Ocular perforation during peribulbar anaesthesia

A Comprehensive Meta-Analysis on the Role of Analgesics and Anti-Inflammatories in Pan-Retinal Photocoagulation

PURPOSE

Pan-retinal photocoagulation (PRP) is the mainstay of treatment for proliferative diabetic retinopathy (PDR), reducing the risk of severe vision loss. Pain poses a potential obstacle to effective laser delivery and patient compliance. Therefore, implementing pain relief strategies can enhance both treatment efficacy and patient comfort.

DESIGN

A systematic review and meta-analysis.

METHODS

We conducted a systematic review and meta-analysis according to PRISMA guidelines. The PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that enrolled patients undergoing PRP due to DR and compared analgesics or non-steroidal anti-inflammatory drugs (NSAID) to placebo. Pain was evaluated with the visual analogue scale. The version 2 of the Cochrane Collaboration's Risk of Bias in Randomized Controlled Trials tool and its version for crossover trials were used to assess the risk of bias. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used to measure the certainty of evidence.

RESULTS

A total of 13 studies were included, comprising 1404 eyes from RCTs, nine of which were crossover. Patients who were administered analgesia reported a significantly lower pain sensitivity compared to those who received placebo (Standardized mean difference [SMD] -0.38; 95% confidence interval [CI] -0.58, -0.17; P < .01; I2 = 69%). Subgroup analysis of systemic administration of analgesics/NSAIDs (metamizole, Entonox, acetaminophen, ibuprofen, caffeine, mefenamic acid, intramuscular ketorolac tromethamine, and potassium diclofenac) also showed a statistically significant reduction in pain when compared to placebo (SMD -0.28; 95% CI -0.50, -0.07; P < .01; I2 = 43%). Exclusive eye drops administration (ketorolac tromethamine 0.5% and sodium diclofenac 0.1%) also showed a significant difference in pain sensitivity (SMD -0.46; 95% CI -0.88, -0.05; I2 = 83%), however with a more significant heterogeneity.

CONCLUSIONS

The results of this meta-analysis including over 1000 patients demonstrated that the use of analgesics significantly reduced pain sensitivity during PRP, and systemic analgesia is potentially better than topical administration when compared to placebo.

Efficacy and safety of trans-sub-Tenon's retrobulbar anesthesia for pars plana vitrectomy: a randomized trial

AIM

To compare the efficacy and safety of trans-sub-Tenon's ciliary nerve block anesthesia and transcutaneous retrobulbar anesthesia in patients undergoing pars plana vitrectomy (PPV).

METHODS

A prospective, randomized, double-blinded clinical trial was conducted at Zhongda Hospital, Affiliated with Southeast University, from February 2021 to October 2021. Patients undergoing PPV were randomly allocated into two groups: the trans-sub-Tenon's anesthesia group (ST group) and the retrobulbar anesthesia group (RB group) in the ratio of 1:1. The ST group received 2 ml ropivacaine through the Tenon capsule to the retrobulbar space, while the RB group received 2 ml ropivacaine via transcutaneous retrobulbar injection. Visual analog score (VAS) was used to evaluate pain during the whole process, including during anesthesia implementation, intraoperatively and on the first day after the operation. Movement evaluation (Brahma scores) and anesthesia-related complications were also noted.

RESULTS

Finally, a total of 120 patients were included in the study (60 in the ST group and 60 in the RB group). There were no significant differences in baseline patient characteristics or surgical features between the two groups. The VAS pain scores for anesthesia implementation were 0.52 ± 0.47 in the ST group and 1.83 ± 0.87 in the RB group (P < 0.001). The VAS scores during the operation were 0.53 ± 0.49 in the ST group and 1.48 ± 1.02 in the RB group (P < 0.001) and those on the first day after the operation were 0.37 ± 0.38 in the ST group and 0.81 ± 0.80 in the RB group (P = 0.002). No patients required supplemental intravenous anesthesia intraoperatively. The Brahma movement scores were 0.70 ± 1.64 in the ST group (scores ranging from 0 to 8) and 2.38 ± 3.15 in the RB group (ranging from 0 to 12) (P = 0.001). Forty-two patients in each group received laser photocoagulation during surgery. Fifteen patients (36%) in the ST group could not see the flashes of the laser, compared to 8 patients (19%) in the RB group (P = 0.087). No serious sight-threatening or life-threatening complications related to anesthesia were observed in either group.

CONCLUSIONS

For PPV, trans-sub-Tenon's ciliary nerve block anesthesia was more effective in controlling pain than transcutaneous retrobulbar anesthesia during the whole surgery process, including during anesthesia implementation, intraoperatively and on the first day after the operation. Additionally, it could achieve better effect of akinesia and was relatively safe. Trans-sub-Tenon's anesthesia could be considered an alternative form of local anesthesia during vitreoretinal procedures.

TRIAL REGISTRATION

The study protocol has been registered at ChiCTR.org.cn on February 2021 under the number ChiCTR2100043109 .

Bupivacaine-lidocaine versus Ropivacaine-lidocaine Retrobulbar Anesthesia in Vitreoretinal Surgery

Purpose: To compare efficacies of bupivacaine-lidocaine and ropivacaine-lidocaine mixtures in terms of inducing retrobulbar anesthesia during vitrectomy.Methods: Sixty patients who underwent retrobulbar anesthesia during vitrectomy were divided into two groups. Patients in group 1 received a mixture of bupivacaine and lidocaine (n = 30); patients in group 2 received a mixture of ropivacaine and lidocaine (n = 30). The effects of the two combinations were retrospectively compared and analyzed. The onset times of analgesia and akinesia were measured. Two hours after surgery, sensory blockade was assessed by touching the corneas with cotton swabs and by communicating with patients. Ocular movement was evaluated in four gaze direction quadrants. A 10-point visual analog pain scale was used to assess pain during and 2 hours after surgery. Intra- and postoperative complications were recorded.Results: The mean analgesia onset times in groups 1 and 2 were 94.62 ± 28.87 and 92.32 ± 35.53 seconds, respectively (p = 0.071); the mean akinesia onset times were 147.89 ± 59.35 and 132.57 ± 76.38 seconds (p = 0.223), respectively. Patients in group 2 reported significantly less postoperative pain and exhibited less postoperative ocular movement, compared with patients in group 1 (both p = 0.002). One patient in group 1 experienced respiratory depression after retrobulbar blockade.Conclusions: When retrobulbar anesthesia is required during vitrectomy, a ropivacaine-lidocaine mixture and a bupivacaine-lidocaine mixture induce anesthesia with similar rapidity. However, the ropivacaine-lidocaine mixture is safer and affords better-quality intra- and postoperative anesthesia.

Clinical presentation and management of eyes with globe perforation during peribulbar and retrobulbar anesthesia: A retrospective case series

Aim

To evaluate the clinical presentation, management, and outcome of eyes with an inadvertent globe perforation during peribulbar or retrobulbar block.

Methods

This retrospective study evaluated the eyes which had an accidental globe perforation during local ocular anesthesia from 2012 to 2020. The patients were divided into three groups; Group 1: Clear media with no rhegmatogenous retinal detachment (RRD); Group 2: significant vitreous hemorrhage (VH) precluding the retinal view without RRD; and Group 3: RRD with/without VH.

Results

Twenty-five patients (25 eyes) were included in the study. The mean axial length (AL) was 24.7±2.7mm (Range, 20.9-31.2mm). Eleven eyes (45.8%) had an AL≥24mm. The most common presenting features were VH (n=14), hypotony (n=7), and RRD (n=7). The treatment included retinal laser barrage (n=7) and vitrectomy (n=17). Retinal breaks were identified in all the eyes (total breaks=37). Other complications included full-thickness macular hole (n=5), subretinal hemorrhage (n=4), and retinal vascular occlusion (n=4). The mean presenting best-corrected visual acuity (BCVA) in groups 1,2 and 3 were logMAR 0.79±0.73, 1.82±0.78, and 2.13±0.59 respectively. All the patients, except the one who did not undergo surgery, had an attached retina at the time of the last follow-up. The mean final BCVA for each group was logMAR 0.59±0.79, 0.48±0.26, and 1.25±0.64 respectively (p=0.006). The development of RRD was associated with a larger AL (p=0.015); while the development of significant VH precluding the retinal view was associated with the superior location of the perforation (p=0.015), late recognition of the perforation (p=0.004), and multiple perforations (p=0.015).

Conclusion

Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer AL, superior, and multiple perforations are at higher risk of developing complications like RRD and VH. Complications like RRD, macular injury, and vascular occlusion are risk factors for poor prognosis.

Pain during pars plana vitrectomy following sub-Tenon versus peribulbar anesthesia: A randomized trial

Purpose

To compare pain during pars plana vitrectomy (PPV) following topical lidocaine jelly and sub-Tenon anesthesia versus peribulbar anesthesia.

Methods

Prospective, single-center, randomized study. Patients scheduled for PPV for macular hole (MH) or epiretinal membrane (ERM) at the Retina and Vitreous Section of the Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo were randomly assigned to one of two groups in a 1:1 allocation ratio. Patients assigned to Group ST received topical anesthesia with 2% lidocaine jelly followed by sub-Tenon anesthesia with 2–4 ml of 1% ropivacaine. Patients assigned to PB received peribulbar anesthesia with 4–6 ml of 1% ropivacaine. After PPV, patients in both groups were asked to rate the level of pain they felt during the entire procedure (including anesthesia administration and PPV) by pointing at a 0–100 Visual Analogue Pain Scale (VAS). Data regarding demographics, patient characteristics and surgical features were also collected.

Results

Fifty-four patients were enrolled in the study (26 in Group ST and 28 in Group PB). Baseline characteristics, including age, gender, and presence of comorbidities, were similar in both groups. The surgery performed was PPV alone in 10 and 14 patients in the ST and PB groups, respectively, and combined phacoemulsification and PPV in 16 and 14 patients in the ST and PB groups, respectively (p = 0.39, Pearson). Surgery duration (mean ± SD minutes) was similar in the two groups (62 ± 12 for ST and 70 ± 20 for PB, p = 0.09, t-Test). No patients needed supplemental topical or intravenous anesthesia during surgery. No sight- or life-threatening complication was observed in either group. VAS score was significantly lower in the ST compared to the PB group (median (interquartile range) was 1 (2.25–0) in the ST group compared to 11.5 (29.75–5) in the PB group, p< 0.0001, Wilcoxon).

Conclusion

In this study of patients who underwent PPV for MH or ERM, topical followed by sub-Tenon anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia. Compared to peribulbar anesthesia which is administered with a sharp needle, sub-Tenon anesthesia administered with a blunt cannula may be associated with a reduced risk of such adverse events as globe perforation, retrobulbar hemorrhage, and inadvertent injection of anesthesia into the optic nerve sheath.

Comparison of Peribulbar with Posterior Sub-Tenon's Anesthesia in Cataract Surgery Among Nigerians

Purpose:

To compare the akinetic and the analgesic effects of peribulbar and posterior sub-Tenon's anesthesia in patients undergoing cataract surgery.

Methods:

In a hospital-based randomized comparative interventional study, patients aged 50 years and above who underwent elective surgery for uncomplicated cataract were randomized to receive either peribulbar block or posterior sub-Tenon block. Pain during injection, surgery, and after surgery was assessed using numerical reporting scale (NRS). Limbal excursion was measured with a transparent meter rule.

Result:

A total of 152 eyes of 152 patients were studied. Peribulbar and sub-Tenon regional blocks provided comparable adequate akinesia (P = 0.06) and similar levels of analgesia (P = 0.10) during cataract surgery. Both techniques also provided similar levels of analgesia to the patient during injection and in the immediate postoperative period. Ninety-two percent of patients who had peribulbar and 97% of those who had sub-Tenon blocks reported either mild pain or no pain at all during surgery (P = 0.49). There was no report of severe pain in all patients during the stages of the surgery. Occurrence of chemosis and subconjunctival hemorrhage was more common in sub-Tenon than peribulbar anesthesia.

Conclusions:

This study shows that peribulbar and posterior sub-Tenon routes of administering anesthetic substances is comparable in providing adequate akinesia and analgesia for cataract surgery with minimal complications. Therefore, both techniques are effective and safe for cataract surgery among Nigerians.

Management of retinal detachment in block related globe perforation with pneumatic retinopexy

Retinal detachment after ocular perforation related to local anesthesia is a common complication, which is usually associated with a poor prognosis despite complex vitreoretinal surgical procedures. We report a case of 62-year-old male with cataract surgery done 4 weeks back with nasal retinal detachment with a posterior break. Pneumatic retinopexy was performed and laser barrage of the breaks was done the next day when the retina got attached. A vision of 20/30 was achieved at the end of 2 months. To the best of our knowledge, this is a first case report in literature where pneumatic retinopexy was used to manage a retinal detachment caused by block-related perforation.

Sub-Tenon's anaesthesia: complications and their prevention

The advent of a new technique that is considered much safer than previously established one leads to its rapid adoption. This usually leads to the identification of previously unreported complications of the new technique, and a re-assessment of its position in clinical care, which is precisely the state of play with the sub-Tenon's block. The sub-Tenon's block was introduced into the clinical practice in early 1990. A systematic recent search of subject headings such as complications of sub-Tenon's block, subtenon, orbital block, orbital block complications, and orbital anaesthesia was performed in Medline, EMBASE, and Cochrane database. Indeed there are complications of sub-Tenon's block published as case reports and the exact incidence of these complications is not known. Management and preventive measures of these complications are described. Although the sub-Tenon's block appears to be relatively safer than needle-based blocks but a proper prospective, randomized, double-blind controlled trial is essential for scientific proof that sub-Tenon's block is better than needle-based blocks.

[Retinal detachment caused by ocular perforation during periocular anesthesia: three case reports]

INTRODUCTION

Local anesthesia for eye surgery was first described in 1884; later Knapp popularized retrobulbar anesthesia. To reduce risks, peribulbar anesthesia appeared in the 1970s. Still used today, periocular anesthesia is not without complications, in particular the risk of ocular perforation.

PATIENTS AND METHODS

Three patients were referred to our department for diagnosis and treatment of an intravitreous hemorrhage following cataract surgery. We report the clinical features, treatment, and visual outcome for these three patients.

RESULTS

The most common presentation was vitreous hemorrhage: the three eyes were found to have associated retinal detachment on initial assessment. One patient presented severe vitreoretinal proliferation with two postoperative recurrences; the globe was finally enucleated. The two other patients presented attached retina after surgery but had achieved very poor visual recovery.

CONCLUSION

Inadvertent globe perforation during local ocular anesthesia is rare. Careful attention to risk factors, early recognition, and prompt referral for management are recommended to improve the visual prognosis. Surgical management must be adapted to the severity of the perforation (vitreous hemorrhage, retinal detachment, vitreoretinal proliferation). The problems treating these patients with severe, often recurrent, retinal detachment, with poor visual prognosis, in a tricky forensic context should be emphasized.

Vitreous haemorrhage in elderly patients: management and prevention

Vitreous haemorrhage can be caused by a disruption of normal retinal vessels, bleeding from diseased retinal vessels, bleeding from abnormal new vessels or extension of haemorrhage through the retina from other sources. In the elderly, vitreous haemorrhage usually occurs spontaneously and only occurs occasionally as a result of trauma. Appropriate management of vitreous haemorrhage is dependent on the most likely cause in a particular patient. As always, an accurate medical history with a careful clinical examination, static and dynamic ultrasonography performed by an experienced examiner, results of other laboratory tests and an understanding of the common causes of vitreous haemorrhage in each age group is essential to come to a 'best guess' diagnosis as to the cause of the vitreous haemorrhage and thus guide the physician toward the appropriate management. Immediate surgical removal of blood if indicated, as well as improving the vision gives the added benefit of allowing a full examination of the underlying retina. For those in whom surgical removal of blood is not recommended, a careful and frequent follow-up with serial B-scan ultrasound allows the 'best guess' diagnosis to be confirmed at each visit, until such time as the vitreous haemorrhage resolves sufficiently to allow a full and proper examination of the retina. Where there is a confirmed retinal tear, retinal detachment or other fundal pathology these are treated appropriately with laser or surgery (vitrectomy). Preventative measures are dependent on the underlying cause of vitreous haemorrhage. Some of the underlying causes such as posterior vitreous detachment cannot be prevented. In others, such as retinal vein occlusion, measures may need to be taken so as to reduce the risk of a similar event in the same or fellow eye and to reduce the risk of potentially life-threatening associated systemic conditions such as a stroke or myocardial infarction.

Consequence of perforation during peribulbar anesthesia in an only eye

A patient with a blind fellow eye had cataract surgery in the right eye; anesthesia comprised an intraocular injection of lidocaine and bupivacaine. Forty-eight hours after surgery, visual acuity in the right eye was light perception (LP). Three days later, fundus examination showed inferotemporal hemorrhage, retinal whitening consistent with needle tracking, and a diffusely pale optic disc in the operated eye. Computed tomography showed an intact optic nerve in both eyes and high-density vitreal lesions in the right eye. Laser photocoagulation was applied to the retinal break. We believe that a jet stream of anesthetic agent may have transiently increased intraocular volume enough to occlude the central retinal artery. Although the retina remained attached, visual acuity failed to improve beyond LP.

Entonox as an analgesic agent during panretinal photocoagulation

BACKGROUND/AIMS

Panretinal photocoagulation (PRP) reduces the risk of visual loss in proliferative diabetic retinopathy but some patients cannot tolerate PRP because of pain. Inhaled Entonox was evaluated as an analgesic during PRP.

METHODS

A randomised, crossover, double masked pilot study was performed. Patients inhaled either air or Entonox and half the PRP was applied. The treatment was completed with the alternate inhaled gas. Patients graded pain experienced during both stages of the treatment using a visual analogue scale. Pain scores were compared using a paired t test.

RESULTS

20 patients participated. Mean pain scores from the Entonox and air treatments were 2.94 (SD 2.73) versus 3.73 (SD 3.20) respectively (p<0.03).

CONCLUSION

Entonox can be used as a safe and effective analgesic agent during PRP treatment.

A single-centre study of 1000 consecutive peribulbar blocks

PURPOSE

To assess the efficacy and safety of the peribulbar block as practised by anaesthetists in a District General Hospital and also to assess the effect of using the 'painless local' subconjunctival injection on the pain of the peribulbar block.

METHOD

Audit data collected from 1000 consecutive patients undergoing peribulbar blocks with 2% lignocaine were analysed. Efficacy was assessed by visual rating scores for operative pain, eye movement, intraocular pressure and reinjection rate, and safety by looking at complications. Comparison of pain of injection scores was used to assess the effect of the 'painless local' injection. Visual rating scores for pain were analysed using the Mann-Whitney U-test.

RESULTS

Akinesia was achieved in 79% of blocks and operative pain scores were very low (median = 0, IQR = 0). All complications recorded were minor and there were no sight- or life-threatening events. The 'painless local' injection given to 499 patients resulted in significantly lower visual rating scores for pain of injection (p<0.05).

CONCLUSION

These data suggest that the peribulbar block is a safe and effective method of providing anaesthesia for eye surgery provided that it is taught methodically and practised by experienced staff. The 'painless local' injection reduces the pain experienced during administration of this block.

Scleral perforation during retrobulbar and peribulbar anesthesia: risk factors and outcome in 50,000 consecutive injections

PURPOSE

To measure the frequency of scleral perforation and identify related risk factors during local anesthetic injection for intraocular surgery.

SETTING

Multispecialty eye hospital.

METHODS

All patients (n = 50,000) having retrobulbar (26,857) or peribulbar (23,143) injections at the King Khaled Eye Specialist Hospital were reviewed. Cases of scleral perforation were analyzed for potential technical and ophthalmic risk factors, management of injuries, and visual and anatomic outcomes. Mean follow-up was 14.4 months (range 8 to 24 months).

RESULTS

Seven (0.014%) needlestick injuries were identified, all of which had posterior staphyloma as the only identifiable risk factor. Applying a previously measured prevalence of 10.7% for posterior staphyloma in our surgery patients gave a scleral perforation rate of 0.13% (7 of 5350) for staphylomatous eyes. All perforated globes had originally planned cataract extraction within 8 weeks of injury. Additional management consisted of observation (2 cases), cryotherapy (2 cases), and vitreoretinal procedures for retinal detachment (3 cases) and subretinal hemorrhage (1 case). At last follow-up, all retinas were attached and 3 cases (42.8%) had a visual acuity of worse than 20/160. Both cases requiring multiple retinal detachment surgeries developed proliferative vitreoretinopathy and poor visual acuity.

CONCLUSIONS

Eyes with posterior staphyloma sustained needlestick injuries at a rate of 1 in 760 compared with 0 injection perforations in more than 44,000 nonstaphylomatous eyes.

Comparison of 0.75% levobupivacaine with 0.75% racemic bupivacaine for peribulbar anaesthesia

In a single centre, randomised, double-blind study 50 patients scheduled for intra-ocular surgery received 0.75% levobupivacaine or 0.75% racemic bupivacaine for peribulbar anaesthesia. There were no significant differences in the mean (SD) volume of levobupivacaine (11 (2.7) ml) or racemic bupivacaine (10 (2.6) ml) required, time to satisfactory block (levobupivacaine-13 (5.6) min; racemic bupivacaine-11 (4.4) min), peri-operative pain scores or frequency of adverse events between levobupivacaine and racemic bupivacaine. The safer side-effect profile of levobupivacaine may offer significant advantages in the elderly population undergoing cataract extraction in whom intercurrent disease is common.

A survey of ocular perforation during ophthalmic local anaesthesia in the United Kingdom

A survey of local anaesthetic related ocular perforation in the United Kingdom is reported. A total of 531 consultant ophthalmologists were sent a postal questionnaire and there was a 71% response rate. Thirty respondents reported 39 perforations occurring under their care during the previous year. Details of the cases are presented. The rate of local anaesthetic related ocular perforation is higher than in previous reported series. Efforts to reduce the incidence will require consideration of alternative techniques, audit, and training.