COMPARISON OF TOPICAL ANESTHESIA AND PERIBULBAR ANESTHESIA FOR 23-GAUGE VITRECTOMY WITHOUT SEDATION

Safety and feasibility of sutureless pars-plana vitrectomy in sub-Tenon anesthesia (SAFE-VISA): a prospective study

BACKGROUND

To determine the safety and feasibility of sutureless pars-plana vitrectomy (ppV) in sub-Tenon anesthesia.

METHODS

In this prospective study. Pain and anxiety at various times after ppV using a visual analogue scale (VAS) and Wong-Baker-FACES scale as well as visual sensations during surgery were investigated. The surgeon evaluated motility, chemosis, overall feasibility.

RESULTS

ppV was performed on 67 eyes (33 sub-Tenon anesthesia, 34 general anesthesia). Pain during surgery in sub-Tenon anesthesia was 1.8 ± 2.2 (0.0-8.0), anxiety was 2.3 ± 2.2 (0.0-8.5). There was a moderate correlation between pain and anxiety (R2 = 0.58). Comparing sub-Tenon and general anesthesia no difference in pain perception was found the day after surgery. 27.3% of patients saw details, 21.2% saw colors, 90.1% saw light/motion perception, 3.0% had no light perception. Median chemosis after surgery was 1.0 (IQR = 1.0). Median motility of the eye during surgery was 1.0 (IQR = 1.0), median grade was 1.0 (IQR = 1.0). 24.2% of patients showed subconjunctival hemorrhage during or after surgery.

CONCLUSIONS

Sutureless pars-plana vitrectomy in sub-Tenon anesthesia was performed safely, with pain and anxiety levels tolerable for the patients and without the necessity for presence of an anesthesiologist. With 88.9% of patients willing to undergo vitreoretinal surgery in sub-Tenon anesthesia again, we recommend it as a standard option. Trial registration This study was approved by the Institutional Ethical Review Board of the RWTH Aachen University (EK 111/19). This study is listed on clinicaltrials.gov (ClinicalTrials.gov identifier: NCT04257188, February 5th 2020).

Adequacy of Anaesthesia for Nociception Detection during Vitreoretinal Surgery

Vitreoretinal surgery (VRS) is one of the most widely performed precise procedures in ophthalmic surgery; the majority of cases are carried out under regional anaesthesia (RA) only. However, in specific situations (such as when the patient fails to cooperate with the operator for various reasons), general anaesthesia (GA), alone or in combination with GA (combined general-regional anaesthesia, CGR), is the only safe way to perform VRS. While monitoring the efficacy of an intraoperative rescue opioid analgesia (IROA) during surgery (assessing the adequacy of anaesthesia (AoA)) may be challenging, the surgical pleth index (SPI) is a useful tool for detecting the reaction to noxious stimuli and allows for the rational titration of opioid analgesics (AO) during surgery. The current study investigated the influence of the SPI-based titration of fentanyl (FNT) in combination with various pre-emptive analgesia (PA) techniques on intraoperative pain perception during various stages of VRS performed under AoA. A total of 176 patients undergoing VRS under GA were enrolled in the study. They were randomly assigned to one of the five following study arms: Group GA (control group)-patients who received general anaesthesia alone; Group PBB-GA with preprocedural peribulbar block (with 0.5% bupivacaine and 2% lidocaine); Group T-GA with preventive, topical 2% proparacaine; Group M-GA with a preprocedural intravenous infusion of 1.0 g of metamizole; and Group P-GA with a preprocedural intravenous infusion of 1.0 g of paracetamol. The whole procedure was divided in four stages: Stage 1 and 2-preoperative assessment, PA administration, and the induction of GA; Stage 3-intraoperative observation; Stage 4-postoperative observation. the SPI values were monitored during all stages. The occurrence of nociception (expressed as ∆SPI >15) during various manipulations in the surgical field was observed, as were cumulative doses of rescue analgesia, depending on the PA administered. During the course of VRS, rescue FNT doses varied depending on the stage of surgery and the group investigated. The majority of patients, regardless of their group allocation, needed complementary analgesia during trocar insertion, with Group GA patients requiring the highest doses. Likewise, the highest cumulative doses of IROA were noted during endophotocoagulation in Group GA. Preventive PBB and topical anaesthesia were proven to be most efficient in blunting the response to speculum installation, while topical anaesthesia and paracetamol infusion were shown to be more efficient analgesics during endophotocoagulation than other types used PA. In the performed study, none of the PA techniques used were superior to GA with FNT dosing under the SPI with respect to providing efficient analgesia throughout the whole surgery; there was a necessity to administer a rescue OA dose in both the control and investigated groups.

Preventive Analgesia, Hemodynamic Stability, and Pain in Vitreoretinal Surgery

Background and Objectives: Although vitreoretinal surgery (VRS) is most commonly performed under regional anaesthesia (RA), in patients who might be unable to cooperate during prolonged procedures, general anaesthesia (GA) with intraprocedural use of opioid analgesics (OA) might be worth considering. It seems that the surgical pleth index (SPI) can be used to optimise the intraprocedural titration of OA, which improves haemodynamic stability. Preventive analgesia (PA) is combined with GA to minimise intraprocedural OA administration. Materials and Methods: We evaluated the benefit of PA combined with GA using SPI-guided fentanyl (FNT) administration on the incidences of PIPP (postprocedural intolerable pain perception) and haemodynamic instability in patients undergoing VRS (p < 0.05). We randomly assigned 176 patients undergoing VRS to receive GA with SPI-guided FNT administration alone (GA group) or with preventive topical 2% proparacaine (topical anaesthesia (TA) group), a preprocedural peribulbar block (PBB) using 0.5% bupivacaine with 2% lidocaine (PBB group), or a preprocedural intravenous infusion of 1.0 g of metamizole (M group) or 1.0 g of paracetamol (P group). Results: Preventive PBB reduced the intraprocedural FNT requirement without influencing periprocedural outcomes (p < 0.05). Intraprocedural SPI-guided FNT administration during GA resulted in PIPP in 13.5% of patients undergoing VRS and blunted the periprocedural effects of preventive intravenous and regional analgesia with respect to PIPP and haemodynamic instability. Conclusions: SPI-guided FNT administration during GA eliminated the benefits of preventive analgesia in the PBB, TA, M, and P groups following VRS.

Effect of Anticoagulant Therapy on the Outcome of Descemet Membrane Endothelial Keratoplasty

PURPOSE

To analyze the effect of anticoagulant therapy (ACT) for systemic diseases on the outcome of Descemet membrane endothelial keratoplasty (DMEK).

METHODS

Consecutive eyes with Fuchs endothelial dystrophy that underwent DMEK between August 4, 2011, and July 15, 2016, were retrospectively analyzed. Data were obtained from the Cologne DMEK database at the University of Cologne, Germany. Best spectacle-corrected visual acuity (logMAR), endothelial cell density (at baseline and postoperatively up to 12 months), and rebubbling rates were compared between patients receiving ACT (ACT group) and those with no anticoagulant treatment (NCT group).

RESULTS

In this study, 329 eyes of 329 patients were included (ACT group n = 97, NCT group n = 232; mean age 69.9 ± 9.1 years). Bleeding was more common in the ACT group (P < 0.001). Preoperative best spectacle-corrected visual acuity was 0.59 ± 0.44 and 0.48 ± 0.35 logMAR for the ACT and NCT groups, respectively, which improved to 0.13 ± 0.08 and 0.08 ± 0.16 logMAR, respectively, at 12 months postoperatively. No significant difference in endothelial cell density loss at 12 months was found between the groups (ACT group 36.2% ± 14.7%, NCT group 38.5% ± 15.1%; P = 0.467). Rebubbling rate was 19.6% in the ACT group and 28.9% in the NCT group (P = 0.08).

CONCLUSIONS

Although ACT increases the risk for preoperative and intraoperative bleeding in DMEK, there seems to be no negative effect on DMEK outcome. Thus, it is not advisable to stop ACT for DMEK surgery.

Evaluating the effectiveness of localized sub-Tenon's anesthesia in 23-gauge vitreoretinal surgery

PURPOSE

To evaluate the effectiveness of localized sub-Tenon's anesthesia for pain control during 23-gauge vitreoretinal surgery.

METHODS

Eighty patients were randomly divided into two groups as localized sub-Tenon's (group 1, n = 41) and retrobulbar (group 2, n = 39) anesthesia groups. In group 1, a small volume of anesthetic was injected into the sub-Tenon's capsules at the trocar entry sites. The 23-gauge vitreoretinal surgery was performed in all patients. In both groups, the pain levels during the surgical steps were evaluated using the visual analog pain scale.

RESULTS

Patients in group 1 experienced less pain than group 2 patients did during placement of the trocars and scleral depression (p = 0.041, p = 0.029). Pain during laser photocoagulation was higher in group 1 (p = 0.008). There was no serious complication due to anesthesia or surgery.

CONCLUSION

Localized sub-Tenon's anesthesia is as effective as retrobulbar anesthesia in many steps of vitreoretinal surgery for providing pain control. It can be considered an alternative form of local anesthesia.

A New Two-Step Anesthesia for 23- or 25-Gauge Vitrectomy Surgery: A Prospective, Randomized Clinical Trial

OBJECTIVE

To investigate the safety and efficacy of topical anesthesia combined with subconjunctival anesthesia (termed two-step anesthesia) for 23- or 25-gauge pars plana vitrectomy or other posterior segment surgery.

METHODS

Patients (n = 90) requiring 23-/25-gauge vitrectomy or other posterior segment surgery were randomized into 3 groups. Group 1 received peribulbar anesthesia, group 2 received retrobulbar anesthesia and group 3 received two-step anesthesia. A 5-point visual analog pain scale (VAPS) was used to measure self-report of patient pain. Complications were recorded for subsequent analysis.

RESULTS

VAPS scores for overall intraoperative pain ranged from 0 to 3 (1.07 ± 1.07) in group 1, from 0 to 2 (0.69 ± 0.93) in group 2 and from 0 to 3 (1.06 ± 0.98) in group 3. Assessment of surgeon discomfort score ranged from 0 to 2 (0.31 ± 0.66) in group 1, from 0 to 3 (0.38 ± 0.82) in group 2 and from 0 to 2 (0.47 ± 0.62) in group 3. Both scores reveal no significant difference among the 3 groups. While there were no complications noted in group 1, there was an ocular perforation in group 2. Additionally, there were no complications in group 3 related to the anesthetic technique.

CONCLUSIONS

Results suggest that two-step anesthesia is a safe and effective anesthetic approach for selected patients undergoing 23- or 25-gauge pars plana vitrectomy or other posterior segment surgeries. It may offer a viable alternative to peribulbar anesthesia and retrobulbar anesthesia for carefully selected 23- or 25-gauge cannular-access ocular surgeries.

Patients' Experience of Anxiety and Pain during Retrobulbar Injections prior to Vitrectomy

Purpose

The purpose of this study was to evaluate the correlation between pain associated with retrobulbar block and anxiety levels before the injection.

Methods

This prospective observational, noninterventional study included consecutive patients who received a retrobulbar block by a single surgeon prior to undergoing 25G PPV at the Department of Ophthalmology, Rambam Health Care Campus, between April 2016 and August 2017. Patients plotted their anxiety levels (scale 0–10) using the visual analogue scale for anxiety (VASA), and immediately after receiving the injection, they plotted their experienced level of pain (scale 0–10) using the visual analogue scale for pain (VAS), with scores ≥7 defined as severe.

Results

Overall, 48 eyes of 48 patients aged 68.4 ± 10.3 years were included, of which 62.5% were of male gender. Severe anxiety and pain were experienced by 10.4% and 12.5%, respectively. There was a significant correlation between VASA and VAS scores (r = 0.43, p=0.002) with no other preprocedural parameters demonstrating a significant association with the VAS score. In multivariate analysis, the VASA score was the only factor that was significant (p=0.01), and a patient with a severe VASA score was 20 times more likely of experiencing severe pain (p=0.006). The ROC curve analysis revealed an area under the curve of 0.89 (p < 0.001), and a VASA score >4 demonstrated a sensitivity of 83.3% and a specificity of 73.8% in predicting severe pain.

Conclusions

Approximately 10% of patients experience severe anxiety and pain during retrobulbar blocks. Considering the importance of compliance, reducing anxiety and premedication may be considered, particularly in high-risk patients (VASA score > 4).

Feasibility and safety of vitrectomy under topical anesthesia in an office-based setting

Purpose

The purpose of this study was to evaluate the feasibility and safety of office-based vitreoretinal procedures.

Methods

Patients undergoing primary elective pars plana vitrectomy were elected for surgery in an office-based setting (performed in a minor procedure room under topical anesthesia [TA] and oral anxiolysis). Rates of surgical objective achievement, surgical timing, and comfort were recorded to evaluate feasibility. Intraoperative and postoperative adverse events were assessed to evaluate safety.

Results

Office-based vitrectomy surgery was performed in 34 eyes of 30 patients. The mean surgical time was 12.351 ± 8.21 min. Surgical objectives were achieved in 100% of cases. The mean best-corrected visual acuity improvement was 9.08 letters (P < 0.0001). During most parts of the procedure, no patient reported pain or discomfort. Neither intraoperative nor postoperative adverse events were reported until the final follow-up visit.

Conclusion

Office-based vitreoretinal procedures under TA could be as feasible and as safe as vitreoretinal procedures under conventional anesthesia.

A comparison between topical and retrobulbar anesthesia in 27-gauge vitrectomy for vitreous floaters: a randomized controlled trial

Background

To compare the safety and efficacy of topical anesthesia versus retrobulbar anesthesia in 27-gauge pars plana vitrectomy (PPV) for vitreous floaters.

Methods

30 patients with vitreous floaters were randomized into Group T (topical anesthesia, proparacaine eye drop) and Group R (retrobulbar anesthesia), and underwent 27-gauge PPV. A 5-point visual analogue pain scale (VAPS) was used to assess patients’ pain experience of anesthesia and surgery procedure (during surgery, 2 h and 1 day after surgery).

Results

The VAPS of anesthesia procedure was 1.27 ± 0.59 for patients in Group R, while it was all 0 for patients in Group T (p < 0.001). There was no significant difference for VAPS during surgery (Group T: 1.13 ± 0.74, Group R: 0.67 ± 0.62, p = 0.67), 2 h (Group T: 0.80 ± 1.01, Group R: 0.67 ± 0.62, p = 0.67) and 1 day (Group T: 0.20 ± 0.41, Group R: 0.27 ± 0.46, p = 0.68) after surgery between these two groups. Only one patient (6.7%) in Group T required additional topical anesthesia during the surgery. Most of the patients reported the pain experience came from initial trocar insertion in both groups. None of the patients required post operative analgesia in both groups. No intraoperative or postoperative complications were noted in both groups.

Conclusion

This study suggested that topical anesthesia is a safe and effective anesthetic approach for patients with floaters who underwent 27-gauge PPV.

Trial registration

ClinicalTrials.govNCT03049163. Registered 8 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0838-7) contains supplementary material, which is available to authorized users.

27-Gauge Vitrectomy for Symptomatic Vitreous Floaters with Topical Anesthesia

Purpose

Traditionally acceptable methods of anesthesia for vitrectomy surgery are quite varied. However, each of these methods has its own potential for complications that can range from minor to severe. The surgery procedure of vitrectomy for symptomatic vitreous floaters is much simpler, mainly reflecting in the nonuse of sclera indentation, photocoagulation, and the apparently short surgery duration. The use of 27-gauge cannulae makes the puncture of the sclera minimally invasive. Hence, retrobulbar anesthesia, due to its rare but severe complications, seemed excessive for this kind of surgery.

Method

Three cases of 27-gauge, sutureless pars plana vitrectomy for symptomatic vitreous floaters with topical anesthesia are reported.

Results

The vitrectomy surgeries were successfully performed with topical anesthesia (proparacaine, 0.5%) without operative or postoperative complications. Furthermore, none of the patients experienced apparent pain during or after the surgery.

Conclusion

Topical anesthesia can be considered for 27-guage vitrectomy in patients with symptomatic vitreous floaters.

Local versus general anaesthesia for adults undergoing pars plana vitrectomy surgery

BACKGROUND

Vitrectomy surgery is one of the commonest ophthalmic procedures performed across the world. It may be performed using general or local anaesthesia encompassing regional or topical anaesthesia depending on a number of factors, including patient suitability, and patient, surgeon or anaesthetist preference. There have so far been no evidence-based recommendations on the best form of anaesthesia for this intervention. There is no clear collated evidence base as to the best type of anaesthesia to reduce harm, and provide best surgical conditions and optimal outcome for patients.

OBJECTIVES

To compare local with general anaesthesia for adults undergoing pars plana vitrectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library and the reference lists of updated studies on the 25th of July 2016; MEDLINE via Ovid SP (1972 to July 2016) and Embase via Ovid SP (1972 to July 2016). In addition we searched the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) in July 2016. We searched the proceedings of the Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) up to July 2016 for information about other relevant studies.We also searched appropriate databases for ongoing reviews. We did not apply any language restriction. We assessed the search as up-to-date on the 25th of July 2016.

SELECTION CRITERIA

We planned to include all published randomized controlled trials (RCTs) involving comparison of different modalities of local anaesthesia with general anaesthesia for pars plana vitrectomy. We considered the following different modalities of local anaesthesia: sub-Tenon's anaesthesia, retrobulbar anaesthesia, topical anaesthesia, peribulbar anaesthesia. We planned to include cluster-randomized controlled trials. We excluded quasi-RCT trials.

DATA COLLECTION AND ANALYSIS

Two review authors conducted independent searches and assessed identified studies for inclusion according to the prespecified selection criteria. Two review authors assessed trial quality and planned to extract the data.

MAIN RESULTS

We found no eligible studies that met our inclusion criteria and were therefore unable to perform a meta-analysis or conduct a methodological quality assessment.

AUTHORS' CONCLUSIONS

This systematic review failed to locate relevant clinical evidence to support or refute a pars plana vitrectomy performed with various modalities of local anaesthesia versus general anaesthesia. Good-quality clinical trials are needed to define the role of local versus general anaesthesia for pars plana vitrectomy.

Comparison of pain experience during 23-G vitreoretinal surgery under topical and retrobulbar anesthesia

The objective of this study is to compare pain and discomfort scores of patients during 23-G vitreoretinal surgery under topical and retrobulbar anesthesia without using sedation. A total of 157 patients with various vitreoretinal disorders were included in this study. Patients were randomly divided into two groups: topical (group 1, n = 76) and retrobulbar anesthesia (group 2, n = 81). Patients underwent 23-G vitreoretinal surgery without using sedation. All patients rated the level of experienced pain during the surgical procedure using a visual analogue pain scale. Pain and discomfort scores while performing anesthesia were significantly higher in group 2 than group 1 (p < 0.001). Patients in group 1 experienced more pain than group 2 during trocar insertion, endolaser photocoagulation, and scleral indentation steps of surgery (for all; p < 0.001). There was no significant difference in overall pain and discomfort scores and surgeon comfort scores between groups (p = 0.163, p = 0.097; respectively). None of the patients required additional anesthesia or sedation during or after the procedure. Topical anesthesia without using sedation is a safe and effective, alternative method for 23-G vitreoretinal surgeries in selected patients with various vitreoretinal pathologies.

A comparison of topical or retrobulbar anesthesia for 23-gauge posterior vitrectomy

Background. To compare the efficacy and safety of topical anesthesia versus retrobulbar anesthesia in 23-gauge vitreoretinal surgery. Materials and Methods. A total of 63 patients scheduled for 23 G posterior vitrectomy without scleral buckling procedures were included in the study. The patients were randomly assigned to receive either topical (Group 1, n = 31) or retrobulbar anesthesia (Group 2, n = 32). Postoperatively, patients were shown a visual analogue pain scale (VAPS) from 1 (no pain or discomfort) to 4 (severe pain or discomfort) to rate the levels of pain. Results. There was more discomfort in patients in Group 2 while anesthetic was administered (Group 1:  1.0 ± 0, Group 2: 2.3 ± 0.7, P = 0.0001). Between the two groups the level of pain during surgery (Group 1: 1.4 ± 0.5, Group 2: 1.5 ± 0.5; P = 0.85) was noted. There was also no significant difference between two groups postoperatively (Group 1: 1.2 ± 0.4, Group 2: 1.3 ± 0.4; P = 0.28). There were no complications in either group related to the anesthetic technique. No patient needed sedation or anesthesia supplement during the surgery or postoperative period. Conclusion. Topical anesthesia in posterior vitrectomy procedures is an effective and safe method that is alternative to retrobulbar anesthesia.