following the dissection and excision of the pterygium, conjunctival autograft was transplanted in each of the patients. Immediately after the operation, pain and discomfort scores were determined using a 10-point linear visual analogue scale.

RESULTS

The mean pain score during anaesthetic administration was 4.26 +/- 1.18 in the injection group and 0.92 +/- 0.56 in the gel group. The mean pain score during surgery was 3.96 +/- 0.95 in the injection group and 4.0 +/- 1.01 in the gel group. There was a statistically significant difference in mean pain scores experienced during anaesthetic administration (p = 0.01). There was no significant difference in mean pain scores experienced during surgery (p = 0.55). No adverse events were noted.

CONCLUSION

In light of these results, we conclude that topical administration of lidocaine 2% gel can be used as an alternative method of anaesthesia in pterygium surgery, especially for patients with needle phobia.

Randomized double-blind clinical trial comparing topical and sub-Tenon's anaesthesia in routine cataract surgery †

BACKGROUND

Several local anaesthetic techniques are available for cataract surgery. Recently, topical anaesthesia has gained in popularity. A randomized trial was designed to compare patient discomfort and intraoperative complications following routine cataract surgery under topical or sub-Tenon's anaesthesia.

METHODS

A randomized double-blinded placebo-controlled clinical trial of 210 patients assigned to either a sub-Tenon's group (sub-Tenon's anaesthesia with placebo topical balanced salt solution, n=140) or a topical anaesthesia group (topical anaesthesia with placebo sub-Tenon's injection of balanced salt solution, n=70) was carried out. All patients underwent phacoemulsification with intraocular lens implantation. Patients in the sub-Tenon's group received a single injection (3 ml) of a combination of lidocaine 2% (2 ml) and bupivacaine 0.75% (1 ml), and four doses of topical placebo (balanced salt solution). Patients in the topical anaesthesia group received four doses of topical proxymethocaine 0.5% and a placebo sub-Tenon's injection (3 ml) of balanced salt solution. No intracameral injection of local anaesthetic was given. A 10-point visual analogue pain scale was used preoperatively and for postoperative pain assessment immediately after the operation and 30 min postoperatively. The intraoperative complications in the two groups were recorded.

RESULTS

The mean pain score immediately after surgery was 2.42 (sd 2.2) in the sub-Tenon's group and 3.44 (2.3) in the topical anaesthesia group (P=0.0043). The mean pain score 30 min after surgery was 1.24 (1.7) in the sub-Tenon's group and 2.25 (2.2) in the topical anaesthesia group (P=0.0009).

CONCLUSIONS

Patients undergoing cataract surgery under topical anaesthesia experience more postoperative discomfort than patients receiving sub-Tenon's anaesthesia. Surgery-related complications were similar in both groups.

Topical Anesthesia for Penetrating Keratoplasty

PURPOSE

To evaluate the use of topical anesthesia for penetrating keratoplasty (PKP) in situations where retrobulbar, peri/parabulbar, or general anesthesia are inadvisable or not readily available.

METHODS

This was a retrospective analysis of a consecutive case series consisting of 8 eyes in 8 patients who had PKP with topical anesthesia between September 1995 and December 1997 in cases where retrobulbar, peri/parabulbar, or general anesthesia either could not be performed or presented too great a risk to the patient. Some cases were supplemented with small limbal injections, mild intravenous sedation (fentanyl), and/or intraocular anesthesia. In one case, intraocular 1% lidocaine was placed directly into the vitreous cavity to allow an open-sky vitrectomy.

RESULTS

In all cases, PKP was completed without complications. All patients tolerated the procedure well and reported only mild discomfort. However, in 2 cases, an ACIOL was left in place because lens manipulation caused pain in the ciliary body and iris root areas.

CONCLUSIONS

PKP can be performed successfully with topical anesthesia in cooperative patients who have perforated corneal ulcers, significant anticoagulation, or severe medical conditions, which make alternative forms of anesthesia more risky.

Prospective study comparing lidocaine 2% jelly versus sub-Tenon's anaesthesia for trabeculectomy surgery

AIMS

To compare the analgesic properties of lidocaine 2% jelly versus sub-Tenon's anaesthesia with lidocaine 2% without adrenaline (epinephrine) for trabeculectomy surgery.

METHODS

A prospective randomised clinical trial. 59 consecutive patients scheduled for trabeculectomy at the Toronto Western Hospital were randomly assigned to topical unpreserved lidocaine 2% jelly or sub-Tenon's anaesthesia with 2% lidocaine. Both groups received a standardised sedative consisting of midazolam, fentanyl. and/or propofol. The visual analogue scale was utilised to measure intraoperative pain. Patient comfort, physician assessment of intraoperative patient compliance, volume of local anaesthetic used, need for supplemental anaesthesia, and any complications were recorded. The two groups were compared using the Student's t test.

RESULTS

The sub-Tenon's anaesthesia group and the lidocaine 2% jelly group did not vary significantly in subjective pain score (18.3 (SD 16.2) v 19.8 (12.4) respectively, p = 0.739) and surgeons' satisfaction scale (3.6 (0.7) and 3.8 (0.6) respectively, p = 0.328). Four patients required additional anaesthesia, all of them in the sub-Tenon's group.

CONCLUSION

Topical lidocaine 2% jelly is as effective as sub-Tenon's anaesthesia for pain control in patients undergoing trabeculectomy. Lidocaine 2% jelly is similar to sub-Tenon's anaesthesia in patient comfort and surgeon satisfaction.

Comparative clinical trial of topical anesthetic agents in cataract surgery

PURPOSE

To assess the efficacy of lidocaine gel, bupivacaine drops, and benoxinate drops as topical anesthetic agents in cataract surgery.

SETTING

Kasr El-Aini Hospital, Cairo University, Cairo, Egypt.

METHODS

This prospective randomized study comprised 90 patients scheduled for routine cataract extraction. Patients were randomized into 3 groups of 30 each based on which anesthetic agent they received: lidocaine 2% gel, bupivacaine 0.5% drops, or benoxinate 0.4% drops. Subjective pain at application of the agent and intraoperatively was quantified by the patients using a verbal pain score (VPS) scale from 0 to 10. The duration of discomfort at application, duration of surgery, rate of supplemental sub-Tenon's anesthesia, and complications were recorded.

RESULTS

The mean VPS at application was 2.97, 1.53, and 1.03 in the lidocaine, bupivacaine, and benoxinate groups, respectively; the VPS in the lidocaine group was statistically significantly higher than in the other 2 groups (P<.001). The mean duration of pain at application was 25 seconds, 14 seconds, and 6 seconds in the lidocaine, bupivacaine, and benoxinate groups, respectively, and was statistically significantly higher in the lidocaine group (P<.001). The mean VPS during surgery was 1.6, 4.1, and 7.1 in the lidocaine, bupivacaine, and benoxinate groups; the lidocaine group had a statistically significantly lower mean VPS than the other 2 groups (P<.001). The incidence of supplemental sub-Tenon's injection was 3.3%, 10.0%, and 73.3%, respectively, and was statistically significantly lower in the lidocaine and bupivacaine groups than in the benoxinate group (P<.001). The patients' overall satisfaction was statistically significantly higher in the lidocaine and bupivacaine groups than in the benoxinate group (93.3%, 83.3%, and 33.3%, respectively) (P<.001). Three patients in the lidocaine group had corneal haze at the time of surgery, which was not statistically significant (P>.1).

CONCLUSIONS

Lidocaine gel was a better topical anesthetic agent than bupivacaine and benoxinate drops. Bupivacaine drops were effective in providing deep topical anesthesia.

Effect of Single-Dose fentanyl on the cardiorespiratory system in elderly patients undergoing cataract surgery

STUDY OBJECTIVES

To evaluate the effects of fentanyl on the cardiorespiratory system in elderly patients undergoing cataract surgery with phacoemulsification method.

DESIGN

Randomized, prospective, double-blind study.

SETTING

University hospital.

PATIENTS

70 ASA physical status I, II, and III patients (>60 years) who underwent cataract surgery with topical anesthesia.

INTERVENTIONS

Patients were randomly divided into two groups. The fentanyl group (35 patients) received fentanyl in 0.7 microg/kg bolus doses in a 2-mL balanced salt solution prior to surgery. The control group (35 patients) received a 2-mL balanced salt solution without any analgesic drug.

MEASUREMENTS AND MAIN RESULTS

Systolic (SBP), diastolic (DBP), mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation (SpO(2)), respiratory rate (RR), end-tidal carbon dioxide (ETCO(2)), inspired CO(2) concentration, and sedation scores were measured preoperatively and at 5, 10, 15, 20, and 30 minutes intraoperatively. Postoperatively, patients were questioned about the presence of intraoperative pain. In the fentanyl group, no significant differences were observed in SPB, DBP, MAP, RR, or peripheral SpO(2). In the control group, RR was higher than baseline values at 10, 15, and 20 minutes. Diastolic blood pressure was higher than baseline values at 20 minutes. End-tidal CO(2) and inspired CO(2) levels were higher than baseline levels in both groups at all measurement times. Intraoperative ETCO(2) levels were higher in the fentanyl group than the control group (p < 0.01). Finally, no hypoxemia was observed in either group.

CONCLUSION

Fentanyl can be used safely in 0.7-microg/kg dosages in elderly patients to improve patient comfort without any cardiorespiratory side effects, when undergoing cataract surgery with topical anesthesia.

Phacoemulsification with topical anesthesia performed by resident surgeons

PURPOSE

To evaluate and compare the outcomes in phacoemulsification cases performed by resident surgeons using topical anesthesia or retrobulbar anesthesia.

SETTING

Department of Ophthalmology, Emory University, Atlanta, and Department of Veterans Affairs Medical Center, Decatur, Georgia, USA.

METHODS

This was a retrospective review of phacoemulsification cases performed by resident surgeons during 1 academic year. Variables analyzed included patient age and sex, preexisting conditions limiting final acuity, and type of anesthesia used. Outcomes measured included intraoperative and postoperative complications and final visual acuity.

RESULTS

Of the 291 cases analyzed, 119 (40.9%) were retrobulbar and 172 (59.1%) were topical. Residents began using topical anesthesia after a brief introductory period with retrobulbar anesthesia. Vitreous loss occurred in 15 cases (5.1%), 8 retrobulbar (6.7%) and 7 topical (4.1%) (P =.42). Postoperative complications occurred in 30 cases (10.3%), 17 topical (9.9%) and 13 retrobulbar (10.9%) (P =.85). Overall, 245 cases (84.2%) achieved a final best corrected visual acuity (BCVA) of 20/40 or better. When cases with preexisting conditions limiting final acuity were eliminated, 92.1% achieved a final BCVA of 20/40 or better. More topical cases (112, 65.1%) than retrobulbar cases (64, 53.8%) achieved a final BCVA of 20/25 or better (P =.06), and more topical cases (149, 86.6%) than retrobulbar cases (96, 80.7%) achieved a final BCVA of 20/40 or better (P =.19).

CONCLUSION

Topical anesthesia is safe and efficacious for phacoemulsification performed by resident surgeons early in training after a brief introduction to phacoemulsification using retrobulbar anesthesia.

Topical versus peribulbar anaesthesia for cataract surgery

BACKGROUND

To assess and compare the efficacy and safety of topical versus peribulbar anaesthesia in patients undergoing routine cataract surgery.

METHODS

The unicentre, prospective, randomized, clinical interventional trial included 140 consecutive patients undergoing routine cataract surgery performed by one of two surgeons. The patients were randomly distributed to either peribulbar anaesthesia or topical anaesthesia. To assess intraoperative pain, each patient was asked immediately after surgery to quantitate his/her pain using a 10-point pain rating scale.

RESULTS

The study groups did not differ significantly in pain score (p=0.54), duration of surgery (p=0.52), anaesthesia-related intraoperative difficulties (p=0.17), postoperative visual acuity (p=0.94), overall intraoperative surgical complication rate, blood pressure rise (p=0.16) or blood oxygen saturation (p=0.74)

CONCLUSIONS

Patient comfort and surgery-related complications did not differ between topical anaesthesia and peribulbar anaesthesia. As there are no significant differences between the two techniques in terms of subjective pain experienced by patients, intraoperative complications and postoperative visual outcome, and in view of the minimally invasive character of topical anaesthesia compared to peribulbar anaesthesia, the present study suggests the use of topical anaesthesia for routine cataract surgery.

Clorazepate dipotassium versus midazolam for premedication in clear corneal cataract surgery

PURPOSE

To evaluate and compare the efficacy of oral clorazepate dipotassium (Tranxilium) and intravenous midazolam (Dormicum) as premedication agents in retrobulbar anesthesia and clear corneal phacoemulsification with intraocular lens (IOL) implantation.

SETTING

Department of Ophthalmology, University of Essen, Essen, Germany.

METHODS

In a prospective clinical trial, 97 consecutive patients (97 eyes) having phacoemulsification with implantation of a foldable IOL were randomized to 2 groups. The first group received 10 mg oral clorazepate dipotassium and the second group, 1 mg intravenous midazolam. The surgeon's subjective experience of patients' cooperation during retrobulbar anesthesia and after surgery was measured on a 5-point Likert scale. The duration of surgery and rate of complications were documented. One day after surgery, the patients' subjective comfort during cataract surgery was evaluated using a 5-point Likert scale and the best corrected visual acuity was determined.

RESULTS

The level of anterograde amnesia tended to be higher in the midazolam group than in the clorazepate dipotassium group (4% versus 0% for anesthesia administration; 14% versus 4% for surgery), but the difference between groups was not significant. There were no significant differences in patient cooperation or complications during surgery. Patient satisfaction scores were not significantly different between the groups (P<.14); however, patients in the midazolam group expected to have significantly less pain during surgery (P<.04). The rate of potential visual acuity recovery was similar between groups.

CONCLUSIONS

Anterograde amnesia occurred more frequently and patients expected less pain before surgery with midazolam. Both anesthetic agents provided safe and effective premedication for retrobulbar anesthesia in clear corneal cataract surgery.

Aqueous humor levels of topically applied bupivacaine 0.75% in cataract surgery

PURPOSE

To measure the intraocular levels of bupivacaine 0.75% topically applied before phacoemulsification and to develop standards for topical anesthesia in cataract surgery.

SETTING

Department of Ophthalmology, University Hospitals of Leicester, Leicester, United Kingdom.

METHODS

Forty eyes having phacoemulsification for senile cataract under topical anesthesia without sedation were randomly assigned to 1 of 2 preoperative topical anesthesia regimens. Bupivacaine 0.75% was applied in 0.1 mL drops 3 times in the 30 minutes before surgery in 18 eyes and 6 times in the 60 minutes before surgery in 22 eyes. Aqueous humor and serum samples were taken at the start of surgery and the bupivacaine levels measured. A visual analog pain score scale was used to indicate intraoperative pain.

RESULTS

The mean aqueous humor level of bupivacaine was 5.9 microg/mL +/- 4.3 (SD) after 3 drops and 5.7 +/- 4.0 microg /mL after 6 drops. The blood levels were less than 1.0 microg/mL. There was no statistically significant difference in the intraocular level of bupivacaine between the 2 groups. There was no difference in the age or sex distribution between the 2 groups, although there was an increase in the intraocular level of bupivacaine with age (approximately 1.4 microg/mL per decade; P =.048). There was no clear pattern associating the pain score with age, sex, or intraocular level of bupivacaine.

CONCLUSIONS

A 3-drop regimen of bupivacaine 0.75% in the half hour before cataract surgery penetrated the eye as effectively as 6 drops in the 1 hour before surgery and provided good analgesia for phacoemulsification. Bupivacaine 0.75% penetrated the eye increasingly effectively with increasing age.

Combined topical anesthesia and sedation for open-globe injuries in selected patients

PURPOSE

To evaluate the efficacy and safety of topical anesthesia (TA) and IV sedation in surgery for less severe open-globe injury (OGI).

DESIGN

Noncomparative consecutive interventional case series.

PARTICIPANTS

Of 67 OGI cases reviewed at the Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy, in the period from 1999 to 2000, 10 eyes (14.9%) of 10 consecutive patients (age range, 6-58 years) were repaired using TA and IV sedation. All patients belonged to the American Society of Anesthesiologists risk class I or II. Nine eyes had corneoscleral wounds, four had vitreous loss, two had traumatic cataract, and three had an intraocular foreign body (IOFB); one patient had interruption of a continuous penetrating keratoplasty suture. Preoperatively, best-corrected visual acuity (BCVA) ranged from hand movement to 20/20.

INTERVENTION

Corneoscleral suture was performed in nine patients, vitreous excision in four, uveal excision or reposition in four, IOFB removal in three, and cataract extraction in two; corneal button resuture was carried out in one patient. All patients received topical oxybuprocaine hydrochloride 0.4%, and IV propofol, midazolam, and fentanyl for anesthesia.

MAIN OUTCOME MEASURES

The change in BCVA was evaluated. Within 24 hours after surgery, each patient was asked to grade subjective pain and discomfort on a 4-point scale. The surgeon was asked to report difficulties attributable to the operating conditions. Complications related to anesthesia and to surgery were assessed.

RESULTS

Best-corrected visual acuity stabilized or improved in all patients. All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during external bipolar cautery and conjunctival closure. No patient required additional anesthesia. The operating conditions as reported by the surgeons were graded slightly difficult in all cases but one, which was graded moderately difficult. No patient had surgical or anesthesia-related adverse events or life-threatening complications.

CONCLUSIONS

Topical anesthesia and IV sedation are safe and effective and could be a reasonable alternative for less severe OGI. The degree of patient discomfort is only marginal during surgery and postoperatively. However, surgical training and patient preparation are the keys to the safe use of this anesthetic modality.

Phacoemulsification with transpupillary silicone oil removal and lens implantation through a corneal incision using topical anesthesia

PURPOSE

To evaluate phacoemulsification combined with transpupillary silicone oil removal and foldable intraocular lens (IOL) implantation through a single corneal incision and planned posterior capsulorhexis after pars plana vitrectomy using topical anesthesia.

SETTING

Department of Ophthalmology, University of Bari, Bari, Italy.

METHODS

This noncomparative nonrandomized noncontrolled interventional case series comprised 34 consecutive patients (34 eyes). The mean age of the 25 men and 9 women was 54.4 years +/- 13.3 (SD). A mean of 8.2 +/- 9.4 months after silicone oil injection, patients had phacoemulsification with transpupillary silicone oil removal and foldable acrylic IOL implantation through a single corneal incision and a planned posterior capsulorhexis under topical anesthesia. Patients were operated on by the same surgeon. Visual acuity, the frequency of retinal redetachment, secondary cataract and vitreous hemorrhage formation, subjective pain and discomfort, the duration of surgery, and intraocular pressure (IOP) were noted. The mean follow-up was 9.4 +/- 5.1 months (range 4 to 21 months).

RESULTS

Vision improved or stabilized in 88.2% of eyes. Retinal redetachment occurred in 4 eyes (11.8%) and transient vitreous hemorrhage in 1 (2.9%). All patients reported minimal discomfort during the procedure. The mean duration of surgery was 17 +/- 4 minutes. There was no significant intraoperative or postoperative IOP variation.

CONCLUSIONS

Combined phacoemulsification, transpupillary silicone oil removal, and IOL implantation through a single corneal incision under topical anesthesia was safe and effective. In general, the visual outcomes were good with improvement in visual acuity.

Effects of intracameral lidocaine on ocular tissues

PURPOSE

To investigate the ultrastructural changes in iris and corneal tissue induced by intracameral 1% lidocaine infusion applied during lens extraction in a rabbit model.

METHODS

The study was conducted using New Zealand rabbits. Eight rabbits received 0.2 mL 1% lidocaine hydrochloride intracamerally and lens extraction was performed, keeping the posterior capsule intact. After lens extraction, cornea and iris tissue samples were obtained for electron microscopy. Eight eyes were included as a control group.

RESULTS

Electron microscopy revealed morphological abnor-malities in both cornea and iris of the lidocaine injected eyes, different from the control group. Cytoplasmic vacuolization, phagosomes and residual bodies were observed in epithelial cells. Corneal fibroblasts contained fluid-filled vacuoles, which could be due to the influx of water into the cells as a result of corneal endothelial damage. Mitochondrial swelling and residual bodies were also seen in the cytoplasm of fibroblasts. Blood vessels in the iris contained fluid material composed of fibrin and proteinaceous material and many vacuoles showed vascular endothelial injury.

CONCLUSION

Even a short period of exposure of intra-cameral lidocaine to the ocular tissues can induce histo-logical changes that may result in functional defects.

Anaesthesia-related diplopia after cataract surgery

BACKGROUND

We studied the incidence and clinical characteristics of persistent diplopia related to anaesthesia for cataract surgery in a general hospital.

METHODS

This was a retrospective review of anaesthesia for 3587 cataract surgeries. Of all the cases of diplopia referred to the ocular motility clinic after cataract surgery, those involving anaesthesia-related diplopia lasting longer than 1 month were studied.

RESULTS

During the study period, 3450 cataract surgeries were performed by phacoemulsification and 137 by extracapsular extraction. Retrobulbar block was used in 2024 cases, peribulbar block in 98, topical anaesthesia in 1420 and general anaesthesia in 43. Twenty-six cases of persistent diplopia were found (0.72% incidence), nine of which (0.25%) were considered to be related to anaesthetic factors; five of the latter involved the left eye. Five were caused by paresis of the inferior rectus muscle and three by fibrosis. In one patient, the inferior oblique muscle was affected. Anaesthesia was by retrobulbar block in eight cases (0.39%) and by peribulbar block in one. No diplopia was found in patients who had topical or general anaesthesia. Treatment was with surgery in two patients and with prisms in six. One patient continues to be studied.

CONCLUSIONS

Persistent diplopia can occur after cataract surgery using retrobulbar block predominantly through direct damage to the inferior rectus muscle. The overall incidence of anaesthesia-related diplopia in this series was 0.25%.