Comparing Peribulbar and Topical Anesthesia in Cataract Surgery among Patients with Cardiovascular Disease

PURPOSE

To compare topical and peribulbar anesthesia in cataract surgery for hemodynamic changes, rate of complications and pain score in patients with cardiovascular disease.

METHODS

A prospective comparative study at a tertiary care center in India. Patients >40 years old with treated/controlled hypertension and cardiovascular disease scheduled for cataract surgery under topical or peribulbar anesthesia were recruited. Heart rate, blood pressure, and ophthalmic and systemic complications were noted: preoperatively, immediately after block, intraoperatively, immediately postoperatively and 1 hour postoperatively. A visual analog scale was used to assess the pain score.

RESULTS

A total of 150 patients (75 in each group) underwent cataract surgery. There was a significant rise in pulse rate and blood pressure after peribulbar injection and intraoperatively, which gradually reduced to baseline 1 hour after surgery in both groups (p < 0.001), with systolic blood pressure intraoperatively being significantly greater in the peribulbar group (155.49 ±18.14 mmHg vs. 147.95 ±17.71 mmHg, p = 0.01). The topical group had slightly lower visual analog scale scores (1.12 ± 0.99) than the peribulbar group (1.44 ± 0.90, p = 0.04).

CONCLUSIONS

Cataract surgery appears safe in patients with adequately controlled cardiovascular disease, and topical anesthesia may be preferable due to noninvasiveness, adequate analgesia, and minimal effect on hemodynamic parameters. Therefore, hemodynamically stable patients of cardiovascular disease undergoing uncomplicated cataract surgery may be counselled for topical anesthesia.

Clinical study of acupuncture combined with surface anesthesia using proparacaine in geriatric cataract phacoemulsification

BACKGROUND

During anesthesia administration for cataract surgery, low pH of proparacaine may induce pain or complications such as corneal damage and poor wound healing, with the use of additional drops intraoperatively increasing the risk of complications. Accordingly, there is a clinical need for adjuncts to local anesthesia needs to improve the efficiency of anesthesia and reduce the required amount of intraoperative proparacaine.

AIM

To identify a method of anesthesia for geriatric cataract phacoemulsification that provides more efficient analgesia and improves clinical efficacy.

METHODS

A total of 130 geriatric patients with cataracts who attended Hebei Eye Hospital from December 2020 to December 2022 were included in the present study. Patients were divided into the proparacaine surface anesthesia (SA) group (65 cases) and the compound acupuncture-medicine anesthesia group (CAMA group, 65 cases). Patients in the CAMA group were provided acupuncture analgesia in addition to SA. Preoperative anxiety [Self-Rating Anxiety Scale (SAS) score and state anxiety inventory (SAI) score], intraoperative stress, vital signs, analgesia, and cooperation, as well as postoperative adverse events, were compared between groups.

RESULTS

More marked reductions in anxiety were observed among patients in the CAMA group, with corresponding reductions in SAS and SAI scores. During the operation, no change in the secretion of E, NE, or Cor group compared to the preoperative period was observed in the CAMA, which was markedly lower than that in the SA group. Heart rate, blood pressure, and respiratory rate were more stable intraoperatively in the CAMA group. In addition, the incidence of intraoperative pain and the number of additional doses of anesthesia required in the CAMA group were markedly lower than in the SA group. Accordingly, patients in the CAMA group were able to avoid eye movements and eyelid closing leading to greater cooperation with surgeons during surgery. Furthermore, marked reductions in intraoperative adverse effects were observed in the CAMA group, indicating greater overall safety.

CONCLUSION

Proparacaine SA combined with acupuncture as an analgesic provides improved analgesia with greater safety compared to surface anesthesia with proparacaine during geriatric cataract phacoemulsification.

Low-Dose Propofol with Peribulbar Anaesthesia for Cataract Surgery

In this paper, we investigate the effect of sedation using low-dose propofol on patient reported outcome measures (PROMS) in patients undergoing cataract surgery. This is a randomised, single-blinded observational prospective study. Patients undergoing elective cataract surgery using peribulbar anaesthesia over consecutive cataract lists were selected for this trial. Patients were randomised to receive either no sedation or low-dose propofol (20 to 30 mg followed by 10 mg increments until the patient developed slurred speech alone) prior to the administration of local anaesthesia. Pain, satisfaction, anxiety, needle recall, pulse, and blood pressure (BP) were measured. A total of 97 patients were included, 50 of whom received propofol. There were 4 senior surgeons and anaesthetists. There were no ocular or systemic complications and all patients had uncomplicated surgery. Anxiety (p = 0.026), needle recall (p < 0.001), difference in systolic BP (p = 0.043), and pulse (p = 0.046) were dependent on patient age (p < 0.001) and the use of propofol (p = 0.007). Lower pain was associated with propofol (p = 0.008), as well as lower anxiety (p = 0.002), and increased patient age (p = 0.014). The administration of propofol was significantly associated with lower needle recall (p < 0.001), pre- to post-operative difference in systolic BP (p = 0.029), and mean BP (p = 0.044). Low-dose propofol given immediately prior to administration of local anaesthesia was associated with reduced pain and needle recall, as well as lower BP.

Comparison of Single Target-Controlled Infusion Pump-Delivered Mixed Propofol and Remifentanil with Two Target-Controlled Infusion Pumps-Delivered Propofol and Remifentanil in Patients Undergoing Breast Cancer Surgery-A Prospective Study

Total intravenous anesthesia (TIVA) with remifentanil and propofol (RP) is considered to be an ideal type of general anesthesia (GA) for pediatric and adult patients undergoing medical procedures. However, delivery of an RP mixture by target-controlled infusion (TCI) for GA in surgical procedures has not been described. We investigated the merit of this approach for breast cancer surgery. Eighty-four patients (n = 42 per group) were randomly allocated to propofol and remifentanil either delivered by separate TCI pumps (S group) or in an RP mixture by a single TCI pump (M group). Dosages were adjusted based on the bispectral index (BIS) and the analgesia nociception index (ANI). The primary outcomes were adequate anesthesia (BIS 40-60 and ANI 50-70, respectively), acceptable hemodynamic fluctuations (<30% of baseline) with less frequent TCI pump adjustments, bolus injections of anesthetics, and total consumption of anesthetics during the procedure. The secondary endpoints included time of emergence from anesthesia, patient satisfaction, postoperative pain, rescue with opioids, and adverse events. The characteristics of patients, hemodynamic parameters, BIS and ANI scores, duration of surgery, anesthesia, and emergence were not significantly different between groups. The adjustment frequency of TCI was significantly higher in the S group (3 (range 0-6) vs. 2 (0-6) times; p = 0.005). The total dosage of anesthetics, pain rating, patient satisfaction, need for opioids postoperatively, and incidence of adverse events were not significantly different. We have demonstrated that this RP mixture provided adequate hypnotic and analgesic effects under BIS and ANI monitoring in patients undergoing breast cancer surgery within 1 h.

Prospective evaluation of remifentanil-propofol mixture for total intravenous anesthesia: A randomized controlled study

Application of total intravenous anesthesia (TIVA) may be considered as unpractical when compared with inhalational anesthesia. Although it is mostly not recommended, mixing intravenous agents is popular in clinical practice. The aim of the present study was to investigate the suitability of using remifentanil-propofol mixture (MIXTIVA) for TIVA. Adult patients with an American Society of Anesthesiologists grade of I-II scheduled for elective thyroidectomy were randomly allocated to 3 groups (n=32 for each) to receive TIVA with remifentanil and propofol infusions separately (control group, Group I) or with MIXTIVA infusion that contained remifentanil/propofol at a proportion of 2/1,000 or 3/1,000 (remifentanil concentration, 20 or 30 µg/ml in 1% propofol in Group II or Group III, respectively). The extubation time (the primary outcome of the study), the orientation time and number of patients in whom intraoperative hypotension, hypertension or bradycardia episodes were encountered during anesthesia were comparable among the groups. The mean remifentanil infusion rate in Group III was significantly higher than that in the other groups. The mean propofol infusion rates and mean bispectral index (BIS) scores during anesthesia were comparable among groups. Hypotension accompanied with a high BIS was encountered in one patient in Group III. In conclusion, compared to the standard TIVA technique using separate drug infusions, MIXTIVA infusion used for thyroidectomies did not result in any statistically significant difference in recovery and clinical outcomes. This technique may be considered as a practical implementation for busy ambulatory centers performing general anesthesia. The present study was retrospectively registered at clinicaltrials.gov (trial registration no. NCT04394897).

Sub-Tenon's anaesthesia for modern eye surgery-clinicians' perspective, 30 years after re-introduction

Sub-Tenon's block (STB) is a good technique of local anaesthesia for many types of eye surgery. It has a relatively good risk profile, in that sight- and life-threatening complications appear to be extremely rare. STB has gained popularity in the last three decades, with refinements including different types of blunt metal cannula, plastic cannulae and 'incisionless' approaches. Usage of STB varies significantly across the globe. This narrative review documents the historical evolution of STB techniques, anatomical and physiological considerations, its utility and suitability, complications, explores the current practice and possible future applications.

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.

[A 23-gauge pars plana vitrectomy after induction of general anesthesia: effect of additional retrobulbar anesthesia on postoperative pain]

PURPOSE

Some studies have shown a significant reduction of postoperative pain by additional regional anesthesia in 20-gauge pars plana vitrectomy (20-G-ppV) with the patient under general anesthesia (AN). This observational study examined whether the advantages of additional retrobulbar anesthesia can also be observed with 23-gauge vitrectomy in AN.

MATERIAL AND METHODS

Surgery was performed in 130 patients under AN of which 88 received an additional retrobulbar block (group AN+) and 42 patients were treated without additional injection of retrobulbar anesthesia (group AN) using bupivacaine 0.5 % and mepivacaine 1%. The AN was performed with fentanyl and propofol. Postoperatively, the subjective patient pain was recorded using a numeric scale and the use and amount of analgesic drugs in the postoperative course were monitored.

RESULTS

The mean age of the patients was 53.6 ± 16.8 years, 52.6% of the patients were male, 31.5% were staged as American Society of Anesthesiologists (ASA) level I, 52.3% as ASA II and 15.4% as ASA III. At no time did the study show a statistically significant difference in pain frequency, intensity and analgesic consumption. However, the results suggest that patients in the AN+ group tended to experienced delayed and more intense postoperative pain, which is also reflected in the postoperative use of pain relief medications.

CONCLUSIONS

This study did not show any advantage by additional retrobulbar anesthesia regarding postoperative analgesia compared to an adequate treatment with peripheral acting analgesics during surgery and the early postoperative period.

Sub-Tenon's anaesthesia versus topical anaesthesia for cataract surgery

BACKGROUND

Local anaesthesia for cataract surgery can be provided by sub-Tenon's or topical anaesthesia. Both techniques offer possible advantages. This review, which originally was published in 2007 and was updated in 2014, was undertaken to compare these two anaesthetic techniques.

OBJECTIVES

Our objectives were to compare the effectiveness of topical anaesthesia (with or without intracameral local anaesthetic) versus sub-Tenon's anaesthesia in providing pain relief during cataract surgery. We reviewed pain during administration of anaesthesia, postoperative pain, surgical satisfaction with operating conditions and patient satisfaction with pain relief provided, and we looked at associated complications.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE (last search in November 2014) and the reference lists of published articles. We looked for conferences abstracts and trials in progress and placed no constraints on language or publication status.

SELECTION CRITERIA

We included all randomized studies that compared sub-Tenon's anaesthesia versus topical anaesthesia for cataract surgery.

DATA COLLECTION AND ANALYSIS

We assessed trial quality and extracted data in the format allowing maximal data inclusion.

MAIN RESULTS

We included eight studies in this updated review but could retain in the analysis only seven studies on 742 operated eyes of 617 participants. Two cross-over trials included 125 participants, and five parallel trials included 492 participants. These studies were published between 1997 and 2005. The mean age of participants varied from 71.5 years to 83.5 years. The female proportion of participants varied from 54% to 76%. Compared with sub-Tenon's anaesthesia, topical anaesthesia (with or without intracameral injection) for cataract surgery increases intraoperative pain but decreases postoperative pain at 24 hours. The amplitude of the effect (equivalent to 1.1 on a score from 0 to 10 for intraoperative pain, and to 0.2 on the same scale for postoperative pain at 24 hours), although statistically significant, was probably too small to be of clinical relevance. The quality of the evidence was rated as high for intraoperative pain and moderate for pain at 24 hours. We did find differences in pain during administration of local anaesthetic (low level of evidence), and indications that surgeon satisfaction (low level of evidence) and participant satisfaction (moderate level of evidence) were less with topical anaesthesia. There was not enough evidence to say that one technique would result in a higher or lower incidence of intraoperative complications compared with the other.

AUTHORS' CONCLUSIONS

Both topical anaesthesia and sub-Tenon's anaesthesia are accepted and safe methods of providing anaesthesia for cataract surgery. An acceptable degree of intraoperative discomfort has to be expected with either of these techniques. Randomized controlled trials on the effects of various strategies to prevent intraoperative pain during cataract surgery could prove useful.

Comparing the effect of topical anesthesia and retrobulbar block with intravenous sedation on hemodynamic changes and satisfaction in patients undergoing cataract surgery (phaco method)

BACKGROUND

Cataract is one of the most common surgical procedures in the elderly. In most cases, the elderly have cardiac ischemia or chronic coronary diseases, which would lead to more ischemic events during general anesthesia. Therefore, surgeons and anesthetists prefer regional aesthesia to the general one owing to its more advantages and less complications.

OBJECTIVES

Therefore, this study aimed to compare topical method and retrobulbar block for pain intensity, patient's satisfaction, hemodynamic changes and intra and postoperative complications.

PATIENTS AND METHODS

In a single-blinded clinical trial, 114 patients scheduled for cataract surgery, aged 50 to 90 years with ASA physical status of I-III, were randomly assigned to two groups under monitored anesthesia care as topical anesthesia and retrobulbar block. After the injection of intravenous sedation, which was the combination of midazolam 0.5-1 mg with fentanyl 0.5-1 µ/kg, patients received retro bulbar block or topical anesthesia. During the operation, heart rate, systolic and diastolic blood pressure, mean arterial blood pressure and arterial saturation of O2were measured every five minutes. In addition, pain (VAS) and satisfaction (ISAS) scores were recorded every 15 minutes, then at recovery and one hour after the ending of operation in the ward. Findings were statistically analyzed using SPSS 16.

RESULTS

In this study, no significant association was found between age, gender, education and physical condition of patients in both topical and retro bulbar block groups. Comparison of pain based on VAS, satisfaction based on ISAS score and MAP in the studied periods had no significant differences between the two groups of patients undergoing cataract surgery. However, significant differences were found between the two groups (P = 0.045, 0.02, 0.042 and P < 0.05) regarding heart rate, systolic and diastolic blood pressure and arterial oxygen saturation percentage after 20-30 minutes of the operation.

CONCLUSIONS

Both methods, topical and retro bulbar block had similar impression in cataract surgery regarding analgesia and patient satisfaction. However, in non-complicated cataract surgeries with short duration, topical anesthesia may be the preferable method, because of non-invasiveness, appropriate analgesia, patient satisfaction and hemodynamic stability.

Patient-Satisfaction Measures in Anesthesia

Patient satisfaction is an important measure of the quality of health care and is used as an outcome measure in interventional and quality improvement studies. Previous studies have found that there are few appropriately developed and validated questionnaires available. The authors conducted a systematic review to identify all tools used to measure patient satisfaction with anesthesia, which have undergone a psychometric development and validation process, appraised the quality of these processes, and made recommendations of tools that may be suitable for use in different clinical and academic settings. There are a number of robustly developed and subsequently validated instruments, however, there are still many studies using nonvalidated instruments or poorly developed tools, claiming to accurately assess satisfaction with anesthesia. This can lead to biased and inaccurate results. Researchers in this field should be encouraged to use available validated tools, to ensure that patient satisfaction is measured and reported fairly and accurately.

[Simplified anesthesia protocol for cataract surgery under topical anesthesia: one year retrospective study]

INTRODUCTION

The reduced supply of anesthesiologists in the hospital setting calls for a reconsideration of anesthesia management for ophthalmology patients. Therefore, a simplified management protocol has been designed through close collaboration between the involved specialists for cataract surgery under topical anesthesia (anesthetic eye drops or sub-Tenon's injection).

MATERIALS AND METHODS

At the conclusion of the visit confirming the need for surgery, the surgeon completes a questionnaire designed to elicit a history of the presence of diabetes mellitus (type I or II), prior organ transplantation, chronic renal insufficiency requiring dialysis, communication difficulties, psychiatric disorders, allergy and/or a complex cataract. If one of the items is positive, the patient is scheduled for a preoperative anesthesia consult. If all the items are negative, this anesthesia evaluation is waived. The surgeon explains the fasting requirement and how to take the patient's usual medications on the morning of surgery. The patient continues his/her medications. No lab tests or chest X-ray are performed. If necessary, the surgeon prescribes preoperative antibiotic prophylaxis and any other preparation. During the surgery, the patient receives IV fluids and is monitored via EKG, non-invasive blood pressure and pulse oxymetry by a certified nurse anesthetist. The anesthesiologist on duty (one per every four rooms) is immediately available for the slightest problem. The surgeon signs the postoperative anesthesia note and discharge order.

RESULTS

This procedure was assessed by one surgeon over a one year period, including 145 patients (60% of the patients recruited for this surgery), primarily outpatient (77%) under topical anesthesia (Oxybuprocaine(®)+Visthesia(®), Zeiss) or under sub-Tenon's injection (Xylocaïne(®)). No major complications were observed. Seven cases of arterial hypertension, treated with calcium channel blockers (nicardipine), and three episodes of brief anxiety were observed.

CONCLUSION

This simplified anesthesia protocol appears to be safe and effective but requires more demanding involvement of the surgeon, whose scope of competence and responsibility must naturally increase. This is the only way by which cataract surgery can remain competitive.

[Sub-tenon block for ocular globe anesthesia: a review]

Sub-Tenon anesthesia is an effective, well-tolerated technique for surgery in the anterior or posterior compartments of the eye. The advantages of this block are comparable to those of peribulbar and retrobulbar anesthesia and complications are minimal. Sub-Tenon anesthesia provides better analgesia than akinesia. Most studies suggest that sub-Tenon anesthesia is a good technique to choose, given that potential adverse effects are fewer than for other regional blocks and analgesia and akinesia are superior.

Effects of propofol versus urapidil on perioperative hemodynamics and intraocular pressure during anesthesia and extubation in ophthalmic patients

AIM

To compare the effect of propofol versus urapidil on hemodynamics and intraocular pressure during anesthesia and extubation for ophthalmic patients.

METHODS

Eighty-two surgical patients (Class: ASA I-II) were randomly assigned to propofol (n=41) and urapidil groups (n=41). Their gender, age, body mass, operation time and dosage of anesthetics had no significant difference between the two groups (P>0.05). The patients of propofol and urapidil groups were given propofol (1.5mg/kg) and urapidil (2.5mg/kg) respectively; and two drugs were all diluted with normal saline to 8mL. Then the drugs were given to patients by slow intravenous injection. After treatment, the patients were conducted immediate suction, tracheal extubation, and then patients wore oxygen masks for 10 minutes. By double-blind methods, before the induction medication, at the suction, and 5, 10 minutes after the extubation, we recorded the systolic and diastolic blood pressure (BP), heart rate (HR), pH, PaO(2), PaCO(2), SaO(2) and intraocular pressure (IOP) respectively. The complete recovery time of the patients with restlessness (on the command they could open eyes and shaking hands) was also recorded during the extubation. The data were analyzed by using a professional SPSS 15.0 statistical software.

RESULTS

The incidence of cough, restlessness and glossocoma was significantly lower in the propofol group than that in the urapidil group after extubation (P<0.05). There were no episodes of hypotension, laryngospasm, or severe respiratory depression. There was no statistical difference in recovery time between two groups (P>0.05). In propofol group, the BP and HR during extubation and thereafter had no significant difference compared with those before induction, while they were significantly lower than those before giving propofol (P<0.05), and had significant difference compared with those in urapidil group (P<0.05). Compared to preinduction, the BP of urapidil group showed no obvious increase during aspiration and extubation. The HR of urapidil group had little changes after being given urapidil, and it was obviously increased compared with that before induction. The stimulation of aspiration and extubation caused less cough and agitation in propofol group than that in urapidil group (P<0.05). The IOP of propofol group showed no obvious increase during extubation compared with that in preinduction, while in the urpidil group, extubation caused IOP significantly increased (P<0.05). The changes in these indicators between the two groups had no significant difference (P>0.05).

CONCLUSION

Compared to urapidil, propofol is superior for preventing the cardiovascular and stress responses and IOP increases during emergence and extubation for the ophthalmic patients. Moreover, it has no effects on patient's recovery.