Local anesthesia for cataract surgery

REVIEW/UPDATE

Local anesthesia f
or cataract surgeryAdeela Malik, MBBS, Emily C. Fletcher, MRCOphth, Victor Chong, FRCOphth, Jay Dasan, FRCA
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Various aspects of local anesthesia for cataract surgery, such as the anesthetic agents and theirinteraction with ocular nerve supply, anesthesia requirements, available clinical techniques andtheir inherent complications are reviewed. A comparative evaluation of clinical techniques in termsof efficacy, akinesia, and patient-perceived pain during both anesthesia administration and intra-operative cataract surgery is presented, along with the prevailing practice patterns of anesthesiatechniques among refractive surgeons in the United Kingdom and United States. More randomizedclinical trials are needed to facilitate statistical methods of metaanalysis to establish convincinglythe overall benefits and efficacy of the various local anesthesia procedures in cataract surgery. Thewide scope of the present review is of relevance in structuring ophthalmology and anesthesia spe-cialist training programs for junior staff.

Financial Disclosure: No author has a financial or proprietary interest in any material or methodmentioned.

J Cataract Refract Surg 2010; 36:133–152 Q 2010 ASCRS and ESCRS

Significant changes in the techniques and instrumenta- complications, and illustration of practice patterns of
tion used for cataract surgery1 over the past 20 yearshave led to the development of the clear corneal su-tureless phacoemulsification technique for cataractsurgery.2,3 Progression of the surgical approach hasled to better outcomes in routine and complex cases.Along with this development has come an inevitablechange in delivery of the accompanying anesthesiafrom general to topical modalities.4–6 This article re-views the changes in anesthesia delivery and the evi-dence behind these changes.
The article includes a brief description of the histor-ical developments in surgical techniques for cataractextraction, typical anesthetic agents used in ocular sur-gery, and the ocular nerves relevant to local anesthe-sia. Discussion of anesthesia requirements for thesafety and comfort of patients, description of the clin-icalmethodologies used for implementation of variouslocal anesthesia modalities along with the associated

ruary 8, 2008.ubmitted: September 29, 2009.ber 1, 2009.

tment of Ophthalmology (Malik), Epsom & St. Helierpitals, Carshalton, Department of Ophthalmologyg,), Oxford Eye Hospital, Headington, and Depart-thesia (Dasan), King’s College Hospital, London,.

author: Adeela Malik, MBBS, Department of Oph-psom & St. Helier University Hospitals, Wrytheon, Surrey, United Kingdom, SM5 1AA. E-mail:gmail.com.

d ESCRS

ier Inc.

use of various anesthesia techniques among the refrac-tive surgeons in the United Kingdom and NorthAmerica are also included. Finally, a comparativeevaluation of the various local anesthesia techniqueswith respect to patient-perceived pain and their effec-tiveness in promoting akinesia is presented, witha view to identifying an optimum local anesthesiastrategy for cataract surgery.

PROGRESSION AND HISTORICAL DEVELOPMENT OFSURGICAL TECHNIQUES IN CATARACT EXTRACTION

During the first half of the 20th century, intracapsularcataract extraction (ICCE) was the predominant formof lens removal. It involved removal of the entirelens and capsule using a large 180-degree limbal inci-sion aided by mechanical or chemical cleaving of zon-ular attachments. In this procedure, vitreous loss,hemorrhage, retinal detachment, chronic cystoid mac-ular edema, and high astigmatismwere common com-plications, with a prolonged recovery time. During thesecond half of the 20th century, with the introductionof the intraocular lens (IOL), ICCE was supersededby extracapsular cataract extraction (ECCCE).7–11

This involved a smaller incision1,3 (10.0 mm to 11.0mm) and the lens nucleus was prolapsed out of thecapsular bag, and eventually out of the eye, after anopening ‘‘capsulectomy’’ was created in the anteriorcapsular bag. The intact posterior capsule providedsupport for the IOL, and also reduced the risk for vit-reous loss. However, the remnant cortical material thatcould not be removed during the procedure resulted in

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mailto:[email protected]

134 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

severe postoperative inflammation and dense poste-rior membranous opacification.

Improvements in automated irrigation/aspirationsystems,7 including capsulectomy techniques8 andthe advent of phacoemulsification,7,12 considerablyimproved ECCE techniques. Today, phacoemulsifica-tion with a small incision is the method of choice formost cataract surgeons. The procedure provides acontrolled, faster, and safer method of removing thenucleus with an intact posterior capsule. The smallwound provides rapid visual recovery for the patient,and also reduces intraoperative complications such asexpulsive hemorrhage, high astigmatism, and trau-matic wound rupture. However, in these procedures,attention to proper wound construction,10 capsulec-tomy, ophthalmic viscosurgical devices, and nucleardisassembly is important.

Phacoemulsification, which removes the lens withultrasonic energy, can be performed in the anteriorchamber, iris plane, or posterior chamber. Ophthalmicviscosurgical devices1,9 have been instrumental in al-lowing the safe adaptation of phacoemulsification inECCE. During cataract surgery, endothelial cell losscan occur from physical contact between the cornealendothelium and IOL, damage from phacoemulsifica-tion energy, loss of fluid during irrigation, air bubbledamage, contact with nuclear fragments, or toxic ef-fects from intracameral medication. Ophthalmic visco-surgical devices reduce mechanical trauma to thecorneal endothelium as well as maintain intraocularspace, even when there is an incision in the eye.

Several methods of anesthesia are available forcataract extraction. General anesthesia was preferredfor ICCE procedures as these techniques involved sig-nificant manipulation of the eye, and required severalcorneal sutures to provide awatertight wound. Extrac-apsular cataract surgery1,7–10 also required a large cor-neal incision, but there was a trend toward localanesthesia such as retrobulbar,13,14 which allowedquicker patient recovery and thus facilitated day-case surgery.

With the introduction of foldable IOLs,15 small-incision surgery developed with phacoemulsifica-tion.1,15–17 Initially, this was performed via a scleraltunnel and thus required sutures, so retrobulbar andperibulbar anesthesia were preferred.13,18 Becausethe corneal incision is inherently small, stepped, andself sealing, very little manipulation is required andthis has allowed the use of sub-Tenon19–22 and topicalanesthesia.13,23–25

Any anesthesia technique for cataract surgery muststrive for patient safety, comfort, and the attainment ofsafe conditions for the necessary surgery. Essentially,the anesthesia modality must be assessed on an indi-vidual patient and surgeon basis. The progression

J CATARACT REFRACT SURG -

and development of the anesthesia technique ensuresminimal risk from the anesthetic agent only if thereis minimal risk from the surgery as a whole.

In some of the literature, retrobulbar, peribulbar,and sub-Tenon anesthesia is referred to as intraconal,extraconal, and parabulbar blocks, respectively; how-ever, in this paper the former terminology is used.

ANESTHETIC AGENTS

The choice of a local anesthetic agent is optimal onlywhen its inherent properties meet both the characteris-tics of the surgical procedure and the requirements ofthe patient in terms of contraindications and perceivedpain. The relative performance, efficacy, and underly-ing complications of local anesthetic agents, includingtoxicity, have been discussed extensively.21,26–36 Thepharmacology and pathogenesis of toxicity of the var-ious agents are also well documented.29 Table 1 liststhe properties of common anesthetic agents. Lido-caine, bupivacaine, and ropivacaine are the most pop-ular traditional agents used for conduction blockades.Levobupivacaine, articaine, and 2-chloroprocaine arerecent developments. Table 2 lists the typical agentsused for various anesthesia techniques, and Table 3depicts the onset time to akinesia for the traditionaland newer agents.

The use of hyaluronidase in regional anesthesia iscontroversial. However, as an adjuvant in retrobulbarand peribulbar anesthesia,6,9,42 it enhances the onset ofthe block. It also improves the onset and quality of theblock in the sub-Tenon procedure by promoting diffu-sion to the periorbital and retroorbital tissue19,43–45

and alleviating the need for a facial nerve block, whichcan be painful.31,45 Hyaluronidase6 helps to preventa decrease in retinal circulation, an increase in intraoc-ular pressure (IOP) and also reduce the risk for muscletoxicity from local anesthetic agents.

Intracameral anesthesia (injection into the anteriorchamber) is often used as an adjunct to topical anes-thesia to enhance the anesthesia and thereby dealwith incremental pain that may arise during topicalanesthesia alone. Ester-linked benoxinate (oxybupro-caine), amide-linked lidocaine, and ester-linked tet-racaine (amethocaine) are the most commonly usedtopical agents6 for anesthesia of the cornea andconjunctiva.

ANATOMY AND OCULAR NERVE SUPPLY IN LOCALANESTHESIA

An understanding of the anatomy of the orbit and itscontents is essential for the safe practice of regionalanesthesia, and these are adequately covered in the liter-ature.46,47 Regional anesthesia can be broadly dividedinto 3 categories: the first attains globe and conjunctival

VOL 36, JANUARY 2010

Table 1. Properties of popular local anesthetic agents used for ocular surgery.26,29,35, 36

Agent Type Onset Potency Toxicity Duration

TraditionalProcaine Ester Slow Low Low Short2-chloroprocaine Ester Rapid Intermediate Low ShortTetracaine(amethocaine)

Ester Slow Intermediate Intermediate Intermediate

Cocaine Ester Slow High Very high: LongBenoxinate(oxybuprocaine)

Ester Must be used in lowest possible dosage36 to avoid (1) lethal reactions in low cholinesteraseactivities; (2) allergy to para-aminobenzoic moities; (3) absorption through nasal–lacrimalapparatus or mucous membrane

Bupivacaine Amide Slow High High LongLidocaine Amide Rapid Intermediate Low ShortRopivacaine Amide Slow Intermediate Intermediate LongEtidocaine Amide Rapid High High Long

Newly developedArticaine Amide Rapid d Low LongLevobupivacaine Amide Slow d High Long2-choloroprocaine Ester Rapid d Low ShortProxymethacaine Ester Rapid d Low Intermediate

135REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

anesthesia; the second leads to globe, lid, andperiorbitalakinesia; and the third gives rise to intraocular hypot-ony. The first category is particularly suited to a compli-cated and prolonged surgery, and the other 2 areadequate for less stringent operating requirements.

Globe and conjunctival anesthesia is achievedthrough conduction blockade of the sensory functions

Table 2. Typical anesthetic agents for various conduction blocksand topical and intracameral anesthesia techniques.

Technique/Anesthetic Agent Remarks

Regional/conduction block(retrobulbar, peribulbar,sub-Tenon)

Lidocaine 2% For short proceduresLidocaine 2% C bupivacaine0.75% or ropivacaine 1%

For procedures lasting1 hour

50%–50% mixtureof lidocaine 2% andbupivacaine 0.75%

For rapid onset and longprocedures

TopicalEyedrops d

Proparacaine d

Tetracaine d

Lidocaine d

Bupivacaine d

Benoxinate d

Viscous lidocaine gel d

IntracameralMixture of preservative-freelidocaine 1% andpreservative-free bupivacaine0.5% eyedrops

d


of the ophthalmic andmaxillary division of the trigem-inal nerve,46,48,49 whereas globe akinesia requires con-duction blockade of the intraorbital portions of theoculomotor cranial nerves III, IV, and VI. Mechanicalorbital compression devices are often used to attainglobe hypotony.36 Sensory innervation of the globeand its internal structures is mainly via the long andshort ciliary division of the nasociliary nerve (Figure 1).The short ciliary nerve progresses anteriorly, provid-ing sensation to the globe and autonomic motor func-tion to the iris. It also traverses the retrobulbar coneand sub-Tenon space and is thus susceptible to block-ade by local anesthesia.

Table 4 lists the various regions of the eye and thesubserving sensory nerve distribution. Figure 2 de-picts the various extraocular muscles responsible foreye movement.46,49 The oculomotor nerve (cranialnerve III) provides most of the motor innervation forthemovements of the globe through all the extraocularmuscles, except the superior oblique and lateral rectus.The lateral rectus muscle is supplied by the abducentnerve (cranial nerve VI) and the superior obliquemuscle, by the trochlear nerve (cranial nerve IV).

The oculomotor nerve or cranial nerve III suppliesthe levator palpebrae muscle for opening the eyelid,and the facial nerve or cranial nerve VII supplies theorbicularis oculi muscle for closing the eyelid.49 Facialnerve block is used rarely as it is painful and causesbruising. However, the orbicularis oculi can beblocked easily from within the orbit, especially by in-jecting into the nasal compartment and spreading theblock using ocular compression devices.28,48 The ocu-lomotor nerve enters the ‘‘bellies’’ of the recti muscles


Table 3. Typical onset times and other properties of traditional (bupivacaine 0.5% C lidocaine 2%) and new (ropivacaine, levobupivacaine,2-choloroprocaine, and articaine) local anesthetic agents.

Anesthetic Agent Onset Time* (Min) Remarks

Bupivacaine26,37 (peribulbar approach)50:50 mixture of bupivacaine 0.5% (with 1:200 000epinephrine C 30 IU/mL hyaluronidase)& lidocaine 2%)

Mean 7.2 G 5.7 (SD) (1) Cardiotoxic(2) No adverse effects due to diplopia, althoughsome reports suggest diplopia not resolveduntil next day

Ropivacaine38 (peribulbar approach)Comparative study:Ropivacaine C lidocaine 2.0% C hyaluronidasevs bupivacaine C lidocaine 2.0% C

hyaluronidase

Median 8.0 (both agents) (1) Ropivacaine: Less cardiotoxic with higherthreshold for central nervous system toxicity thanbupivacaine(2) Recovery of motor function after 15 min, 55% forropivacaine 0.50% and 82% for ropivacaine 0.75%;after 60 min, 37% and 5%, respectively.(2) Diplopia persists for 30 hoursfor ropivacaine 1.00%

Levobupivacaine39 (sub-Tenon approach)Comparative study (sub-Tenon approach) (1) Levobupivacaine less cardiotoxic

Levobupivacaine 0.75% C hyaluronidasevs lidocaine 2.00% C hyaluronidase

5.06 levobupivacaine3.02 lidocaine

Median 2.0 both agents

(2) For (A) Onset difference between levobupivacaine0.75% and lidocaine 2.00% not clinically significant39

Levobupivacaine (peribulbar approach)Comparative study:

Levobupivacaine 0.75% C hyaluronidasevs bupivacaine 0.75% C hyaluronidase

2-Choloroprocaine40 (peribulbar approach)Comparative study: Full recovery of extraocular muscle

and eyelid motion !85 min for 2-choloroprocaine2% and !100 min for 2-choloroprocaine 3%

2-choloroprocaine 2% vs 2-choloroprocaine 3%(both preservative free)

!4 for 2% and 6 for 3%

Articaine41 (peribulbar approach)Comparative study:

(A) Articaine 2% C 1:200 000 epinephrineC hyaluronidase vs bupivacaine 0.5%C lidocaine 2.0%C hyaluronidase

Degree of ocular akinesia after 1 min, same with articaine 2.0% and bupivacaine0.5%; after 5 min, greater with articaine 2.0% than with bupivacaine 0.5%;at discharge, extraocular motion regained quicker with articaine 2.0% thanwith bupivacaine 0.5%.

Articaine (inferotemporal injection approach)Comparative study:Repeat of (A) Onset times same as for peribulbar approach

Atticaine (sub-Tenon approach)Comparative study:Articaine 2.0% vs bupivacaine 0.5%C Lidocaine 2%

Onset times faster with articaine 2.0% than with bupivacaine 0.5%

*To akinesia or time to start surgery


from the conal surface, and the local anesthetic agenthas to reach the exposed 5.0 to 10.0 mm segment ofthe motor nerves in the posterior intraconal space forconduction block of these nerves to promote akinesiain the associated muscles.

The apex and superomedial parts of the orbit are themost vascular areas, congestedwith nerves, blood ves-sels, and muscles; hence, needle penetration should be


avoided in these parts. Table 5 indicates the extent ofblockade achievable for various regional anesthesia in-jection approaches.36,41

LOCAL ANESTHESIA REQUIREMENTS

Efficacy

The efficacy of anesthesia partly depends on the easeof irrigation and partly on its spread after injection. A


Figure 1. Diagram of the division of the ophthalmic nerve. Left: Long and short ciliary division of the nasociliary branch. Right: Lacrimal andfrontal branches.


study using magnetic resonance imaging has exam-ined the distribution of local anesthesia solution in var-ious modalities such as combined peribulbar andretrobulbar, superomedial retrobulbar, and sub-Tenoninjection modalities. It reported that for a combinedperibulbar and retrobulbar block,50 a relatively largevolume of local anesthetic solution spreads through-out the orbit and a reliable anesthesia is achieved.For the superomedial retrobulbar or sub-Tenon injec-tions, the local anesthetic solution accumulates behindthe globe, and good analgesia and slight akinesia areachieved with a small volume of anesthetic solution.However, as discussed, the superomedial approachis not favored because of the close proximity to thecluster of nerves and blood vessels. The effectiveness

Table 4. Distribution of sensory nerve supply to various regionsof the eye and its structures.

Region Nerves

Sclera, cornea, ciliarybody, and iris

Nasociliary branches:short ciliary long ciliary

Conjunctiva:Superior Frontal branches: supraorbital,

supratrochlear Nasociliarybranch: infratrochlear

Inferior Maxillary branch: infraorbitalLateral Lacrimal Maxillary branch:

zygomaticofacialCircumcorneal Long ciliary

Periorbital skin Frontal branches: supraorbital,supratrochlearMaxillary branch:infraorbital Lacrimal


of various anesthesia modalities is discussed furtherunder ‘‘Comparative Evaluation of Various Local An-esthesia Techniques.’’

Akinesia

Manysurgeonsdonot considerakinesia an importantrequirement for cataract surgery, but some prefer to op-erate under conditions in which eye movements areblunted if not completely paralyzed. Friedman et al.27

report that both retrobulbar and peribulbar blocks pro-duce the samedegree of akinesia. The samesurvey com-paring retrobulbar and sub-Tenon techniques reportsthat akinesia was slightly less effective with sub-Tenon;but, the statistical evidence for this was poor. Topicalprocedures, however, do not lead to akinesia.

Patient Preference (Pain Experience)

Significant pain during anesthetic administration,intraoperative surgery, or after the cataract procedureare the major reasons for low patient satisfaction.51

Perceived pain level thus determines patient’s prefer-ence for the anesthesia technique and is an importantfactor in the selection of an optimum strategy for anes-thesia management during cataract surgery. Duringthe anesthesia administration phase, topical anesthe-sia, unlike injection-type anesthesiamodalities, is asso-ciated with minimal discomfort. However, withtopical anesthesia, only the trigeminal nerve endingsin the cornea and the conjunctiva are blocked,52 leav-ing the intraocular structures in the anterior segmentunanesthetized. Thus, manipulation of the iris orstretching of the ciliary and zonular tissues irritatesthe ciliary nerves, resulting in discomfort. Injectable


Figure 2. Extraocular muscles.


anesthesia overall provides a higher level of analgesiaand akinesia than topical anesthesia, but the degree ofpain perceived by patients during anesthesia adminis-tration and intraoperative surgery for individual retro-bulbar, peribulbar, or sub-Tenon modalities varies.The patient-reported pain for various anesthesia tech-niques is discussed in detail under ‘‘ComparativeEvaluation of Various Local Anesthesia Techniques.’’

Visual Recovery

Rapid vision recovery is highly desirable in cataractsurgery and is extremely useful, especially in monocu-lar patients having surgery in the better eye. Modernophthalmologic surgery is becoming faster and ina typical ophthalmology clinic, an uneventful cataractsurgerymay take 20minutes or less; this allows the pa-tient to be discharged without an eye patch and good


vision. Compared with a regional block, topical anes-thesia permits early visual rehabilitation, primarily be-cause in this modality only a limited block or no blockof the optic nerve is involved.

The overall onset and duration times of any selectedanesthetic agent depends on its specific pharmacolog-ical properties, on the method of administration, themixture properties including hyaluronidase content(Tables 1 to 3). The duration of the anesthesia deter-mines the postoperative recovery and assessment inmost cases, but, as in other procedures, children or pa-tients with learning difficulties are treated under gen-eral anesthesia.

Sedation

Administration of an orbital block can result ina great deal of pain; consequently, some clinicians


Table 5. Various regional anesthetic injection approaches andthe resulting blockade of relevant nerves.

Injection location Blockade

Inferotemporal approach Lacrimal, nasociliary, andfrontal (supraorbital andsupratrochlear) nerves

Medial approach (placedbetween the caruncle andthe medial canthal angle)

Medial branches of nasociliary(long ciliary) nerve;infratrochlear nerve andmedialcomponents of supraorbitaland supratrochlear nerves

Superomedial approach Here the needle would be incontact with a path congestedwith nerves, blood vessels, andmuscles, and this approach istherefore best avoided.

Superolateral approach This would avoid theimpediments encountered inthe superomedial approach.The needle is placed throughthe skin of the upper lid as therelevant area of conjunctiva isinaccessible.

Figure 3. Typical initial instrument entry/incision points (unfilledmarkers), and the associated terminal points for anesthetic delivery(filled markers) within the orbit for various anesthetic techniques (cor-onal section, right eye). See also Tables 5 and 6.


use deep sedation. However, many believe the patientshould not be sedated deeply so that he or she remainscooperative. In the UK, the use of sedation decreasedfrom 5.85 % in 1996 to 3.9% in 2002/2003.53,54 Thepractice of sedation is, however, not recommendedby the Royal College of Anaesthetists55 and thusshould be used to cover only anxiety, not inadequateblocks. Complications of sedation include excessiverestlessness, sudden movement, and airway obstruc-tion, which can significantly increase the risk of thesurgery.6,51,56 If the patient is sedated, monitoring isrequired. The anesthetist should be present and re-sponsible for the intravenous (IV) sedation. It is con-sidered safer to abandon surgery than to convert togeneral anesthesia, and to continue with general anes-thesia only when the patient is fully prepared. ‘‘Con-scious’’ sedation, which allows full cooperation ofthe patient, is recommended.57 The level of sedationdesired, the route of administration, and the choiceof drugs commonly used in ophthalmic anesthesiahave been reviewed elsewhere.58

Cost

Literature on the economic evaluation of differentsystems for cataract surgery and anesthesia is limited,and there is ongoing discussion of the most appropri-ate methods that can be used.59 According to a surveyreported by Mojon-Azzi and Mojon,60 outpatient sur-gery is more cost-effective, primarily because thereare no costs for overnight stays and lower out-of-


pocket expenses. In some European countries (eg,Holland), the cost savings are estimated at about20%. The survey also reports that the rate of outpatientcataract surgery in 10 European countries is influencedmainly by acute-bed density, density of practicingphysicians, and public expenditure on health.60

CHOICE OF ANESTHESIA DELIVERY

General Anesthesia

Especially with the advent of day surgery, generalanesthesia is reserved for cases that are unsuitablefor local anesthesia: patients (such as a child or a youn-ger adult) intolerant to the local anesthesia procedure,confused patients unable to comply, patients withmarked uncontrolled tremor or jerky movements, pa-tients with a history of allergic reaction to local anes-thesia, and patients who refused consent for localanesthesia.

Local Anesthesia

Local anesthesia for cataract surgery promises a bet-ter procedural safety profile6,28 and has allowed devel-opment of day-surgery cases and quicker patientrecovery generally and visually; it is also amore viabletechnique financially. Figure 3 illustrates the initial en-try/incision and the final anesthesia-delivery pointsfor the cannula/needle tip for the various local anes-thesia techniques. A typical initial cannula entry/inci-sion point, the terminal anesthetic delivery point andthe path traversed by the cannula tip are illustratedin Figure 3. Table 6 describes an appropriate entry lo-cation for the cannula in this modality, including typ-ical procedural maneuvers involved, and the extent ofthe resulting anesthesia. Table 6 lists the typical proce-dural details for each technique.


Table 6. Typical cannula entry/incision locations for various local anesthetic modalities, procedural techniques, and nature of anesthesiaachieved (see also Figure 3).

Technique Cannula Entry Point/Incision Location Procedure/Remarks

(1) Retrobulbar Avascular area inferotemporal quadrant(or nasal side of medial rectus muscle)

The syringe needle is initially inserted horizontally in an axial directionthrough the lower eyelid (just above the lateral orbit margin) up to theeye–equator plane, and then the needle is inclined upward and pushedposterior to the bulb. Both themotor and the sensory nerves are affected49;the oculomotor (III) and abducent (VI) motor nerves paralyze allextraocular muscles except the superior oblique. Ciliary ganglion is alsoblocked. The entire globe is anesthetized as a result of blocking thenasociliary and the long ciliary nerves (from Lipatka et al.62, Hamilton64,and Freeman and Freeman65).

(2) Peribulbar Avascular areaNasal side of medial rectus(or inferotemporal quadrant)

For the needle tip to end up beyond the equator plane, the syringe needleis inserted horizontally through the conjunctiva or the lower eyelid, in anaxial direction above the infraorbital margin. It is angled upward fordelivery. Here the injectate is deposited within the orbit and does notenter the geometric confines of the cone of the rectus muscle. 48 Duringthis procedure, local anesthesia affects the motor nerve supply of thesuperior obliquemuscle and also the orbicularis muscle due to the spreadof local anesthesia through the orbital septum (fromHamilton64, Freemanand Freeman65, and Kumar and Fanning66).

(3) Sub-Tenon Incision of tented conjunctiva,inferonasal quadrant

A small incision is made inferonasally through the conjunctival and sub-Tenon layers. Using a sub-Tenon curved blunt cannula placed throughthe incision to the sub-Tenon space; 3.5 to 5 mL of local anesthetic isinjected. Ocular massage is optional. Iris and anterior segment anesthesiais achieved,48 and is better than subconjunctival injection alone. Thedegree of abolition of extraocular muscle movement is proportional to thevolume and depth of the injectate.With age,19 the posterior Tenon capsuledegenerates and fenestration probably aids diffusion of anesthetic intoretrobulbar cone (from Canavan et al.19 and Kumar and Dodds63).

(4) Topical Drops administered tocornea and fornix

Drops or gel are/is applied to the surface of the conjunctiva and corneapreoperatively. Trigeminal nerve endings in the cornea and conjunctivaonly are blocked.52 Intraocular structures in the anterior segment are notanesthetized (from Cass26 and Fichman67).

(5) Intracameral Injected though cornealincision during surgery

Preservative-free anesthetic agent (usually lidocaine 1%) is injected intothe anterior chamber at the beginning of the operation through 1 of thecorneal incisions required for phacoemulsification. It provides sensoryblockage of the axis and the ciliary body (from Cass26 and Gills et al.68).


LOCAL ANESTHESIA TECHNIQUES

Retrobulbar (Intraconal) Anesthesia

The retrobulbar procedure achieves good ocularakinesia and analgesia and generally requires an injec-tion of 3.5mL to 5.0mL of anesthetic agent into the ret-robulbar space.14,32,61,62 According to Feibel,14 in thistechnique, a shorter needle (31 mm versus 38 mm) isintroduced into the retrobulbar space by having thepatient in primary gaze. Precision placement of theneedle is essential to avoid complications (Figure 3and Table 6).

In a survey of members of the American Society ofCataract and Refractive Surgery (ASCRS),69 the per-centage of respondents using retrobulbar anesthesiawith some facial block decreased from 76% in 1985 to


9% in 2003; and the procedure was used primarily forlonger operations in eyes with a less stable anteriorchamber.

Peribulbar (Extraconal) Anesthesia

The peribulbar technique involves administrationof several (up to 4) injections external to the musclecone (Figure 3 and Table 6) and achieves good oc-ular akinesia and anesthesia.13,18,70 An audit of peri-bulbar blockade using short (15.0 mm), medium(25.0 mm), and long (37.5 mm) needles (disregard-ing the inherent safety aspects of the length of theneedles in this particular study for teaching pur-poses) concluded that the efficacy of peribulbar an-esthesia depends on the proximity of the deposition



of the local anesthetic solution to the globe or theorbital apex.71 Consequently, peribulbar anesthesiacan be classified as circumocular (sub-Tenon epis-cleral), periocular (anterior, superficial), periconal(posterior, deep), and apical (ultra deep). Peribulbarblockade can lead to significant reduction in pulsa-tile ocular blood flow and IOP, which may be ofbenefit in certain operations.72

Peribulbar anesthesia is the local anesthesia ofchoice in complex cataract cases that need total aki-nesia or iris manipulation. It provides superior aki-nesia and anesthesia, and in well-trained hands,there is an extremely low risk for globe penetration.However, an inherently large-volume injection re-quirements for peribulbar anesthesia leads to a rela-tively higher chemosis compared to that inretrobulbar anesthesia.

Sub-Tenon (Parabulbar) Anesthesia

Sub-Tenon anesthesia has been popular.13,19,20,63,73

The technique begins with instillation of topical anes-thesia. The Tenon capsule is then dissected, and a bluntcannula is introduced48 into the sub-Tenon space toadminister the anesthetic agent. This produces ante-rior segment and conjunctival anesthesia.19,63,73 Anes-thesia sets in rapidly, followed after a few minutes byglobe akinesia.

The Tenon capsule is a fascial layer of connective tis-sue surrounding the globe and extraocular muscles.19

It is attached anteriorly to the limbus of the eye, ex-tends posteriorly over the surface of the globe, andfuses with the dura surrounding the optic nerve. Thecavity is bound by the Tenon capsule and sclera.

The sub-Tenon technique has been used increas-ingly for posterior segment eye surgery such as retinaldetachment surgery.74,75 However, the technique re-quires a certain amount of skill to dissect into thesub-Tenon space and correctly placing the anestheticagent, as well as competence to deal with an increasedrisk of conjunctival bleeding and chemosis.

The incidence of conjunctival swelling associatedwith the sub-Tenon block is around 39.4%.19,76

Some of this is attributable to anterior leakage ofthe injectate, and chemosis is exaggerated if the solu-tion is administered incorrectly into the anteriorcompartment of sub-Tenon space or the subconjunc-tival space. The reported incidence of subconjuncti-val hemorrhage is 32% to 56%.19,77 Cauterization ofthe conjunctival incision is often used to reducehemorrhage.

Amin et al.74 suggest the use of a standard IV can-nula (instead of the sub-Tenon cannula) to puncturethe anesthetized and tented conjunctiva to reduce che-mosis and subconjunctival hemorrhage. It is claimed


that here the ‘‘minimal risk’’ of puncturing the eye isassured because of the clear visibility of the needletip at all times. Gray and Lucas20 point out that theneedle tip is not clearly visible once under the conjunc-tiva and in the event of hemorrhage, it would quicklybe obscured. Thus, Amin et al methodology has noadditional safety compared with the normal peribulbartechnique.

Topical Anesthesia

For fast recovery and rehabilitation after surgery,cataract patients are often managed under topical an-esthesia, which can be supplemented with intracam-eral anesthesia6,13,24 oral or IV sedation.23 One bonusof topical anesthesia, especially in patients who havevision in the operated eye only, is that visual recoveryis almost immediate.

Several methods of topical anesthesia are available,but the use of eyedrops or viscous gels are the mostcommonmodalities. Considerations such as corneal en-dothelial toxicity,81 patient comfort, and patient historyof allergies to local anesthetic determine the choice ofsuitable anesthetic eyedrops for use in any particularsituation. Primarily, proparacaine, tetracaine, lidocaine,bupivacaine, or benoxinate anesthetic eyedrops(Table 2) into the fornix of the operative eye are used.

Topical anesthesia has also been used with varyingdegrees of success for combined cataract and glau-coma surgery, trabeculectomy,78 viscocanalostomy,and secondary IOL transplantation.

It has been demonstrated to be a safe and effective al-ternative to retrobulbar and peribulbar procedures, butit does not provide akinesia and may even give inade-quate sensory blockade for the iris and ciliary body.26

Consequently, it is used for short surgeries and incooperativepatientswith low tomediumanxiety.A sig-nificant number of surgeons reckon that for routinesmall-incision cataract surgery, ocular anesthesia witha topical anesthetic agent is sufficient.13,26,79

Topical anesthetic agents52 block trigeminal nerveendings in the cornea and the conjunctiva only, leav-ing the intraocular structures in the anterior segmentunanesthetized. Thus, manipulation of the iris andstretching of the ciliary and zonular tissues during sur-gery can irritate the ciliary nerves, resulting in discom-fort. For this reason, the addition of intracameralanesthesia as an adjunct is popular.5,13,26,80

High or prolonged doses of local anesthetic agentsare toxic to the corneal epithelium, and this prolongswound healing and causes corneal erosion. Also, re-peated administration of drops can cause clouding ofthe cornea, rendering surgery more difficult. Tetra-caine (an ester-type anesthetic agent) is the most irri-tating of the eyedrops listed above and should be



avoided in patients allergic to this particular family ofanesthetic agents.26 Proparacaine, although an estertype, does not metabolize to p-aminobenzoate moiety,and thus may be used safely in patients allergic toother ester-type anesthetic agents.

An alternative to eyedrops for topical application isthe use of viscous lidocaine gel. The gel is often mixedwith dilating medications, antibiotics and nonsteroi-dal antiinflammatory agents. It is reported that 5 mLof lidocaine gel 2% mixed with 4 drops tropicamide,4 drops cyclopentolate 1%, 4 drops phenylephrine10%, 10 dropsmoxifloxacin, and 4 drops ketorolac, ap-plied to the operative eye twice before the surgery typ-ically achieves excellent dilation and anesthesia.26

However, drug absorption and corneal epithelialsafety of this mixture have not been fully investigated.

A comparative clinical trial of topical anestheticagents in cataract surgery82 suggests that lidocainegel is a better agent than bupivacaine or benoxinatedrops. However, bupivacaine drops are effective inproviding deep topical anesthesia. The reported verbalpain score (VPS) during surgery for lidocaine gel, bu-pivacaine, and benoxinate drops was 1.6, 4.1, and7.1, respectively (using an arbitrary pain scale of 0 to10 where zero represents no pain and a score of 10,high pain). The VPS during application of the agentwas 2.97, 1.53, and 1.03, respectively.

Several studies have compared the relative perfor-mance of topical anesthesia and regional blocks. Onestudy shows that although the topical route is well tol-erated, there is greater overall satisfaction and less im-mediate and post-procedure pain with sub-Tenonblockade.83 Another concludes that patient comfortand surgery-related complications did not differ be-tween topical anesthesia and peribulbar anesthesiaand that in view of the minimally invasive characterof topical anesthesia compared with that of peribulbaranesthesia, the use of topical anesthesia for routine cat-aract surgery is justified.84

A study comparing topical anesthesia and retrobul-bar anesthesia85 reports that phacoemulsification withtopical anesthesia is more painful than retrobulbar an-esthesia and that in hypertonic patients and youngerpatients more susceptible to pain, topical anesthesiashould be avoided or used in conjunction with seda-tion. Yet, another study86 suggests that topical anesthe-sia is justified as a means of improving safety withoutcausing discomfort to the patient even in complicatedcataract surgery cases. The Royal College of Anaesthe-tists55 recommends the presence of an anesthetist onlywhen a sharp-needle block or sedation is undertaken.

Intracameral Anesthesia

Intracameral anesthesia is a common adjunct totopical anesthesia in phacoemulsification.26 Normally


preservative free lidocaine 1% is injected into the ante-rior chamber through the corneal incision at the begin-ning of the operation. It probably provides sensoryblockage of the iris and ciliary body and thereby re-lieves discomfort experienced during IOL placement.Intracameral lidocaine alone dilates the pupil well,87

and this is believed to be due to the direct action oflidocaine on the iris, which in turn causes muscle re-laxation. Preservative-free lidocaine 1% with 1:100 000epinephrine enhances pupillary dilation more thanlidocaine 1% alone and thus obviates the need forpreoperative dilating drops.88

Intracameral anesthesia has several advantages: in-juries to ocular tissue or life-threatening systemicside-effects are minimal, the vision is restored in-stantly after the operation, the undesirable cosmeticside-effects are avoided, the technique is economical,and there is no need for an anesthetist to be present.The efficacy of intracameral anesthesia with regardto possible retinal and corneal endothelial toxicity isdiscussed in a report by the American Academy ofOphthalmology.26,89 Some of the papers clearly indi-cate the efficacy of intracameral anesthesia, whereasothers fail to support this conclusion. However, thereport concludes that as topical anesthesia alone iseffective, intracameral anesthesia should be reservedto deal with incremental pain arising during theprocedure.

Short-term studies of the safety of intracameral an-esthesia indicate that preservative-free lidocaine 1%is well tolerated by the corneal endothelium, whereashigher concentrations are toxic.26 Although short-termstudies indicate safety, the long-term effects are notknown.

Retinal toxicity can occur because of posterior diffu-sion of local anesthesia to the retina, and a temporaryloss of light perception has been reported after intra-cameral anesthesia.26 Several in vitro studies suggestthat both lidocaine and bupivacaine may be toxic tothe retina; therefore, a minimal concentration of localanesthesia must be used.26 Although the toxic effectsof the commonly available topical anesthetic agentson the corneal epithelium have been studied exten-sively,52 their effect on corneal endothelium as partof intracameral anesthesia administration is not fullyunderstood. Preservative-free lidocaine 1% in dosesof 0.1 to 0.5 mL is not associated with corneal endothe-lial toxicity,26 but higher concentrations may be toxic.Compared with lidocaine, intracameral bupivacaine isnot well studied, but it may be more toxic to cornealendothelium than lidocaine 1%. Thus, preservative-free lidocaine 1% has been suggested as the local anes-thesia of choice for intracameral anesthesia.26

A study in rabbits shows that the preservative ben-zalkonium chloride (at a concentration of 0.025% to


Table 7. Contraindications to local anesthesia.

Relative Contraindication Avoid

Prolonged complex surgery All localanesthesia techniques

Uncontrollable neurologicalmovements

All localanesthesia techniques

Uncooperative mentallydebilitated patient

All localanesthesia techniques

Highly myopic cases Retrobulbar and peribulbartechniques

Allergy Topical anesthesiaNystagmus Topical anesthesia


0.05%) in commercially available anesthetic agentsmay cause irreversible damage to corneal tissues.52 In-jecting unpreserved lidocaine hydrochloric acid 4%into the anterior chamber over a period of severaldays81 produced significant corneal thickening andopacification in rabbit models.

Exposure time to the agent and the preservative inthe agent are important in determining the effect of li-docaine. However, a brief exposure (typically equal tothat needed for uneventful foldable IOL implantation)to unpreserved lidocaine is considered unlikely to in-jure the corneal endothelium.

Several incidents of visual sensations ranging fromlight perception to increasing clarity have been re-ported during surgery under topical anesthesia proce-dures.90 Many patients find this an unexpected anddisturbing experience, but this fear may be reducedwith adequate patient counseling.

COMPLICATIONS OF ANESTHESIA TECHNIQUES

Contraindications

The contraindications to various modalities arelisted in Table 7.

Safety Considerations

Safety considerations concern both the inherentsafety of the anesthetic agent and also the modalitytechnique used. AUK-based survey concludes that po-tentially life-threatening complications exist with alltechniques except topical/intracameral local anesthe-sia.53 This suggests that an anesthetist must be presentto deal with adverse events when intraocular surgeryis performed. Another UK-based survey54 showedthat in 1996, an anesthetist was present for 84% ofthe cases monitored and IV access was established in60% of these cases. The UK-based survey53 alsoshowed that from 2002 to 2003, potentially sight-threatening complications were mostly associatedwith retrobulbar and peribulbar techniques.

Orbital Hemorrhage

Orbital hemorrhage can be reduced by avoiding in-jection into the apex (vascular area), using fine andshort needles (25-gauge and 25 mm needles). 31,48,91–93

Fanning61 discusses a choice of needles for use in orbitalregional anesthesia. The use of needles longer than 31mm is not recommended. The use of retrobulbar andperibulbar anesthesia is decreasing primarily becauseof the increased risk and severity of complicationssuch as globe perforation and retrobulbar hemorrhage,especially as other modalities have been found to be aseffective. Delivery of the anesthetic agent with a bluntneedle, such as that used in sub-Tenon delivery,reduces this risk substantially.


Globe Perforation

Globe perforation is a rare complication, more likelyto occur in myopic eyes (which are thinner and lon-ger), especially when carrying out retrobulbar andperibulbar blocks.31,94 The reported incidence of globeperforation ranges from 0 in 2000 to 1 in 16 224 forperibulbar procedures,95 3 in 4000 for retrobulbar,and 1 in 12 000 for a mixture of peribulbar and retro-bulbar procedures.16 A significant proportion of globepenetrations are not detected during administration ofthe anesthetic agent but are noticed following the de-velopment of hypotony, poor red reflex, and vitreoushemorrhage during surgery.31

During delivery of the anesthetic agent, patients areoften asked to move their eyes from side to side to en-sure that no contact with the globe has occurred. Therisk with this is that a patient will move his or herhead instead and in doing so run the risk of deepeningthe depth of penetration.

The complication rate of globe perforation can be re-duced by correct knowledge of anatomy (especially ifprevious ocular surgery that may alter the anatomyhas occurred), patient cooperation, and the use ofblunt needles. Although perforation is less likelywith blunt needles, in the event of a perforation,more trauma is involved.28

Systemic Adverse Events

Systemic risk such as brainstem anesthesia can oc-cur with local anesthesia. For this reason, the patientmust be monitored carefully after administration ofthe anesthesia and also during surgery. Symptomssuch as drowsiness and loss of or confused verbal con-tact often suggest brainstem anesthesia, which canlead to respiratory and cardiac arrest.31 The onset usu-ally occurs within 8 to 10 minutes of local anesthesiadelivery. Resuscitation equipment and personneltrained to use it must be available. The oculocardiacreflexdepisodes of bradycardia provoked by eye sur-gery or eye manipulationdis blocked when the ciliary



ganglion is anesthetized (Figure 1, left). The oculocar-diac reflex is rare with local anesthesia because block-ade of the ciliary ganglion ablates the afferentoculocardiac reflex,28 but rapid distension of the tissuesby volume or hemorrhage can occasionally provoke it.

Death can result from local anesthesia as a conse-quence of spread of the anesthetic agent along the op-tic nerve sheath or intraarterial injection of theanesthetic solution with retrograde flow, giving riseto systemic toxicity that causes brainstem anesthe-sia.28,31 This is more likely to occur with retrobulbaranesthesia (0.1% to 0.3%); it rarely occurs with peribul-bar and short needles, as they avoid the cone of the ex-traocular muscles. This risk is also reduced if shortneedles are used in primary gaze to avoid rotation ofthe needle towards the nerve,13 which reduces the in-cidence of direct trauma to the optic nerve. In the UKduring the period 2002 to 2003, 7 of 8 reported neuro-logical complications (consistent with brainstem) weredue to retrobulbar and peribulbar anesthesia.53

A study of the management of cataract in a predom-inantly elderly female population exhibiting signifi-cant systemic illness and coexisting advancedcataract, presenting for surgery in a typical public hos-pital in New Zealand, reported adverse intraoperativeevents of only 5%.96

Allergy

The adverse effects of some common drugs used inrefractive surgery have been discussed in variousstudies.29,31,97,98 Toxicity (arising because of overdoseor intravascular injection) and allergic or vasovagal re-actions are themost common complications associatedwith local anesthesia and can lead to systemiccomplications.31

There have been several case reports of allergy fromuse of local anesthesia or proparacaine eyedrops.99,100

Although cross-sensitization between proparacaineand other related topical ophthalmologic anestheticagents such as tetracaine is a rare occurrence, somestudies100 suggest that allergic sensitization and possi-ble cross reaction to topical anesthetic agents in oph-thalmologists is an occupational hazard.

The development of amide local anesthetic agentshave effectively reduced allergic reactions, and amidesare now considered rare allergens; only about 1% al-leged reactions are believed to be caused by a truly im-mune-mediated process.29 Hyaluronidase, an additiveused to promote the onset and quality of the block,may rarely cause allergic reactions.101,102

Other Complications

Persistent diplopia (overall incidence 0.25%), lastingover a month and due to direct damage to the inferior


rectus muscle, can occur as a result of the retrobulbartechnique.103,104 Muscle palsy (diplopia and ptosis)can be prevented by not using high concentrations oflocal anesthesia, which can become both neurotoxicand myotoxic. Facial nerve blocks can lead to dyspha-gia or respiratory obstruction31 from spread of the an-esthesia to the glossopharyngeal nerve and should beused only in the presence of severe blepharospasm.Adjuvant IV anesthetic agents for the reduction ofpain are normally associated with an increase in med-ical events.105

The incidence of perioperative myocardial ischemiain elderly patients having cataract surgery is signifi-cantly less under local anesthesia than general anes-thesia.106 High or prolonged doses of local anesthesiaare toxic to the corneal epithelium; this prolongswound healing and causes corneal erosion. Repeatedadministration of topical local anesthetic agents fre-quently sting and occasionally cause temporary cloud-ing of the cornea, rendering surgery difficult.30,31

COMPARATIVE EVALUATION OF LOCAL ANESTHESIATECHNIQUES

Patient-Reported Pain

Friedman et al.27 performed a systematic literaturesearch using PubMed and Cochrane Collaboration’sdatabase (Central) to synthesize the findings of vari-ous randomized trials in regional anesthesia manage-ment strategies for cataract surgery,. They concludedthat because of the large heterogeneity in thecontents, design, and outcomes of the studies, thescientific justification for the metaanalysis were notmet and they instead used an unconventional con-sensus-type approach to grade the outcomes basedon the methodology proposed by Garbutt et al.107

Recently, Alhassan et al.108 compared patient-per-ceived pain during cataract surgery for retrobulbarversus peribulbar interventions invoking metaanaly-sis. Both studies reached the same conclusion that:Retrobulbar and peribulbar blocks perform similarly,and there is little difference between them in termsof patient-perceived pain and anesthesia during cat-aract surgery.

The applicability of metaanalysis for the study un-dertaken by Alhassan et al.108 is probably justified asthe number of patients in their study was large (N Z221) compared with the number in the study byFriedman et al.27 (N Z 40). Also, the statistical powerof the study byAlhassan et al. exceeds that of the studyby Friedman et al. However, as the available data forthe comparative study of the patient-perceived painfor most of the local anesthetic modalities are limited,it is prudent to be guided by themethodology adoptedby Friedman et al.27 There is, however, a trend to use


Figure 4.Global display of comparative patient-reportedpain between various pairs of anesthesia techniques dur-ing anesthesia administration (compiled from data inreference 27). The width of the horizontal bars representsthe patient-perceived pain level and a scheme of ‘‘more,’’‘‘less,’’ or ‘‘equal’’ pain level representation is adoptedfor any comparative pair of modalities. The degree of as-sociated confidence (in descending order: A, B, C, and‘‘poor’’), representing the strength of evidence, efficacyof the intervention, and the choice of controls used isalso indicated. The modalities for any pair are arrangedto align along a fixed set of markers along the verticalaxis that represent the various modalities involved.The modality-markers are arranged along the verticalaxis in a descending order and correspond to the meanpain scores evaluated in the text (PB Z peribulbar; STZ sub-Tenon) (compiled from Friedman et al.27).

Figure 5. Relative quantitative rating of patient-perceived pain forvarious anesthetic modalities during anesthetic administrationalong an arbitrary (0 to 10) scale.


random-effect modeling to accommodate the signifi-cant heterogeneity assumption and thereby justifythe use of metaanalysis, but the inherent weakness ofthis method is that the sources of bias are not con-trolled by the method.109

More randomized clinical trials of various local an-esthesia procedures in cataract surgery are needed tofacilitate statistical methods of metaanalysis in orderto establish the relative merits of these proceduresconvincingly. The rationale is that a larger numberof studies and larger number of patients per studywould reduce bias with proper statistical modelingin metaanalysis and also overcome the problem ofany shortfall in the number of degrees of freedom.

The presentation of the results of the comparativestudy by Friedman et al.27 for the assessment of pa-tient-perceived pain for various modalities is a lengthynarrative description, which is not easy to assimilate.We present these descriptive findings selectively, asa global superimposed graphical display and/or asa table for easy comparative evaluation. Our presenta-tions reveal the qualitative and, in some cases, even thequantitative trends.

Alhassan et al.108 assert that some of the dataincluded by Friedman et al.27 (ie, Murdock110 andSaunders et al.111) is ‘‘with high risk of bias,’’ imply-ing that this probably led to the large observed ‘‘sta-tistical heterogeneity’’ unjustifiably invalidating theuse of metaanalysis. We exclude these specific studiesfrom our data for the construction of Figures 4 to 7.

The work of Friedman et al.27 is extensive, as itcompares the parameters of interest for a number ofcomparative modalities such as retrobulbar versusperibulbar, retrobulbar versus sub-Tenon, peribulbar


versus sub-Tenon, and peribulbar versus topicaland spans the period 1993 to 1998. The study of Al-hassan et al.108 is limited to the comparison of retro-bulbar and peribulbar only and the data refers tothe earlier period 1989 to 1991.

Patient-Perceived Pain During AnesthesiaAdministration

Figure 4 is a global plot of superimposed data forcomparative patient-perceived pain during anesthesia


Figure 6.Global display of comparative patient-reportedpain between various pairs of anesthesia techniques dur-ing intraoperative cataract surgery (PB Z peribulbar; STZ sub-Tenon) (compiled from Friedman et al.27).

Figure 7. Relative qualitative rating of patient-perceived pain forvarious anestheticmodalities during intraoperative cataract surgery.


administration for the various pairs of anesthesia mo-dalities. The global plot is constructed using the painscores reported by Friedman et al,27 and only thedata for pairs of modalities without sedation hasbeen included. Performing statistical averaging of thetabulated pain scores27 for the various modalities indifferent setups, the mean pain levels for retrobulbar,peribulbar, sub-Tenon, and topical anesthesia is 2.25,1.96, 1.8, and 0.1, respectively. The spread (range) ofthemean pain scores in different setups for retrobulbarand peribulbar is (G2.2% � mean) and (G8.2% �mean) respectively. The spread of the results for sub-Tenon and topical anesthesia for different setups isnot known as only a single trial result is available forthese 2 modalities. However, an assumption is madethat the spread is probably of the same order as thatfor retrobulbar or peribulbar modalities. As the range(dispersion) may at least for one-half of the modalities,considered is a mean pain level can be assigned to var-ious modalities for quantitative purposes, within anarbitrary scale 0 to 10, where zero score representsno pain, 1 to 2 mild pain, 3 to 5 moderate pain, anda score of more than 5 severe pain. However, heresome uncertainty remains mainly due to insufficientdata, especially for sub-Tenon and topical anesthesia.

The modality-markers in the global plot (Figure 4)are arranged vertically in descending order of themean values, and this is used as a datum for the align-ment of the various superposed comparative pairs ofmodalities. Figure 4 shows that qualitatively, amongthe injection types, the perceived pain least with thesub-Tenon approach and, generally, the application


of anesthesia by injection is relatively more painfulthan that by topical procedures. A plot of the meanvalues for the various modalities yields the


Table 8. Effectiveness of regional anesthesia.

Parameter Effectiveness of various modalities

Akinesia Retrobulbar and peribulbar anesthesia produce equally good akinesia.27,108

Addition of hyaluronidase Addition of hyaluronidase appears to increase the effectiveness of these blocks inproducing akinesia; however, the use of hyaluronidase in procedures other thanretrobulbar is controversial.There is insufficient evidence to determine whether retrobulbar or peribulbarblocks produce better akinesia than sub-Tenon block. Comparing betweenretrobulbar and sub-Tenon procedures, akinesia is slightly less effective in sub-Tenon procedure, but there is insufficient evidence to support this conclusion.In summarizing above conclusions, the survey27 combined the qualitativestatements and the actual muscle movement measurements.

Patient-reported pain during anesthetic administration Application of anesthesia by injection is more painful than by topical means inpatients not receiving sedation.Of the injection-type procedures, the sub-Tenon approach is the least painful.There is weak evidence that peribulbar blocks are slightly less painful thanretrobulbar blocks.27

Patient-reported intraoperative pain Intraoperative pain is greater with topical anesthesia than with injection blocks.Addition of intracameral nonpreserved lidocaine to topical anesthesia improvesthe pain control of this modality.Among injection-type procedures, pain during intraoperative surgery is lesswith sub-Tenon procedure compared to retrobulbar or peribulbar procedures.Duration of surgery is an important factor in assessing the intraoperative pain;however, the effect of this on the above observations is not known27)

Visual recovery Retrobulbar, peribulbar, and sub-Tenon methods cause optic-nerve conductiondelay. Visual recovery is normally up to 6 hours postoperatively, whereas instantrecovery is attained under topical anesthesia.


quantitative grading of the patient-perceived pain(Figure 5) during anesthesia administration.

Patient-Perceived Pain During IntraoperativeSurgery

Figure 6 is a global plot of superimposed data forpatient-perceived pain during intraoperative cataractsurgery for various pairs of anesthesia modalities. It


is constructed using the data reported by Friedmanet al.,27 and the arrangement for plotting the variouscomponents of the comparative modalities is thesame as that described for Figure 4, except that place-ment of modality markers along the vertical axis is notbased on the mean values.

Statistical averaging of the tabulated data reportedby Friedman et al.27 indicates a large spread (range)in the perceived pain levels for retrobulbar and

Figure 8. Trend in the use of various local anesthetic tech-niques in the U.S. from 1995 to 2003 (compiled fromLeaming69).


Table 9. Comparison of the trend and use of various anesthesiatechniques for ocular surgery in U.K. for the years 1996 and2002–2003 (based on references53,54).

Percentage

TechniqueTrendin 1996

Trend in2002–2003

General anesthesia 24.2 4.1Local anesthesia alone 70.0 92.1Local anesthesia with sedation 5.8 3.9Retrobulbar 16.9 3.5Peribulbar 65.6 30.6Sub-Tenon 6.7 42.6Topical 2.9 9.9Topical C intracameral 2.3 11.0Subconjunctival 4.4 1.7


peribulbar modalities in different comparative setups.The spread around the mean value is G92.4% �mean(mean Z 1.4) for retrobulbar and G60% � mean(mean Z 0.5) for peribulbar. The spread for sub-Tenonand topical anesthesia is not known as only a singletrial result was available for these 2 modalities. Asthe spread (range) the mean for different setups ofthe variousmodalities is large, it is inappropriate to as-sign mean values to the various modalities for quanti-tative purposes. Consequently, the global plot inFigure 6 is purely a qualitative display based on com-parative inference. The weighted pain level scores(taken as the product of the mean pain scores andthe percent of caseswith severe pain) for both retrobul-bar and peribulbar are the same, indicating that theperceived pain for these 2 modalities is the same;and this is in agreement with the conclusions reachedby Friedman et al.27 Using this as a datum, the relative


order of sub-Tenon and topical anesthesia readily fallin place when the pair results are superimposed onthe global plot (Figure 6).

Qualitative grading of the various modalities asderived from Figure 6 is illustrated in Figure 7. Itindicates that the patient-perceived pain during intra-operative surgery was greater with topical anesthesiathan with injection blocks. For the injection types,pain was less with the sub-Tenon procedure thanwith retrobulbar and peribulbar.

Patient-Perceived Pain with Various Anesthetic Agents

The VPS between 0 and 10 (zero represents no painand 10, high pain) for pain during surgery for differenttypes of topical anesthetic agents such as lidocaine gel2%, bupivacaine 5% drops, and benoxinate 0.4% dropshas been reported as 1.6, 4.1, and 7.1, respectively.82

Akinesia and Effectiveness of Various AnesthesiaModalities

Table 8 summarizes the effectiveness of various re-gional anesthesia modalities in terms of akinesia, pa-tient-reported pain during anesthetic administration,patient-reported intraoperative pain, and visual recov-ery. The results show that retrobulbar and peribulbarprocedures produce equally good akinesia, and sub-Tenon procedures produce slightly less akinesia, butthe supporting evidence for this is insufficient.

The patient-reported pain results in Table 8 for ‘‘dur-ing anesthetic administration’’ and ‘‘intraoperativesurgery’’ are consistent with the trends depicted in Fig-ures 4 to 7. Table 8 also indicates that visual recoveryafter topical anesthesia compared with retrobulbar,peribulbar, and sub-Tenon is relatively a lot quicker.

Figure 9. Relative changes in the use of various local an-esthetic modalities in the U.S. from 1995 to 2003 (com-piled from Leaming69).


Figure 10.Relative changes in the use of various local an-esthetic modalities in the UK for the years 1996 and2002/2003 (GA Z general anesthesia; LA: local anesthe-sia) (compiled from Eke and Thompson53,54).


Practice Patterns Among Refractive Surgeons in theUnited Kingdom and the United States

The results of the practice-pattern survey of ASCRSmembers69 (Figure 8) clearly indicates that from 1998to 2003, there was a significant decline in the use of ret-robulbar anesthesia procedures and an increase in top-ical procedures. The results also indicate a renewedinterest in sub-Tenon techniques. The survey suggeststhat the use of topical anesthesia varied according tothe surgical volume: In 2003, it was 38% for institu-tions with 1 to 5 procedures a month and 76% for insti-tutions with more than 75 procedures a month.

A 2002 European survey112 comparing anesthesiatechniques and practices internationally suggestedthat peribulbar block was the most frequently usedtechnique and that topical anesthesia was used bya sizeable minority of surgeons. However, the Ameri-can survey69 is considered more thorough and is alsomore widely accepted.

Table 9 lists the findings of UK-based studies (TheBritish Ophthalmological Surveillance Unit),53,54 illus-trating the changing trend in anesthesia techniquesover the period 1996 to 2002/2003. The results showthat local anesthesia techniques were more popularthan general anesthesia.

Figures 9 and 10 illustrate the relative change in thepractice of various anesthesia techniques from 1995 to2003 in the United States and from 1996 to 2003 in theUK. In both countries, there was a decline in the use ofretrobulbar and peribulbar injection techniques,with sub-Tenon and topical techniques gainingpopularity.

In conclusion, patient safety and comfort, combinedwith anesthesia efficacy, and the surgeon’s expertise,are important in determining the overall usefulnessof various anesthetic techniques in cataract surgery.In local anesthesia, the trend from sharp needle to


blunt needle and topical treatments has improvedthe safety profile of anesthesia delivery. Both modali-ties appear acceptable for patient comfort during anes-thesia delivery and intraoperative surgery. However,consideration of contraindications and the desired du-ration of anesthesia for the accomplishment of set sur-gical objectives determine the choice between these 2modalities. Other modalities have their place andshould be considered if the surgery is complicated,likely to be of prolonged duration, or especially if thepatient is intolerant of local or topical procedures.

There is a need formore randomized clinical trials ofvarious local anesthesia procedures in cataract sur-gery, to facilitate the statistical methods of metaanaly-sis and thus establish the relative merits and efficacy ofthese procedures. This would, in turn, prompt the in-clusion of relevant anesthesia strategies for cataractsurgery within ophthalmology and anesthesia train-ing programs.

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VOL
36, JANUARY 2010
First author:Adeela Malik, MBBS

Department of Ophthalmology Epsom;St. Helier University Hospitals,Surrey,United Kingdom










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