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Current Anaesthesia & Critical Care 21 (2010) 174e179

Contents lists available at ScienceDirect

Current Anaesthesia & Critical Care


journal homepage: www.elsevier.com/locate/cacc

FOCUS ON: OPHTHALMIC ANAESTHESIA

Anaesthesia for vitreo-retinal surgery


K.L. Kong*, Graham Kirkby
Birmingham & Midland Eye Centre, City Hospital, Dudley Road, Birmingham, West Midlands B18 7QH, United Kingdom

s u m m a r y
Keywords:
Vitreo-retinal surgery
Local anaesthesia
General anaesthesia

Many patients presenting for V-R surgery are elderly with a high incidence of associated medical
conditions. Thorough preoperative assessment is essential especially for those scheduled for general
anaesthesia.
Patients on anticoagulants and antiplatelet drugs scheduled for V-R surgery should continue their
routine medication. However, where there are specic concerns, the anaesthetist, surgeon and patient
should discuss the risks and benets of continuing their routine medication to agree an acceptable
approach.
Local anaesthetic techniques are now far more commonly used than general anaesthesia for V-R
surgery. Clinicians must recognize the limitations and contraindications of both approaches.
Whenever local anaesthetic techniques are used, attention to small details can make a huge difference
to patient comfort. This often entails meticulous patient positioning and clear lines of communication
between patient and the theatre team. Sometimes, sedative drugs are benecial to patient care.
Careful patient monitoring is recommended during V-R surgery because of the darkened theatre
environment, the age and associated medical conditions of many of these patients, and the risk of
precipitating abnormal cardiac rhythms from drugs and the oculocardiac reex.
2010 Elsevier Ltd. All rights reserved.

1. Introduction

2. Scope of surgery and implications

the operation can stimulate the oculocardiac reex under GA and if


there is an inadequate local anaesthetic block. A non-absorbable
silicone sponge or solid explant is sutured to the globe and sometimes sub-retinal uid (SRF) is drained. If SRF is not drained, the
intraocular pressure (IOP) rises as the sutures securing the explant
are tightened to raise an indent inside the eye. If the IOP rises above
the perfusion pressure in the central retinal artery (about
70 mm Hg), it will be occluded. The surgeon ensures perfusion of
the central retinal artery (CRA) either by ocular massage or paracentesis but it is essential that the anaesthetist maintains a normal
blood pressure so that the surgeon can rely on the perfusion
pressure in the CRA present at the end of the operation.

2.1. Cryo-buckle procedure

2.2. Vitrectomy

This operation has been used for more than 50 years for the
treatment of retinal detachment and may be undertaken under
local (LA) or general anaesthesia (GA).
The operation involves observing with the indirect ophthalmoscope to locate retinal holes and treating them externally with
cryotherapy. To enable easy movement of the globe, traction
sutures are placed round the recti muscles. Pulling on these during

A vitrectomy operation involves an internal approach to diseases


of the vitreous or retina. The operation is usually done under LA
nowadays. Generally there is no traction on the extraocular muscles
and therefore painful pulling on the globe does not occur. Three tiny
holes are made in the sclera so that instruments can enter the eye
through the pars plana without damaging intraocular structures. A
wide angle indirect viewing system is attached to the operating
microscope. The surgeon can then examine and treat the retina
directly so as to manage retinal detachment, severe diabetic retinopathy and a variety of macular diseases such as macular holes and

Vitreo-retinal (V-R) surgery has evolved rapidly over the last 30


years allowing the surgical treatment of a wide variety of diseases
affecting predominantly the posterior segment of the eye.
Approximately 18,000 retinal surgical procedures were performed
in England between 2005 and 2006 (Department of Health Hospital
Episode Statistics). There are essentially 2 types of operation; one
that approaches the problem externally (the cryo-buckle procedure), and the other, internally (vitrectomy).

* Corresponding author. Tel.: 44 121 507 4343; fax: 44 121 507 4349.
E-mail address: k-l.kong@swbh.nhs.uk (K.L. Kong).
0953-7112/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cacc.2009.11.008

K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179

pucker. This technique is also applicable to the management of


complex trauma and intraocular infections.
The operation frequently involves the use of agents such as air,
airegas mixtures and silicone oils to tamponade the retina. Gases
used include air, sulphahexauoride (SF6) and peruoropropane
(C3F8). Sometimes these gases are used neat, in which case
expansion occurs slowly within the eye over 24 h to twice (SF6) and
four times (C3F8) their volume. Often they are diluted with air in
non-expansile concentrations to prolong the presence of an air
bubble in the eye.
2.3. Urgency of operation
V-R surgery is required urgently in those patients whose macula
is still attached at presentation (macular-on retinal detachment)
and in whom sub-retinal uid is likely to extend rapidly, e.g., upper
bullous retinal detachments. This is because, once the macula
detaches, the chances of getting a good visual outcome are much
reduced. On the other hand, once the macular has detached, the
outcomes are similar provided the operation is performed within
the next seven days.1
2.4. Treatment to the contralateral eye
Rhegmatogenous retinal detachment is often associated with
areas of weakness in the contralateral eye that could predispose
that eye to the same condition. Therefore surgeons always examine
the good eye preoperatively. If areas of lattice degeneration or other
predisposing lesions are found, then commonly laser treatment
will be applied around these areas using the indirect ophthalmoscope laser at the time of surgery on the affected eye. If the patient
is under general anaesthesia, this prolongs the operation by 15 min
or so, and has important implications if the rst operated eye has
a gas bubble in it (see later).
3. Preoperative assessment and preparation
Many presenting for V-R surgery are older patients with
a higher incidence of associated systemic disease. Complication
rates associated with anaesthesia correlate with the number of
associated disease conditions.2
3.1. History and examination
When a local anaesthetic is planned, history taking and physical
examination must focus on issues that might preclude such an
anaesthetic approach (See Table 1).
Features such as deep set eyes and nystagmus make a local
anaesthetic technique more challenging. General anaesthesia may
be indicated when the proposed surgery is on the patient's only eye
because local anaesthetic often renders the eye sightless due to
temporary effect on the optic nerve, and an anaesthetized eye is
prone to corneal ulceration. Some patients who have had previous
cryo-buckling procedures may also be better treated under GA
principally because the spread of local anaesthetic agents around
the globe is hindered by the scarring induced after previous
surgery. In addition the anatomy is altered which may predispose
to globe perforation. True allergy to local anaesthetic drugs is
fortunately very rare and previous adverse reactions to local
anaesthetics are most commonly due to the effects of adrenaline or
overdosage, or the result of vaso-vagal effects.
Careful preoperative assessment is necessary for V-R patients
especially those scheduled for a general anaesthetic due to the
higher incidence of associated medical conditions. Issues that
require specic consideration include the following:

175

Table 1
Contraindications to local anaesthesia.
Absolute Patient refusal
True allergy to local anaesthetic
Orbital infection
Inability of patient to cooperate with theatre staff (dementia, children
and those with learning disabilities)
Inability to lie still (tremors, epilepsy, dystonic movements)
Relative Inability to lie at (cardiac or respiratory disease)
Intractable cough
Patients with communication difculties (profound deafness,
language difculties)
Prolonged surgery (greater than 2 h)
Claustrophobia
Previous surgery in the same eye (scleral buckling, excision of orbital
tumours)
Deep set eyes
Nystagmus
Operations on the only one sighted or partially sighted eye
Young patients

1. Cardiac disease e Patient's condition should be stabilized or


optimized prior to surgery. Routine cardiac drugs must be
continued throughout the perioperative period. Ideally, elective surgery is deferred for three to six months after
a myocardial infarction. Antibiotic prophylaxis is not necessary
in patients with valvular heart lesions undergoing V-R surgery.
2. Hypertension e Although common in the elderly population,
white coat hypertension should be excluded by multiple
readings. Patients with severe hypertension (stage 3) dened
as a systolic blood pressure of >180 mm Hg and/or a diastolic
pressure of >110 mm Hg should be treated prior to elective
surgery. They are at risk of dangerous hypertensive crises
causing intracranial haemorrhage, acute left ventricular failure,
life-threatening ventricular arrhythmias or renal failure.3
3. Chronic obstructive pulmonary disease (COPD) e LA is ideal for
these patients provided they are able to lie at and still for the
duration of surgery. In theory, GA may provoke dangerous
bronchospasm or lead to postoperative sputum retention, chest
infection and respiratory failure. Fortunately, V-R surgery does
not interfere with the mechanics of breathing and most V-R
patients can be safely managed under GA. Whenever possible,
the chest should be optimized prior to surgery using bronchodilators, steroids or antibiotics, and the patient is advised to
stop smoking where appropriate.
4. Diabetes mellitus e Diabetes mellitus is also common in
patients presenting for V-R surgery. LA has the advantage of
minimal disruption of meals, drug treatment and blood sugar
control. When assessing these patients, careful attention must
be paid to the potential cardiac, renal and neurological
complications of the disease.
5. Current drug therapy e As patients presenting for V-R surgery
have a higher incidence of associated systemic disease,
a complete list of current medication must be documented,
allowing essential drugs to be continued perioperatively and
potential drug interactions to be avoided.

3.2. Investigations
As far as ophthalmic patients are concerned, no routine
screening tests have been shown to be helpful or to improve the
outcome. A large multicentre trial4 showed that routine preoperative blood tests and electrocardiogram in cataract patients did not
increase the safety of surgery. The Joint Colleges' Guidelines (2001)5
for local anaesthesia recommend that tests should only be

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K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179

considered when the patient history or ndings on physical


examination would have indicated the need for an investigation
even if surgery had not been planned. However, it also recommends
that the blood sugar in diabetic patients should be controlled and
the international normalized ratio (INR) checked in those patients
on warfarin. We recommend further investigations in the V-R
patient undergoing LA should be ordered only when specically
indicated and when the results of such investigations will make
a positive difference to the perioperative management of the
patient.
When GA is considered, most eye units adopt recommendations
published by NICE in 2003.6 However, it is essential that ophthalmology units develop and implement guidelines to ensure
consistency of care and minimize any disruption to patient care.
3.3. Patients on anticoagulants and antiplatelet medications
Of special concern are those patients on anticoagulants and
antiplatelet medications. Many presenting for cataract and V-R
surgery are on aspirin, warfarin or clopidogrel. These medications
are prescribed to reduce the incidence of potentially life-threatening thromboembolic events in patients with cardiovascular
disease. It is therefore desirable to continue these medications
during the perioperative period provided that they do not
adversely affect the safety of anaesthesia and the success of surgery.
No randomized controlled trial that specically addresses the
risks and benets of anticoagulants and antiplatelet drugs during
ophthalmic surgery has been undertaken. However, large observational studies in cataract surgery7,8 found that it was safe to
continue with these agents during the perioperative period
without a higher incidence of potentially sight-threatening local
anaesthetic or operative haemorrhagic complications. Similarly,
results from smaller observational studies on V-R surgery
patients9,10 also suggest that no change in on-going anticoagulants
or antiplatelet drugs is necessary. Until evidence to the contrary is
available, it seems sensible to continue these drugs in V-R patients.
For those on warfarin, the Royal Colleges of Anaesthetists and
Ophthalmologists5 advise that the INR should be checked and this
should be within the recommended therapeutic ratio determined
by the condition for which the patient is being anticoagulated.
Where there are any specic concerns (e.g., complicated surgery or
only eye surgery), there should be a discussion between anaesthetist, surgeon and patient regarding the risks and benets of
continuing anticoagulants and antiplatelet drugs to agree an
acceptable approach.
4. Choice of anaesthetic technique
There has been a major change in practice from general to local
anaesthesia for vitreo-retinal surgery over the last 10 years, and this
trend of LA for V-R surgery is similar to that for cataract surgery.
Some reasons for this increase of LA in V-R surgery are shown in
Table 2. In practice, the choice of anaesthetic technique is largely
governed by the general health of the patient, and the preferences
of both the patient and surgeon.
Perceived advantages of local anaesthesia for vitreo-retinal
surgery are presented in Table 3. However, it is important to recognise

Table 2
Reasons for increased local anaesthesia rate for vitreo-retinal surgery.
Safer and effective LA techniques (peribulbar and sub-Tenon's anaesthesia)
Reduction in in-patient hospital beds
Patients more accepting of LA to avoid the disadvantages of GA
Efforts of anaesthetists in promoting LA

Table 3
Advantages of local anaesthesia for vitreo-retinal surgery.
Patient benets

Less or no postoperative nausea and vomiting


Superior postoperative analgesia
Minimal interference with diabetic control as
patients do not need to be starved
Minimal postoperative cognitive dysfunction
Faster recovery from anaesthesia and discharge from
hospital

Anaesthetic and surgical


considerations

No cardiovascular or respiratory depression


Partial or complete blockade of the oculocardiac
reex
Suitable for patients at risk of general anaesthesia
such as sickle cell disease, malignant hyperpyrexia,
atypical cholinesterase, porphyria
Patients who need to posture postoperatively can
commence immediately

Resource benets

Faster list turnover


Faster postoperative rehabilitation in
a predominantly day case service
Minimal equipment required
Cost savings

the circumstances where local anaesthesia is contraindicated or


a general anaesthetic preferred, especially in younger patients and for
more complex procedures. These are listed in Table 1.
4.1. Local anaesthetic techniques
Subconjunctival and topical anaesthesia are unsuitable for V-R
surgery since they do not provide adequate analgesia and immobility of the eye. Dangers of retrobulbar anaesthesia are now widely
appreciated and consequently it is seldom used. Both peribulbar
and sub-Tenon's anaesthesia provide excellent operating conditions for the range of V-R procedures commonly carried out and are
the local anaesthetic techniques of choice. However, a more
profound block than that used for cataract operations is required in
V-R surgery, particularly when buckling and retinopexy procedures
are anticipated. Good akinesia is more important for certain V-R
procedures such as membrane peeling. Local anaesthesia
comprising a 50/50 mixture of 2% lignocaine and 0.75% bupivacaine
with hyalase is often used. Intraoperatively, the surgeon must be
prepared to top-up the anaesthetic with a sub-Tenon's injection,
particularly in patients undergoing scleral buckling procedures or
when surgery is either unexpectedly difcult or prolonged.
In cataract surgery under LA, the biometry measurement of axial
length is routinely available, however, this is mostly not the case in
V-R surgery. Axial length is useful in determining those highly
myopic eyes which would be best anaesthetized using either subTenon's technique or the medial canthal peribulbar approach.
Anaesthetists providing local anaesthetic should therefore check
with the surgeon or patient the degree of myopia and modify their
approach accordingly.
4.2. General anaesthesia
It should be remembered that whilst local anaesthetic techniques have gained in popularity, they are not without risks. For
many years, general anaesthesia has proven to be very safe despite
the general state of health and advanced age of many of these
patients. Both inhalational and intravenous techniques are suitable
and the aim is to achieve optimal operating conditions by avoiding
coughing, straining and vomiting both at induction and recovery
from anaesthesia, and to maintain stable haemodynamics and
intraocular pressure.

K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179

5. Intraoperative considerations
5.1. Optimal operating conditions
Surgical requirements for V-R surgery include a well anaesthetized eye that is still in the neutral gaze position. For patients
receiving a general anaesthetic, this requires the administration of
muscle relaxants and mechanical ventilation which also facilitates
the control of end-tidal carbon dioxide concentrations. When
muscle relaxants are used, neuromuscular transmission should be
monitored to avoid any sudden wearing off of relaxant and patient
movement. A continuous infusion of an appropriate muscle
relaxant such as atracurium has its merits in avoiding the peak and
trough concentration effects. A remifentanil infusion in place of
nitrous oxide during V-R surgery is gaining popularity. However, it
is inadvisable to rely on a remifentanil infusion to provide immobility as sudden patient movement has occurred during surgery and
resulted in surgical instruments damaging the patient's eye.
5.2. Laryngeal Mask Airway (LMA) versus endotracheal tube (ETT)
Airway access is limited during V-R surgery under general
anaesthesia, therefore it is essential to secure the airway prior to
commencement of surgery, either with a LMA or an ETT. In the
absence of specic contraindications, the armoured/exible LMA is
increasingly favoured by ophthalmic anaesthetists as the airway
device of choice. It has the advantage of minimal change in systemic
arterial and intraocular pressure during insertion and removal, and
a lower incidence of sore throat compared to endotracheal intubation.
5.3. Monitoring
Vitrectomy operations, cryotherapy, laser therapy and indirect
ophthalmoscopy take place in a darkened room. The anaesthetists'
vision may be further obscured by protective goggles during laser
treatment. Anaesthetists must have access to some form of
controlled lighting to ensure safety in patient monitoring, record
keeping, and the routine checking of equipment and drugs. Under
these adverse conditions where patient access may also be limited,
full patient monitoring with appropriate alarms is essential.
5.4. Nitrous oxide (N2O) and intraocular pressure
During vitreo-retinal surgery, intraocular gases are often used to
tamponade retina holes so that the neuroretina is in apposition
against the pigment epithelium and retinopexy can take effect. If
there is a gas bubble in the eye and the patient is under nitrous
oxide anaesthesia, then N2O can enter the gas bubble, causing it to
expand leading to a rise in intraocular pressure in the closed eye. If
this rises above the perfusion pressure of the central retinal artery
(about 70 mm Hg), then occlusion may occur, carrying the risk of
permanent blindness.
Traditional recommendations are either to avoid the use of N2O
completely or to withdraw the agent 15 min or more before the
injection of intraocular gas. However, the clinical benets of such
anaesthetic approaches have never been demonstrated for
primary vitreous surgery. Briggs and colleagues (1997)11 found

177

that anaesthesia using nitrous oxide does not adversely affect the
size of a C3F8 gas bubble as the gas kinetics would only apply to
the closed eye situation. During vitrectomies, uncontrolled leakage
from sclerostomy sites is the predominant factor in determining
bubble size. Moreover, the diffusion of N2O into intraocular gas
bubbles is time dependent and if intraocular gas is introduced just
before the cessation of surgery and anaesthesia, then the effects of
N2O would be negligible.
The risk does arise however, in the situation where the surgeon
has nished operating on one eye, closes it and then proceeds to do
some procedure on the other eye. In this situation, N2O must be
discontinued as soon as the rst eye has been closed.
A major danger arises if patients with intraocular gas are
subsequently subjected to general anaesthesia using N2O.12 Several
case reports have described severe visual loss in those patients
undergoing nitrous oxide anaesthesia in the presence of an intraocular gas bubble. Intraocular gas duration varies. Generally, larger
and more concentrated volumes of gases that are less soluble last
longer. Air is typically absorbed within a few days; SF6 lasts
approximately 10 days and C3F8 about 6 weeks although durations
in excess of 70 days have been reported.
In an aircraft, during decompression, intraocular gas expands
and can produce the same deleterious effects.
Patients who have had intraocular gas injections should be
advised of these risks and provided with a notication wristband
(Fig. 1) warning against both ying and the use of nitrous oxide
until the gas has been completely absorbed.
5.5. The oculocardiac reex
The oculocardiac reex is a trigemino-vagal reex rst
described in 1908. It can result in dangerous atrial and ventricular
arrhythmias including severe bradycardia or cardiac standstill. The
incidence of the reex is high in certain V-R procedures such as
cryo-buckling surgery where traction of the extraocular muscles
may precipitate this reex. Hypoxaemia, hypercarbia or light levels
of general anaesthesia are known to exacerbate the bradycardic
response of this reex. A remifentanil infusion would also make the
bradycardic response worse.
The afferent limb of the reex is via the long and short ciliary
nerves (ophthalmic division of the trigeminal nerve) relaying via
the ciliary ganglion, terminating in the trigeminal sensory nucleus
in the oor of the fourth ventricle. The efferent limb passes down
the vagus nerve to the heart.
Local anaethetic eye blocks attenuate the afferent limb of this
reex and may be preferable to general anaesthesia for adult
surgery in which traction of the extraocular muscles is a signicant
problem. The efferent limb is blocked by antimuscarinics such as
glycopyrrolate.
However, as no one anaesthetic technique reliably abolishes the
oculocardiac reex, patients undergoing V-R surgery must be
carefully monitored.
5.6. Mydricaine
It is vital that the pupil stays dilated during a V-R operation so
that the surgeon has an excellent view of the posterior segment.

Fig. 1. Picture of wristband warning against ying and repeat nitrous oxide anaesthesia in patients with intraocular gas.

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K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179

Many V-R units routinely use Mydricaine to ensure maximal and


long lasting dilatation of the pupil. This drug is not listed in the
British National Formulary (BNF) or Monthly Index of Medical
Specialities (MIMS). It is administered by sub-conjunctival injection, usually at the start of the operation and is available in two
strengths. No.1 injection (used in children) supplied as 0.5 ml
ampoules contains procaine HCl 3 mg, atropine sulphate 0.5 mg,
and adrenaline 108 mcg. No.2 injection (used in adults) supplied as
0.5 ml ampoules contains procaine HCl 6 mg, atropine sulphate
1 mg, and adrenaline 216 mcg.
There have been several reports of the cardiovascular effects of
this medication. Severe hypertension, cardiac arrhythmias and
myocardial infarction as well as prolonged sinus tachycardias
have been reported. Tachycardia and transient myocardial
ischaemia may develop in patients with no previous history of
ischaemic heart disease, and using a smaller dose of the less
concentrated Mydricaine No.1 solution is no guarantee against
side effects. It therefore follows that whenever Mydricaine is used,
the surgeon must inform the anaesthetist and the patient closely
monitored.
5.7. The use of lasers
Argon Laser is commonly used during V-R surgery for retinopexy or the treatment of ischaemic retina, for example, during
surgery for advanced diabetic retinopathy. Laser treatment is
administered either via a bre-optic probe inserted into the eye
(endolaser) or externally using a specially adapted indirect
ophthalmoscope. In both instances, the surgeon controls the ring
of the laser using a footswitch. Clearly there is the possibility of
inadvertent ring with consequent dangers for theatre staff,
therefore all those present must wear protective goggles at all
times when the laser is switched on. Warning signs must be erected
at all portals of entry to the room and any windows or glass doors
occluded.
5.8. Role of sedation during local anaesthesia
Time spent establishing a good rapport with the patient is
usually more effective in allaying anxiety than the use of pharmacological agents. However, there remains a proportion of
patients undergoing V-R surgery who would benet from sedation. Common indications for this include patient's request,
allaying anxiety, controlling claustrophobia, long and complex
surgery, and attenuating the undesirable cardiovascular reactions
to stress.
There is a suggestion that as more V-R surgery is being performed under LA, the use of sedation has increased with it. Costen
et al. (2005)13 reported that the use of sedation in V-R surgery
increased from 7.8% in 2001 to 20.2% in 2005 following a rise in LA
rate for V-R procedures from 82% to 92% over this period of time. In
general, younger patients having scleral buckling procedures are
more likely to benet from sedation than elderly patients having
vitrectomies. Several drugs are available for this purpose, the most
popular being a small dose of midazolam (1e2 mg in 0.5 mg
increments) or propofol (10e20 mg given in 5 mg increments).
The main problem with the use of sedatives during V-R surgery
(particularly vitrectomies) is sudden patient movement especially
when patients wake up with a start having fallen asleep. Other
potential complications include respiratory depression, falling
oxygen saturations and excessive restlessness. The majority of eye
patients are elderly and the doses and effects of sedative drugs in
these patients can vary markedly. Fine judgement is therefore
required to select the correct drug and dose to produce a calm
sedated patient who remains both awake and cooperative.

Whenever sedation is administered, the recommendations of


the Joint Royal Colleges5 must be followed:
 Sedation should only be used to allay anxiety and not to cover
inadequate blocks which would require further administration of local anaesthetics
 Sedation should not be used to manage patients with preexisting mental confusion as this may well aggravate the
condition
 Intravenous sedation should only be administered under the
supervision of an anaesthetist whose sole responsibility is to
that list
 A similar level of continuous monitoring should be used
during sedation as that used during general anaesthesia
5.9. Specic issues (ensuring patient comfort and tolerance)
Attention to small details can make a big difference to patient
comfort. The tolerance of patients during LA is often limited by the
comfort of the operating table rather than the surgery itself.
Therefore careful patient positioning prior to commencement of
surgery is essential.
It is imperative that patients are informed before hand that if
they experience any discomfort, they must alert the theatre team
and analgesia can be given. It is relatively simple for the surgeon to
perform a sub-Tenon's top-up of local anaesthetic when required
during the operation.
As V-R surgery is not associated with signicant blood loss or
uid shifts, excessive infusions of intravenous uids should be
avoided. It is also sensible to ensure an empty bladder prior to
surgery as operations can last for an hour or longer.
6. Postoperative care
6.1. Postoperative posture
Patients may need to posture postoperatively, to ensure that the
bubble in the eye is in the best position to close the retinal break. If
the retinal break is superior, the best position for the patient is
upright and if the hole is posterior (e.g., in a macular hole) this
would be face down.
LA has the advantage that patients can posture immediately.
After GA, the patient will need to have recovered sufciently rst.
The length of time the patient has to posture varies with their
condition and the duration of the gas bubble, but is often for 5e10
days. Patients are allowed 10e15 min off per hour to prevent deep
vein thrombosis (DVT) and stiffness and a reasonable time for
meals. At night, sleeping left or right semi-prone is usually sufcient as more complicated positions are not compatible with
comfortable sleep.
6.2. Pain relief
Following V-R surgery, mild to moderate pain is common and is
effectively treated with combinations of paracetamol, nonsteroidal anti-inammatory analgesics and codeine phosphate.
Strong opioid analgesics such as morphine sulphate may cause
nausea, vomiting and sedation and are rarely indicated. If postoperative pain is so severe that strong opioid analgesics are
required, surgical complications such as an unacceptable rise in
intraocular pressure must rst be excluded. It is well recognized
that the use of local anaesthesia as part of the general anaesthetic
technique for V-R surgery contributes to improved postoperative
patient comfort and recovery from anaesthesia. In our hospital,
a sub-Tenon's injection of local anaesthetic is routinely given for
patients undergoing a general anaesthetic.

K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179

6.3. Postoperative nausea and vomiting (PONV)


Postoperative nausea and vomiting is common following
general anaesthesia for V-R surgery and incidence rates of 20e30%
are frequently reported. This has the potential to cause serious eye
complications including intraocular haemorrhage, wound rupture,
loss of vitreous and iris prolapse. In those patients who have
received intraocular gas injection, vomiting may also interfere with
postoperative posturing.
Intraoperative antiemetics reduce the incidence of PONV;
combinations of 5HT3 antagonists, dexamethasone and cyclizine
are popular in eye surgery. A LA block with GA benets both
postoperative pain relief in addition to reducing PONV, possibly due
to the reduced usage of opioid analgesics and/or the attenuation of
the oculo-emetic reex.14
6.4. Thromboembolism and prophylaxis
Patients undergoing V-R surgery may be perceived to have
several risk factors predisposing them to deep vein thrombosis
(DVT) and pulmonary embolism (PE). They are often elderly with
associated co-morbidities such as cardiac disease and diabetes. V-R
procedures can be lengthy (>90 min) and patients may be required
to posture postoperative, rendering them relatively immobile for
several days after their operation. However, there is little information documenting the incidence of severe systemic adverse
events such as DVT and PE after an eye surgery is performed under
general anaesthesia. Currently, there is insufcient data to recommend the routine use of thromboprophylaxis in patients undergoing V-R surgery under GA. However, this should be considered on
an individual basis in patients at particular risk such as those with
previous history of DVT or PE.

179

Conict of interest
None.
References
1. Liu F, Meyer CH, Mennel S, Hoerle S, Kroll P. Visual recovery after scleral
buckling surgery in macula-off rhegmatogenous retinal detachment. Ophthalmologica 2006;220:174e80.
2. Tiret L, Desmonts JM, Hatton F, Vourc'h G. Complications associated with
anaesthesia e a prospective survey in France. Can Anaesth Soc J 1986;33:
226e344.
3. Foex P, Sear JW. The surgical hypertensive patient. Cont Educ Anaesth Crit Care
Pain 2004;4(5):139e43.
4. Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, et al. The
value of routine preoperative medical testing before cataract surgery. N Eng J
Med 2000;342:168e75.
5. The Royal College of Anaesthetists and The Royal College of Ophthalmologists.
Local anaesthesia for intraocular surgery. The Royal College of Anaesthetists and
The Royal College of Ophthalmologists; 2001.
6. NICE Clinical Guideline 3. Preoperative testsethe use of routine preoperative tests
for elective surgery. NICE, Http://guidance.nice.org.uk/CG3; June 2003.
7. Katz J, Feldman MA, Bass EB, Lubomski LH, Tielsch JM, Petty BG, et al. Risks and
benets of anticoagulant and antiplatelet medication use before cataract
surgery. Ophthalmology 2003;110:1784e8.
8. Benzimra JD, Johnston RL, Jaycock P, Galloway PH, Lambert G, Chung AKK, et al.
The Cataract National Dataseteelectronic multi centre audit of 55,567 operations: antiplatelet and anticoagulant medications. Eye 2009;23:10e6.
9. Narendran N, Williamson II T. The effects of aspirin and warfarin therapy on
haemorrhage in vitreo-retinal surgery. Acta Ophthalmol Scand 2003;81:38e40.
10. Chauvaud D. Anticoagulation and vitreo-retinal surgery. Bulletin de l Academie
Nationale de Medecine 2007;191:879e84.
11. Briggs M, Wong D, Groenewald C, McGalliard J, Kelly J, Harper J. The effect of
anaesthesia on the intraocular volume of the C3F8 gas bubble. Eye 1997;11:47e52.
12. Lee EJK. Use of nitrous oxide causing severe visual loss 37 days after retinal
surgery. Br J Anaesth 2004;93(3):464e6.
13. Costen MTJ, Newsom RS, Wainwright AC, Luff AJ, Canning CR. Expanding role of
local anaesthesia in vitreoretinal surgery. Eye 2005;19:755e61.
14. Van den Berg AA, Lambourne A, Clyburn PA. The oculoemetric reex;
a rationalization of post ophthalmic anaesthesia vomiting. Anaesthesia
1989;44:110e7.