Anesthesia modalities for cataract surgery

User Friendliness and Perioperative Guidance Benefits of a Cataract Surgery Education App: Randomized Controlled Trial

BACKGROUND

Cataract surgeries are among the most performed surgeries worldwide. A thorough patient education is essential to inform patients about the perioperative process and postoperative target results concerning the intraocular lens and objectives for visual outcomes. However, addressing all relevant aspects and questions is time-consuming. Mobile apps can facilitate this process for both patients and physicians and thus be beneficial. However, the success of such an app depends on its user friendliness and acceptance by patients.

OBJECTIVE

This study aimed to evaluate the user friendliness and acceptance of a cataract surgery education app on mobile devices among patients undergoing cataract surgery, the characteristics of patients who benefit the most from app use, and the influence of the app on patient satisfaction with treatment.

METHODS

All patients who underwent cataract surgery at an ophthalmological practice from August 2020 to July 2021 were invited to participate in this randomized controlled trial. Out of 493 invited patients, 297 (60.2%) were enrolled in this study. Patients were randomized into 3 different groups. Half of the patients were offered to participate in Group 1 with use of the "Patient Journey" app. However, if they decided not to use the app, they were included in Group 2 (app denial). The other half of the patients were included in Group 3 (control) with no use of the app and with information provided conventionally. The app provided general information on the ophthalmological center, surgeons, cataract, and treatment options. Different questionnaires were used in all 3 groups to evaluate satisfaction with the perioperative process. Group 1 evaluated the app. Demographic characteristics, such as age, gender, and educational degree, were assessed.

RESULTS

Group 1 included 77 patients (median age 69 years). Group 2 included 61 patients, and their median age was higher (median age 79 years). Group 3 included 159 patients (median age 74 years). There was no difference in satisfaction with the perioperative process and clinic between the 3 groups. Almost all app users appreciated the digital details provided for the organization and the information on the surgery. Age did not play a major role in appreciation of the app. Female patients tended to appreciate the information provided more than male patients. Patients who did not have a higher university degree experienced more benefits from the informational content of the app and were the most satisfied with the information. However, male patients and academics were in general more aware of technology and handled the app more easily.

CONCLUSIONS

The app showed high user friendliness and acceptance, and could particularly benefit specific patient groups. App users demonstrated a noninferior high satisfaction with the treatment in the ophthalmological center in comparison with patients who were informed about the surgery only conventionally.

Preferred Surgical and Anesthesia Techniques for Cataract Surgery in Jordan

Purpose

To study the current practices in Jordan regarding cataract surgical procedures and anesthesia trends for cataract surgery.

Methods

A cross-sectional survey of members of the Jordanian Ophthalmology Society was conducted in October 2020. The questionnaire included questions about participants' demographics, the preferred surgical techniques for cataracts, the preferred anesthesia technique for cataract surgery, the factors which affect the choice of anesthesia technique, the use of sedation, who gives the anesthesia, if there is an anesthesia-trained person who observes the patient during cataract surgery, and the changing trends towards anesthesia between the surgeons.

Results

More than half of the respondents (59.1%) had been in practice for more than 5 years. The preferred method for routine cataract was phacoemulsification for most participants (98.4%). For mature cataract, phacoemulsification was the preferred method for 61.4% of participants. More than half (55.1%) used topical with intracameral anesthesia for phacoemulsification. Two thirds of the participants (66.3%) performed retrobulbar anesthesia for extracapsular cataract surgery. In the majority of cases (86.6%), the respondent themself is the one who administers the anesthesia. No sedation was used before surgery in 62.6% of cases. Two thirds of the respondents (70.1%) reported that they had an anesthesia-trained person monitoring the patient during surgery. Patient cooperation was the most important factor (70.9%) affecting the surgeon's choice of anesthesia technique followed by surgeon skill and experience (57.5%).

Conclusion

Presently, phacoemulsification is the preferred surgical technique for cataract in Jordan. Topical with intracameral anesthesia is the most common anesthesia for phacoemulsification while retrobulbar anesthesia is the most common for extracapsular cataract extraction.

Safety and efficacy of fentanyl versus pethidine in cataract surgery under propofol- based sedation: A double-blind randomized controlled clinical trial

Background:

The study was aimed to evaluate the safety and efficacy of fentanyl and pethidine on the sedative quality of patients who underwent phacoemulsification cataract surgery with Propofol.

Materials and Methods:

In this double-blind randomized controlled clinical trial, patients who were candidates for elective phacoemulsification surgery with topical anesthesia were enrolled. The selected patients were randomly allocated into the two groups for receiving sedation with Propofol-Pethidine (PP) or propofol-fentanyl (PF) combinations. Demographic characteristics, hemodynamic parameters before, during, and after the operation, sedation and pain scores, and patients' and surgeons' satisfaction scores were compared in the two studied groups.

Results:

In this trial, 70 patients (35 patients in each group) have completed the study. Mean (standard deviation) operation time was 22.9 (6.8) and 25.46 (7.7) minutes in PF and PP groups (P = 0.118).Mean pain score in PF 0.46 (0.14) was significantly higher than PP groups 0.236 (0.06) (P = 0.011). The mean value of diastolic and systolic blood pressures, pulse rate, and mean arterial pressure dioxide were significantly decreased in both PF and PP groups (P_Time < 0.001), although there was no significant difference between groups.

Conclusion:

Our findings indicated the equivalence effects on hemodynamic parameters for both pethidine and fentanyl in combination with propofol in which they could provide appropriate sedation and safe anesthesia with lower complications and acceptable patients' and surgeons' satisfaction.

A Comparison of Retrobulbar Versus Topical Anesthesia in Trabeculectomy and Aqueous Shunt Surgery

PURPOSE

The purpose of this study was to compare the required supplemental anesthesia and postoperative patient pain score in individuals undergoing glaucoma surgery under topical anesthesia (TA) versus retrobulbar anesthesia (RB).

MATERIALS AND METHODS

A retrospective, interventional, comparative cohort study of 261 eyes of 225 patients undergoing glaucoma and combined glaucoma with cataract surgery were included in the study. The main outcome measures were the amount of supplemental, systemic intraoperative anesthesia used and the postoperative pain scale between patients undergoing TA versus RB anesthesia. A secondary analysis was performed between combined glaucoma and cataract surgery versus glaucoma surgery alone.

RESULTS

About 6.2% patients complained of pain after glaucoma surgery (8.1% among TA group and 3.1% among RB group; P=0.049). Overall, pain tended to be mild with a mean score of 0.32 of 10 for TA and 0.08 of 10 for RB (P=0.027). The amount of IV anesthetics used intraoperatively was lower in the RB anesthesia compared with the TA group (midazolam, P=0.042; fentanyl, P<0.001; propofol, P<0.001). In addition, patients undergoing RB anesthesia were less likely to use postoperative pain medication (P<0.001). There was no difference in pain score (P=0.707) or in the amount of IV anesthetics (all P>0.350) between eyes undergoing combined versus glaucoma surgery alone.

CONCLUSIONS

Although supplemental anesthesia and pain scores were statistically increased in the topical group, the prevalence and the severity of pain was low. Therefore, TA is feasible and a reasonable option for glaucoma surgery. Furthermore, this conclusion applies when glaucoma surgery is performed alone or in combination with the other eye surgery.

Does phacoemulsification under topical anesthesia affect retrobulbar blood flow?

PURPOSE

To investigate with color Doppler imaging the effects of phacoemulsification surgery under topical anesthesia on retrobulbar vessels hemodynamics.

METHODS

In this prospective study, color Doppler imaging was used to measure the maximum (Vmax) and minimum flow velocity (Vmin) of the central retinal vein, and the Vmax and Vmin, pulsatility index and resistance index of the central retinal artery, nasal, and temporal posterior ciliary arteries, and ophthalmic artery blood flow before and 1 day after phacoemulsification surgery under topical anesthesia.

RESULTS

After phacoemulsification surgery under topical anesthesia, Vmin of the central retinal artery increased (p ≤ 0.05), whereas the other variables showed no significant change.

CONCLUSIONS

Phacoemulsification surgery under topical anesthesia has a minor effect on retrobulbar blood flow. Therefore topical anesthesia should be suitable for patients with ocular perfusion disorders (eg, glaucoma).

Anesthesiologist intervention during cataract surgery under topical or peribulbar anesthesia: a propensity model comparison

PURPOSE

To compare the incidence and type of anesthesiologist intervention during cataract surgery under peribulbar (PA) or topical (TLA) anesthesia in a day-surgery monitored anesthesia care setting (monitoring provided by nurses with the anesthesiologist available on an on-call basis).

METHODS

From a prospective database of all phacoemulsifications performed in our hospital (January 2008-January 2009), 97 patients submitted to cataract surgery under PA were matched with 97 patients submitted to the same surgery under TA by a propensity model. The resulting groups were homogeneous as to history of antihypertensive therapy administered on the day of surgery and not administered on the day of surgery, cardiologic history, neurologic history, psychiatric history, anxiolytic assumption, and history of diabetes mellitus. We compared the incidence of intervention of the anesthesiologist between groups and the type of adverse event triggering such interventions.

RESULTS

The anesthesiologist was called in 37(38.14%) cases in the PA group and in 27 (27.84%) cases in the TA group (37 [38.14%]) (p = 0.123). Only the occurrence of agitation differed significantly between groups (9 [9.28%] patients in the TA group vs 24 [24.74%] patients in the PA group; p = 0.004).

CONCLUSIONS

Monitored anesthesia care is feasible for cataract surgery both under PA or TA. PA still remains an appealing alternative to TA during cataract surgery for patients incapable of keeping the operating eye in the primary position or with incoercible blinking, photophobia, or phacodonesis. A greater incidence of agitation is to be expected and adequate premedication with anxiolytics should be considered if PA is chosen.

Tetracaine 0.5% eyedrops with or without lidocaine 2% gel in topical anesthesia for cataract surgery

Background and objective:

To evaluate the level of pain during phacoemulsification and foldable intraocular lens implantation under instillation of tetracaine 0.5% eyedrops versus a combination of lidocaine 2% gel and instillation of tetracaine eyedrops.

Methods:

This prospective, randomized, controlled study included 51 patients undergoing phacoemulsification under topical anesthesia. They were randomized into two groups based on the topical anesthetic method they were to receive. Preoperatively all patients were asked to answer a questionnaire. One hour postoperatively, they were asked to grade their intraoperative and postoperative pain on a visual analog scale from 0 to 10.

Results:

There were no statistically significant differences between the two methods of anesthesia. Gender and the presence of relatives or friends were independent factors playing a significant role in pain sensitivity.

Conclusions:

The combination of lidocaine 2% gel and tetracaine eyedrops does not have a better analgesic result than a single instillation of tetracaine 0.5% eyedrops.

Combination auriculopalpebral nerve block and local anesthesia for placement of a nictitating membrane-to-superotemporal bulbar conjunctiva flap in dogs

The purpose of this study was to evaluate the efficacy of combined local anesthesia in dogs undergoing nictitating membrane (NM)-to-superotemporal bulbar conjunctiva flap construction. Medical records of 47 dogs that had received local anesthesia for NM-to-superotemporal bulbar conjunctiva flap were reviewed. Combined local anesthetic technique included auriculopalpebral nerve block, topical anesthesia of the eye, and infiltration anesthesia of the superotemporal bulbar conjunctiva and palpebral surface of the NM. Forty-two (89.3%) dogs complied with the anesthetic procedures and underwent NM flap without general anesthesia or sedation. No complications were related to the combined local anesthesia. Combined local anesthesia for NM-to-superotemporal bulbar conjunctiva flap may be a time- and cost-effective method that produces both analgesia of the surgical site and akinesia of the eyelid.

"Instant vision" compared with postoperative patching: clinical evaluation and patient satisfaction after bilateral cataract surgery

PURPOSE

To compare two methods of postoperative dressing regimen: patching vs "instant vision" without patch.

DESIGN

Prospective randomized clinical trial.

METHODS

Sixty consecutive hospitalized, nonambulatory patients with cataract surgery under topical anesthesia on both eyes at different days were enrolled prospectively. In randomized order, one eye was patched for the first 24 hours postoperatively; the other eye was left open without patch to obtain "instant vision." Both eyes received the same anti-inflammatory and antibiotic drop therapy.

RESULTS

Twenty-four hours postoperatively, no significant differences between patching and "instant vision" could be found for corrected and uncorrected visual acuity, corneal epithelial defects, conjunctival inflammation, anterior chamber flare, and intraocular pressure (P > .05). During the first 24 hours postoperatively, all tear film parameters were significantly worse in the "instant vision" eyes (P < .001), indicating a transient tear film instability. During the first four hours after cataract surgery, pain scores in the "instant vision" eyes were significantly higher than in the patched eyes (P < .001). Eight hours postoperatively and later, there were no significant differences in any pain scores (P > .05). After experiencing both methods, 27% of the patients subjectively rated the two methods as equivalent; 8% of the patients preferred "instant vision." Despite of the benefits of immediately improved orientation, 65% of the tested patients preferred patching to "instant vision" because of lower pain and foreign body sensations and psychologic arguments.

CONCLUSIONS

The clinical examinations showed that both methods were equally safe for postoperative therapy. However, further efforts have to be made to increase the patients' comfort with "instant vision" in the first hours after cataract surgery.

Phacoemulsification with topical anesthesia: Resident experience

PURPOSE

To compare the intraoperative and postoperative complications and outcomes of phacoemulsification performed by residents using topical and retrobulbar anesthesia.

SETTING

Two university ophthalmology departments.

METHODS

One hundred fifty phacoemulsification procedures were performed by 3 residents who used retrobulbar anesthesia (retrobulbar group), and 146 phacoemulsification procedures were performed by another 3 residents who used topical anesthesia and who had no experience with retrobulbar or peribulbar anesthesia (topical group). Case notes were prospectively compared. The data analyzed included the ocular history, intraoperative and postoperative complications, and final best spectacle-corrected visual acuity (BSCVA).

RESULTS

There were no differences between the 2 groups in complication rates. Anterior capsule tears occurred in 8 eyes (5.3%) in the retrobulbar group and 7 eyes (4.7%) in topical group. Capsulorhexis was continuous but not curvilinear in 14 eyes (9.3%) and 12 eyes (8.2%), respectively. Capsulorhexis tear or posterior capsule rupture that necessitated conversion to extracapsular cataract extraction occurred in 3 eyes (2.0%) in the retrobulbar group and in 1 eye (0.6%) in the topical group. Posterior capsule rupture with vitreous loss occurred in 10 eyes (6.6%) and 9 eyes (6.1%), respectively. Loss of lens fragments in the vitreous cavity occurred in 3 eyes (2.0%) and 4 eyes (2.7%), respectively. The 63 postoperative complications (41 eyes [27.3%], retrobulbar group; 22 eyes [15.0%], topical group) included cystoid macular edema, intraocular lens decentration, endophthalmitis, bullous keratopathy, transient intraocular pressure elevation, temporary corneal edema, and vitreous hemorrhage. Some cases had more than 1 complication. The BSCVA, including in eyes with preexisting ocular pathology, was 20/40 or better in 86.7% in the retrobulbar group and 84.9% in the topical group.

CONCLUSION

When supervised and in selected patients, residents who have no retrobulbar or peribulbar anesthesia experience can safely perform phacoemulsification using topical anesthesia.

Comparison of lidocaine 2% gel versus retrobulbar anaesthesia for implantation of Ahmed glaucoma drainage

PURPOSE

To compare patient comfort and the efficacy of lidocaine 2% gel versus retrobulbar anaesthesia for Ahmed glaucoma implant surgery.

PATIENTS AND METHODS

This prospective study included 32 eyes of 32 patients scheduled to undergo implantation of an Ahmed glaucoma drainage device for refractory glaucoma in one institution, randomized to receive either topical lidocaine 2% gel or retrobulbar anaesthesia. Sixteen eyes were randomized to each group. Patient assessment of pain was recorded during delivery of anaesthesia, during surgery and after surgery, using a visual analogue pain scale. The need for additional anaesthesia during tissue manipulation was recorded. Surgeon assessments of operative conditions, patient co-operation and intraoperative complications were also recorded.

RESULTS

The patients in the retrobulbar group reported significantly more discomfort during administration of the anaesthetic agent than the patients in the topical anaesthesia group (p = 0.000). There was no significant difference in patient-reported pain scores intraoperatively (p = 0.317) or postoperatively (p = 0.875). Surgeon assessment showed similar levels of patient co-operation in both groups (p = 0.615). The overall operating conditions were overwhelmingly positive in each group (p = 0.186). The mean duration of surgery was significantly longer in the topical group compared with the retrobulbar group (p = 0.049).

CONCLUSIONS

Lidocaine 2% gel is a safe alternative to retrobulbar anaesthesia for Ahmed drainage implant surgery and avoids the significantly greater pain associated with the administration of retrobulbar anaesthesia. It provides a reasonably safe and comfortable surgical environment and is well tolerated by patients.

Monitored anesthesia care provided by registered respiratory care practitioners during cataract surgery

OBJECTIVE

To evaluate the safety and feasibility of having monitored anesthesia care during cataract surgery provided by registered respiratory care practitioners (RRCPs).

DESIGN

Retrospective case series.

PARTICIPANTS

One thousand nine hundred fifty-seven consecutive patients undergoing cataract surgery at one surgical center between November 2001 and October 2003.

METHODS

Phacoemulsification cataract surgery with intraocular lens insertion was performed using topical anesthesia, with or without IV sedatives. An RRCP, trained to function as an anesthesia assistant, provided monitored anesthesia care during all stages of surgery, with an anesthesiologist immediately available for consultation or assistance as required.

MAIN OUTCOME MEASURES

The number of serious medical complications resulting from the anesthesia or surgery was measured. The rate of anesthesiologist intervention required at each stage of surgery--preoperative, intraoperative, and postoperative--was determined, along with the reasons for the interventions. Age, American Society of Anesthesiologists (ASA) risk class (a rating of preoperative physical status), and number of IV sedative agents given were analyzed as potential predictors of the need for anesthesiologist intervention.

RESULTS

Among the 1957 cataract surgeries, there were no adverse medical events that resulted in death, hospitalization, or tracheal intubation. Two cases were aborted intraoperatively for medical reasons. A total of 78 cases (4.0%) required anesthesiologist intervention, with 34 (1.7%) requiring preoperative intervention, 43 (2.2%) requiring intraoperative intervention, and 3 (0.2%) requiring postoperative intervention; 4 cases required 2 separate interventions. The mean age of the intervention group (73.9 years) was statistically greater than that of the nonintervention group (71.0) (P = 0.02). A higher ASA rating (>2) correlated with an increased need for anesthesiologist intervention in terms of the total intervention rate (P<0.0001) and the intraoperative rate alone (P<0.0001). The use of more IV sedative agents (2 or 3 vs. 0 or 1) was marginally associated with a higher total intervention rate (P = 0.053) but not with a higher intraoperative intervention rate (P = 0.68).

CONCLUSION

With the inherent safety of cataract surgery and the relatively low need for anesthesiologist intervention, we believe it is justified to allow RRCPs, trained as anesthesia assistants, to provide monitored anesthesia care during cataract surgery so long as anesthesiologist support is directly available when required. Potential benefits include cost savings in health care and decreased demand for anesthesiology services. To validate formally the preservation of patient safety from such a change in practice, however, a larger sample size would be required due to the inherently low rate of cataract surgery complications.

Contact-topical plus intracameral lidocaine versus peribulbar anesthesia in combined surgery: a randomized clinical trial

PURPOSE

To compare the efficiency and safety of contact-topical anesthesia versus peribulbar injection anesthesia for phacotrabeculectomy.

MATERIALS AND METHODS

A total of 80 patients undergoing combined cataract and glaucoma surgery were randomly allocated to receive either contact or peribulbar anesthesia. No systemic sedatives were used in either group. Patients were asked to rate their pain level on a 5-point scale for 4 periods: during administration of the anesthetic agent; during surgery; immediately after surgery; and 24 hours postoperatively, while the surgeon recorded his subjective assessment of ease of surgery using a standardized template. The patients' general condition during surgery, as well as the results and short-term complications, were assessed.

RESULTS

The injected anesthesia group showed higher rates of discomfort and pain, and 37 patients reported pain ranging from mild to severe during anesthetic administration. The difference between groups was statistically significant (P < 0.001). During surgery, there were no differences in vital signs, patients' subjective pain evaluation, or surgeon stress. We found no differences between pain rates after surgery. Complications included prolonged chemosis, and we also noted that conjunctival hemorrhage occurred more frequently in the peribulbar group than in the contact anesthesia group.

CONCLUSION

Both anesthetic methods provide high levels of pain control without additional sedation during surgery. The use of contact-topical anesthesia avoids pain and reduces the possibility of complications during administration of anesthetics.

Structured assessment tool to evaluate patient suitability for cataract surgery under local anaesthesia

INTRODUCTION

Cataract extraction and intraocular lens implantation is a common surgical procedure. While the vast majority of these operations are performed under local anaesthesia (LA), this is not an appropriate technique for every patient. Likewise it is time-consuming to assess all patients fitness for general anaesthesia when most will not need it.

METHODS

We developed an eight-item questionnaire that can be administered before admission to assess patient suitability for surgery under LA. In a prospective study over a 9-month period, 128 patients were seen in a pre-admission clinic, and according to the responses to the questionnaire administered by junior medical staff, 123 were deemed suitable for surgery under LA, and five under general anaesthetic (GA).

RESULTS

All 123 patients went on to have surgery successfully performed under LA. A further two patients from the GA group were determined by the attending anaesthetist to be suitable for surgery under LA.

CONCLUSION

This assessment instrument has been shown to be a highly specific means of selecting patients for surgery under LA, and can be administered by medical or nursing staff.

Effects of intracameral injection of preservative-free lidocaine on the anterior segment of the eyes in dogs

OBJECTIVE

To evaluate effects of intracameral injection of preservative-free 1% and 2% lidocaine hydrochloride solution on the anterior segment of the eyes in dogs.

ANIMALS

16 adult healthy dogs (8 male and 8 female) judged to be free of ocular disease.

PROCEDURE

Dogs were randomly assigned to 2 groups of 8 dogs each. Group 1 dogs received an intracameral injection of 0.10 mL of preservative-free 1% lidocaine solution in the designated eye, and group 2 dogs received 0.10 mL of preservative-free 2% lidocaine solution in the designated eye. After injection, intraocular pressure was measured every 12 hours for 48 hours and then every 24 hours until 168 hours after injection. Slit-lamp biomicroscopy was performed preceding intracameral injection, 8 hours after injection, and then every 24 hours until 168 hours after injection. Ultrasonic pachymetry and specular microscopy were performed preceding intracameral injection and 72 and 168 hours after injection. Corneal thickness and endothelial cell density and morphology were compared with baseline measurements.

RESULTS

No significant differences were found in intraocular pressure, corneal thickness, endothelial cell density, and morphologic features in either group, compared with baseline. A significant difference in aqueous flare was found for treated and control eyes 8, 24, and 48 hours after injection, compared with baseline. No significant difference in aqueous flare was found between treated and control eyes within either group.

CONCLUSIONS AND CLINICAL RELEVANCE

No adverse ocular effects were detected after intracameral injection of preservative-free 1% or 2% lidocaine solution; thus, its use would be safe for intraocular pain management in dogs.

Combined Topical and Intracameral Anesthesia in Penetrating Keratoplasty

BACKGROUND

The standard of care for penetrating keratoplasty (PKP) is either retrobulbar or peribulbar anesthesia combined with seventh cranial nerve akinesia or general anesthesia. These methods are known to be associated with rare but potentially serious adverse ocular and systemic events.

PURPOSE

To determine the safety and efficacy of combined topical and intracameral anesthesia in addition to intravenous sedation for repeat penetrating keratoplasty (PKP).

SETTING

Tertiary-care university hospital.

METHODS

In this prospective study, combined topical tetracaine 0.5% and 0.2 cc intracameral 1% lidocaine along with i.v. sedation with midazolam and fentanyl were used for patients undergoing repeat PKP in 15 eyes of 15 selected patients. The indication for surgery was failed corneal graft. Verbal pain scale (VPS, 0-3) was recorded preoperatively, intraoperatively at 3 time-points (after trephination, after placing 8 interrupted sutures, and after placing the running suture), and postoperatively (1 hour postoperatively, overnight pain, and 1 day postoperatively). Patient and surgeon satisfaction were assessed postoperatively using a scale (1-5). After surgery patients were asked for their preferences comparing the current use of topical anesthesia compared with retrobulbar anesthesia used for their initial PKP.

RESULTS

The mean intraoperative VPS score was 0.51 +/- 0.32 (range 0-1.33), and the mean postoperative VPS score was 0.47 +/- 0.50 (range 0-1.67). There were no serious intraoperative or postoperative complications. All patients reported high mean satisfaction score of 4.67 +/- 0.49 (range 4-5). The mean satisfaction score reported by the surgeon was 4.47 +/- 0.63 (range 3-5). All patients but 1 (93.3%) preferred combined topical over retrobulbar anesthesia, which they had in their previous surgery.

CONCLUSIONS

We found combined topical and intracameral anesthesia to be safe and effective in our selected group of patients undergoing repeat PKP, and it may provide a satisfactory alternative anesthetic modality for patients in whom general, retrobulbar, or peribulbar anesthesia may be contraindicated.

Viscoanesthesia. Part II: toxicity to intraocular structures after phacoemulsification in a rabbit model

PURPOSE

To investigate the toxicity of a solution that combines sodium hyaluronate 1.5% with lidocaine (0.5%, 1.0%, or 1.65%) to intraocular structures.

SETTING

Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Phacoemulsification was performed in both eyes of 29 rabbits. They were divided into 3 groups; in each group (n = 7), 1 viscoanesthetic solution was used before capsulorhexis. After irrigation/aspiration, 0.2 mL of the solution was purposely left in the capsular bag. In 1 rabbit in each group, the solution was injected into the vitreous cavity through a posterior capsulorhexis. In 8 rabbits used as controls, balanced salt solution (BSS(R)) (n = 4) or sodium hyaluronate 1.5% (n = 4) was injected into the vitreous cavity. Enucleations were performed 15, 30, and 60 days postoperatively. Histological sections were cut and stained with hematoxylin-eosin, periodic acid-Schiff, and Masson trichrome stains.

RESULTS

Light microscopic evaluation of the eyes enucleated after 15, 30, and 60 days in the study and control groups showed similar findings in intraocular structures such as the ciliary body and retina. No evidence of an inflammatory reaction, cell necrosis, or cell degeneration was observed in the histological sections.

CONCLUSIONS

The use of viscoanesthesia during phacoemulsification appeared to be safe, with no histologic abnormalities observed with the 3 lidocaine concentrations. The efficacy of the anesthetic effects of these solutions will be addressed in clinical trials.

Techniques for managing common complications of cataract surgery

Cataract surgery has evolved dramatically over the last two decades, largely as a result of technological advances. As a result, visual outcomes and patient convalescence have improved significantly. A second consequence of increased instrumentation and technology, however, is increased complexity of cataract surgery and the advent of complications unique to these advances. Cataract surgeons must be aware and capable of managing the many possible adverse events that can occur during cataract surgery. This review identifies many of the common complications of cataract surgery, describes methods to avoid these complications and discusses techniques to address complications that do occur. It is the ability to avoid, quickly identify, and properly manage complications that defines the accomplished cataract surgeon.

Anesthesia through a novel retrobulbar catheter provides perioperative pain control for 24 h after pars plana vitrectomy

PURPOSE

The purpose of this study was to assess the retrobulbar catheter technique for perioperative pain control in pars plana vitrectomy.

METHODS

One hundred consecutive pars plana vitrectomies (duration 20-220 minutes) in 88 patients (age range 37-88 years) were performed by the same surgeon under retrobulbar anesthesia using a commercially available retrobulbar needle. Initially, 7 ml of mepivacaine 2% were injected, a 28-gauge flexible catheter was introduced into the retrobulbar space and the needle was withdrawn. The catheter was removed 24 h after surgery. Intraoperatively and postoperatively, the patients were asked to rate pain using a numerical scale from 0 to 10. When pain was more than grade 3, 2 ml of a local anesthetic were re-injected through the catheter.

RESULTS

A first re-injection was given intraoperative/y 53.0 +/- 34.6 minutes after the start of surgery during 35/100 procedures, and second and third injections were needed during 12 /100 and 4/100 procedures, respectively. The first postoperative re-injection was given 3.9 +/- 1.5 hours after the start of surgery in 54 procedures, and second and third injections were carried out in 35/100 and 10/100 procedures respectively.

CONCLUSIONS

The results suggest that a temporary indwelling retrobulbar catheter allows long-lasting titratable local anesthesia during pars plana vitrectomy and titratable postoperative analgesia.

Use of piritramide for analgesia and sedation during peribulbar nerve block for cataract surgery

PURPOSE

To investigate the effects of pre-block analgesia and sedation using piritramide on haemodynamic stability, endocrine stress response and patients' pain perception.

METHODS

In a randomized, single-blinded, placebo-controlled study, 60 patients having cataract surgery with peribulbar block were randomly assigned into two groups: group A (n = 30) received 0.05 mg/kg piritramide (Dipidolor) intravenously; group B received normal saline intravenously prior to peribulbar block. Mean arterial pressure, heart rate, respiratory rate and pulse oximetry were recorded perioperatively. Pain from peribulbar block was assessed using a verbal analogue scale. Urinary excretion of vanillylmandelic acid was measured to assess the endocrine stress response. Using a questionnaire, patients assessed their anxiety and back pain before and during surgery.

RESULTS

Mean arterial pressure remained near baseline in group A. In group B, a significant increase in mean arterial pressure after peribulbar block was found (p < 0.001). In addition, a significant increase in urinary excretion of vanillylmandelic acid was found in group B (p = 0.013). Pain scores (p < 0.001), anxiety before nerve block (p = 0.02) and during surgery (p < 0.001) and back pain (p = 0.003) were significantly lower in group A.

CONCLUSION

The presented study suggests that using piritramide for analgesia and sedation prior to peribulbar block produces haemodynamic stability and reduces pain perception and endocrine stress response.

Lidocaine versus ropivacaine for topical anesthesia in cataract surgery(1)

PURPOSE

To assess the anesthetic efficacy and safety of topical ropivacaine versus topical lidocaine in cataract surgery.

SETTING

Institute of Ophthalmology, University of Modena and Reggio Emilia, Modena, Italy.

METHODS

This prospective controlled randomized double-blind study comprised 64 patients scheduled for planned routine cataract extraction. Patients were randomized into 2 groups; 1 received topical ropivacaine 1% and the other, topical lidocaine 4%. The duration of surgery, intraoperative and early postoperative complications, and the need for supplemental intracameral anesthesia were recorded. Intraoperative and postoperative subjective pain was quantified by patients using a scale from 1 to 10. An endothelial cell count was performed preoperatively and 2 months after surgery.

RESULTS

The mean endothelial cell density decreased from 2334 cells/mm(2) +/- 496 (SD) to 2016 +/- 674 cells/mm(2) in the ropivacaine group and from 2519 +/- 404 cells/mm(2) to 1847 +/- 607 cells/mm(2) in the lidocaine group. The difference in cell density between groups was not significant before (P =.154) or after surgery (P =.329); however, the difference in mean cell loss between groups was statistically significant (P =.031). The duration of surgery and intraoperative complications were the same in both groups. Four patients in the ropivacaine group and 5 in the lidocaine group required supplemental anesthesia (P >.05). The mean subjective analog pain score was slightly higher in the lidocaine group (P >.05). The day after surgery, 12 eyes in the ropivacaine group and 6 in the lidocaine group had transient corneal edema (P =.150).

CONCLUSIONS

Topical ropivacaine performed at least as well as topical lidocaine in efficacy and safety in cataract surgery. It provided sufficient and long-lasting analgesia without the need for supplemental intracameral anesthesia in most cases.

Topical plus intracameral lidocaine versus retrobulbar anesthesia in phacotrabeculectomy: prospective randomized study

PURPOSE

To compare the efficacy and safety of topical and retrobulbar anesthesia for phacotrabeculectomy.

SETTING

Hospital Ramón y Cajal, Madrid, Spain.

METHODS

This prospective study comprised 60 patients (60 eyes) having phacotrabeculectomy surgery. Patients were randomly assigned to 1 of 2 groups receiving topical anesthesia plus intracameral lidocaine 1% or retrobulbar anesthesia. Patients were asked to document the discomfort they experienced during the administration of the anesthetic agent, during surgery, and postoperatively using a numeric pain scale. Complications and surgical conditions were also evaluated.

RESULTS

The retrobulbar group reported significantly more discomfort during administration of the anesthetic agent than the topical group (P < .001). The topical group reported significantly more discomfort intraoperatively (P < .01). Eyelid squeezing and eyeball movement were more common in the topical group; however, neither was a problem to the surgeon. There was no difference in surgical conditions (P = .38) or the postoperative pain scores between the 2 groups (P = .06). One patient receiving topical anesthesia developed a suprachoroidal hemorrhage intraoperatively.

CONCLUSIONS

Topical anesthesia supplemented with intracameral lidocaine was an effective alternative to retrobulbar anesthesia for phacotrabeculectomy. Although the degree of patient discomfort was significantly higher during surgery under topical anesthesia, the method avoids the pain and complications associated with a retrobulbar injection.