Ropivacaine for topical anesthesia in pterygium surgery with fibrin glue for conjunctival autograft

Multimodal prevention of emergence cough following nasal endoscopic surgery under general anesthesia: a double-blind randomized trial

Purpose

Cough during emergence from anesthesia is a common problem and may cause adverse events. Monotherapy faces uncertainty in preventing emergence cough due to individual differences. We aimed to evaluate the efficacy and safety of multimodal intervention for preventing emergence cough in patients following nasal endoscopic surgery.

Methods

In this double-blind randomized trial, 150 adult patients undergoing nasal endoscopic surgery were randomly allocated into three groups. For the control group (n = 50), anesthesia was performed according to clinical routine, no intervention was provided. For the double intervention group (n = 50), normal saline 3 mL was sprayed endotracheally before intubation, 0.4 μg/kg dexmedetomidine was infused over 10 min after intubation, and target-controlled remifentanil infusion was maintained at an effect-site concentration of 1.5 ng/mL before extubation after surgery. For the multimodal intervention group (n = 50), 0.5% ropivacaine 3 mL was sprayed endotracheally before intubation, dexmedetomidine and remifentanil were administered as those in the double intervention group. The primary endpoint was the incidence of emergence cough, defined as single cough or more from end of surgery to 5 min after extubation.

Results

The incidences of emergence cough were 98% (49/50) in the control group, 90% (45/50) in the double group, and 70% (35/50) in the multimodal group, respectively. The incidence was significantly lower in the multimodal group than those in the control (relative risk 0.71; 95% CI 0.59 to 0.86; p < 0.001) and double (relative risk 0.78; 95% CI 0.63 to 0.95; p = 0.012) groups; the difference between the double and control groups was not statistically significant (relative risk 0.92; 95% CI 0.83 to 1.02; p = 0.20). The severity of sore throat was significantly lower in the multimodal group than that in the control group (median difference-1; 95% CI -2 to 0; p = 0.016). Adverse events did not differ among the three groups.

Conclusion

For adult patients undergoing endonasal surgery, multimodal intervention including ropivacaine topical anesthesia before intubation, dexmedetomidine administration after intubation, and remifentanil infusion before extubation after surgery significantly reduced emergence cough and was safe.

[Pterygium: pathogenesis, diagnosis and treatment]

The pterygium is a frequent ultraviolet (UV) light-induced focal fibrovascular proliferation of the conjunctival tissue onto the cornea. Surgical excision should be performed in the case of reduced visual acuity, progressive astigmatism, impending invasion of the optical axis and ocular surface complaints. The main factors in preventing recurrence include optimal surgical treatment by an excision combined with a free conjunctival autograft, consistent postoperative treatment with preservative-free artificial tears and topical steroids as well as long-term UV protection.

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.

Recurrence and complications after 1,000 surgeries using pterygium extended removal followed by extended conjunctival transplant

OBJECTIVE

To document the recurrence rate and complication rate of pterygium extended removal followed by extended conjunctival transplant.

DESIGN

An open, prospective study of consecutive pterygium patients undergoing pterygium extended removal followed by extended conjunctival transplant.

PARTICIPANTS AND CONTROLS

The study included 1000 consecutive patients undergoing pterygium surgery between August 2001 and September 2009.

INTERVENTIONS

All patients underwent pterygium extended removal followed by extended conjunctival transplant by the author with attempted follow-up for 1 year.

MAIN OUTCOME MEASURES

Recurrence and complication rates.

RESULTS

Follow-up of >1 year was obtained in 99% of patients. There was 1 recurrence in the 1000 surgeries (0.1%) with 95% confidence intervals of 0.003%-0.56% (Fischer exact test). Seven patients required further surgery: 3 had graft replacements, and 1 each for recurrence, strabismus, inclusion cyst, and granuloma. One patient lost 4 lines of vision from a corneal ulcer.

CONCLUSIONS

Pterygium extended removal followed by extended conjunctival transplant results in one of the lowest recurrence rates reported in the world's literature and an acceptable complication rate.

[Operative techniques for surgical treatment of primary and recurrent pterygia]

Surgical treatment of pterygia is indicated when there is a reduction of visual acuity secondary to the development of irregular astigmatism and an (impending) obscuration of the visual axis by the tumor. Poor cosmetic appearance and an insufficient corneal lubrication are more rare indications. The most popular surgical technique in this country appears to be a free conjunctival autograft which, depending on the priority of the surgeon, is combined with adjunctive antimetabolite therapy applied either in primary or recurrent cases. A simultaneous transplantation of conjunctival and limbal stem cell autografts is an excellent method to be considered particularly in cases of recurrent pterygia. In the case of non-existing healthy autologous tissue the resection bed can be covered by preserved amniotic membrane. A lamellar sectorial corneal graft might become necessary if there is a deep corneal defect. The well established technique of suturing the graft has been replaced by fibrin glue in some surgical centers.