Ophthalmol Clin N Am 19 (2006) xi

Preface

Ocular Anesthesia

Marlene R. Moster, MD

Augusto Azuara-Blanco, MD, PhD, FRCS (Ed) Guest Editors

The goal of this volume is to provide practical clinical information about anesthesia for ocular surgery. These articles have been written for both anesthetists and ophthalmologists, and so we have tried to integrate the most commonly used techniques and important recent developments, especially in local anesthesia. We have dedicated an article to each of the types of anesthesia (eg, general, orbital regional, subTenons) and to different types of ocular surgery (eg, cataract, glaucoma, vitreoretinal, pediatric) to help incorporate the latest updated material with current usage. The practical approach of this volume is also reflected in the articles on preparation for anesthesia and preoperative medical testing, sedation techniques, anesthesia for the open globe, treatment of the blind painful eye, and management of complications. Numerous illustrations have been used to provide a natural and easily understandable flow of information. We believe this volume has been greatly enriched by the inclusion of articles on history, pharmacology, and cost-effectiveness of ocular anesthesia.

We are indebted to the contributors to this volume for giving so generously of their time and work. They are all recognized leaders in ophthalmic anesthesia and surgery. Our expert collaborators have written comprehensive articles and have also shared their personal preferences. We are also extremely grateful to Maria Lorusso, our commissioning editor at Elsevier, for her help, patience, and advice, and to Yvette Williams for her expert editorial assistance. Marlene R. Moster, MD Wills Eye Hospital Glaucoma Service 900 Walnut Street Philadelphia, PA 19107, USA E-mail address: marlenemoster@aol.com Augusto Azuara-Blanco, MD, PhD, FRCS (Ed) Department of Ophthalmology Aberdeen University Hospital Foresterhill Road Aberdeen, AB25 2ZN, UK E-mail address: aazblanco@aol.com

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Ophthalmol Clin N Am 19 (2006) 151 154

Seeing an Anesthetic Revolution: Ocular Anesthesia in History

Douglas R. Bacon, MD, MA
Department of Anesthesiology, Mayo Clinic College of Medicine, Ch1-140, 200 First Street, SW, Rochester, MN 55905, USA

Each surgical procedure places unique demands on the anesthesiologist to create surgical anesthesia with minimal physiologic trespass on the patient as well as the surgical repair. In surgery of the eye, the quest for an anesthetic that does not harm the eye or the patient can be a challenge. The removal of cataracts is one of the most frequently performed operations in the United States, and the majority of patients requiring the procedure are elderly and often have other significant medical conditions.

Early ocular anesthesia Historically, ocular procedures have had an enormous influence on the discovery of anesthetic modalities. Before the discovery of surgical anesthesia in the 1840s, operations on the eye were difficult, as the sensitive organ would not willing yield to the surgeons knife. On October 16, 1846, William Thomas Green Morton demonstrated the anesthetic effects of diethyl ether as a jaw tumor was removed from Gilbert Abbott at the Massachusetts General Hospital [1]. News of this event traveled around the world, and operations were soon performed that had only been dreamed about for centuries before. When Lister conquered infection some 20 years later, surgery began an explosive growth, with new, more invasive operations successfully done around the world. Ocular surgery began to grow. For example, both William J. and Charles H. Mayo began to perform procedures on the eye shortly after their respective

E-mail address: bacon.douglas@mayo.edu

graduations from medical school. In fact, the first operation done at St. Marys Hospital was an eye operation [2]. But there was a problem. Before thin suturing material was available to close the eye, the wound was left open. Ether was notorious for causing postoperative retching, and therefore damage to the eye. A solution was needed. In Vienna, Sigmund Freud began working with cocaine. He shared some of the crystals with Carl Koller (Fig. 1) just before leaving to go on vacation. Koller noticed that his lips became numb when he put a solution of cocaine crystals on his tongue. In a eureka moment, Koller realized that this same solution ought to make the surface of the cornea numb. Going into the laboratory, he placed drops of the cocaine solution on the eyes of several experimental animals, and was able to touch the eye without any reaction. Koller then numbed his own eye, and that of an assistant. He realized he now had a topical anesthetic for the eye [3]. Koller quickly took this new anesthetic to the ophthalmology clinic. He was successful in its use in eye surgery in a large number of patients. Putting the results together in a paper, which was accepted for presentation at the prestigious Congress of German Ophthalmologists meeting, September 15 and 16, 1884 in Heidelberg, Koller was anxious to tell his colleagues of his discovery. Koller, however, could not afford to go. His friend, Josef Brettauer presented the paper, which caused a number of people to begin to see the potential of cocaine as an anesthetic, and a rival to ether [4]. William Halstead, who traveled to Europe and was at the Allgemiene Krankenhouse at the time of Kollers discovery, came back to the United States

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Fig. 1. Carl Koller. (Courtesy of the Wood Library-Museum, Park Ridge, IL.)

and began to work with cocaine. He would infiltrate the cocaine into the skin and dissect down to nerve trunks. While looking at the dissected nerve, Halstead instilled a solution of cocaine to cause blockage in nerve transmissionthe first regional anesthesia. Halstead published the results of his experience [5] before he entered treatment for a cocaine addiction [6]. Kollers fellow Europeans picked up on the idea of regional anesthesia. Schleich began infiltrating cocaine into the spinal cord when attempting a lumbar puncture [7]. Bier and Hildenbrand were successful in injecting cocaine intrathecally, and producing spinal anesthesia [8]. James Corning, in New York, produced the first epidural anesthetic [9]. Thus, the quest for better anesthesia for ophthalmologic surgery resulted in a new form of anesthesiaregional! And its founder, Carl Koller, was forced to leave Vienna after a duel, settled in New York City, and practiced as an ophthalmologist [4].

Regional blockade of the eye The blocks in use for ophthalmologic surgery today have developed in the years since Kollers remarkable discovery. Most interestingly, H. Knapp described a block in the eye using a needle and syringe, very similar in technique to the retrobulbar block. Writing in 1884, months after the discovery of cocaines local anesthetic quality, Knapps work never gained popularity [10], most likely because of the unique properties of cocaine. Blocks are often

patchy, and absorption of the agent causes hypertension and tachycardia, as well as a feeling of euphoria [11]. Increasing blood pressure may have contributed to an increase in intraocular pressure, and without fine suture to close the incision, intraocular contents may well have been extruded. However, in 1905, a new local anesthetic, procaine, was synthesized and used clinically. An ester, this agent had a predicable onset and duration of action [12]. Yet this did not change ocular anesthesia. Gaston Labat, writing in the first textbook of regional anesthesia published in the United States believed topical anesthesia was sufficient and commented, The following operations need no other form of anesthesia: superficial interventions on the conjunctiva, treatment of corneal ulcers by cautery, removal of foreign bodies from the conjunctiva and cornea, plastic on the cornea, cataract operations, iridectomy and other operations on the lens and iris (p. 141) [13]. In 1934, W. S. Atkinson described the classic retrobulbar block [14]. Atkinson had the patients look upward and inward before the block was performed. Using procaine, this form of regional anesthesia of the eye was very successful and slowly gained popularity across the United States [15]. However, the retrobulbar block had some significant complications associated with it, including damage to the optic nerve. Other options were sought, and cadaveric study demonstrated that local anesthetics placed outside intraorbital muscle cone would penetrate and create an anesthetic eye. First described in 1986, the peribulbar block is felt to be safer than the retrobulbar block as the needle is placed at a greater distance from the eye and optic nerve than with the retrobulbar block [15]. In the early 1990s, an additional technique was rediscovered. First described by K. C. Swan in 1956 [16], sub-Tenons block involves the injection of local anesthetic into the episcleral space, which will create acceptable anesthetic conditions for operations on the eye. An injection of 6 to 11 milliliters of local anesthetic is enough to both anesthetize the eye and the muscles around it, thus making the eye motionless. Since the eye muscles are paralyzed, there is no need for any additional blocks [17]. Since its reintroduction in the 1990s, Kollers topical anesthesia for eye surgery has gained in popularity. With improved local anesthetics, the anesthetic produced by this method was equal, in many surgeons and anesthesiologists hand, to that produced by block, without some of the complications. However, studies indicate that there may be some slight increase in postoperative discomfort

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when topical anesthesia is used alone. The experience of the surgeon is critical in ensuring that the anesthetic is successful [18].

General anesthesia In ocular surgery, general anesthesia has been used, especially since the rise of regional and topical anesthetics, for those who cannot cooperate in the operating room or who may have medical conditions, such as Parkinsons disease, which cause tremors that would interfere with the operation. However, in many ocular trauma cases, the globe is open, and repair may take longer than regional anesthesia will last. Thus, a general anesthetic is necessary. In most trauma cases, because of a full stomach rapid securing of the airway is necessary, and the use of succinylcholine as a quick onset, ultrashort-acting neuromuscular blocking agent has been recommended. Succinylcholine, however, raises intraocular pressure [19]. In the 1950s, shortly after the clinical introduction of succinylcholine, concerns were raised about its use in open globe procedures. Experimentally, it was noted that vitreous humor could be extruded while the eye muscles fasciculated. This potentially had devastating consequences for the patient. In several letters to the editor, anecdotal case reports of just such phenomena occurring were reported. It soon became widely accepted that succinylcholine was contraindicated in the indication of anesthesia when an open globe was present. Indeed, the combination of penetrating eye trauma, difficult airway, and a full stomach became one of the anesthesiologists least favorite nightmares [19]. In the 1990s, however, the trend toward evidencebased medicine made many physicians questions accepted teaching in anesthesiology. In fully reviewing the literature, there were no peer-reviewed case reports of ocular damage when succinylcholine was used for induction. In point of fact, there were several large series that pointed in just the opposite direction [19]. The subject remains controversial.

matters of importance to the field, new research, and education are presented. More importantly, there is a community of anesthesia professionals who can interact with each other and develop this subspecialty area. The societys newsletter, posted on their Web site, is a marvelous reference for those interested in the field. In 2006, the society will celebrate its 20th anniversary with an exciting meeting in Chicago, Illinois.

Summary The history of ocular anesthesia reflects the broader history of anesthesiology and has made important contributions to the field. Carl Kollers search for an anesthetic that was superior to the general anesthesia available to him led to the creation of an entire new division of anesthesia. Regional anesthesia has been used successfully in countless cases. Specifically, Kollers demonstration of topical anesthesia of the eye has remained in use, although slightly modified, since its inception. The popularity of cutaneous regional anesthesia in the first four decades of the twentieth century may have been responsible for Atkinsons description and the subsequent popularity of the retrobulbar block. Further research and cadaveric demonstrations have developed additional regional anesthetic techniques including the peribulbar and sub-Tenons blocks. Finally, the use of succinylcholine in open globe anesthesia is a marvelous example of the continuing examination of the evidence within medicine. New conclusions drawn from old data, supplemented by new investigations can successfully challenge old accepted ideas in medicine.

References
[1] Fenster J. Ether day. New York7 HarperCollins Publishers, Inc; 2001. [2] Clapesattle H. The doctors Mayo. Minneapolis (MN)7 University of Minnesota Press; 1941. p. 252. [3] Koller C. Personal reminiscences of the first use of cocain as local anesthetic in eye surgery. Curr Res Anesth Analg 1928;7:9 11. [4] Wyklicky H, Skopec M. Carl Koller (1857 1944) and his time in Vienna. In: Scott DB, Mc Clure J, Wildsmith JAW, editors. Regional anesthesia 1884 1984. Sodertalje, Sweden7 ICM; 1984. p. 12 6. [5] Halstead WS. Practical comments on the use and abuse of cocaine; suggested by its invariably successful employment in more than a thousand minor surgical operaitons. New York Medical Journal 1885;42:294.

Subspecialty society In 1986, the Ophthalmic Anesthesia Society was formed to ensure that the highest quality anesthesia care is provided to patients undergoing cataract and other ophthalmic surgical procedures (p. 1) [20]. The society holds 2-day annual meetings where

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bacon [13] Labat G. Regional anesthesia: its techniques and clinical application. Philadelphia7 WB Saunders; 1924. [14] Atkinson WS. Retrobulbar injection of anesthetic within the muscular cone. Arch Ophthal 1936;16:494. [15] McGoldrick KE, Gayer SI. Anesthesia and the eye. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical anesthesia. 5th edition. Philadelphia7 Lippencott Williams & Wilkins; 2006. p. 974 96. [16] Swan KC. New drugs and techniques for ocular anesthesia. Trans Am Acad Ophthalmol Otolaryngol 1956;60:368 75. [17] Ripart J, Nouvellon E, Chaumeron A. Regional anesthesia for eye surgery. Reg Anesth Pain Med 2005;30:72 82. [18] Crandall AS. Anesthesia modalities for cataract surgery. Curr Opin Ophthalmol 2001;12:9 11. [19] Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe: tracing the teaching. Anesthesiology 2003;99:220 3. [20] Ophthalmic Anesthesia Society. Available at: http:// www.eyeanesthesia.org/index.html. Accessed January 16, 2006.

[6] Olch PD, William S. Halstead and local anesthesia. Contributions and complications. Anesthesiology 1975;42:479 86. [7] Goerig M, Schulte am Esch J. Carl-Ludwig Schleich and the scandal during the annual meeting of the German Surgical Society in Berlin in 1892. In: Fink BR, Morris LE, Stephen CR, editors. The history of anesthesia. Park Ridge (IL)7 The Wood LibraryMuseum; 1992. p. 216 22. [8] Goerig M, Argarwal K, Schulte am Esch J. The versatile August Bier (1861 1949)father of spinal anesthesia. J Clin Anesth 2000;12:561 9. [9] Marx GF. The first spinal anesthesia. Who deserves the laurels? Reg Anesth 1994;19:429 30. [10] Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthal 1884;13:402 8. [11] Bacon DR. Regional anesthesia and chronic pain therapy: a history. In: Brown DL, editor. Regional anesthesia and analgesia. Philadelphia7 W.B. Saunders Co; 1996. p. 10 22. [12] Calatayud J, Gonzalez A. History of the development and evolution of local anesthesia since the coca leaf. Anesthesiology 2003;98:1503 8.

Ophthalmol Clin N Am 19 (2006) 155 161

Pharmacology of Local Anesthetics

Tim Jackson, MB, ChB, MRCP, FRCAT, Hamish A. McLure, MB, ChB, FRCA
Department of Anesthesia, St Jamess University Hospital, Beckett Street, Leeds LS7 9TF, UK

The stimulus for the development of regional anesthesia was the retreat from poor surgical conditions afforded by primitive general anesthesia in the latter half of the 19th century. Karl Koller, an eager young ophthalmic surgeon, was investigating the effects of cocaine. He found that a few drops instilled into his own conjunctival fornix produced insensitivity to injury. These magical properties made it possible to perform painful procedures on patients who were awake, in quiet surgical conditions without the systemic toxicity of general anesthesia. However, cocaine is not without serious adverse effects and reports of toxicity limited universal uptake by the ophthalmic community. Two events brought new life to the field of ophthalmic local anesthesia: (1) the development of procaine, a much safer alternative to cocaine, and (2) the description of retrobulbar anesthesia by Atkinson [1]. The agents and injection methods have since been refined and local anesthesia is now the most common technique used to provide anesthesia for ocular surgical procedures. Despite improvements, there is still the potential for complications, both local and systemic, during routine procedures. To reduce risks, it is vital for the practitioner to have a thorough understanding of the physiology of neuronal function, the chemistry of various local anesthetic agents, and the pathogenesis of toxicity.

Physiology of nerve conduction Impulses are transmitted along the nerve in the form of a wave of electrical activity called an action potential. This rapid process (1 2 msec) is mediated
T Corresponding author. E-mail address: tim.jackson15@btinternet.com (T. Jackson).

by alterations in the permeability of the neuronal membrane to various cations, notably sodium and potassium. In the non-excited resting state, chemical and electrical gradients exist across the neuronal membrane. These gradients are established by various ion channels, which may be passive, active, or voltage gated. The nerve membrane is relatively impermeable to the passage of sodium (Na), but permeable to potassium (K). In addition to these passive movements, active Na/K-ATPase channels pump potassium into the cell and sodium outwards, in a molar ratio of 3:2 respectively. The net effect of these two processes, active and passive, is to create a resting potential across the neuronal membrane, in which the interior is negatively charged (70 to 90 mV). The membrane also contains voltage-gated sodium channels, which open and close based upon the membrane potential. Each channel molecule consists of a pore formed of one a subunit and one or two b subunits. The a subunit is in turn composed of four domains (D1 4), each of which comprises six transmembrane helical segments (S1 6). These channels are able to cycle through four states or phases: resting, activated, inactivated, and deactivated (Fig. 1). Functionally, the channel can be considered to possess two gates, an outer m gate and an inner h gate. At the resting membrane potential, the m gate is closed, but the h gate is open. On stimulation (activation) the m gate opens, and there is an influx of sodium ions down their electrochemical gradient, which causes a rise in the membrane potential. If this occurs with sufficient magnitude, a threshold potential of about 60 mV is reached, there is widespread opening of sodium channels, and even greater influx of sodium ions such that the membrane potential overshoots neutral to reach a peak of +20 mV. At this point the h gate closes, which inactivates the channel and prevents further sodium flux. This process of

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Fig. 1. Diagramatic representation of sodium channel in three main conformational states.

depolarization produces a potential difference relative to neighboring areas of the neuronal membrane, which in turn generates an electrical current that tends to depolarize those neighboring areas of membrane. Thus, a wave of depolarization flows along the nerve, propagating the initial stimulus. During the inactivated phase there is no inward movement of sodium through the voltage gated channels, and the resting membrane potential is restored by continued action of the Na/K-ATPase and passive potassium leakage. When the membrane potential reaches 60 mV, the m gate closes and the channel is said to be deactivated. During these latter two phases the nerve is refractory to further stimulation, which prevents rapid re-depolarization of that section of neuronal membrane and retrograde conduction.

Mechanism of action Local anesthetics reversibly block conduction of action potentials by interacting with the D4 S6 portion of the a subunit of the voltage-gated sodium channels. This site of action is intracellular, so the local anesthetic must first diffuse through the lipophilic nerve membrane. Local anesthetics are administered in an acidic solution that causes most of the drug to be present in the ionized form, which is lipophobic. Therefore, the drug must first be converted to the unionized form in sufficient quantity to enter the nerve cell. This depends upon the pKa of the local anesthetic and the pH of the tissue. Once inside the nerve cell, the lower pH converts the drug back into the ionized form, which is then able to block the sodium channels. This reduces the influx of sodium ions and subsequently, the depolarization of the membrane potential slows. If sufficient channels are blocked, it will prevent the threshold potential from being reached, and prevent propagation of an action potential, without affecting either the resting membrane potential (which is independent of voltage-gated sodium channels) or the threshold potential itself.

In addition to the action of the ionized local anesthetic moiety on the intracellular portion of the trans-membrane sodium channel, the non-ionized form also affects the intra-membrane areas of the channel: it has direct physical effects on the expansion of the lipid bilayer. The action of local anesthetics is augmented by the blockade of potassium channels, calcium channels, and G-protein coupled receptors [2 4]. Local anesthetic agents exhibit differing affinities with their binding site depending on the state of the channel, as the conformational changes in the channel inherent in the cycling of these states reveal or obscure the binding site. Affinity is greatest when the channel is open (activated or inactivated) and least when it is closed (deactivated and resting). Although this suggests that access of the local anesthetic to its binding sites will differ based on the frequency of nerve stimulation, there is no evidence that this use-, phase-, or frequency-dependent block can be manipulated to alter the quality of the block [5]. In addition to these state-dependent differences in channel affinity, there are also differences between local anesthetic agents. Lidocaine binds and dissociates rapidly, whereas bupivacaine dissociates more slowly. This difference is relatively unimportant for neuronal conduction, but is crucial to cardiac toxicity. Conduction of the cardiac impulse is mediated by voltage-gated sodium channels. Lidocaine binds and dissociates from these channels quickly; there is little chance that a frequency-dependent block of the impulse would occur. However, bupivacaine, and particularly the R-isomer, which dissociates more slowly than the S-isomer, can produce a more profound frequency-dependent block [6]. Cardiac conduction is slowed and lethal arrhythmias may occur.

Chemistry The molecular structure of the standard local anesthetics conforms to a similar pattern of a lipophi-

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Fig. 2. Generic structure of local anesthetic agents.

lic aromatic ring, linked to a hydrophilic tertiary or quarternary amine derivative. The intermediate hydrocarbon chain is joined to the amine moiety by an ester, amide, ketone or ether, and may be used to classify the drug as such (Fig. 2). Other dissimilar compounds may also possess local anesthetic properties, although they are seldom used in ophthalmic regional anesthesia (eg, amitryptiline, meperidine) [7,8]. The clinically used agents are the ester and amide local anesthetics. The ester bond is relatively unstable, during hydrolysis, which ensures rapid metabolism in vivo, but shelf life is dramatically shortened and autoclave sterilization is impossible.

librium as described by the Henderson-Hasselbach equation. The proportions of each form of the drug depend on the pH of the solution and the pKa of the particular drug in question, which is the dissociation constant and denotes the pH at which the ionized and neutral forms are present in equal amounts. pH pKa logbase=acid For a base pH=pKa + log [un-ionized] / [ionized] Because the pKa for a given local anesthetic agent is constant, the clinical relevance is in comparing the speed of onset. Most clinically available local anesthetics have pKa values in excess of the pH of extracellular fluid; therefore, the ionized form dominates after injection, which makes it unable to penetrate the cell. Those agents with pKa values at the lower end of the range will have a greater proportion present in the neutral form, which diffuses more rapidly into the nerve cell and their site of action. Increasing the pH of the carrier solution will similarly favor the formation of a more neutral base, although chemical stability is reduced by this maneuver. The converse is true for inflamed tissue, which inherently has a lower

Ionization Local anesthetics are weak bases (pKa 7.6 8.9) (Table 1); poorly soluble in water and therefore usually presented in acidic hydrochloride salt solutions (pH 3 6). In this form, the local anesthetic rapidly becomes reduced to a cationic form. This process is readily reversible, and the relative proportions of neutral base and ionized form develop equiTable 1 Physicochemical and clinical properties of local anesthetics Agent Amide agents Bupivacaine Levobupivacaine Etidocaine Lidocaine Mepivacaine Prilocaine Ropivacaine Ester agents Cocaine Amethocaine Procaine
a b

pKa (25C) 8.1 8.1 7.7 7.7 7.6 7.8 8.2 8.7 8.5 8.9

Speed of onset Intermediate Intermediate Fast Fast Fast Fast Intermediate Slow Slow Slow

Partition coefficienta 346 346 800 43 21 25 115 Ub 221 1.7

Potency High High High Intermediate Intermediate Intermediate Intermediate High Intermediate Low

Toxicity High Intermediate High Low Low Low Intermediate Very high Intermediate Low

Protein bound (%) 95 96 94 64 75 55 94 98 76 6

Duration Long Long Long Intermediate Intermediate Intermediate Long Long Intermediate Short

Partition coefficient with n-octanol/buffer. U unknown.

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pH than the usual physiological value (7.4), and renders the local anesthetic less effective.

Lipid solubility Lipid solubility is a property of the hydrocarbon chain and aromatic group, and is represented by the partition coefficient which is a measure of the relative distribution of agent between an aqueous phase (eg, buffer at pH 7.4) and non-ionized solvent phase (eg, octanol, heptane, hexane). As the partition coefficient gets higher, the drug becomes more lipid soluble, and the concentration of the drug within the nerve membrane goes up. This is a major determinant of potency; agents that have high partition coefficients (eg, bupivacaine, etidocaine) have correspondingly high potency (see Table 1).

which have been marketed separately. They have similar physicochemical properties, including those relating to their pharmacokinetics, but behave differently at biological receptors. As previously mentioned, S-bupivacaine (and indeed S-ropivacaine) demonstrates significantly reduced toxicity.

Metabolism Ester local anesthetics are hydrolyzed very rapidly by tissue and plasma cholinesterases. The metabolites are inactive as local anesthetics, but include paraaminobenzoic acid (PABA) which can be allergenic. The rapidity of this metabolism provides some degree of safety from toxicity, because plasma levels fall so rapidly. The exception, although no longer used directly in ophthalmology, is cocaine, which is metabolized more slowly in the liver. Amides are much more stable in plasma than esters. They are initially absorbed, then distributed to the pulmonary circulation, where they are temporarily sequestered by ion-trapping because of the relatively low pH of extravascular lung water. They are predominantly cleared by hepatic microsomal phase I and II reactions, although a small percentage is cleared by renal mechanisms. The rate of metabolism depends heavily on liver blood flow, and differs between agents. Prilocaine and etidocaine are the most rapid, lidocaine and mepivacaine are intermediate, and bupivacaine and ropivacaine are the slowest. The clearance of prilocaine exceeds what the liver could do alone, which suggests that extra-hepatic mechanisms are also involved, most likely in the lung [9].

Protein binding Local anesthetics bind to tissue and plasma proteins (albumin, a1-acid glycoprotein). Albumin is considered high volume, low affinity binding, whereas, a1-acid glycoprotein is low volume, high affinity. These proteins represent a reservoir of the drug, although it is the free drug that is active. The amount of protein binding correlates well with duration of action of local anesthetic agents; however, other factors such as potency, dose, presence of vasoactive substances, and vascularity of the tissue also have effects. As local anesthetics are absorbed systemically, the binding sites are occupied gradually, and have apparent stability in free plasma concentrations. However, once the binding sites are saturated, toxic levels can be rapidly reached and have disastrous consequences. This may also occur with more modest doses in the presence of acidosis, when local anesthetic dissociates from the binding sites.

Toxicity Toxic reactions may be local or systemic. Local toxicity occurs when local anesthetic is injected directly into a structure, such as a nerve or muscle, whereas systemic toxicity follows absorption of excessive amounts or inadvertent intravascular injection. An exaggerated effect with systemic toxicity may also occur following accidental sub-dural injection. Neurotoxicity Local anesthetics may cause damage to neural tissue, either by direct injection into a nerve, or in situations where highly concentrated local anesthetic solutions bathe nerves for a prolonged period. It may also occur with concentrations of lidocaine that would be used in clinical practice. An in vitro squid

Chirality Organic molecules contain asymmetric carbon atoms, which may exist as mirror image or stereoisomers. They can be identified by the way they rotate polarized light, and are either R or L, or + for dextro- or levorotatory respectively. Bupivacaine, etidocaine, mepivacaine, prilocaine, and ropivacaine all have such carbon atoms, and most are produced as racemic mixtures: composed of equal amounts of both dextrorotatory and levorotatory isomers. The exceptions are S-ropivacaine and S-bupivacaine,

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axon model showed neurotoxicity with lidocaine 2% [10]. Lidocaine-induced neurotoxicity has also been seen in patients with the use of spinal micro catheters and 5% lidocaine [11]. The presumed mechanism is relatively concentrated lidocaine that bathes vulnerable nerves for a prolonged period of time. Fortunately, in ophthalmic regional anesthesia, neither the concentration, nor the duration of proximity to nerves of the local anesthetic is sufficiently high, so the local anesthetic is unlikely to be the sole culprit in neurological damage. In these cases many patients have coexistent vascular pathology. Highly concentrated local anesthetic is often used with vasoconstrictors, and high orbital pressures may develop. It is not surprising that nerve ischemia and subsequent damage may occur in this adverse environment.

Myotoxicity Direct injection into muscle can cause muscle necrosis. The subsequent fibrosis and contracture of the muscle can significantly impair function and cause diplopia, which could require surgery. This can be particularly devastating in elderly patients whose balance and mobility may already be compromised. The inferior oblique, inferior rectus, and medial rectus muscles are most frequently involved. This injury may occur by direct injection into the muscle, but it has also been reported with sub-Tenons injection, where the mechanism of action may be caused by local anesthetic that pools around or penetrates the muscle through small fenestrations in Tenons fascia. It has been suggested that the risks of local anesthetic induced myotoxicity may be reduced by the addition of hyaluronidase, which allows dispersal of local anesthetic away from the muscle [12].

Systemic toxicity Systemic reactions are uncommon, but may prove disastrous. In ocular regional anesthesia, systemic reactions may occur when anesthetic agent is injected through the dural cuff into cerebrospinal fluid around the optic nerve. Brainstem anesthesia could occur along with loss of consciousness and respiratory and cardiovascular depression. Supportive treatment is aimed at securing the airway, providing positive pressure ventilation, and using fluids and vasopressors to support the circulation. Systemic reactions may also result from administration of an inappropriately large dose, or follow intravascular injection of even a small

dose. Intravenous injections of an appropriate dose may cause significant effects. Reactions can also occur when much smaller doses are injected at high pressure into the arterial system, which results in the retrograde spread of high concentrations of local anesthetic solution direct to the brain. The effect of these mishaps depends upon the drug injected, the speed of injection, the total dose administered, and the physiology of the patient. Methods aimed at reducing these complications include techniques to carefully position the injecting needle, aspiration before every injection (although a negative aspiration does not exclude the possibility of intravascular injection), the use of a test dose, fractionated doses, adequate time between doses, the use of a less toxic local anesthetic, awareness of maximum doses in different settings, and the addition of other agents (opioids, clonidine, hyaluronidase, bicarbonate, epinephrine) to reduce the amount of local anesthetic required. The sequence of toxic phenomena depends upon the rate of increase in plasma concentration. If the plasma concentration rises slowly, symptoms develop such as circumoral and tongue paraesthesiae, a metallic taste, and dizziness, followed by slurred speech, diplopia, tinnitus, confusion, agitation, muscle twitching, and convulsions. At even higher plasma levels, the effects become depressive, and lead to coma and death. As with direct subarachnoid injection, the treatment is supportive and anticonvulsants are administered to control seizure activity. As plasma levels of local anesthetics increase, neurological effects are accompanied by cardiovascular complications, which can be difficult to treat. Impending toxicity may be signaled by bradycardia with prolonged PR interval (the time, in seconds, from the beginning of the onset of atrial depolarization to the beginning of the onset of ventricular depolarization) and broad QRS complex (the EKG representation of the hearts electrical impulse as it passes through the ventricles). This may be followed by a range of dysrhythmias, such as heart block, multifocal ectopics, tachycardia, and ventricular fibrillation. Again, treatment is supportive, but is likely to involve the use of antiarrhythmics such as amiodarone, phenytoin, and bretyllium. There is evidence that suggests lipid emulsion infusions (intralipid) and clonidine may also have a supportive role. Although lidocaine has a role in the treatment of ventricular tachydysrrhythmias, it would be sensible to avoid it if local anesthetic cardiotoxicity has been established. Resuscitation is difficult and may require prolonged efforts, but clinicians should remember that the local anestheticinduced neuronal depression may be protective against brain injury.

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Increasing laboratory data suggest that modern, single-isomer local anesthetic preparations provide improved safety profiles. Nancarrow and colleagues [13] compared the toxic effects of intravenous bupivacaine, ropivacaine, and lidocaine in sheep, and found a ratio of lethal doses of 1:2:9. The group that received lidocaine died with respiratory depression, bradycardia, and hypotension, but without arrhythmias, whereas, three of four sheep treated with bupivacaine died because of ventricular arrhythmias in the absence of hypoxia or acidosis. The group treated with ropivacaine died from a combination of these causes, or as a result of sudden onset ventricular arrhythmias alone. The arrhythmias precipitated by local anesthetics are caused by depression of the rapid depolarization phase (Vmax) of the cardiac action potential. This leads to slowed conduction, re-entrant rhythms, and predisposition to ventricular tachycardia. The effects of arrhythmias on cardiac output are augmented by myocardial depression, although this may be offset by the myocardial stimulation associated with seizures [14]. In an attempt to isolate the cardiovascular effects, Chang and colleagues [15] infused bupivacaine, levobupivacaine, and ropivacaine directly into the coronary arteries of conscious sheep. No significant differences were found in survival or fatal doses, which indicate that these agents may have equal cardiac toxicity [16]. Using an anaesthetised swine model, Morrison and colleagues [17] administered intracoronary injections of bupivacaine, levobupivacaine, and ropivacaine. They found little difference in fatal dose between levobupivacaine and ropivacaine, but racemic bupivacaine had greater cardiotoxicity. Feldman and colleagues [18] showed that similar doses of ropivacaine and bupivacaine caused convulsions in dogs, but that the mortality rate was lower in the animals treated with ropivacaine. Isolated organ experiments have linked local anesthetic toxicity in the brain to disturbances in the heart [19]. The varied results of these studies may reflect inter-species variation, or may be a reflection of the complex interplay between the central nervous system, the myocardium, and general anesthesia during local anesthetic toxicity. Although the conclusions of these animal studies are compelling, it is difficult to confirm their results in human subjects, particularly with respect to lethal doses. Scott [20] administered a maximum of 150 mg of ropivacaine and racemic bupivacaine to healthy volunteers. Of the 12 subjects, 7 tolerated the maximum dose of ropivacaine, whereas only 1 subject was able to tolerate 150 mg of bupivacaine. Plasma levels showed that central nervous system and cardiovascular symptoms occurred at lower plasma levels with

bupivacaine than ropivacaine. In addition, ropivacaine reduced myocardial depression and widening of the QRS (wave) complex. Bardsey and colleagues [21] used intravenous infusions of lidocaine to familiarize 12 healthy volunteers with the central nervous system effects of local anesthetic toxicity. A few days later the volunteers received intravenous infusions of levobupivacaine or bupivacaine at a rate of 10 mg/min until they had received 150 mg, or had begun to experience central nervous system toxic effects. Cardiovascular monitoring demonstrated that, despite higher plasma levels, levobupivacaine depressed myocardial function significantly less than bupivacaine. Equal doses of intravenous levobupivacaine were compared with ropivacaine by Stewart and colleagues [22]. No differences were found in terms of central nervous system symptoms or cardiovascular effects. Animal and human studies have shown improved safety with the single-isomer local anesthetics levobupivacaine and ropivacaine. However, they may still provoke severe toxic reactions. In addition, the marginally reduced potency of ropivacaine requires a larger total dose and may reduce any benefit of the single isomeric form.

Allergy The first reports of allergy to local anesthesia were from a dentist who developed contact dermatitis after repeated exposed to apothesin, an ester local anesthetic [23]. Further minor reactions were reported, but very few individuals developed anaphylaxis. The trigger for these reactions was found to be PABA, an intermediate metabolite of ester hydrolysis. Sensitivity to PABA may also occur as a result of exposure to certain foodstuffs or cosmetics, and because sulphonamides structurally resemble PABA, cross-reactivity to all these substances may occur. The development of amide local anesthetics in the 1940s effectively reduced reports of allergic reactions. Amides are now considered to be very rare allergens; only about 1% of alleged reactions are believed to be caused by a truly immune-mediated process [24]. Reports of previous allergic reactions come largely from the dentists surgery. This is likely to have been a vagal response in a patient who was anxious and in a semi-upright position, or an inadvertent intravascular injection of local anesthetic solution and its associated vasopressor, which produced some unpleasant cardiovascular effects. Nevertheless, it is important to exclude allergy by referral to an allergist, who will perform skin-prick tests for

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mild reactions or in-vitro testing for patients who have suffered an anaphylactoid reaction.
[10]

Summary Local anesthesia forms the backbone of all ophthalmic anesthetic techniques. From its inception in the 19th century to the modern era, developments in the chemistry of local anesthetic agents and improvements in operative conditions have led to reductions in the incidence of adverse reactions. Nevertheless, use of this powerful group of agents is not without hazard, and it is vital to have a thorough understanding of the underlying chemistry, and their potential to cause local and systemic toxicity when they are used for ophthalmic regional anesthesia. The single-isomer preparations show great promise in the laboratory, but have yet to demonstrate a clinical difference.

[11]

[12]

[13]

[14]

[15]

[16]

References
[1] Atkinson WS. Retrobulbar injection of anesthetic within the muscular cone. Arch Ophthalmol 1936;16:494 503. [2] Xiong Z, Strichartz G. Inhibition by local anesthetics of Ca 2+ channels in rat anterior pituatary cells. Eur J Pharmacol 1998;363:81 90. [3] Hollman M, Wieczorek K, Berger A. Local anesthetic inhibition of G protein-coupled receptor signaling by interference with Galpha(q) protein function. Mol Pharmacol 2001;59:294 301. [4] Olschewski A, Hemplemann G, Vogel W. Blockade of Na + currents by local anesthetics in the dorsal horn neurons of the spinal cord. Anesthesiology 1998;88: 172 9. [5] Courtney K. Mechanism of frequency-dependent inhibition of sodium currents in frog myelinated nerve by the lidocaine derivative GEA 968. J Pharmacol Exp Ther 1975;195:225 36. [6] Vanhoutte F, Vereecke J, Verbeke N, et al. Stereoselective effects of the enantiomers of bupivacaine on the electrophysiological properties of the guuinea-pig papillary muscle. Br J Pharmacol 1991;103:1275 81. [7] Sudoh Y, Cahoon E, Gerner P, et al. Tricyclic antidepressants as long-acting local anesthetics. Pain 2003; 103:49 55. [8] Acalovschi I, Cristea T. Intravenous regional anesthesia with meperidine. Anesth Analg 1995;81:539 43. [9] Tucker G. Local anesthetic drugs: mode of action and pharmacokinetics. In: Nimmo W, Rowbotham D,

[17]

[18]

[19]

[20]

[21]

[22]

[23] [24]

Smith G, editors. Anesthesia, vol. 2. Oxford7 Blackwell Scientific Publications; 1994. p. 1371. Kanai Y, Katsuki H, Takasaki M. Lidocaine disrupts axonal membrane of rat sciatic nerve in vitro. Anesth Analg 2000;91:944 8. Lambert L, Lambert D, Strichartz G. Irreversible conduction block in isolated nerve by high concentration of local anesthetic. Anesthesiology 1994;260:121 8. Brown S, Brooks S, Mazow M, et al. Cluster of diplopia cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999;25:1245 9. Nancarrow C, Rutten A, Runciman W, et al. Myocardial and cerebral drug concentrations and the mechanism of death after fatal intravenous doses of lidocaine, bupivacaine, and ropivacaine in sheep. Anesth Analg 1989;69:276 83. Rutten A, Nancarrow C, Mather L, et al. Hemodynamic and central nervous system effects of intravenous bolus doses of lidocaine, bupivacaine, and ropivacaine. Anesth Analg 1989;69:291 9. Chang D, Ladd L, Copeland S, et al. Direct cardiac effects of intracoronary bupivacaine, levobupivacaine and ropivacaine in sheep. Br J Pharmacol 2001;132: 649 58. Huang Y, Pryor M, Mather L, et al. Cardiovascular and central nervous system effects of intravenous levobupivacaine and bupivacaine in sheep. Anesth Analg 1998;86:797 804. Morrison S, Dominguez J, Frascarolo P, et al. A comparison of the electrocardiographic effects of racemic bupivacaine, levobupivacaie, and ropivacaine in anesthetized swine. Anesth Analg 2000;90:1308 14. Feldman H, Arthur G, Pitkanen M, et al. Treatment of acute systemic toxicity after rapid intravenous injection of ropivacaine and bupivacaine in the conscious dog. Anesth Analg 1991;73:373 84. Heavner J. Cardiac dysrhythmias induced by infusion of local anesthetic into the lateral ventricles of cats. Anesth Analg 1986;65:133 8. Scott D, Lee A, Fagan D, et al. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989;78:1125 30. Bardsley H, Gristwood R, Baker H, et al. A comparison of the cardiovascular effects of levobupivacaine and rac-bupivacaine following intravenous administration to healthy volunteers. Br J Clin Pharmacol 1998;46:245 9. Stewart J, Kellet N, Castro D. The central nervous sytem and acrdiovascular effects of levobupivacaine and ropivacaine in healthy volunteers. Anesth Analg 2003;97:412 6. Monk W. Skin reactions to apothesin and quinine (sic) in susceptible persons. Arch Derrmatol 1920;1:651 5. Finucane B. Allergies to local anesthetics - the real truth. Canadian Journal of Anesthetics 2003;50:869 74.

Ophthalmol Clin N Am 19 (2006) 163 177

Preoperative Medical Testing and Preparation for Ophthalmic Surgery

Bobbie Jean Sweitzer, MD
University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA

As the practice of medicine becomes more outcome-driven and cost-conscious, clinicians need to reevaluate and streamline methods of patient care. A preoperative evaluation is important to Screen for and optimize co-morbid conditions. Assess and lower the risk of anesthesia and surgery. Establish baseline results to guide perioperative decisions. Facilitate timely care and avoid cancellations on the day of surgery. The Australian Incident Monitoring Study (AIMS) found that adverse events were unequivocally related to insufficient (3.1%; 197 of the first 6271 reports) and inadequate (11%) preoperative assessments [1]. More than half the incidents were considered preventable. Delays, complications, and unanticipated postoperative admissions have been significantly reduced by preoperative screening and patient contact. Ophthalmologic procedures are considered low risk because of their general lack of physiologic disturbances such as hemodynamic perturbations, significant stress response, hypercoagulable state, blood loss, or postoperative pain [2]. However, ophthalmic patients are often elderly and have multiple comorbid conditions that are a constant threat to wellbeing, even without surgery. If general anesthesia (GA) is necessary, the risk of the procedure may increase. In a study of patients who had cataract surgery, there was significantly more myocardial ische-

mia in the group that was given GA compared with the group that was given local anesthesia. There was a surprisingly high incidence (31%) of perioperative ischemia detected by Holter monitoring for 24 h after surgery. Interestingly, there was no difference in occurrence of ischemia between the two groups (probably because of the high rate of coronary heart disease in this elderly population) but the GA group had more episodes per patient, especially intraoperatively [3]. Patients who undergo retinal surgery have a particularly increased risk because of their associated co-morbid conditions [4].

Preoperative assessment At a minimum, a preoperative visit should include the following: Interview the patient to review medical, anesthesia, surgical, and medication history. Conduct an appropriate physical examination. Review the pertinent diagnostic data (laboratory, electrocardiogram). Refer the patient to primary care or specialist physicians to manage new or poorly controlled diseases. Formulate and discuss care plan with patient or responsible adult. Several studies have proven the utility of a patient history and physical examination when making a diagnosis. A study of patients in a general medical clinic found that 56% of correct diagnoses were made based on the history alone, and rose to 73% based on

E-mail address: bsweitzer@dacc.uchicago.edu

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.007

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history plus physical examination [5]. In patients who have cardiovascular disease, the history established the diagnosis two-thirds of the time, and the physical examination contributed to one-quarter of diagnoses. Routine investigations, mainly chest radiographs and ECG, helped with only 3% of diagnoses, and special tests, mainly exercise ECG, assisted with 6% [5]. History is also the most important diagnostic method in respiratory, urinary, and neurologic conditions. The patients medical problems, past surgeries, previous anesthesia or surgical-related complications, medications, allergies, and use of tobacco, alco-

hol, or illicit drugs should be documented (Fig. 1). A screening review of systems should emphasize airway abnormalities, personal or family history of adverse events related to surgery, and cardiovascular, pulmonary, endocrine, or neurologic symptoms. In addition to identifying the presence of a disease, it is equally important to establish the severity, the stability, and any prior treatment of the condition. The patients medical problems, previous surgeries, and responses, will elicit further questions to establish the extent of disease, current or recent exacerbations, and recent or planned interventions.

Patient's Name Planned Operation Surgeon Primary Doctor 1. Please list all operations (and approximate dates) a. d. b. e. c. f.

Age Sex Date of Surgery Cardiologist?

2. Please list any allergies to medicines, latex or other (and your reactions to them) a. c. b. d. 3. Please list all medications you have taken in the last month (include over-the-counter drugs, inhalers, herbals, dietary supplements and aspirin) Name of Drug a. b. c. d. e. Dose and how often Name of Drug f. g. h. i. j. Dose and how often

(Please check YES or NO and circle specific problems) 4. Have you seen your primary care doctor within the last 6 months? 5. Have you ever smoked? (Quantify in packs/day for years) Do you still smoke? Do you drink alcohol? (If so, how much?) Do you use or have you ever used any illegal drugs? (we need to know for your safety) 6. Can you walk up one flight of stairs without stopping? 7. Can you lie flat (or with only 1-2 pillows) for at least one hour? 8. Have you had any problems with your heart? (circle) (chest pain or pressure, heart attack, abnormal EKG, heart murmur, palpitation, heart failure) 9. Do you have high blood pressure? 10. Have you had any problems with your lungs or your chest? (circle) (shortness of breath, emphysema, bronchitis, asthma, TB, abnormal chest x-ray) 11. Are you ill now or were you recently ill with a cold, fever, chills, flu or productive cough?
Fig. 1. Sample patient preoperative history form.

YES

NO

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Knowledge of the patients cardiorespiratory fitness or functional capacity can help guide additional preoperative evaluation, and help predict outcome and perioperative complications [2,6]. An ability to exercise is two-pronged; better fitness decreases diseases such as diabetes and hypertension, as well as mortality, and a patients inability to exercise may be a result of cardiopulmonary disease and therefore may identify a patient who warrants further investigation [7]. Several studies have shown that inability to perform average levels of exercise (walking 1 2 flights of stairs) identifies patients at risk of perioperative complications [8]. The important components of the patient history are shown in Fig. 1. The form can be completed by the patient in person (paper or electronic version), by way of web-based programs, by a telephone interview, or by office staff. This form can be used to identify patients who may be in need of referral to a primary care physician, an anesthesiologist, or a specialist, for further evaluation or management before surgery. Alternately, the form can be forwarded

for an anesthesiologist or a primary care physician to review and make the determination if an appointment is needed. A more detailed discussion of important components of the patient history for specific medical conditions is presented below. At a minimum, the preoperative examination should include vital signs (blood pressure, pulse and room air oxygen saturation), and a heart and lung examination. If general anesthesia is not planned, the ability of the patient to lie flat for the estimated duration of the procedure is extremely important. A guide to help determine the patients ability to lie recumbent follows: Disease. Certain conditions such as heart failure, lung disease, chronic cough, musculoskeletal disease like kyphoscoliosis, or a movement disorder such as a tremor, may prevent a patient from lying still during the planned procedure. Dementia. If the patients mental capacity precludes being able to stay still and follow simple commands, local anesthesia will likely fail.

Describe recent changes 12. Have you had any problems with your blood (circle) (anemia, leukemia, sickle cell disease, blood clots, transfusions within the last 6 months)? 13. Have you ever had problems with your: (circle) Liver (cirrhosis, hepatitis, jaundice)? Kidney (infection, stones, failure, dialysis)? 14. Have you ever had: (circle) Seizures, epilepsy, or fits? Stroke, facial, leg or arm weakness, difficulty speaking? 15. Have you ever been treated for cancer with chemotherapy or radiation therapy? (circle) 16. Women: Could you be pregnant? Last menstrual period began: 17. Have you ever had problems with anesthesia or surgery? (circle) (malignant hyperthermia (in blood relatives or self) or problems during placement of a breathing tube) 18. Do you snore? 19. Please list any medical illnesses not noted above:

22. Additional comments or questions for nurse or doctor?

Fig. 1 (continued ).

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Dialect. Patients who are unable to communicate because they speak a language different than operating room personnel may not be cooperative. Deafness. Patients who have hearing problems may have difficultly communicating. The physical examination contributes one-quarter of diagnoses in patients who have cardiovascular disease [5]. Auscultation of the heart, palpation of the pulses, and inspection of the extremities for the presence of edema are important diagnostically and for risk assessment when care plans are developed. The practitioner should auscultate for murmurs, rhythm disturbances, and signs of volume overload. Murmurs, without a previous diagnosis, warrant further evaluation. The pulmonary examination should include auscultation for wheezing, decreased or abnormal breath sounds, and notation of cyanosis or clubbing and effort of breathing. Observing whether the patient can walk up 1 2 flights of stairs can predict a variety of medical conditions and postoperative complications including pulmonary and cardiac events and mortality.

testing versus batteries of screening tests [10]. Fortunately, without specific clinical indication, few abnormalities detected by nonspecific testing have been shown to result in changes in management and rarely have such changes been shown to have a beneficial patient effect [11]. It has been suggested that not following up on an abnormal test result is a greater medico-legal risk than not identifying the abnormality to begin with. A preoperative ECG is one of the most frequently ordered and costly noninvasive tests. A preoperative ECG might be ordered because Occult heart disease is common in a middle-aged population and increases with advancing age Pre-existing heart disease increases perioperative risk It is useful to establish a baseline. However, a resting ECG is not a reliable screen for coronary artery disease and is a poor predictor of heart disease (without a supporting history) in nonsurgical patients. There is evidence that only some ECG abnormalities are important in the perioperative period (eg, new Q waves and arrhythmias). One study found only 2% of patients had one or both of these abnormalities [12]. Gold [13] found that in ambulatory surgical patients, the incidence of abnormal ECGs was quite high (43%). However, only 1.6% had an adverse perioperative cardiac event, and the preoperative ECG was of potential value in only half (6/751) of these. It has been suggested that routine preoperative ECG testing is not indicated in patients who do not have a history of cardiovascular disease or significant risk factors [14]. Even though ECG abnormalities are increasingly more common with advanced age, abnormalities alone have not been shown to predict postoperative cardiac complications in the elderly [13,15]. Although abnormal ECG findings are common in the elderly, significant abnormalities that impact care are low in the absence of a history or symptoms of cardiac disease [13]. Centers for Medicare and Medicaid Services will not provide coverage for age-based ECGs or ECGs performed simply as a preoperative test. A practitioner must provide a supporting diagnosis with an acceptable ICD-9 code [16]. ECGs are acceptable if performed within 6 months and the patient has had no change in symptoms. Indications for ECG testing include History of coronary artery disease, myocardial infarction, angina or chest pain History of congestive heart failure

Preoperative testing Preoperative testing is performed to evaluate existing medical conditions and screen for asymptomatic conditions based on known risk factors for particular diseases. Diagnostic tests can help assess the risk of anesthesia and surgery, guide medical intervention to lower this risk, and provide baseline results to direct intra- and postoperative decisions. The choice of laboratory tests should depend on the probable impact of the test results on the differential diagnosis and on patient management. A test should be ordered only if the results will (1) affect the decision to proceed with the planned procedure, (2) influence the type of anesthesia used, or (3) alter the care plans. The history and physical examination should be used to direct which tests are ordered. (Fig. 2). Preoperative tests without specific indications lack clinical utility and may actually lead to patient injury because of unnecessary interventions, delay of surgery, anxiety, and perhaps even inappropriate therapies. The patient history is responsible for the diagnosis 75% of the time and is more important than the physical examination and laboratory investigations combined [9]. In addition, the evaluation of abnormal results is costly. Many studies have evaluated the benefits of disease- or condition-indicated

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Disease /Therapy/Procedure based Indications

(applies to all patients scheduled for general anesthesia, or newly diagnosed or unstable conditions only)

-hCG
BUN; Creatinine ECG

Possible pregnancy

Diabetes; Heart failure; Renal disease; Sickle cell anemia; Use of Diuretics

Alcohol abuse; Cardiovascular, Cerebrovascular, Peripheral vascular, Pulmonary, or Renal disease; Diabetes; Morbid Obesity; Murmurs; Poor exercise tolerance (unable to walk up a flight of stairs); Poorly controlled hypertension (BP >180/110 mmHg); Rheumatoid arthritis; Sickle cell anemia; Sleep apnea; Smoking >40 pk-yr; Systemic lupus; Radiation therapy to chest or left breast; Use of Digoxin

Electrolytes

Cerebrovascular, Hepatic or Renal disease; Diabetes; Sickle cell anemia; Use of Digoxin, or Diuretics

Glucose

Cerebrovascular Disease; Diabetes; Morbid obesity; Steroid use

Platelets; PT; aPTT*

Alcohol abuse; Hepatic disease; Personal or Family history of bleeding; Use of Anticoagulants.

Thyroid Tests

Thyroid disease; Use of Thyroid medications

* Only indicated for these conditions if peri- or retrobulbar blocks are planned or bleeding is an issue Abbreviations: -hCG=pregnancy test; BUN= blood urea nitrogen; ECG=electrocardiogram; PT= prothrombin time; a-PTT= activated partial thromboplastin time; All tests are valid for 6 months before surgery unless abnormal, or patients condition has changed; with the exception of -hCG for pregnancy, glucose in diabetics and blood tests in patients with renal failure. Guidelines may not apply for low-risk procedures without general anesthesia where testing is only indicated if the medical condition is newly diagnosed or unstable.

Fig. 2. Sample preoperative diagnostic testing order form.

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History of atrial fibrillation, arrhythmias, irregular or skipped beats, heart block History or presence of murmur Presence of a pacemaker or implantable cardioverter-defibrillator Chronic lung disease, >40 pack-years of tobacco use or significant shortness of breath Diabetes mellitus Cerebrovascular (stroke, TIA) or peripheral vascular disease (claudication) Renal insufficiency or failure Age-based recommendations for testing are based on few data. No correlation has been established, independent of co-existing disease, a positive history, or findings on physical examination, between age and abnormalities in hemoglobin (Hgb), serum chemistries, radiographs, or pulmonary function testing [17 19]. Hemoglobin and hematocrit (Hct) levels are frequently abnormal in otherwise healthy patients but rarely impact anesthetic care or management, unless the planned procedure involves the potential for significant bleeding. Coagulation studies (platelet count, prothrombin time [PT], or activated partial thromboplastin time [a-PTT]) are not recommended unless the patient history is suggestive of a coagulation disorder. It is generally accepted that the cost of screening coagulation tests before minor surgery outweighs the benefit of non-life threatening bleeding (because of the minor nature of the procedure) in the rare patient with what would have to be a minor bleeding disorder, if there is a negative history [20]. Healthy patients of any age who undergo low or intermediate risk procedures (without expected significant blood loss) are unlikely to benefit from any tests. Patients who have stable, well-controlled, mild to moderate severity co-existing diseases, and who follow up regularly with primary care or specialist physicians are unlikely to benefit from additional diagnostic testing before surgery. In general, tests are only recommended if they will result in A change, cancellation, or postponement of the surgical procedure A change in anesthesia and medical management A change in monitoring or guidance of intra- or post-operative care Confirmation of a suspected abnormality based on the patients history and physical examination Generally, test results are valid and acceptable for up 6 months before surgery if the medical history has

not substantially changed [21]. Suggested tests are shown in Fig. 2. Patients who undergo cataract surgery are often elderly and have extensive co-morbid disease. The procedure is minor, however, and systemic physiologic disturbances or significant postoperative pain are not expected. Topical anesthesia is commonly used and because general anesthesia is rarely required, the risk is lessened. The cost of routine medical testing before cataract surgery is estimated at $150 million annually. In one study, more than 18,000 patients were randomly allocated to either a group that received no routine testing before cataract surgery or a a group that received a battery of tests (ECG, complete blood cell count, electrolytes, serum urea nitrogen, creatinine and glucose levels). No differences in postoperative adverse events were found between the two groups [10]. The study of cataract patients eliminated routine tests, not tests indicated for a new or worsening medical problem. All patients underwent a preoperative medical assessment. The group that crossed over from no testing to some testing had significantly more coexisting illnesses and poor self-reported health status. This finding suggests that the preoperative care provider screen patients to order tests for those who require them. In the study described, exclusion criteria were general anesthesia or a myocardial infarction within 3 months. More than 85% of subjects enrolled in the study reported good to excellent health status, almost 25% reported no coexisting illnesses (including hypertension, anemia, diabetes, and heart or lung disease), almost 30% were <70 years, and 65% were American Society of Anesthesiologists physical status (ASA-PS) 1 or 2 (Table 1); all of which suggests a fairly healthy group. The results of this study do not suggest that patients who undergo cataract surgery require no laboratory testing [10]. If patients are comparable to those in the study, are routinely evaluated by primary care physicians, have stable mild disease, and will undergo cataract surgery under topical or bulbar block, then no special testing is required for cataract surgery. Serious, poorly controlled conditions must be normalized before surgery, and selective testing suggested by history and physical examination may be necessary. Rarely is testing necessary because of cataract surgery, but patients with limited access to health care services may benefit from medical evaluation. Often physicians are concerned about their failure to diagnose a condition because a diagnostic screening test was not ordered, for which legal action can be brought. The traditional system of ordering routine

preoperative assessment Table 1 American Society of Anesthesiologists physical status classification Class ASA 1 ASA 2 Description Healthy patient without organic, biochemical, or psychiatric disease. A patient with mild systemic disease (eg, mild asthma or well-controlled hypertension). No significant impact on daily activity. Unlikely impact on anesthesia and surgery. Significant or severe systemic disease that limits normal activity (eg, renal failure on dialysis or class 2 congestive heart failure). Significant impact on daily activity. Likely impact on anesthesia and surgery. Severe disease that is a constant threat to life or requires intensive therapy (eg, acute myocardial infarction, respiratory failure that requires mechanical ventilation). Serious limitation of daily activity. Major impact on anesthesia and surgery. Moribund patient who is equally likely to die in the next 24 hours with or without surgery. Brain-dead organ donor.

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ASA 3

ASA 4

Yet risk assessment, at its best, is hampered by individual patient variability. One of the most common risk assessment tools used perioperatively is the ASA-PS scoring system (see Table 1). Though ASA-PS is usually determined by anesthesiologists for patients having anesthesia, it is often used for any comparison of surgical patients. Studies have corroborated an association of mortality and morbidity with ASA-PS. The other important risk assessment tool is the joint guideline published by The American College of Cardiology and the American Heart Association (ACC/AHA), which identifies risk factors and cardiac complications in noncardiac surgery. Cardiac complications are the most common cause of significant perioperative morbidity and mortality. For the purposes of this article, the ACC/AHA guideline considers ophthalmic procedures to be low risk and therefore, further risk assessment is only necessary for high-risk comorbid conditions [2].

ASA 5 ASA 6

Hypertension Poorly controlled hypertension (HTN) is one of the most common reasons for ophthalmic procedures to be cancelled on the day of surgery. HTN, defined by two or more measurements of blood pressure (BP) greater than 140/90 mmHg, affects one billion individuals worldwide and increases with age. In the United States, 25% of adults and 70% of patients older than 70 years have HTN and less than 30% are adequately treated [22]. The degree of end-organ damage and morbidity and mortality correlate with the duration and severity of HTN. Heart failure, renal insufficiency, and cerebrovascular disease are more common in hypertensive patients. Ischemic heart disease is the most common form of organ damage associated with HTN. Uncontrolled HTN is only a minor cardiac risk factor and the odds ratio for an association between HTN and perioperative cardiac risk is 1.31 [2,23]. There is little evidence of an association between preoperative BPs <180/110 mmHg and perioperative cardiac risk [23]. It is generally recommended that elective surgery be delayed for severe HTN (diastolic blood pressure >115 mmHg; systolic blood pressure >200 mmHg) until BP <180/110 mmHg. If severe end-organ damage is present, the goal should be to normalize BP as much as possible before surgery [23]. For BP <180/110 mmHg there is no evidence to justify cancellation of surgery, although if time allows, interventions preoperatively are appropriate. Severely elevated BP should be lowered over several weeks.

preoperative tests evolved from the mistaken belief that more information, no matter how irrelevant or expensive, will improve care, enhance safety, and decrease liability. In reality, non-selective screening may actually increase legal culpability. Unanticipated abnormalities (ie, not suggested by the history or physical examination) are uncommon and the relationship between these abnormalities and surgical and anesthetic morbidity is weak at best. In addition, it has been documented that over half of all abnormal test results obtained in routine preoperative screening are ignored or at least not noted in the medical record, which is the document of interest to the courts. Failure to follow up an abnormal result is, from a legal point of view, probably riskier than failure to order the test in the first place. AIMS found that communication problems were predominant in most reported incidents that involved a failure of preoperative preparation [1].

Risk assessment Risk assessment is useful to compare outcomes, control costs, allocate compensation, and assist with the difficult decision to cancel or recommend that a procedure not be done when the risks are too high.

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Discontinue 24 hours before surgery Box 1. Preoperative medication guidelines Erectile dysfunction medications Continue on the day of surgery a Discontinue on the day of surgery Antidepressant, anti-anxiety, and psychiatric medications Anti-hypertensive medications Anti-seizure medications Aspirin, unless the risk of minor bleeding is significant Asthma medications Birth control pills Cardiac medications (eg, digoxin) Cox-2 inhibitors Diuretics (eg, triamterene or hydrochlorothiazide) for hypertension Heartburn or reflux medications Insulin- all intermediate, combination, or long-acting insulin, or insulin pumps  Type 1 diabetics should take a small amount (one-third to onehalf) of their usual morning longacting insulin (eg, lente or NPH) on the day of surgery  Type 2 diabetics should take one third to one-half dose of longacting (eg, lente or NPH) or combination (70/30 preparations) insulin on the day of surgery  Patients with an insulin pump should continue only their basal rate on the day of surgery Narcotic pain medications Statins Steroids, oral or inhaled Thyroid medications Discontinue 7 days before surgery Clopidogrel (Plavix), except patients scheduled for cataract surgery with topical or general anesthesia Herbals and non-vitamin supplements Hormone replacement therapy Discontinue 4 days before surgery Warfarin (Coumadin), except for patients scheduled for cataract surgery with topical or general anesthesia Diuretics, except triamterene or hydrochlorothiazide for hypertension, which should be continued Insulin- all regular insulin (see insulin to continue on day of surgery above) Iron Oral hypoglycemic agents Topical medications (eg, creams or ointments) Vitamins Special considerations before surgery Monoamine oxidase inhibitors: patients taking these antidepressant medications need an anesthesia consultation before surgery (preferably 3 weeks before) if general anesthesia is planned
a Patients should take medications with a small sip of water even if otherwise instructions are nothing per mouth.

Guidelines suggest that cardioselective beta-blocker therapy is the best treatment preoperatively because of a favorable profile in lowering cardiovascular risk [2]. It may take 6 8 weeks of therapy to effectively lower the risk and to allow regression of vascular changes, because too rapid or extreme lowering of BP may increase cerebral and coronary ischemia. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial showed that effective treatment of HTN is not simply a matter of lowering BP [24]. Continuation of antihypertensive treatment preoperatively is critical (Box 1). Testing should be determined by the history and physical examination and may include ECG, electrolytes, serum urea nitrogen, and creatinine if general anesthesia is planned (see Fig. 2). An elevated BP during the ophthalmology visit or a history of poorly controlled HTN should prompt a referral to a primary care physician for BP control before elective surgery.

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Cardiac disease The goals of the ophthalmologist should be to identify the presence and severity of heart disease (HD) or significant risk of HD based on associated conditions, such as diabetes, renal insufficiency or failure, cerebrovascular or peripheral vascular disease, and determine the need for preoperative consultation and interventions (almost always medical, not invasive) to modify the risk of perioperative adverse events. The basis of cardiac assessment is the history, physical examination, and ECG. The most recent guidelines for the cardiac evaluation for noncardiac surgery from the ACC/AHA have become the national standard of care [2]. These guidelines indicate that patients without high-risk comorbid conditions defined as unstable or new onset angina, decompensated heart failure, significant arrhythmias (ventricular tachycardia or atrial fibrillation with a rapid rate, >100 bpm) or severe valvular disease (regurgitation or stenosis) can safely undergo low-risk procedures without stress testing or cardiology intervention. Currently, the benefits of coronary revascularization before noncardiac surgery, versus medical risk modification are controversial [25]. Unless patients will benefit from revascularization regardless of the planned procedure, or have unstable angina, revascularization is not indicated before ophthalmic surgery. Noncardiac surgery soon after revascularization (bypass grafting and percutaneous coronary intervention with or without stents) is associated with high rates of perioperative cardiac morbidity and mortality [26,27]. Patients who have recently had angioplasty with stent placement (within 6 months), especially with newer, drug-eluting stents, require several months of anti-platelet therapy to avoid restenosis or acute thromboses. These patients need to be identified and close management with a cardiologist is required. Case reports have indicated that patients can have stent thromboses perioperatively even if anti-platelet agents are continued [28]. Patients who have a history of coronary artery disease or significant risk factors (diabetes, renal insufficiency, cerebrovascular or peripheral vascular disease) need an ECG within 6 months of a planned GA (see Fig. 2). Heart failure affects 4 5 million people in the United States and is a significant risk factor for postoperative adverse events [29]. The goal for the ophthalmologist is to identify patients who have decompensated heart failure. Recent weight gain, complaints of shortness of breath, fatigue, orthopnea, paroxysmal nocturnal dyspnea, edema, hospitaliza-

tions, and recent changes in medication are important. Physical findings should focus on examination for third or fourth heart sounds, rales, jugular venous distention, ascites, hepatomegaly, and edema [30]. Decompensated heart failure requires referral to a cardiologist for optimization preoperatively. Minor procedures can be done with little risk as long as heart failure is stable. If GA is planned an ECG, electrolytes, BUN, and creatinine are required (see Fig. 2). New onset or poorly controlled atrial fibrillation (HR >100 bpm), symptomatic bradycardia, or highgrade heart block (second or third degree) warrants postponement of elective procedures and referral to cardiology for further evaluation. Left bundle branch block (LBBB) is highly associated with coronary artery disease and a recent onset, or a patient without a previous evaluation of a LBBB requires stress testing or cardiology consultation. Right bundle branch block (RBBB) is more likely to be congenital, a result of calcification and degeneration of the conduction system or secondary to pulmonary disease. If the history and physical examination are not suggestive of significant pulmonary disease, no further evaluation is warranted just because of a RBBB. Patients who have a history of arrhythmias should be queried about syncope, chest pain, dyspnea or light-headedness. An ECG is necessary within 6 months or more recently if there has been a change in symptoms (see Fig. 2). The quandary with heart murmurs is to distinguish between significant murmurs and clinically unimportant ones. Diastolic murmurs are always pathologic and require further evaluation. Regurgitant disease is tolerated perioperatively better than stenotic disease. Aortic stenosis is the most common valvular lesion in the United States and affects 2% 4% of adults >65 years of age; severe stenosis is associated with a high risk of perioperative complications with GA [2]. Aortic stenosis was once considered to be a degenerative lesion that increased with age or a congenital bicuspid valve, but is now believed to have much in common with coronary heart disease and is an independent marker of ischemic disease [31]. The classic symptoms of severe aortic stenosis are angina, heart failure, and syncope, though patients are much more likely to complain of a decrease in exercise tolerance and exertional dyspnea. Aortic stenosis causes a systolic ejection murmur, which is best heard in the right upper sternal border and often radiates to the neck. Any patient with a previously undiagnosed murmur needs an ECG, and any ECG abnormality warrants an echocardiogram or a car-

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diology consultation. Current guidelines recommend echocardiography annually for patients who have severe aortic stenosis, every 2 years for moderate stenosis, and every 5 years for mild stenosis [32]. Aortic sclerosis, which causes a systolic ejection murmur similar to that of aortic stenosis, is present in 25% of people 65 74 years of age and almost half of those >84 years. However, there is no hemodynamic compromise with aortic sclerosis. Aortic sclerosis is associated with a 40% increase in the risk of myocardial infarction and a 50% increase in the risk of cardiovascular death in patients who do not have a history of heart disease [31]. It is estimated that more than 100,000 pacemakers and implantable cardiac defibrillators (ICDs) are implanted annually in the United States. Electromagnetic interference (EMI) is likely to occur with electrocautery and radiofrequency ablation, and result in malfunction or adverse events [33]. Some patient monitors and ventilators may cause EMI in patients who have rate-adaptive pacemakers. The preoperative evaluation should determine the type of device and the features (eg, rate-adaptive mechanisms) likely to malfunction if perioperative EMI should occur. Consultation with the device manufacturer, cardiologist, or the electrophysiology service is necessary. Ideally, patients should have these devices interrogated preoperatively. Special features such as rate adaptive mechanisms and anti-tachyarrhythmia functions need to be disabled or be reprogrammed to an asynchronous pacing mode before surgical procedures and anesthesia where EMI is anticipated [33]. Newer generation devices are more complex and reliance on a magnet, except in emergency situations, is not recommended. Disabling ICDs will prevent unanticipated discharges during delicate procedures. However, external defibrillators must be immediately available. A baseline ECG is needed in patients who have pacemakers and ICDs (see Fig. 2).

monary function tests, are not predictive of pulmonary complications. Sleep-disordered breathing affects up to 9% of middle-aged women and 24% of middle-aged men; less than 15% of these cases have been diagnosed. Obstructive sleep apnea (OSA), the most common serious manifestation of sleep-disordered breathing, is caused by intermittent airway obstruction. Cardiovascular disease is common in patients who have OSA. These patients have an increased incidence of hypertension, atrial fibrillation, bradyarrhythmias, ventricular ectopy, endothelial damage, stroke, heart failure, dilated cardiomyopathy, and atherosclerotic coronary artery disease (CAD) [34]. Patients who have moderate to severe OSA are unlikely to be able to lie flat without general anesthesia. Mask ventilation, direct laryngoscopy, endotracheal intubation, and even fiberoptic visualization of the airway are more difficult in patients who have OSA than in healthy patients. The Berlin Questionnaire is useful to identify patients who have undiagnosed OSA [35]. The presence of any two of the following is considered a high risk for sleep apnea: snoring, daytime sleepiness, hypertension, and obesity. Preoperative evaluation should focus on identifying patients who are at risk for OSA and improving associated co-morbid conditions. ECG and echocardiography may be indicated if heart failure or pulmonary hypertension is suspected or GA is required (see Fig. 2). Patients should be instructed to bring their continuous positive airway pressure devices to the hospital on the day of surgery.

Obesity It is estimated that 64% of adults in the United States are overweight or obese and 4.7% are extremely obese. Obesity is an independent risk factor for heart disease. Hypertension, stroke, hyperlipidemia, diabetes mellitus, and OSA are more common in obese people. Morbidly obese patients require special operating room tables and gurneys to support excessive weight. Venous access and invasive and noninvasive monitoring may be difficult, and airways may require specialized equipment, techniques, and personnel. Preoperative identification and planning for these contingencies will avoid delays on the day of surgery. Preoperative evaluation should be directed toward identifying significant co-existing diseases such as OSA, pulmonary hypertension, and heart failure. Many of these patients will not be able to lie flat and will require general anesthesia. An

Pulmonary disease Patients who have significant chronic obstructive pulmonary disease (COPD), asthma, or a cough, may not be able to lie supine for an extended period. Treating exacerbations of their disease (eg, infection, bronchospasm) may make it possible for them to remain recumbent and still, and is necessary to decrease complications if GA is planned. However, routine chest radiographs, arterial blood gases, and the degree of airway obstruction measured by pul-

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ECG is indicated preoperatively if GA is required (see Fig. 2).

Diabetes An estimated 18 million US adults have diabetes mellitus, which increases the risk of coronary artery disease and is considered equivalent to angina for predicting heart disease [2]. Heart failure is twice as common in men and five times as common in women who have diabetes as in individuals who do not have diabetes. Poor glycemic control is associated with an increased risk for heart failure and both systolic and diastolic dysfunction may be present. Recent studies suggest that tighter perioperative control is warranted, especially to reduce the risk of infections. Patients who have poor preoperative management of glucose are likely to be more out of control perioperatively. Aggressive management of hyperglycemia decreases postoperative complications. The American College of Endocrinologists position statement recommends a target fasting glucose of < 110 mg/dL in non-critically ill patients [36]. The focus of the preoperative visit should be to assess organ damage and control blood sugar. Cardiovascular, renal, and neurologic systems should be evaluated. Ischemic heart disease is often asymptomatic in the diabetic patient. An ECG should be done within 6 months of surgery. Electrolytes, BUN, and creatinine levels need to be determined (see Fig. 2). The goal of perioperative diabetic management should be to avoid hypoglycemia and marked hyperglycemia (see Box 1).

hemorrhage [38]. There have been reports of bleeding in the anterior eye chamber and subconjunctival hemorrhages in patients who undergo ophthalmic surgery while on warfarin. No studies of long-term visual acuity have been done in patients who continued warfarin therapy during eye surgery. A survey of 135 surgeons in the United States found that 75% stopped anticoagulation 3 5 days preoperatively. They reported two deaths that were caused by cerebrovascular accidents, and 7 nonfatal thromboembolic episodes in the group in which anticoagulants were discontinued. No complications were reported by the 7.4% of surgeons who continued anticoagulants [39]. There is little harm in continuing aspirin throughout the perioperative period for ophthalmic patients and evidence suggests benefit for patients at high risk for cardiovascular and cerebrovascular complications [37]. More potent antiplatelet therapy such as clopidogrel (Plavix) may have a risk of bleeding intermediate between aspirin and warfarin. Clopidogrel or similar drugs should probably be discontinued for procedures in which one would discontinue warfarin but do not need to be stopped before cataract surgery performed with topical anesthesia.

Anemia Consequences from moderate levels of anemia and Hgb levels >7.0 g/dL in patients without CAD are minimal. Transfusion is rarely indicated when the Hgb is >10 mg/dL and is almost always needed when the Hgb is <7 mg/dL. The focus of the preoperative visit is to determine the etiology, duration, and stability of the anemia, and the patients co-morbid conditions that may impact oxygenation, such as pulmonary, cerebrovascular, or cardiovascular disease. Sickle cell disease is a hereditary hemoglobinopathy and vaso-occlusion is responsible for most of the associated complications. Preoperative assessment should focus on identification of organ dysfunction and acute exacerbations. Frequent hospitalizations or a recent increase in hospitalizations, advanced age, preexisting infections, and pulmonary disease predict perioperative vaso-occlusive complications [40]. The preoperative history and physical examination should focus on the frequency, severity, and pattern of vasoocclusive crises and the degree of pulmonary, cardiac, renal, and central nervous system damage. An ECG, electrolytes, BUN, and creatinine are necessary before GA (Table 2). Patients who have significant pulmonary or cardiac symptoms need an echocardiogram. Prophylactic transfusion may be beneficial

Anticoagulated patients There is no consensus on the optimal perioperative management of patients who are taking warfarin. There are risks if therapy is continued and risks if it is stopped [37]. The location and extent of surgery is important and the ability to compress the bleeding site is a consideration. Warfarin may be associated with increased bleeding, except for minor procedures such as cataract surgery without peri- or retrobulbar blocks. One study found grade 1 hemorrhages in 2.3% of patients, grade 2 3 hemorrhages in 2%, and no grade 4 hemorrhages in patients who were undergoing a variety of ophthalmic procedures with retro- or peribulbar blocks. However, they concluded that preoperative use of aspirin, other antiplatelet drugs, and warfarin, (whether they were continued or not) was not associated with significant

174 Table 2 Guidelines for food and fluids before elective surgery Time before surgery Up to 8 hours Up to 6 hoursa Food or fluid intake

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Up to 4 hoursa Up to 2 hoursa During the 2 hours

a

Food and fluids as desired Light meal (eg, toast and clear liquidsb); infant formula; nonhuman milk Breast milk Clear liquidsb only; no solids or foods that contain fat in any form No solids, no liquids

This guideline applies only to patients who are not at risk for delayed gastric emptying. Patients who have the following conditions are at risk for delayed gastric emptying: morbid obesity, diabetes mellitus, pregnancy, a history of gastroesophageal reflux, a surgery that limits stomach capacity, a potentially difficult airway; opiate analgesic therapy. b Clear liquids are water, carbonated beverages, sports drinks, coffee or tea (without milk). The following are not clear liquids: juice with pulp, milk, coffee or tea with milk, infant formula, any beverage with alcohol. From American Society of Anesthesiologists Task Force on Preoperative Fasting. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology 1999;90: 896 905; Available at: http://www.asahq.org. Accessed October 25, 2005.

ance and shifting of electrolytes between intra- and extracellular compartments. Hemodialysis should be performed to correct volume overload, hyperkalemia, and acidosis. Patients with renal insufficiency or failure undergoing GA need an ECG, BUN, creatinine and electrolytes before surgery (see Fig. 2). It is appropriate to delay elective surgery until after an acute episode of hepatitis or an exacerbation of chronic disease has resolved. If GA is planned for patients who have hepatic or renal disease, electrolytes, BUN, and creatinine levels need to be evaluated. If retro- or peribulbar blocks, or a procedure where bleeding may compromise vision are planned for patients who have cirrhosis, a PT and a-PTT need to be determined (see Fig. 2).

Neurologic patients A history focused on recent events, exacerbations, or evidence for poor control of the medical condition is necessary for a patient who has neurologic disease (eg, stroke, seizure disorder, multiple sclerosis, Parkinsons disease). If a stroke or transient neurologic deficit has not been fully evaluated or has occurred within 1 month, elective surgery should be delayed pending complete evaluation. Patients who have significant movement disorders or poorly controlled seizures may require general anesthesia.

before general anesthesia. Preoperative prophylactic transfusion is controversial and the decision to transfuse should be made in concert with a hematologist who is familiar with sickle cell disease.

Consultations Collaborative care of patients is often necessary and beneficial. Consultation initiated by the preoperative physician should seek specific advice regarding diagnosis and status of the patients condition(s). The first step is to ask specific questions such as, Is this patient in the best medical condition for planned vitrectomy under general anesthesia? Letters or notes that state cleared for surgery are rarely sufficient to design a safe anesthetic. A letter that summarizes the patients medical problems and condition, along with the results of diagnostic tests, is necessary. In many practices, the cardiology service is most frequently consulted perioperatively. In one survey, however, the utility of such consultations was questioned. Forty percent of the consultations contained only the recommendation to proceed with the case, cleared for surgery, or continue with current medications [41]. Part of this responsibility lies with the consulting physicians (surgeons or anesthesiologists) and the long-standing practice of asking

Renal or hepatic disease The focus of the preoperative evaluation of patients with renal insufficiency or failure should be on the cardiovascular and cerebrovascular systems, fluid volume, and electrolyte status. Chronic metabolic acidosis is common but usually mild and compensated for by chronic hyperventilation. Chronic renal disease is a significant risk factor for cardiovascular morbidity and mortality and is an intermediate cardiac risk factor equal to a history of known CAD [2]. The annual incidence of death from CAD in patients with both diabetes and end stage renal disease and on hemodialysis is 8.2%. In elective cases, hemodialysis should be performed within 24 hours of surgery but not immediately before. Hemodialysis is associated with fluid and electrolyte (sodium, potassium, magnesium, phosphate) imbal-

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for, or receiving cardiac clearance. This is a vague request and often results in a vague response. In general, preoperative consultations should be sought for diagnosis, evaluation, and improvement of a new or poorly controlled condition. Close coordination and good communication among the anesthesiologist, surgeon, and consultant is vitally important. Miscommunication among care providers was central to most reported incidents in the Australian Incident Monitoring Study whenever preoperative assessment was implicated [1].

Medication instruction Most medications should be continued on the day of surgery because of their beneficial effects, although some may be harmful or contraindicated. Box 1 details classes of drugs and varying protocols of continuation before surgery. Medications associated with withdrawal effects (eg, beta-blockers, centrally acting sympatholytics, benzodiazepines, and opioid analgesics) should be continued through the preoperative period [42]. Medications used by patients who have a history of or are at risk for heart disease, such as beta blockers, digoxin, anti-arrhythmics, and statins should not be withdrawn before surgery. Not only are they beneficial but risk may increase when they are not taken [2,42]. Oral hypoglycemic agents should be held the day of surgery to avoid hypoglycemia unless only local anesthesia is planned and the patient is instructed to eat. Patients who have type 1 and type 2 diabetes mellitus should discontinue all short-acting insulins on the day of surgery. Type 1 and type 2 diabetics should take one-third to one-half the dose of longacting (eg, lente or Neutral Protamine Hagerdorn) or combination (70/30 preparations) insulins on the day of surgery. Small amounts of long-acting insulin on the day of surgery present little risk of hypoglycemia but improve perioperative control and avoid diabetic ketoacidosis. Patients who have an insulin pump should continue their basal rate only. It is usually not necessary to discontinue aspirin before ophthalmic surgery [37]. More potent antiplatelet agents such as clopidogrel (Plavix) need to be stopped 1 week before surgery if bleeding is a concern. There is general agreement that aspirin, nonsteroidal anti-inflammatory drugs and potent antiplatelet agents (eg, clopidogrel) and warfarin should be continued in patients who are scheduled for cataract surgery with general or topical anesthesia. Most surgeons discontinue warfarin for retinal surgery and practices vary widely as to whether warfa-

rin is discontinued when peri- or retrobulbar blocks are planned. If warfarin is stopped it is usually necessary to withhold four doses before surgery to allow the International Normalized Ratio to decrease to <1.5, a level considered safe for surgical procedures. Substitution with shorter acting anticoagulants such as unfractionated or low molecular weight heparin, referred to as bridging, is controversial and should be individualized [43]. Kearon and Hirsh [43] only recommend preoperative bridging with intravenous heparin for patients who have had an acute arterial or venous thromboembolism within 1 month before surgery, if surgery cannot be postponed. Patients who take narcotic pain medications should be told to continue these medications. Missed doses may result in withdrawal symptoms and significant pain with the associated stress response and hemodynamic perturbations. For similar reasons, anti-anxiety and psychiatric medications should be continued up until the time of the procedure. Herbals and supplements may interact with anesthetic agents, alter the effects of prescription medications, and increase bleeding. Many patients do not consider supplements medications and will not report them unless specifically asked. Gingko, echinacea, garlic, ginseng, kava, St. Johns wort and valerian may be associated with bleeding and interactions with anesthetic and sedative medications. It is recommended that herbals and supplements be stopped 7 14 days before surgery. The exception is valerian, a central nervous system depressant which may cause a benzodiazepine-like withdrawal when discontinued. Patients who are particularly anxious should be offered a prescription for a short course of benzodiazepines such as lorazepam to be taken in the days preceding surgery as well as on the day of surgery.

Fasting guidelines If GA is planned, patients should be instructed to follow the ASA guidelines for preoperative fasting as shown in Table 2 [44]. Many practitioners allow food and fluids ad lib if the patient will receive topical or local anesthesia without sedation.

Future developments The ophthalmologist is in a unique position during an ophthalmologic examination to identify patients who have an increased risk of systemic disease. One study found an association between retinal arteriolar

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sweitzer elective abdominal and noncardiac thoracic surgery in geriatric patients. Am J Med 1990;88:101 7. Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. BMJ 1975;2:486 9. Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000;342:168 75. Blery C, Charpak Y, Szatan M, et al. Evaluation of a protocol for selective ordering of preoperative tests. Lancet 1986;18:139 41. Rabkin SW, Horne JM. Preoperative electrocardiography: its cost-effectiveness in detecting abnormalities when a previous tracing exist. Can Med Assoc J 1979; 121:301 6. Gold BS, Young ML, Kinman JL, et al. The utility of preoperative electrocardiograms in the ambulatory surgical patient. Arch Intern Med 1992;152:301 5. Tait AR, Parr HG, Tremper KK. Evaluation of the efficacy of routine preoperative electrocardiograms. J Cardiothorac Vasc Anesth 1997;11:752 5. Liu LL, Dzankic S, Leung JM. Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients. J Am Geriatr Soc 2002;50:1186 91. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov. Accessed October 25, 2005. OConnor ME, Drasner K. Preoperative laboratory testing of children undergoing elective surgery. Anesth Analg 1990;70:176 80. Charpak Y, Blery C, Chastang C, et al. Prospective assessment of a protocol for selective ordering of preoperative chest x-rays. Can J Anaesth 1988;35: 259 64. Zibrak JD, ODonnell CR, Marton K. Indications for pulmonary function testing. Ann Intern Med 1990;112: 763 71. Pruthi RK. Five things oculoplastic surgeons should know about the preoperative assessment of hemostasis. Ophthal Plast Reconstr Surg 2002;18:396 401. Pasternak LR, Arens JF, Caplan RA, et al. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on preanesthesia evaluation. Anesthesiology 2002;96: 485 96. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560 72. Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth 2004;92:570 83. Furberg CD, Psaty BM, Pahor M, et al. Clinical implications of recent findings from the Antihypertensive and Lipid-Lowering Treatment To Prevent Heart Attack Trial (ALLHAT) and other studies of hypertension. Ann Intern Med 2001;135:1074 8.

narrowing and coronary heart disease [45]. Another study found that diabetic retinopathy was associated with a higher risk of renal failure and death in patients who had type 2 diabetes mellitus [46]. Ophthalmologists need to identify at-risk patients and not only inform the patient of the implications of their findings but ensure the patient receives appropriate referral and follow-up.

[9]

[10]

[11]

Summary The prevention of complications during and after procedures is the most important goal of preoperative evaluation. Identification of risk requires fundamentally good medicine, systems of care, clinical and laboratory assessment, and experienced, knowledgeable, and dedicated health care providers. Risk reduction is the ultimate goal of preoperative assessment and management.

[12]

[13]

[14]

[15]

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Ophthalmol Clin N Am 19 (2006) 179 191

General Anesthesia for Ophthalmic Surgery

Kathryn E. McGoldrick, MDa,b,T, Peter J. Foldes, MDb
a

Department of Anesthesiology, New York Medical College, Valhalla, NY 10595, USA b Westchester Medical Center, Valhalla, NY 10595, USA

Anesthetic management plays a vital role in contributing to the success or failure of ophthalmic surgery. Patients with eye conditions are often at the extremes of age, ranging from tiny, fragile infants with retinopathy of prematurity or congenital cataracts to nonagenarians with submacular hemorrhage, and may have extensive associated systemic or metabolic diseases [1]. Moreover, with more than 13% of Americans characterized as elderly (older than 65 years), we must acknowledge that the increased longevity typical of developed nations has produced a concomitant increase in the longitudinal prevalence of major eye diseases, including diabetic retinopathy, primary open-angle glaucoma, and age-related macular degeneration [2]. Clearly, the challenges of caring for an aging population with complex coexisting diseases undergoing sophisticated and technically demanding ophthalmic procedures require a high level of anesthetic expertise. The objectives of anesthesia for ophthalmic surgery include safety, akinesia, satisfactory analgesia, minimal bleeding, avoidance or obtundation of the oculocardiac reflex, prevention of intraocular hypertension, and awareness of potential interactions between ophthalmic drugs and anesthetic agents. Other exigencies include an understanding of the anesthetic implications intrinsic to delicate ophthalmic procedures, including the necessity for an especially smooth induction, maintenance, and emergence from anesthesia. Indeed, a closed claims analysis by Gild

and colleagues [3] disclosed that 30% of eye injury claims related to anesthesia management were associated with patient movement during ocular surgery. Most of the problems transpired during general anesthesia, but in one fourth of the cases the patients were receiving monitored anesthesia care during procedures performed under local or regional anesthesia. Tragically, the outcome was blindness in all cases. Clearly, strategies to ensure patient immobility during ophthalmic surgery are mandatory. Moreover, safety issues are complicated by the logistic necessity for the anesthesiologist frequently to be positioned at a considerable distance from the patients face, thus preventing immediate, direct access to the airway. It is axiomatic that open, clear, and effective communication among the anesthesiologist, ophthalmologist, and patient is integral to optimal outcome of ophthalmic surgery.

Indications for general anesthesia In selecting the anesthetic technique for eye surgery, numerous issues must be considered. General anesthesia remains the technique of choice for children, mentally retarded individuals, and demented or psychologically unstable patients. It is also the favored technique for patients with suspected or apparent open-globe injuries, although recent literature supports the use of regional eye blocks in selected patients with open-eye trauma. Recognizing that there are several distinct permutations of eye injuries, Scott and colleagues [4] developed techniques to safely block patients with certain open-globe injuries. In a 4-year period, 220 disrupted eyes were repaired via regional anesthesia at Bascom Palmer Eye Institute.

T Corresponding author. Westchester Medical Center, Macy Pavilion, Room 2389, Valhalla, NY 10595. E-mail address: kathryn_mcgoldrick@nymc.edu (K.E. McGoldrick).

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.005

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Many of these injuries were caused by intraocular foreign bodies and dehiscence of cataract or corneal transplant incisions. Blocked eyes tended to have smaller, more anterior wounds than those repaired via general anesthesia. There was no outcome differencethat is, change of visual acuity from initial evaluation until final examinationbetween the eyes repaired with regional versus general anesthesia. Additionally, combined topical analgesia and sedation for selected patients with open-globe injuries has also been reported [5]. General anesthesia is the technique of choice for removal of infected scleral buckles or for patients with very high myopia, where a perforating injury from peribulbar or retrobulbar block is feared. Other indications may include claustrophobia, deafness, a language barrier, Parkinsons disease, and intractable arthritis or orthopnea, which impair the patients ability to lie flat and remain motionless during surgery. Furthermore, the anticipated duration of the procedure must be factored into the selection process, because few geriatric patients under regional anesthesia can remain comfortable on a narrow, hard operating table for procedures that exceed 2 or 3 hours. With general anesthesia the risks of retrobulbar or peribulbar hemorrhage, globe perforation, myotoxicity, central spread of local anesthetic with possible brain stem anesthesia, and inadequate intraoperative analgesia are virtually eliminated. Nonetheless, general anesthesia may be associated with a greater likelihood of airway complications and postoperative nausea and vomiting. Although regional and topical anesthetic techniques have gained enormous popularity in recent years, it is imperative to appreciate the vital role that general anesthesia maintains in the care of certain ophthalmic patients. Major retrospective and prospective nonrandomized studies have failed to demonstrate the superiority of one anesthetic approach over the other in terms of morbidity and mortality [6 10]. Accordingly, the risks, benefits, and alternatives of all anesthetic options should be explained clearly to the patient, with the choice determined after discussion among patient, anesthesiologist, and surgeon.

varying rates and often in different ways. Typically, however, virtually all physiologic systems decline with advancing chronological age. Nevertheless, chronological age is a poor surrogate for capturing information about fitness or frailty. Moreover, perioperative functional status can be difficult to quantitate because many elderly patients have reduced preoperative function related to deconditioning, ageassociated disease, or cognitive impairment. Thus, it is challenging to satisfactorily evaluate the patients capacity to respond to the specific stresses associated with anesthesia and surgery. How, for example, does one determine cardiopulmonary reserve in a patient severely limited by osteoarthritis and dementia? Even normal aging results in alterations in cardiac, respiratory, neurologic, and renal physiology that are linked to reduced functional reserve and ability to compensate for physiologic stress. Moreover, the consumption of multiple medications so typical of the elderly can alter homeostatic mechanisms. Preoperative testing In the general population there is strong consensus that most so-called routine tests are not indicated. In the subset of geriatric patients our knowledge is somewhat more limited. Nonetheless, a recent study on routine preoperative testing in more than 18,000 patients undergoing cataract surgery is worthy of comment. Patients were randomly assigned to undergo or not undergo routine testing (ECG, complete blood cell count, electrolytes, serum urea nitrogen, creatinine, and glucose) [11]. The analysis was stratified by age and disclosed no benefit to routine testing for any group of patients. Similar conclusions were drawn in a smaller study of elderly noncardiac surgical patients by Dzankic and colleagues [12]. Some physicians and lay people, however, misinterpreted the results of Schein and colleagues [11] study, believing that patients having cataract surgery need no preoperative evaluation. It is vital to note that all patients in this trial received regular medical care and were evaluated by a physician preoperatively; they simply were not subjected to a robotic battery of routine laboratory testing. Patients whose medical status indicated a need for preoperative laboratory tests were excluded from the study. Because routine testing for the more than 1.5 million cataract patients in the United States is estimated to cost $150 million annually, the favorable economic impact of this targeted approach is obvious. From these investigations and others, a few concepts emerge. First, routine screening in a general population of elderly patients does not significantly

Preoperative evaluation The preoperative evaluation of the geriatric patient characteristically is more complex than that of the younger patient owing to the heterogeneity of seniors and the increased frequency and severity of comorbid conditions associated with aging. The process of aging is highly individualized. Different people age at

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augment information obtained from the patients history and physical examination. Testing should be selective, based on abnormalities found from the patients history and physical examination. Second, the positive predictive value of abnormal findings on routine screening is limited. Third, positive results on screening tests have modest impact on patient care. The preoperative period is not the appropriate time to screen for asympotomatic disease. The dearth of population studies of perioperative risk and outcomes specifically addressing the geriatric population can make selecting the most appropriate course of care challenging. Because age itself adds very modest incremental risk in the absence of comorbid disease, most risk-factor identification and risk-predictive indices have focused on specific diseases [13 15]. Considerations for patients with cardiac disease It is well known that normal aging produces structural changes in the cardiovascular system, as well as changes in autonomic responsiveness/control, that can compromise hemodynamic stability. The superimposition of such comorbid conditions as angina pectoris or valvular heart disease can further impair cardiovascular performance, especially in the perioperative period. According to the guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA) for preoperative cardiac evaluation, the patients activity level, expressed in metabolic units, is a primary determinant of the necessity for further evaluation, along with the results obtained from history and physical examination [13]. These findings are then evaluated in conjunction with due consideration for the invasiveness of the planned surgical procedure. Fortunately, most ophthalmic procedures are typically considered to represent relatively noninvasive, low-risk surgery. Clearly, the goal of the preoperative evaluation should be the identification of major predictors of cardiac risk such as unstable coronary syndromes (for example, unstable angina or myocardial infarction [MI] less than 30 days ago), decompensated congestive heart failure (CHF), severe valvular disease, and significant arrhythmias. These patients have a prohibitive rate of perioperative morbidity and mortality, and are inappropriate candidates for elective outpatient surgery. They deserve the benefit of further cardiology consultation and optimization. In patients with intermediate clinical predictors (mild angina, previous MI more than 30 days ago, compensated or prior CHF, diabetes mellitus, or renal insufficiency),

the invasiveness of the surgery and the functional status of the patient will play major roles in determining the nature and extent of preoperative testing or intervention. Importantly, no preoperative cardiovascular testing should be performed if the results will not change perioperative management. Patients with minor clinical predictors, such as advanced age, ECG abnormalities, rhythm other than sinus, low functional status, history of stroke, or hypertension, who are having low- or intermediate-risk surgery typically will not require further cardiovascular testing. For those in whom further testing is warranted, there are several options including Holter monitoring, radionuclide ventriculography, thallium scintigraphy, dobutamine stress echocardiography, and coronary angiography. The use of perioperative b-blockade in intermediate or high-risk patients undergoing vascular surgery can be beneficial and may obviate the need for more invasive interventions [16]. A recent study demonstrated that perioperative b-blocker therapy is associated with a reduced risk of inhospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery [17]. However, there is an absence of data pertaining to the use of perioperative b-blockade in patients undergoing less invasive outpatient surgery that is characteristic of most ophthalmic procedures. Increasingly, patients with coronary artery disease are undergoing stent placement. A frequently asked question in this context is how long should one wait after stent placement before scheduling a patient for elective surgery under general anesthesia. Kaluza and colleagues [18] in 2000 published a recommendation (based on a study of 40 patients) that elective surgery should be postponed for 2 to 4 weeks after stent placement to allow completion of the antiplatelet protocol. A few years later, however, Wilson and colleagues [19] studied more than 200 patients and recommended that nonemergency surgery should be delayed for 6 weeks after stent insertion to permit completion of the antiplatelet therapy and to allow for endothelialization of the stent. It should be emphasized that diabetes mellitus is an intermediate predictor of such adverse cardiac outcomes as perioperative MI and CHF after elective surgery because of the accelerated atherosclerosis that occurs with associated aberrations of lipid and cholesterol metabolism. The Diabetes Control and Complications Trial, a clinical study of young (average age 27 years) diabetic patients, showed that intensive treatment delayed the onset and severity of retinopathy, nephropathy, and neuropathy [20]. However, the cohort was probably too young to demonstrate a

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reduction in cardiovascular complications with aggressive insulin therapy, but the results suggest that a well-controlled diabetic patient may be at lesser risk than a poorly controlled diabetic patient. Nonetheless, this issue is not addressed in the ACC/AHA guidelines. It is important to appreciate that the diagnosis of myocardial ischemia may be more challenging in a diabetic patient owing to the high incidence of autonomic neuropathy. Patients with autonomic neuropathy may not complain of chest pain even when experiencing an acute MI.

General anesthesia: physiologic principles and pharmacologic agents Those patients who require or prefer general anesthesia for eye surgery experience a favorable outcome provided the airway is satisfactorily maintained, hemodynamic stability is achieved, and the eye is kept motionless with a constant intraocular pressure (IOP). The latter is especially critical during open-eye operations such as corneal transplantation or open-sky vitrectomy procedures when the risk of vitreous loss or expulsive choroidal hemorrhage is present. Moreover, it is important to appreciate that drugs administered to produce pupillary dilation or to reduce IOP may be absorbed systemically from the conjunctiva or (predominantly) from the nasal mucosa after drainage through the nasolacrimal duct. Such systemic absorption has important anesthetic implications. Nasolacrimal duct occlusion is an effective way to minimize systemic absorption, and this maneuver is important in small children who are extremely vulnerable to the toxic effects of such drugs as scopolamine or phenylephrine. Additionally, topical administration of these drugs should be avoided in eyes with open conjunctival wounds. Examples of potentially worrisome topical ocular drugs include cyclopentolate, echothiophate iodide, epinephrine, and timolol. Intraocular drugs also have important anesthetic implications. Nitrous oxide, for example, should not be used concomitantly in eyes that receive intraocular air or gas. To avoid significant changes in the volume of the injected bubble and associated dangerous changes in IOP, nitrous oxide should be discontinued 15 to 20 minutes before an intravitreous air or gas injection administered to tamponade a detached retina [21]. Furthermore, if a patient requires a repeat operation after intravitreous gas injection, the typical recommendation is that nitrous oxide should be omitted for 5 days after an air injection and for 10 days after a sulfur hexafluoride injection [22]. In

cases where perfluoropropane has been injected, the nitrous oxide proscription should be in effect for longer than 30 days [23]. It is important to point out, however, that resorption time is not uniform or always predictable. For example, reports have appeared where a 19-year-old woman with type 1 diabetes injected with sulfur hexafluoride 25 days before subsequent surgery and a 37-year-old male with insulindependent diabetes injected with perfluoropropane gas 41 days before subsequent surgery were given nitrous oxide and developed central retinal artery occlusion and permanent blindness in the affected eye [24]. Because the pressure in retinal arterial vessels is lower in patients with diabetes, the elderly, and those with atherosclerosis, these patients are probably at higher risk for this devastating complication [25 29]. The international distributor of medical-grade gases, in cooperation with the American distributors and the US Food and Drug Administration (FDA), has begun to provide hospital band-type warning bracelets for patients who receive intraocular gas injection to alert other health professionals to the presence of the bubble and the need to avoid nitrous oxide administration. Because many eye surgery patients are elderly, they may have arthritic involvement of the cervical spine and the temporomandibular joint, which can make laryngoscopy difficult or, occasionally, impossible. Thus, equipment designed to facilitate intubation, such as gum elastic bougies, fiberoptic endoscopes, laryngeal mask airways, and a variety of laryngoscope blades and endotracheal tube sizes, should be readily available. The logistic exigencies of ophthalmic anesthesia are such that the anesthesiologist is positioned remote from the patients airway. It is, therefore, essential to meticulously secure the endotracheal tube. Additionally, the anesthetic tubing should be positioned so that torsional strains do not occur that might inadvertently occlude the endotracheal tube by causing it to kink or twist. All connections should be firmly secured because movement of the head by the surgeon might dislodge a weak connection. Finally, the eye that is not undergoing surgery should be taped shut and a shield applied to prevent injury. Many ophthalmologists request that the patients nares be packed with gauze to prevent nasal secretions from contaminating the eye during surgery. The laryngeal mask airway (LMA) has gained great popularity in the past 15 years. Having the advantage of being easy to position without laryngoscopy or muscle relaxants, the LMA does not produce the same marked degree of vasopressor and oculotensive reflexes associated with endotracheal intubation and is less apt to cause dental damage. Initially, it

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was thought that the LMA was less likely to produce a sore throat [30,31], but more recent prospective investigations question the purported advantage of the LMA versus an endotracheal tube in regard to minor laryngopharyngeal morbidity [32]. The classic LMA does not protect against aspiraton, however, and many geriatric patients have an incompetent esophagogastric junction that may allow reflux of gastric contents. Moreover, many patients with diabetes mellitus also have gastroparesis. These patients, and others with significant risk factors for aspiration, are managed prudently by intubation with a cuffed endotracheal tube to protect the lungs. A wide assortment of anesthetic agents can be administered safely and effectively in ophthalmic surgery. Virtually any of the inhalation agents can be administered after intravenous induction with a barbiturate or propofol. Similarly, a total intravenous anesthetic technique with a propofol infusion and other intravenous medications as needed can be administered. Because it is consistently associated with less postoperative nausea and vomiting than other agents [33 35], propofol is an excellent drug for patients undergoing ophthalmic surgery. Recovery from propofol is rapid and typically associated with a sense of well-being [36], even euphoria, making it a very suitable drug for ambulatory surgery. Moreover, propofol attenuates the hypertensive response to intubation and reduces IOP, similar to most intravenous anesthetic drugs commonly used during eye surgery, such as narcotics and other sedative-hypnotics [37,38]. Propofol, however, frequently produces discomfort or pain when injected into small veins. This complication can be minimized or prevented by preadministration of, or admixing with, 20 mg lidocaine. Moreover, new formulations of propofol designed to be less irritating to veins are currently being evaluated. In patients with significant coronary artery or other types of heart disease, the cardiodepressant effects of barbiturates or propofol are unwelcome. Induction with intravenous etomidate may be more benign in terms of the cardiovascular system but, unfortunately, can trigger postoperative nausea and vomiting and possibly also result in short-term depression of adrenocortical function. The selection of the optimal muscle relaxant to facilitate intubation is made after assessing the patients airway and the probable degree of difficulty of intubation, the presence of symptomatic reflux, the hemodynamic consequences of the neuromuscular blocking agent, and the estimated duration of the surgery. Satisfactory control of arterial blood pressure is always important, but it has special implications for retinal perfusion in patients having vitreoretinal sur-

gery. If the patients mean arterial pressure is markedly reduced, the retinal perfusion may be inadequate and compromise the visual outcome of surgery. Alternatively, marked elevation of retinal arteriole pressure can be dangerous. Therefore, it behooves the anesthesiologist to be cognizant of the patients normal blood pressure and endeavor to maintain hemodynamic variables within an acceptable range for each individual patient. Various inhalation agents are available for intraoperative maintenance of anesthesia, including isoflurane, desflurane, and sevoflurane. All these agents lower IOP in a dose-dependent fashion, provided oxygenation and ventilation are satisfactorily maintained. Desflurane and sevoflurane, the two newest inhalation agents in widespread use, have lower blood-gas solubilities than all previously used potent inhaled agents. In theory, this solubility advantage allows greater control of anesthetic depth and more rapid recovery from general anesthesia. Desflurane has the lowest blood-gas solubility of all volatile agents and is associated with the fastest immediate awakening after surgery. Data indicate that desflurane resists in vivo degradation more than any other potent halogenated agent. The limited biodegradation that does occur appears to be approximately one tenth that of isoflurane, the least degraded of the other available halogenated agents. This lack of significant biotransformation suggests relative safety in terms of potential toxicity from metabolites. The cardiovascular effects of desflurane involve the direct effects of the agent, and a transient response linked to sympathetic nervous system activation. The direct hemodynamic effects of desflurane are quite similar to those of isoflurane, including a reduction in peripheral vascular resistance and blood pressure. Prolongation of the QTc interval has been reported with many anesthetic drugs including isoflurane, sevoflurane, and desflurane [39]. However, the transient sympathetic activation seen with desflurane administered in combination with nitrous oxide is not encountered with isoflurane, but had been reported with diethyl ether. Although the precise mechanism responsible for this response has not been definitively established, beta-adrenergic activation leading to major increases in blood pressure and heart rate through increased plasma epinephrine and norepinephrine levels has been postulated [40]. The extent of sympathetic activation is related, at least partially, to the absolute concentration of desflurane as well as to the rapidity of increase in the concentration of desflurane. Thus, an extremely rapid progression to high concentrations of desflurane triggers more dramatic sympathetic stimulation [40,41]. This sympa-

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thetic response can be attenuated by pretreatment with clonidine or intravenous fentanyl, esmolol, or propofol. Nonetheless, many clinicians think it is best to avoid desflurane in patients with a history of myocardial ischemia, or else to administer only relatively low concentrations of the agent and to increase the concentration gradually as indicated. Many of the physicochemical characteristics and pharmacologic properties of sevoflurane suggest that it is well suited for use in ophthalmic surgery. Compared with desflurane, sevoflurane has the advantage of being nonirritating to the airway. Inhalational induction of anesthesia with sevoflurane is accomplished smoothly and quickly, making it the agent of choice in young children who are afraid of needles and would, therefore, prefer to avoid an intravenous induction. Coughing, laryngospasm, and breathholding are lesser problems than they are with isoflurane or desflurane, even with so-called single breath inductions. Additionally, sevoflurane, unlike desflurane, has a cardiovascular profile that is quite predictable, and it does not activate the sympathetic nervous system [42]. The incidence of bradycardia and arrhythmias during inhalation induction in children is also much lower than with halothane [43]. Occasionally, the occurrence of opisthotonic and seizurelike activity with sevoflurane has been noted [44 46]. The seizurelike activity has been reported at variable sevoflurane concentrations and during induction, maintenance, and recovery. The phenomenon has been observed in adults as well as children. It is reassuring that all of the patients who demonstrated the seizurelike activity recovered without incident. Nonetheless, clinicians should be aware of this problem, which is listed in the drug insert provided by Abbott Pharmaceuticals [47]. Sevoflurane is unstable under in vitro and in vivo conditions, producing compound A and fluoride. Compound A has been shown to be nephrotoxic in rats, and high fluoride concentrations can be nephrotoxic in humans. However, despite extensive clinical investigations, multiple studies have not demonstrated any clinically significant renal or hepatic dysfunction in humans, even at very low gas flows [48,49]. Indeed, sevoflurane has been administered to more than 120 million patients worldwide with an impressive safety record. It appears that the likelihood of long-term toxicity in humans from sevoflurane administered according to the guidelines in the package insert is extremely low, even when given for prolonged procedures. Similar to desflurane, awakening and emergence from sevoflurane are rapid and complete. However, emergence excitement or agitation is not uncommon with desflurane and

sevoflurane. The times until discharge for ambulatory patients in whom desflurane or sevoflurane was used are comparable with more soluble agents like isoflurane or enflurane [50]. Whether this finding reflects a true lack of improvement in recovery time, or merely inertia in the ambulatory center system, remains to be determined. Regardless of which agent is selected, it should be carefully titrated and, because akinesia is important for delicate ocular surgery, administration of a nondepolarizing muscle relaxant is advised, in conjunction with peripheral nerve monitoring to ensure a twitch height suppression of 90% to 95% during open-eye surgery. Ventilation should be controlled and continuously monitored by end-tidal CO2 determination to avoid hypercarbia and its ocular hypertensive effect as well as to detect inadvertent disconnection of the endotracheal tube from the anesthesia circuit, a dangerous event that can be obscured by the surgical drapes. Continuous monitoring of arterial oxygen saturation by pulse oximetry is also essential. After completion of surgery, any residual neuromuscular block should be reversed. Intravenous lidocaine can be administered a few minutes before extubation to prevent or attenuate periextubation coughing. Depending on such factors as the patients airway anatomy, NPO (nil per os) status, and history of reflux, either awake or deep extubation may be selected. In skilled hands, either technique is satisfactory for patients who were fasting, who have normal airway anatomy, and who have no risk factors for reflux.

Postoperative nausea and vomiting: prevention and therapy Postoperative nausea and vomiting (PONV) account for a major proportion of unanticipated admissions to the hospital after intended ambulatory surgery, especially in children. Fortunately, after age 50 the incidence of PONV declines by more than 10% during each subsequent decade. The incidence of PONV is higher with narcotic-based anesthesia and with volatile agents. The incidence is lowest with a total intravenous anesthetic technique using propofol. The emetic effect of anesthetics are modulated in the chemoreceptor trigger zone, where serotonergic, histaminic, muscarinic, and dopaminergic receptors are found [34]. Input also comes from vagal and other stimulation directly to the emetic center. Although pharmacologic agents that act on the chemoreceptor trigger zone are well represented in our antiemetic armamentarium, the neurokinin1

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(NK1) antagonists are the only available antiemetics that act on the vomit center. Traditional antiemetics include benzamides such as metoclopramide, butyrophenones such as droperidol, and phenothiazines such as prochlorperazine. These three classes of drugs antagonize dopamine receptors. Scopolamine and atropine are anticholinergics that antagonize muscarinic receptors. Dimenhydrinate, diphenhydramine, and hydroxyzine antagonize histamine receptors. Other useful antiemetics include steroids such as dexamethasone and assorted agents such as ephedrine and propofol. Newer drugs include the 5-HT3 serotonergic receptor antagonists, such as ondansetron, tropisetron, and granisetron, which are expensive but generally effective. The 5-HT3 blockers are attractive because of the paucity of side effects associated with their use. Unlike many other antiemetics, which can cause drowsiness, dry mouth, or extrapyramidal symptoms, the 5-HT3 antagonists have a clean profile, except for headache and mild effects on liver function tests. However, similar to droperidol, some of the drugs in this category can prolong the QT interval. Unlike droperidol, however, these drugs have not been subject to a black box warning from the FDA. Our knowledge concerning the pathophysiology and management of PONV has grown impressively in the past 15 years. We now believe, for example, that universal PONV prophylaxis is not cost-effective. Rather, prophylactic treatment should be directed toward those at increased risk for the complication. Apfel and colleagues have developed a simplified risk score that identifies four major risk factors: female gender, nonsmoking status, history of PONV, and opioid use [51]. In this investigation of inpatients receiving balanced inhaled anesthesia the incidence of PONV with none, one, two, three, or all four risk factors was approximately 10%, 20%, 40%, 60%, and 80%, respectively. Apfel and colleagues claimed that, for inpatients, the type of surgery was not an independent risk factor. Sinclair and colleagues, however, reported that certain ophthalmic procedures, such as strabismus correction, were predictive of an increased risk of PONV [52]. Recently, guidelines have been developed to provide a comprehensive, evidence-based reference tool for the management of patients at moderate or high risk for PONV [53]. Double and triple antiemetic combinations (each with a different mechanism of action) are recommended prophylactically for patients at high risk for PONV. All prophylaxis in children at moderate or high risk for postoperative vomiting should be with combination therapy using a 5-HT3 antagonist and a second drug from a different category. Antiemetic rescue therapy should be admin-

istered to patients who have an emetic episode after surgery. If PONV occurs within 6 hours after surgery, patients should not receive a repeat dose of the prophylactic antiemetic(s). Rather, a drug from another class should be given.

Guidelines for diabetic patients undergoing general anesthesia Estimates reflect that as many as 15 million people in the United States have diabetes mellitus. Ninety percent of diabetic individuals have noninsulin-dependent, or type 2, diabetes mellitus, and 10% have insulin-dependent, or type 1, diabetes mellitus requiring exogenous insulin to prevent ketoacidosis. Diabetes affects virtually every tissue of the body and shortens average life expectancy by up to 15 years. The emotional toll and financial costs of diabetes and its complications are an estimated $132 billion annually. This estimate reflects both direct health care costs as well as lost productivity. More than one of every four Medicare dollars is spent on people with diabetes. It is sobering to realize that diabetes and its complications rank as the third leading cause of death by disease in the United States. Given the pandemic of obesity currently afflicting our country, one can anticipate that the number of diabetic individuals will continue to climb. End-organ disease The renal, neurologic, cardiovascular, and ophthalmic complications of diabetes mellitus have been well described. Both the presence and extent of endorgan disease in an individual diabetic patient and the metabolic perturbations induced by the stress of anesthesia and surgery must be thoroughly comprehended if one is to formulate a rational and effective perioperative management plan. Cardiovascular abnormalities include coronary artery disease, hypertension, cardiac autonomic neuropathy, and impaired ventricular function. Occasionally, unexpected sudden death may occur in association with autonomic nervous system dysfunction. Because atherosclerosis and microangiopathy occur at an earlier age in diabetic patients compared with nondiabetic individuals, a diabetic patients physiological age is much older than the stated chronologic age. Thus, coronary artery disease is common in long-standing type 1 diabetes, even at age 25 or 30 years. Myocardial infarction is 5 to 10 times more common in type 1 and type 2 diabetic individuals with end-organ disease than in the general

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population. Because diabetic adults are considered at high risk for perioperative myocardial ischemia, a baseline ECG should be obtained on all adult diabetic individuals. Anesthetic management is then adjusted appropriately to the results of preoperative assessment and intraoperative hemodynamic performance. Hypertension is extremely common in diabetic patients, and may be a marker for possible coronary artery disease. The presence of left ventricular hypertrophy suggests impaired autoregulation of coronary perfusion, rendering these patients vulnerable to ischemia with even a moderate reduction in blood pressure. Satisfactory control of blood pressure before surgery should foster stable intraoperative and postoperative hemodynamic function. However, perioperative hemodynamic instability may occur owing to altered sympathetic tone, reduced baroreceptor function, relative hypovolemia associated with chronic vasoconstriction, and anesthetic interactions with some antihypertensive medications. Because of the diabetic patients limited ability to autoregulate coronary perfusion, the anesthesiologist should attempt to maintain blood pressure within 20% of baseline values. The presence of orthostatic hypotension, an elevated resting heart rate, or a reduction or absence of a normal beat-to-beat variation of heart rate during deep breathing suggests the possibility that the patient may have cardiac autonomic neuropathy. This condition manifests as an impaired cardiovascular stress response and may be accompanied by painless myocardial ischemia. Additionally, diabetic patients with autonomic neuropathy may have abnormal hypoxic drive mechanisms centrally or peripherally and hence are at greater risk for sudden, unexpected cardiac and respiratory arrest in the setting of hypoxia [54,55]. Those with painless myocardial ischemia may also have occult left ventricular dysfunction, which can result in CHF if the patient is given a volume overload perioperatively. Impaired gastric emptying is also a consequence of autonomic dysfunction, and can increase the risk of perioperative aspiration and PONV. Administration of IV metoclopramide to facilitate gastric emptying may be helpful. Diabetic renal disease, including renal papillary necrosis and glomerulosclerosis, renders the diabetic patient susceptible to perioperative acute renal failure. Additionally, a diabetic patient is at greater risk for urosepsis, which may contribute to systemic sepsis and acute renal failure. Fixation of the atlanto-occipital joint with limitation of head extension may make endotracheal intubation difficult [56]. Stiff joint syndrome typi-

cally occurs in type 1 diabetic patients and is associated with short stature, small joint contractures, and tight, waxy skin. The etiology is thought to be abnormal collagen cross-linking by nonenzymatic glycosylation, which may occur in up to 25% of juvenile diabetic individuals [57]. This abnormal collagen glycosylation may also lead to possible atlanto-occipital dislocation. A defective palm print or prayer sign in these patients (owing to an inability to approximate the interphalangeal joints of the hand) is often associated with difficult intubation and, therefore, should be assessed preoperatively so that appropriate airway management can be planned, enabling the necessary equipment to be immediately available. Clearly, meticulous attention must be paid to a thorough preoperative assessment and optimization of the patients medical condition, as well as careful titration of the drugs and fluids administered perioperatively. Attention must also be paid to proper positioning and padding intraoperatively, because the diabetic patients are especially vulnerable to pressure ischemia of nerves and vasculature. A retrospective study assessed perioperative risk of nonocular surgery in diabetic patients [58]. Overall, 15% of patients had significant complications, and there were major differences in outcome depending on the presence or absence of end-organ damage. Patients with serious cardiac disease were more prone to major perioperative cardiac complications. Noncardiac complications, including infection, renal insufficiency, and cerebral ischemia, occurred in 24% of patients with end-organ disease (retinopathy, neuropathy, or nephropathy), in 29% of those with CHF, and in 35% of those with peripheral vascular disease. In patients without preexisting conditions, noncardiac complications (6%) and cardiac complications (4%) were rare. Moreover, the type of anesthetic selected was not predictive of risk of complications. The study emphatically underscored, however, that increased morbidity and mortality occur in diabetic patients with cardiac and end-organ disease. Control of glucose Despite the known advantages of tight or near euglycemic control in the chronic diabetic state, the concept of rigidly tight control is controversial in the perioperative period. Aggressive attempts to achieve euglycemia may result in dangerous episodes of hypoglycemia that may be masked by anesthesia and sedation. Therefore, the perioperative blood sugar level should be maintained in the range of approximately 100 to 180 mg/dL. Patients with insulin-

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dependent diabetes mellitus (type 1) tend to be more brittle than those with type 2 diabetes, and surgery for type 1 patients should be scheduled as early in the day as possible. Several regimens for insulin and substrate infusions have been advocated, but one of two protocols is generally followed. All treatment options require frequent measurement of blood glucose and treatment of hypoglycemia and hyperglycemia as needed. The blood glucose level is determined preoperatively, and an intravenous infusion of dextrose 5% (D5) and 0.25 normal saline is begun. One half of the usual neutral protamine Hagedorn (NPH) insulin dosage is administered, provided the blood sugar level is above 150 mg/dL. Blood glucose levels are monitored frequently (usually hourly) during the intraoperative period. Regular insulin doses of 0.1 unit/kg are given when the plasma glucose level exceeds 200 mg/dL. In contrast, if the blood glucose level is below 100 mg/dL, more intravenous dextrose is administered. Alternatively, a simultaneous insulin and glucose infusion may be given to a type 1 patient after a preoperative blood sugar level has been established. The infusion contains 1 to 2 units of insulin per 100 mL of 5% dextrose in water, and the infusion rate allows for 0.2 to 0.4 units of insulin per gram of glucose. Blood glucose levels are maintained in the desired range by titrating the infusion rate. Type 2 diabetic patients taking daily insulin are managed in a manner analogous to that for type 1 diabetic individuals. Those patients on oral hypoglycemics should refrain from taking the hypoglycemic agent on the day of surgery. After the fasting blood sugar level has been established an appropriate intravenous infusion is initiated. A postoperative blood sugar level is determined, with therapeutic and dietary instructions provided accordingly. An ophthalmic patient is usually able to tolerate oral intake within a relatively brief period after surgery. When oral intake is adequate, the patient may resume his or her usual diabetic regimen.

Considerations for select high-risk patients Marfan syndrome Marfan syndrome is a disorder of connective tissue, involving primarily the cardiovascular, skeletal, and ocular systems. However, the skin, fascia, lungs, skeletal muscle, and adipose tissue may also be affected. The etiology is a mutation in FBNI, the gene that encodes fibrillin-1, a major component of extracellular microfibrils, which are the major compo-

nents of elastic fibers that anchor the dermis, epidermis, and ocular zonules [59]. Connective tissue in this disorder has decreased tensile strength and elasticity. Marfan syndrome is inherited as an autosomal dominant trait with variable expression. Ocular manifestations of the syndrome include severe myopia, spontaneous retinal detachment, lens displacement, and glaucoma. Cardiovascular manifestations include dilation of the ascending aorta and aortic insufficiency. The loss of elastic fibers in the media may also account for dilation of the pulmonary artery and mitral insufficiency resulting from extended chordae tendinae. Myocardial ischemia owing to medial necrosis of coronary arterioles as well as dysrhythmias and conduction disturbances have been well documented. Heart failure and dissecting aortic aneurysms or aortic rupture are not uncommon. The patients are tall, with long, thin extremities and fingers (arachnodactyly). Joint ligaments are loose, resulting in frequent dislocations of the mandible and hip. Possible cervical spine laxity can also occur. Kyphoscoliosis and pectus excavatum can contribute to restrictive pulmonary disease. Lung cysts have also been described, causing an increased risk of pneumothorax. A narrow, high-arched palate is commonly found. The early manifestations of Marfan syndrome may be subtle, and therefore the diagnosis may not yet have been made when the patient comes for initial surgery. The anesthesiologist, however, should have a high index of suspicion when a tall young patient with a heart murmur presents for repair of a spontaneously detached retina. These young patients should have a chest radiograph as well as an electrocardiogram and echocardiogram before surgery. Antibiotics for subacute bacterial endocarditis prophylaxis should be considered, as well as b-blockade to mitigate increases in myocardial contractility and aortic wall tension (dP/dT). The anesthesiologist should be prepared for a potentially difficult intubation. Laryngoscopy should be carefully performed to circumvent tissue damage and, especially, to avoid hypertension with its attendant risk of aortic dissection. The patient should be carefully positioned to avoid cervical spine or other joint injuries, including dislocations. The dangers of hypertension in these patients are well known. Clearly, the presence of significant aortic insufficiency warrants that the blood pressure (especially the diastolic pressure) be high enough to provide adequate coronary blood flow but should not be so high as to risk dissection of the aorta. Maintenance of the patients normal blood pressure is typically a good plan. No single intraoperative anesthetic agent

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or technique has demonstrated superiority. If pulmonary cysts are present, however, positive pressure ventilation may lead to pneumothorax [60]. At extubation, one should take care to avoid sudden increases in blood pressure or heart rate. Adequate postoperative pain management is vitally important to avoid the detrimental effects of hypertension and tachycardia. Myotonic dystrophy Myotonic dystrophy, also known as myotonia dystrophica or Steinerts disease, is a genetically transmitted autosomal dominant disease with variable and unpredictable penetrance and phenotypic presentation. Myotonia denotes a characteristic persistent contracture after cessation of voluntary contraction or electrical or percussive stimulation. This inability of skeletal muscle to relax is diagnostic. Electromyography is corroborative and pathognomonic, showing continuous, low-voltage activity with high-voltage, fibrillation-like potential bursts. Myotonia can be initiated or exacerbated by exercise or cold temperature and a host of other conditions and drugs. The most common form of myotonic dystrophy is localized to chromosome 19, locus q12.3, the gene that codes for serine/threonine kinase. An abnormally long trinucleotide repeat is thought to lead to the disease. Moreover, within a given patient there is mosaicism in the aberrant repeat sequences in different tissues. A defect in sodium and chloride channel function produces electrical instability of the muscle membrane and self-sustaining runs of depolarization. Additionally, abnormal calcium metabolism may be involved. In contrast to most myopathies, the distal muscles are more affected than proximal muscles. Although patients can present at any age from infancy to late life, typically myotonic dystrophy manifests in the second or third decade. Myotonia is the predominant manifestation early in the disease, but as the condition progresses, muscle weakness and atrophy become more apparent. Facial muscles (orbicularis oculi and oris, masseter, and so forth) frequently develop marked atrophy, producing a characteristic expressionless facial appearance sometimes described as hatchet face. Multiple organ systems are affected. Cardiac manifestations, which are often noted before the appearance of other clinical symptoms, consist of atrial or ventricular tachyarrhythmias, conduction abnormalities including varying degrees of heart block, and, less frequently, impaired ventricular function [61,62]. Mitral valve prolapse is said to occur in approximately 15% of myotonic patients [62]. Respiratory involvement consists of a restrictive pattern of dis-

ease, with respiratory and sternocleidomastoid muscle weakness leading to reduced vital capacity. Patients typically develop a weak cough, dyspnea, and frequent episodes of pneumonia. Alveolar hypoventilation is caused by either pulmonary or central nervous system dysfunction. Chronic hypoxemia may result in cor pulmonale. Assorted other stigmata include presenile cataracts, ptosis, strabismus, and premature frontal balding. Endocrine dysfunction leads to adrenal [63], thyroid, pancreatic [64], and gonadal insufficiency. Central nervous system manifestations include mental retardation, central sleep apnea, and hypersomnolence, as well as psychiatric aberrations. Delayed esophageal and gastric emptying [65], in combination with compromised ability to swallow [66], can predispose patients to pulmonary aspiration. Moreover, uterine atony can retard labor and increase the likelihood of retained placenta. Treatment of myotonic dystrophy can be undertaken with membrane-stabilizing medications, such as phenytoin, quinine sulfate, and procainamide. Although phenytoin has not been implicated in the exacerbation of cardiac conduction abnormalities, quinine and procainamide may prolong the P-R interval. A cardiac pacemaker should be inserted in patients with significant conduction defects, even if they appear to be asymptomatic. Patients with myotonic dystrophy offer multiple challenges to the anesthesiologist because they are at high risk for serious perioperative respiratory and cardiac complications. (Apparently, this condition can also complicate surgical results. Three case reports, for example, describe seemingly uneventful cataract surgery that was complicated postoperatively by recurrent opacifications and intraocular fibrosis [67].) It is vital to appreciate that a small number of patients with this condition may be presymptomatic and undiagnosed. Indeed, although rare, there are reports of patients with myotonic dystrophy in whom the diagnosis was made only after an episode of prolonged apnea occurred following general anesthesia. Typically, however, the patients diagnosis is known, and that individual suffers from a host of associated conditions including restrictive lung disease, conduction defects, cardiomyopathy, hypothyroidism, diabetes, dysphagia, and delayed gastric emptying. Patients with myotonic dystrophy have altered responses to a vast spectrum of anesthetic drugs. They are frequently extremely sensitive to even small doses of opioids, sedatives, and inhalation agents, all of which may trigger prolonged apnea. Succinylcholine is considered relatively contraindicated because it can precipitate intense myotonic contractions. Moreover, trismus can abolish the ability to open the mouth for

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oral intubation. Myotonic contraction of respiratory, chest wall, or laryngeal muscles can render ventilation difficult or impossible. Additionally, hypothermia, shivering, struggling during an inhalation induction, application of a tourniquet, performing a painful needle stick for intravenous induction, surgical manipulation, and using electrocautery or a peripheral nerve stimulator can all trigger myotonic contractions. Other drugs that act at the motor end plate, such as neostigmine and physostigmine, can exacerbate myotonia. Regional anesthesia can be administered but does not reliably prevent myotonic contractions, which do respond to intramuscular injection of procaine or intravenous administration of 300 to 600 mg quinine hydrochloride. Even nondepolarizing muscle relaxants do not consistently prevent myotonic contractions. Because reversal agents can theoretically trigger myotonic contractions, the use of relatively short-acting nondepolarizing drugs, such as mivacurium, is recommended. Small doses of meperidine may be judiciously administered to prevent the shivering commonly associated with hypothermia and the use of volatile anesthetics. Short-acting opioids, such as alfentanil or remifentanil, are recommended to avoid prolonged postoperative respiratory depression and obtundation. Obviously, temperature monitoring is important, as is the use of warmed IV fluids, warmed humidified inhaled gases, and use of a warming blanket. Moreover, aspiration prophylaxis is probably prudent. Aggressive pulmonary hygiene with physical therapy, incentive spirometry, and vigilant postoperative monitoring are warranted. In the past, there was speculation about an association between myotonic dystrophy and malignant hyperthermia. This possible link has not been confirmed, however. Interestingly, both conditions map to chromosome 19, but have different loci. The literature suggests that there is no association between the type of anesthesia administered and any postoperative complications. Risk of pulmonary complications appears to be greatest in those with severe disability and those having upper abdominal surgery. Because a variety of approaches have been used successfully, there is no single best method. The risks and benefits should be assessed individually to tailor an appropriate anesthetic plan.

the majority of ophthalmic operations in the United States are performed with local anesthetic techniques, nonetheless general anesthesia may be either necessary or advisable in several challenging circumstances. Ophthalmic patients are often at the extremes of age, and not uncommonly have extensive associated systemic or metabolic diseases. Because the complications of ophthalmic anesthesia can be vision threatening or life threatening, it is imperative that the ophthalmologist and the anesthesiologist understand the complex and dynamic interaction among patient disease(s), anesthetic agents, ophthalmic drugs, and surgical manipulation. Effective communication and planning among all involved are essential to safe and efficient perioperative care.

References
[1] McGoldrick KE. Ocular pathology and systemic diseases: anesthetic implications. In: McGoldrick KE, editor. Anesthesia for ophthalmic and otolaryngologic surgery. Philadelphia7 WB Saunders; 1992. p. 210 26. [2] Lee PP, Feldman ZW, Ostermann J, et al. Longitudinal prevalence of major eye diseases. Arch Ophthalmol 2003;121:1303 10. [3] Gild WM, Posner KL, Caplan RA, et al. Eye injuries associated with anesthesia. Anesthesiology 1992;76: 204 8. [4] Scott IU, McCabe CM, Flynn Jr HW, et al. Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries. Am J Ophthalmol 2002; 134:707 11. [5] Boscia F, LaTegola MG, Columbo G, et al. Combined topical anesthesia and sedation for open-globe injuries in selected patients. Ophthalmology 2003;110: 1555 9. [6] Goncalves JCM, Turner L, Chang S. Monitored local anesthesia for pars plana vitrectomy. Ophthalmic Surg 1993;24:63 4. [7] Duncalf D, Gartner S, Carol B. Mortality in association with ophthalmic surgery. Am J Ophthalmol 1970; 69:610 5. [8] Petruscak J, Smith RB, Breslin PM. Mortality related to ophthalmological surgery. Arch Ophthalmol 1973; 89:106 9. [9] Quigley HA. Mortality associated with ophthalmic surgery. Am J Ophthalmol 1974;77:517 24. [10] Lang DW. Morbidity and mortality in ophthalmology. In: Bruce RA, McGoldrick KE, Oppenheimer P, editors. Anesthesia for ophthalmology. Birmingham (AL)7 Aesculapius; 1982. p. 195 204. [11] Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000;342:168 75. [12] Dzankic S, Pastor D, Gonzalez C, et al. The prevalence and predictive value of abnormal preoperative labo-

Summary Skillful anesthetic management is integral to optimal outcomes after ophthalmic surgery. Although

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mcgoldrick ratory tests in elderly surgical patients. Anesth Analg 2001;93:301 8. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery. J Am Coll Cardiol 2002;39:342 53. Goldman L. Cardiac risks and complications of noncardiac surgery. Ann Intern Med 1983;98:504 13. Liu LL, Leung JM. Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc 2000;48:405 12. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 1999;341:1789 94. Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005;353:349 61. Kaluza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after stenting. J Am Coll Cardiol 2000;35:1288 94. Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003;42:234 40. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977 86. Stinson TW, Donlon Jr JV. Interaction of intraocular air and sulphur hexafluoride with nitrous oxide: a computer simulation. Anesthesiology 1982;56:385 8. Wolf GL, Capriano C, Hartung J. Effects of nitrous oxide on gas bubble volume in the anterior chamber. Arch Ophthalmol 1985;103:418 9. Chang S, Lincoff HA, Coleman DJ, et al. Perfluorocarbon gases in vitreous surgery. Ophthalmology 1985; 92:651 6. Seaberg RR, Freeman WR, Goldbaum MH, et al. Permanent postoperative vision loss associated with expansion of intraocular gas in the presence of a nitrous oxide-containing anesthetic. Anesthesiology 2002;97: 1309 10. Dallinger S, Findl O, Strenn K, et al. Age dependence of choroidal blood flow. J Am Geriatr Soc 1998;46: 484 7. Langham ME, Grebe R, Hopkins S, et al. Choroidal blood flow in diabetic retinopathy. Exp Eye Res 1991; 52:167 73. Groh MJ, Michelson G, Langhans MJ, et al. Influence of age on retinal and optic nerve head blood circulation. Ophthalmology 1996;103:529 34. Recchia FM, Brown GC. Systemic disorders associated with retinal vascular occlusion. Curr Opin Ophthalmol 2000;11:462 7. Hayreh SS. Retinal and optic nerve head ischemic disorders and atherosclerosis: role of serotonin. Prog Retin Eye Res 1999;18:191 221.

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[30] Alexander CA, Leach AB. Incidence of sore throats with the laryngeal mask [letter]. Anaesthesia 1988;43:239 40. [31] Maltby JR, Loken RG, Watson NC. The laryngeal mask airway: clinical appraisal in 250 patients. Can J Anaesth 1990;35:509 13. [32] Rieger A, Brunne B, Hass I, et al. Laryngopharyngeal complaints following laryngeal mask airway and endotracheal intubation. J Clin Anesth 1997;9:42 7. [33] Borgeat A, Wilder-Smith OHG, Saiah M, et al. Subhypnotic doses of propofol possess direct antiemetic properties. Anesth Analg 1992;74:539 41. [34] Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology 1992;77:162 84. [35] McCollum JSC, Milligan KR, Dundee JW. The antiemetic effect of propofol. Anaesthesia 1988;43:239 40. [36] Sanders LD, Isaac PA, Yeomans WA, et al. Propofol induced anaesthesia: double blind comparison of recovery after anaesthesia induced by propofol or thiopentone. Anaesthesia 1989;44:200 4. [37] Guedes Y, Rakotoseheno JC, Leveque M, et al. Changes in the intraocular pressure in the elderly during anesthesia with propofol. Anaesthesia 1988;43:43 58. [38] Mirakhur RK, Elliott P, Shepherd WF, et al. Intraocular pressure changes during induction of anaesthesia and tracheal intubation: a comparison of thiopentone and propofol followed by vecuronium. Anaesthesia 1988;43:54 7. [39] Owczuk R, Wujtewicz MA, Sawicka W, et al. The influence od desflurane on QTc interval. Anesth Analg 2005;101:419 22. [40] Weiskopf RB, Moore MA, Eger II EI. Rapid increase in desflurane concentration is associated with greater transient cardiovascular stimulation than with rapid increase in isoflurane concentration in humans. Anesthesiology 1994;80:1035 45. [41] Muzi M, Lopatka CW, Ebert TJ. Desflurane-mediated neurocirculatory activation in humans: effects of concentration and rate of change on responses. Anesthesiology 1996;84:1035 42. [42] Ebert TJ, Muzi M, Lopatka CW. Effects of sevoflurane on hemodynamics and sympathetic neural activity in humans: a comparison to isoflurane. Anesthesiology 1994;80:71 6. [43] Meretoja OA, Taivainen T, Raiha L, et al. Sevofluranenitrous oxide or halothane-nitrous oxide for paediatric bronchoscopy and gastroscopy. Br J Anaesth 1996;76: 767 71. [44] Hilty CA, Drummond JC. Seizure-like activity on emergence from sevoflurane anesthesia. Anesthesiology 2000;93:1357 9. [45] Hsieh SW, Lan KM, Luk HN, et al. Postoperative seizures after sevoflurane anesthesia in a neonate. Acta Anaesthesiol Scand 2004;48:663. [46] Kuczkowski KM. Sevoflurane and seizures: deja vu. ` Acta Anaesthesiol Scand 2004;48:1216. [47] Sevoflurane [product insert]. Reference 58-7208-Rev. Abbott Park (IL)7 Abbott Laboratories; August 2003. p. 10.

general anesthesia for ophthalmic surgery [48] Bito H, Ikeda K. Closed-circuit anesthesia with sevoflurane in humans. Effects on renal and hepatic function and concentration and concentration of breakdown products with soda lime in the circuit. Anesthesiology 1994;80:71 6. [49] Bito H, Ikeuchi Y, Ikeda K. Effects of low-flow sevoflurane anesthesia on renal function: comparison with high-flow sevoflurane anesthesia and low-flow isoflurane anesthesia. Anesthesiology 1997;86:1231 7. [50] Philip BK, Kallar SK, Bogetz MS, et al. A multicenter comparison of maintenance and recovery with sevoflurane or isoflurane for adult ambulatory anesthesia. Anesth Analg 1996;83:314 9. [51] Apfel CC, Laara E, Koivuranta M, et al. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91:693 700. [52] Sinclair DR, Chung F, Mezei C. Can postoperative nausea and vomiting be predicted? Anesthesiology 1999; 91:109 18. [53] Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003;97:62 71. [54] Page MM, Watkins PJ. Cardiorespiratory arrest and diabetic autonomic neuropathy. Lancet 1978;1:14 6. [55] Ciccarelli LL, Ford CM, Tsueda K. Autonomic neuropathy in a diabetic patient with renal failure. Anesthesiology 1986;64:283 7. [56] Salzarulo HH, Taylor LA. Diabetic stiff joint syndrome as a cause of difficult endotracheal intubation. Anesthesiology 1986;64:366 8. [57] Grgic A, Rosenbloom AL, Weber FT, et al. Joint

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contractiona common manifestation of childhood diabetes mellitus. J Pediatr 1976;88:584 8. MacKenzie CR, Charlson ME. Assessment of perioperative risk in the patient with diabetes mellitus. Surg Gynecol Obstet 1988;167:293 9. Pyeritz RE. The Marfan syndrome. Annu Rev Med 2000;51:481 510. Steward DJ. Manual of pediatric anesthesia. New York7 Churchill Livingstone; 1979. Bassez G, Lazarus A, Desguerre I, et al. Severe cardiac arrhythmias in young patients with myotonic dystrophy type 1. Neurology 2004;63:1939 41. Bhakta D, Lowe MR, Groh WJ. Prevalence of structural cardiac abnormalities in patients with myotonic dystrophy type 1. Am Heart J 2004;148:224 7. Zargar AH, Bhat MH, Ganie MA, et al. Polyglandular endocrinopathy in myotonic dystrophy [letter]. Neurol India 2002;50:105 7. Perseghin G, Caumo A, Arcelloni C, et al. Contribution of abnormal insulin secretion and insulin resistance to the pathogenesis of type 2 diabetes in myotonic dystrophy. Diabetes Care 2003;26:2112 8. Bellini M, Alduini P, Costa F, et al. Gastric emptying in myotonic dystrophy patients. Dig Liver Dis 2002;34: 484 8. Wong VA, Beckingsale PS, Oley CA, et al. Management of myogenic ptosis. Ophthalmology 2004;109:1023 31. Gjertsen IK, Sandvig KU, Eide M, et al. Recurrence of secondary opacification and development of a dense posterior vitreous membrane in patients with myotonic dystrophy. J Cat and Refract Surg 2003;29:213 6.

Ophthalmol Clin N Am 19 (2006) 193 202

Sedation Techniques in Ophthalmic Anesthesia

Shireen Ahmad, MD
Northwestern University, Feinberg School of Medicine, Department of Anesthesiology, 251 East Huron Street, F5-704, Chicago, IL 60611, USA

The majority of ophthalmologic surgeries are performed with regional nerve block anesthesia. Preoperatively, sedation may be required during the placement of the nerve block to decrease the discomfort of the injection, limit patient motion, relieve anxiety, and produce amnesia about the procedure. Intraoperatively, sedatives may also be administered to relieve anxiety and prevent uncontrolled and unexpected movement. However, it is also important during surgery for the patient be calm, cooperative, and aware; reflexes should not be obtunded; and the airway should not be obstructed. Ideal sedation levels can be achieved by careful intravenous titration of suitable agents while monitoring the effect of the sedative and analgesic agents.

Evidence-based medicine Sedation practices for ophthalmologic surgery range from none to multiple drug combinations that result in a level of sedation that borders on general anesthesia. There are limited data regarding the question of whether there is a sedation strategy that is safer and more effective, with most studies, despite being randomized and placebo controlled, not having a large enough sample size to detect any adverse medical event with a low incidence. One study of 90 subjects who underwent cataract surgery following intramuscular analgesic agents found that intramuscular sedation was associated with a higher incidence of bradycardia compared with no sedation [1], and another found an increased need for supplemental oxygen when intramuscular sedative use

was compared with placebo [2]. Oral sedatives were not associated with any adverse events in two studies [3,4], neither was intravenous propofol [5,6]. Barbiturates have been evaluated also and revealed no hemodynamic complications [7,8]. A large cohort study of 19,354 patients reported a 1.95% and 1.23% incidence of intraoperative and postoperative adverse events, respectively [9]. There was a strong association between the use of intravenous agents in conjunction with topical or nerve block anesthesia and intraoperative adverse medical events after adjusting for age, gender, length of surgery, and American Society of Anesthesiologists Physical Status classification [10]. Use of more than one agent also was associated with an increased risk of adverse events, suggesting that use of multiple agents may not be advisable. Most of the events were bradyarrhythmias and hypertension.

Levels of sedation The American Society of Anesthesiologists has defined the levels of sedation [11,12] that are commonly used to monitor patients perioperatively and have also been used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to establish standards and guidelines on sedation. These levels of sedation are as follows. Minimal sedation (anxiolysis) Minimal sedation (anxiolysis) produces a druginduced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

E-mail address: sah704@northwestern.edu

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.004

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Moderate sedation or analgesia (conscious sedation) Moderate sedation or analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep sedation and analgesia Deep sedation and analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

decreases the excitability of the cuneate nucleus in the brainstem [17] and acute block of retinal discharges results in synchronization of cortical electroencephalogram (EEG), which is normally desynchronized [18]. More recently it has been suggested that decrease in ascending somatosensory transmission can modulate the activity of the reticulo-thalamo-cortical mechanisms that regulate arousal [19,20] and thus neuraxial blockade could result in a reduced level of consciousness. Ongoing assessment of the level of consciousness throughout the surgical procedure is essential to prevent the patient from progressing into deep sedation with loss of protective airway reflexes. The accurate assessment of the depth of sedation requires a tool that is reliable and valid, and at the same time is easy to use in the clinical arena. Various such tools have been developed [21 29]. The Ramsay sedation scale is a commonly used subjective assessment of level of consciousness that uses an ordinal scaling system to describe the level of consciousness [21]:
 Level 1: Patient awake, anxious/restless, or both  Level 2: Patient awake, cooperative, oriented

Anesthesia General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. The JCAHO standards require that moderate or deep sedation be administered by a practioner with appropriate credentials who can rescue the patients from deep sedation and general anesthesia.

and tranquil
 Level 3: Patient awake responds to

commands only
 Level 4: Patient asleep, brisk response to light

glabellar tap or loud auditory stimulus

 Level 5: Patient asleep, sluggish response to

light glabellar tap/loud auditory stimulus

 Level 6: Patient asleep, no response to light

glabellar tap or loud auditory stimulus The Observers Assessment of Alertness/Sedation Scale (OAA/S) was designed to measure changes in the level of consciousness during procedures, but it is limited with deeper levels of sedation (Table 1) [22]. The Neurobehavioral Assessment Scale [23] and the Vancouver Sedative Recovery Scale (VSRS) [30] are better at assessing the patient at the two extreme ends of the scale. Children may progress rapidly from light to deeper levels of sedation and greater vigilance is necessary. The University of Michigan Sedation Scale (UMSS) [31] is a validated scoring system that has been used in children undergoing nonpainful procedures and may be useful in the child undergoing minor ophthalmologic surgery:
 0, Awake and alert  1, Minimally sedated: tired/sleepy, appropriate

Monitoring level of sedation Patients undergoing surgery may become sedated as a result of the effects of regional blockade. Spinal anesthesia is known to be accompanied by significant sedation [13] and both spinal and epidural anesthesia reduce hypnotic requirements for midazolam [14,15] and thiopental [16]. Patients undergoing ophthalmologic surgery under regional block may also fall asleep during the procedure. The mechanism for this effect is not completely understood, but it has been demonstrated that temporary peripheral denervation

response to verbal conversation and/ or sound

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easily aroused with light tactile stimulation or a simple verbal command  3, Deeply sedated: deep sleep, arousable only with significant physical stimulation  4, Unarousable

used in combination these drugs have a synergistic effect and need to be titrated carefully [32 34]. Additionally, it is important to differentiate between patient movement as a result of anxiety and that as a result of pain. Administration of additional sedatives in the presence of pain resulting from inadequate regional block will only worsen the situation and result in a deeply sedated, uncooperative patient with uncontrolled movement. Sedative agents

Conscious sedation versus sedation/analgesia The term conscious sedation was coined by the American Dental Association to describe the practice of using sedatives and analgesics to alleviate the fear, anxiety, and pain of dental surgery. Deeper levels of sedation induced by an anesthesiologist are referred to as sedation/analgesia or monitored anesthesia care.

Route of administration The intravenous route is the preferred method of administration, however in some very young children, oral and inhalation agents may be necessary. The enteral, subcutaneous, or intramuscular routes are best avoided whenever possible because of unpredictability of absorption and distribution of the drugs.

Choice of drugs The drugs commonly used fall into two main categories, namely sedatives and analgesics. When

Table 1 Observers Assessment of Alertness/Sedation Scale (OAA/S) [22] Subscore 5 4 Responsiveness Responds readily to name in normal tone Lethargic response to name spoken loudly repeatedly Responds only after name spoken loudly or repeatedly Responds after mild prodding or shaking Does not respond to mild prodding or shaking Speech Normal Mild slowing or thickening Slurring or slowing

2 1

Few recognized words

Benzodiazepines Benzodiazepines are the most commonly used drugs for peri-operative sedation. They act by binding to the g-aminobutyric acid (GABA) complex and inhibit neuronal transmission. These drugs exhibit hypnotic, anxiolytic, and amnestic properties and lower intraocular pressure. Cardiovascular and respiratory depression is seen with excessive doses. Diazepam has a long half-life, which is further prolonged in the elderly. Its original formulation (Valium; Roche Laboratories, Nutley, NJ), which contained propylene glycol, was associated with venous irritation and phlebitis [35]. The newer lipid-based formulation (Dizac; Ohmeda, Liberty Corner, NJ) is less irritating [36]. Midazolam is a water-soluble imidazo-benzodiazepine, with a rapid onset and short duration of effect. The half-life of midazolam is 1.7 to 2.6 hours, whereas that of diazepam is 20 to 50 hours [37]. Midazolam is metabolized in the liver by hydroxylation to 1-hydroxy-midazolam, which has 20% to 30% the activity of midazolam and a shorter duration of action. It is excreted by the kidneys and could have a prolonged effect in patients with renal failure [38]. Respiratory depression and apnea occurs with all benzodiazepines and is more likely to occur in the presence of opioids, old age, and debilitating disease. Low doses of midazolam (0.075 mg/kg) do not affect the ventilatory response to carbon dioxide, suggesting that clinically significant respiratory depression is unlikely at that dose range [39]. In a study of midazolam in male volunteers, the elimination half-life was prolonged more than twofold in the elderly group as compared with the young males [40]. This study also revealed that the volume of distribution was increased in the elderly, the obese, and in women. Used alone, the benzodiazepines have modest hemodynamic effects. The predominant hemodynamic change is a slight reduction in arterial blood pressure that results from a decrease in systemic vascular resistance. The hemodynamic effects of midazolam are dose related: the higher the plasma level, the greater the decrease in systemic blood

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pressure [41]. The amnesic effect of midazolam has been compared with diazepam and it was found to produce better antegrade amnesia and faster recovery, making it a more suitable drug for the elderly patient having outpatient surgery than diazepam [42]. Midazolam has been administered in small doses in the range of 0.015 mg/kg, before administration of local anesthetic in patients undergoing phacoemulsification and lens implant surgery [43 45] and resulted in high patient satisfaction scores and low levels of intraoperative anxiety. In children ranging from 2 to 10 years of age, midazolam has been administered orally (0.5 mg/kg) before diagnostic and minor ophthalmologic surgical procedures [46]. Administration of intranasal midazolam has been reported in pediatric patients aged 3.5 months to 10 years for sedation before ocular examination. This method of administration was associated with a rapid onset and was preferable to the rectal route [47]. Lorazepam has twice the sedative potency of midazolam, a slower onset of action, and longer duration of action. A prospective randomized placebocontrolled study of sublingual lorazepam 1 mg administered an hour before peribulbar block for cataract or glaucoma surgery resulted in good patient comfort and amnesia related to the injection [48]. Propofol Propofol (2, 6-di-isopropylphenol) is an alkylphenol nonbarbiturate sedative-hypnotic that modulates the GABAA receptor. It is rapidly metabolized in the liver by conjugation to glucuronide and sulfate to produce water-soluble compounds, which are excreted by the kidneys [49]. The elimination half-life of propofol is 4 to 23.5 hours [50,51]. Propofol pharmacokinetics are affected by age, with elderly having decreased clearance rates [52] and children a more rapid clearance [53]. The degree of sedation and reliable amnesia, as well as preservation of respiratory and hemodynamic function, are better overall with benzodiazepines than with other sedativehypnotic drugs used for conscious sedation. When midazolam is compared with propofol for sedation, the two are generally similar except that emergence or wake-up is more rapid with propofol. Because of the potential for significant respiratory depression it is recommended that propofol be administered under close medical supervision by physicians with airway management skills [54]. Propofol in small incremental intravenous doses (20 mg) has been used to achieve amnesia for regional eye blocks [55]; however, propofol provides no analgesia for insertion of the block needle and

therefore semiconscious patients may have a startle response to needle insertion. A single dose of propofol (0.98 mg/kg) has been shown to reduce intraocular pressure (IOP) by 17% to 27%, which is also beneficial during ophthalmologic surgery [56]. This change occurs immediately following injection and may be related to relaxation of the extraocular muscles. Continuous infusion of propofol (1.5 mg/kg/hour) has been found to be effective during cataract surgery under topical anesthesia but does require close monitoring for signs of respiratory depression [57]. Patient-controlled sedation using propofol (0.3 mg/kg, lockout interval of 3 minutes) in 55 elderly patients undergoing cataract surgery has been reported [58]. Patients used less than 1 mg/kg and reported a high degree of satisfaction. One patient developed excessive sedation and transient respiratory depression, which responded to patient stimulation. Ketamine Ketamine is a phenylcyclidine derivative and differs from other sedative-hypnotic agents in that it also has significant analgesic effects. It is metabolized by hepatic microsomal enzymes to form norketamine (metabolite I), which has been shown to have significantly less (between 20% and 30%) activity than the parent compound [59]. Ketamine produces a dissociative state in which patients have profound analgesia but keep their eyes open and maintain their corneal, cough, and swallow reflexes. Ketamine administration results in pupillary dilation, nystagmus, lacrimation, salivation, and increased skeletal muscle tone, often with coordinated but seemingly purposeless movement of the arms, legs, trunk, and head. Ketamine is associated with psychic emergence reactions, including excitement, confusion, euphoria, and fear, which usually abate within 1 to several hours [60]. The incidence of emergence reactions is higher in adults [61], women [62], and with larger doses [63] and can be reduced by concomitant use of benzodiazepines [64]. Ketamine has minimal effect on the central respiratory drive [65] and does not usually depress the cardiovascular system [63]. Early studies reported an increase in IOP after intramuscular or intravenous administration of ketamine. However, subsequent studies of ketamine given with diazepam and meperidine showed no affect on IOP, and intramuscularly administered ketamine may even lower IOP in children [66]. The use of ketamine in conjunction with droperidol and diazepam has been reported to be a useful adjunct in patients undergoing cataract surgery with regional block [67].

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Barbiturates Barbiturate compounds such as methohexital and thiopental have been used for sedation in ophthalmologic surgery in the past, but have been replaced by newer agents such as propofol and midazolam, which have better pharmacologic profiles and fewer side effects. Methohexital is administered in incremental doses of 10 to 20 mg [68]. Residual sedation is greater with methohexital than with propofol [69]. Chloral hydrate Chloral hydrate has been used in children undergoing diagnostic procedures in offices and outpatient clinics [70] and in elderly patients before cataract surgery [71]; however, midazolam was found to be preferable for the amnesic properties. Dexmedetomidine Dexmedetomidine is an a2-adrenergic agonist and produces a sedative-hypnotic effect by an action on a2-receptors in the locus ceruleus and an analgesic effect by its action on a2-receptors within the locus ceruleus and the spinal cord [72]. In volunteers, dexmedetomidine sedation reduced minute ventilation but did not alter the slope of the ventilatory response to increasing CO2 [73]. The effects on the cardiovascular system are a decreased heart rate; decreased systemic vascular resistance; and indirectly decreased myocardial contractility, cardiac output, and systemic blood pressure [74]. Used as a premedicant at intravenous doses of 0.33 to 0.67 mg/kg given 15 minutes before surgery, dexmedetomidine appears to be efficacious with minimal cardiovascular side effects [75]. When used for intraoperative sedation, dexmedetomidine (0.7 mg/kg/hr) had a slower onset than propofol but had similar cardiorespiratory effects. With continuous infusion sedation after termination of the infusion was more prolonged, as was recovery of blood pressure; however, lower doses of opioid were needed in the first hour postoperatively [76]. A double-blind placebo-controlled comparative study of intramuscular dexmedetomidine (1 mg/kg) and midazolam (20 mg/kg) before peribulbar block for cataract surgery revealed comparable sedation in both groups, but dexmedetomidine was more effective at lowering IOP [77].

operating microscope, iris manipulation, irrigationaspiration, and intraocular lens manipulation [78,79] necessitating intraoperative analgesics. Fentanyl Fentanyl is the opioid analgesic most commonly used to supplement regional blockade. It is usually administered intravenously, in small doses in the range of 50 to 100 mg. Onset of action is within 3 to 5 minutes but fentanyl has a relatively long half-life, in large part because of this widespread distribution in body tissues. The elimination half-life is 2 to 3 hours. Fentanyl is primarily metabolized in the liver by N-dealkylation and hydroxylation to norfentanyl, which is detectable in the urine for up to 48 hours after intravenous administration [80]. Elderly patients are more sensitive to fentanyl and lower doses (0.7 mg/kg) have been recommended in this age group [81,82]. Fentanyl is available for oral transmucosal administration and results in reasonably rapid absorption, with peak blood levels achieved within 15 to 30 minutes [83]. A recent study found that the liquid intravenous formulation administered orally was rapidly absorbed and may be a reasonable substitute for intramuscular opioid administration in children who do not have intravenous access. An advantage of this method may be the shorter and less variable consumption time and greater versatility in dosing in comparison to the Fentanyl Oralet [84]. Alfentanil Alfentanil is a more rapid and shorter-acting analog of fentanyl [85].The main metabolic pathways of alfentanil include oxidative N-dealkylation and O-demethylation, aromatic hydroxylation, and ether glucuronide formation. The degradation products of alfentanil have little, if any, opioid activity. Human alfentanil metabolism may be predominantly, if not exclusively, by cytochrome P-450 3A4 /5. Alfentanil has been reported to have fewer side effects and similar or shorter recovery times than fentanyl [86,87]. Onset of action is in 1 to 3 minutes and the elimination is 1 to 2 hours [80]. The elderly exhibit an increased sensitivity to the opioids and the dose of alfentanil should be reduced by half [88]. Remifentanil Remifentanil is chemically related to the fentanyl congeners, but it is structurally unique because of its ester linkages that render it susceptible to hydrolysisprimarily by enzymes within the erythrocytes resulting in its rapid metabolism. Remifentanil has a 30- to 60-second onset time and a 5- to 10-minute

Opioid Analgesic Agents Analgesic agents may be administered before performing regional nerve block to decrease the pain associated with the injection. Additionally, pain may occur intraoperatively as a result of the light from the

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duration. The primary metabolic pathway of remifentanil is de-esterification to form a carboxylic acid metabolite, GI90291, which is 0.001 to 0.003 times as potent as remifentanil. Excretion of GI90291 is dependent on renal clearance mechanisms [89]. Its pharmacokinetics are not appreciably influenced by renal or hepatic failure [90,91]. Remifentanil (0.3 to 0.6 mg/kg IV) has been used to prevent the pain associated with placement of the peribulbar block [92]. A double-blind, randomized study of remifentanil (remifentanil 1 mg/kg, remifentanil 1 mg/kg + infusion of 0.2 mg/kg/min) administered before performing peribulbar block found it to be more effective than alfentanil (0.7 mg/kg) [93]. It was noted that the patients were calm and cooperative, although aware during the eye block and did not move or startle. In this study the group that had the bolus dose followed by an infusion had a higher incidence of respiratory depression; however, in clinical situations the bolus dose alone would be adequate.

Nonpharmacologic measures It has been suggested that music may be able to modulate the human stress response [102] and studies have suggested that music may be used as an adjunct to sedatives. It has also been shown that music can reduce pain reported by patients [103] and may decrease analgesic requirements. The music selected needs to have specific characteristics, namely, the music needs to be of the patients choice, tracks need to be mixed to convey homogeneous ambience, and the playing device needs to be of good quality to avoid auditory fatigue [104 106].

Type of surgery Besides cataract surgery, regional anesthesia and sedation has been used for trabeculectomy [107], keratoplasty [108], vitreoretinal surgery [109], open globe injuries [110], and enucleations and eviscerations [111].

Combinations of sedatives and analgesics It is a common practice to combine sedatives and analgesics in an attempt to minimize the side effects of the individual agents by using smaller doses than would be necessary if they were used alone. In most situations the drugs have synergistic effects and may result in significant hemodynamic and respiratory depression, especially in the elderly patient. Propofol has been used in combination with alfentanil [94] and a combination of midazolam, propofol, and alfentanil revealed the increased risk of apnea with multiple drug combinations [95]. A combination of propofol and ketamine provided better analgesia and sedation than propofol alone and was not associated with an increase in IOP [96]. Summary Sedation/analgesia for ophthalmologic surgery is safe and effective [9]. The choice of sedation/analgesia strategy should be based on patient preference and the assessment of risk for adverse events. Preoperative screening and preparation of the patient is most important in obtaining cooperation and patient acceptance. Despite the obvious effectiveness of the various strategies, there is a small group of patients who are not suitable for regional anesthesia with sedation. Patients with chronic spontaneous cough, shortness of breath while lying flat, parkinsonian head tremor, Alzheimers disease, or claustrophobia may be very difficult to manage with regional anesthesia and light sedation. These patients may best be managed with a general anesthetic.

Patient-controlled sedation and analgesia The level of stimulation and discomfort may vary during the peri-operative period and the need for sedation/analgesia varies considerably among patients, making the patient-controlled administration a useful alternative [97,98]. Successful use of the technique in patients undergoing ophthalmologic surgery has been reported [99 101]. The main advantage with this technique is the increased patient satisfaction; however, it is important that patients be appropriately monitored to prevent excessive sedation.

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ahmad [108] Riddle KH, Price MO, Price FW. Topical anesthesia for penetrating keratoplasty. Cornea 2004;23: 712 4. [109] Newsom R, Luff A, Wainwright C, et al. UK attitudes to local anaesthesia for vitreoretinal surgery. Eye 2001;15:708 11. [110] Boscia F, Tegola MGL, Columbo G, et al. Combined topical anesthesia and sedation for open-globe injuries in selected patients. Ophthalmology 2003;110: 1555 9. [111] Burroughs JR, Soparkar CNS, Patrinely JR, et al. Monitored anesthesia care for enucleations and eviscerations. Ophthalmology 2003;110:311 3.

[103] Menegazzi JJ, Paris PM, Kersteen CH, et al. A reandomized controlled trial of the use of music during laceration repair. Ann Emerg Med 1991;20:348 50. [104] Allen K, Blascovich J. Effects of music on cardiovascular reactivity among surgeons. JAMA 1994;272: 882 4. [105] Spinge R. Some neuroendocrinological effects of so called anxiolytic music. Int J Neurol 1985;19: 186 96. [106] Cruise CJ, Chung F, Yogendran S, Little D. Music increases satisfaction in elderly outpatients undergoing cataract surgery. Can J Anaesth 1997;44:43 8. [107] Zabriskie NA, Ahmed IIK, Crandall AS, et al. A comparison of topical and retrobulbar anesthesia for trabeculectomy. J Glaucoma 2002;11:306 14.

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Choices of Local Anesthetics for Ocular Surgery

Gary D. Cass, MD
Tampa Eye and Specialty Surgery Center, 4302 N. Gomez Avenue, Tampa, FL 33607, USA

The choice of local anesthetic solution to perform either topical anesthesia or conduction blockade for ocular surgery is made based on the specific requirements of the patient, the surgical procedure, and the properties of the local anesthetic. It is important for clinicians to be aware of the options before selecting an ophthalmic anesthetic delivery system. This article discusses the rationale for using different local anesthetics, anesthetic combinations, and additives, in different clinical situations and with different anesthetic deliveries.

Topical ocular anesthesia Topical ocular anesthesia has been demonstrated to be a safe and effective alternative to retro or peribulbar anesthesia [1]. However, topical anesthesia does not provide ocular akinesia and may provide inadequate sensory blockade for the iris and ciliary body. Therefore, topical techniques are best reserved for short surgeries and cooperative patients who have low to moderate anxiety. Sedation should be carefully administered to help relieve anxiety but not affect the patients cooperation and movement. Topical anesthesia can be successfully achieved by several different methods and combinations of these methods. A few popular approaches to topical ocular anesthesia will be discussed, although there are many variations of these practices. The first approach simply involves administering local anesthetic eye drops, most commonly proparacane, tetracaine, lidocaine, or bupivacaine, to the operative eye three or four times, usually separated by

E-mail address: gcassmd@aol.com

a few minutes just before surgery. The choice of which anesthetic to use can be based on concerns regarding corneal epithelial toxicity, patient comfort, and the patients history of local anesthetic allergies. High doses or prolonged use of local anesthetics are toxic to the corneal epithelium, which prolongs wound healing and causes corneal erosion [2,3]. All of these local anesthetics are safe and effective in brief perioperative exposure. Tetracaine is the most irritating of the eye drop anesthetics mentioned; it is an ester anesthetic and should be avoided in patients allergic to that family of local anesthetics. Proparacane is also an ester anesthetic, but it is not metabolized to the p-aminobenzoate (PABA) moiety and, therefore, may be safely used in patients who are allergic to other ester anesthetics. It is common practice to administer topical anesthesia using viscous lidocaine gel instead of drops. Often this gel is mixed with dilating medications, antibiotics, and non-steroidal anti-inflammatory agents. An anecdotal description of such a mixture is 5 mL 2% lidocaine gel with 4 gtts tropicamide (Mydriacyl), 4 gtts 1% cyclopentolate (Cyclogel), 4 gtts 10% phenylephrine (Neosynephrine), 10 gtts moxifloxacin (Vigamox) and 4 gtts ketorlac (Acular). This mixture applied to the operative eye twice before surgery reportedly achieves excellent results in both dilation and anesthesia [4]. Predictability of drug absorption or corneal epithelial safety with this mixture has not been well investigated. A common adjunct to topical anesthetic eye drops is intracameral injection of local anesthetics. Intracameral anesthetics have included preservative free 1% lidocaine and preservative free 0.5% bupivacaine injected in doses of 0.1 to 0.5 mL instilled into the anterior chamber. Intracameral injection may provide sensory blockade for the iris and ciliary body, which

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relieves discomfort that patients may have when the intraocular lens is placed. This topic has been the subject of many studies. In 2001, in a report by the American Academy of Ophthalmology, Karp and colleagues [5] reviewed over 180 literature citations to address questions about intracameral anesthesias efficacy and safety in regard to possible corneal endothelial and retinal toxicity. Regarding efficacy, the ideal timing and placement of intracameral anesthesia was not determined. Some of the articles reviewed in this report showed efficacy of intracameral injection whereas others did not. The authors concluded that because topical anesthesia alone is effective, surgeons may elect to use intracameral anesthesia to manage patients that had incremental pain with topical anesthesia alone. Regarding the safety of intracameral anesthesia, short-term studies seem to indicate that preservativefree 1% lidocaine is well tolerated by the corneal endothelium, whereas higher concentrations are toxic. Retinal toxicity is another concern because local anesthetics diffuse posteriorly to the retina. There have been reports of patients loosing light perception temporarily after intracameral anesthesia. Several in vitro studies suggest lidocaine and bupivacaine may be toxic to the retina. This report suggests that minimal amounts and concentrations of local anesthetic be used. Preservative-free 1% lidocaine in doses of 0.1ml to 0.5 mL has not been associated with corneal endothelial toxicity, but studies suggest that higher concentrations may be toxic. Intracameral bupivacaine is not as well studied as lidocaine and it may be more toxic to the corneal endothelium than 1% lidocaine. The authors suggested, therefore, that the local anesthetic of choice for intracameral anesthesia is preservative-free 1% lidocaine. Intracameral lidocaine alone has been shown to dilate the pupil well [6]. This may be because of its direct action on the iris which causes muscle relaxation. A recent practice of using intracameral preservative-free 1% lidocaine with 1:100,000 epi-

nephrine is reported to enhance the pupillary dilation more than 1% lidocaine alone, and may obviate the need for preoperative dilating drops [7].

Conduction ocular anesthesia The most common choices of local anesthetics for either retro or peribulbar (intra or extraconal) or subTenons (episcleral) technique are bupivacaine, lidocaine, ropivacaine, levobupivacaine, articaine, and 2-chloroprocaine. The following discussion considers the pros and cons of each of these local anesthetics and the indications for their use. Considerations include cardiovascular and central nervous system safety, family of local anesthetics, and onset and duration of each agent. Properties of local anesthetics for ocular conduction blockade are summarized in Table 1. When reviewing the literature about onset and duration times of local anesthetics in ocular anesthesia, it is very difficult to make comparisons because shorter acting local anesthetics with faster onset times are often combined with longer acting anesthetics. In addition to combining local anesthetics, hyaluronidase is frequently added to the mix, which also confounds the true onset time and duration of a specific local anesthetic. Hyaluronidase shortens the onset and duration of local anesthetics used for ocular conduction blockade. Another variable from study to study is the volume and concentration of anesthetic injected. Bupivacaine and lidocaine are familiar local anesthetics that have been used for many years in retro and peribulbar anesthesia as well as sub-Tenons technique. Studies regarding the onset and duration of lidocaine and bupivacaine in ocular anesthesia compare them to the newer local anesthetics. The onset time to ocular akinesia of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 1:200,000 epinephrine and 30 IU/mL hyaluronidase is reported to be 7.2 minutes with a 5.7 minute standard devia-

Table 1 Properties of local anesthetics for ocular conduction blockade Generic name 2-chloroprocaine Articaine Lidocaine Ropivacaine Bupivacaine Levobupivacaine Brand name Nesacaine Septocaine Xylocaine Naropin Marcaine Chirocaine Class Ester Amide Amide Amide Amide Amide Onset Rapid Rapid Rapid Slow Slow Intermediate Duration Short Short Intermediate Long Long Long Toxicity Low Intermediate Intermediate Intermediate High Intermediate

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tion [8]. The duration is not so well investigated. A patient can usually remove their eye patch in 4 to 6 hours after a block where bupivacaine was used and not be troubled by diplopia. Many practitioners, however, report instances where the diplopia did not resolve until the next day. Ropivacaine is a long-acting, pure S-enantiomer, amide local anesthetic similar to bupivacaine in duration. The use of ropivacaine is attractive because it is less cardiotoxic than equal concentrations of racemic bupivacaine and has a significantly higher threshold for central nervous system toxicity than bupivacaine. Ropivacaine and bupivacaine were compared with each other when mixed with 2% lidocaine and hyaluronidase and both mixtures were equally effective in peribulbar anesthesia [9]. In this study, the median time at which the block was adequate to start surgery was 8 minutes. This comparatively quick onset is representative of the quicker acting lidocaine with hyaluronidase rather than the ropivacaine. Another recent study compared onset and duration of different concentrations of ropivacaine with hyaluronidase. At 15 minutes ropivacaine 0.75% had an 82% complete motor block, whereas the 0.5% ropivacaine had a 55% complete motor block. Complete recovery of motor function 1 hour after surgery was 37% with 0.5% ropivacaine with hyaluronidase, whereas complete motor recovery was only 5% in the 0.75% ropivacaine with hyaluronidase group [10]. Another study reported that diplopia lasted up to 30 hours past peribulbar block when 1% ropivacaine was used [11]. Ropivacaine would be a good clinical choice when longer anesthesia is needed and a large enough dose will be used that there is concern about toxicity. Levobupivacaine is the S enantiomer of racemic bupivacaine. Because of findings that cardiotoxicity observed with racemic bupivacaine, although infrequent, is based on entantioselectivity, the S enantiomer, levobupivacaine, was developed for use as a long acting, local anesthetic that shows reduced cardiotoxicity. Recently McLure and colleagues [12] compared the onset of 2% lidocaine with 0.75% levobupivacaine, both with hyaluronidase, in subTenons block. The speed of onset for the lidocaine group was 3.02 minutes, which statistically was significantly faster then the onset time for the levobupivacaine group, which was 5.06 minutes. The authors concluded, however, that this difference in onset time was not clinically significant. Levobupivacaine 0.75% was compared with bupivacaine 0.75%, each with hyaluronidase, in peribulbar anesthesia [13]. After a 5 cc injection, both agents reportedly achieved satisfactory anesthesia in a median

time of 2 minutes. The authors concluded that both levobupivacaine and bupivacaine are equally successful in achieving clinically satisfactory peribulbar anesthesia with few adverse effects. The most common post operative adverse effect reported was prolongation of the block in 15% of the patients. Bupivacaine, ropivacaine, and levobupivacaine all have clinically acceptable onset times when mixed with lidocaine. However, the duration can be up to 30 hours when most surgeries last only 15 minutes. Prolonged diplopia is disturbing to the patients and dissatisfying to the clinician. Articaine is a comparatively new local anesthetic. It is chemically unique and offers a shorter duration than the previously discussed drugs. In a number of European countries, articaine is the most widely used local anesthetic in dentistry. Articaine is classified as an amide local anesthetic but is structurally different from other amide local anesthetics in that it contains a thiophene ring. It also contains an ester linkage which is quickly hydrolyzed by esterase to inactive artinic acid. In 2001, Allman and colleagues [14] compared the onset of 2% articaine mixed with epinephrine (1:200,000), with the onset of a mixture of 0.5% bupivacaine and 2% lidocaine in peribulbar anesthesia, where a single medial canthus injection is used. Hyaluronidase was added to both solutions. The degree of akinesia was measured at 1, 5, and 10 minutes after block, at the end of surgery, and at discharge from the day unit. At 1 minute the score in both groups was the same, but at 5 minutes articaines onset was significantly greater. At discharge it was apparent that the articaine group regained extraocular motion quicker. The authors, however, dont specify how much time elapsed between initial injection and discharge. Eyelid motion was the same for both groups at all measurements. A similar study [8] was repeated at the same institution and compared the same agents, but used an inferotemporal injection with similar results. In 2004, 2% articaine was compared with a mixture of 0.5% bupivacaine and 2% lidocaine in a sub-Tenons approach, and once again articaine had the faster onset times and appeared to be a safe agent to use [15]. Articaine appears to have a desirable onset and duration for shorter ocular surgeries. In the United States articaine is prepared in a solution that contains both epinephrine and sodium metabisulfate as a preservative. Currently articaine has only been approved in the United State for dental use. For shorter surgeries, 2-choloroprocaine is a desirable choice of a local anesthetic for conduction blockade. Cass and colleagues [16] compared 2% versus 3%

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preservative-free 2-cholroprocaine in peribulbar anesthesia. Onset time of ocular akinesia and surgical anesthesia was < 4 minutes in the 2% group and 6 minutes in the 3% group. Full recovery of extraocular muscle and eyelid motion was less than 85 minutes in the 2% group and was less than 100 minutes in the 3% group. Both 2% and 3% 2-cholroprocaine were safe and effective in peribulbar aesthesia. Modern ophthalmic surgeries are being performed faster and faster. At the typical outpatient surgery center where cataract surgery takes 20 minutes or less, a patient can be blocked in a preoperative area, moved to the operating room, have surgery, then go to a recovery area where they can have a cup of coffee or juice. By the time postoperative instructions are given, the patient has regained full extraocular and eyelid motion. This allows the patient to be discharged without an eye patch and with good vision. Although the duration of 2-cholroprocaine is relatively short, it still affords the surgeon enough time to handle circumstances such as an unanticipated anterior vitrectomy. A particular circumstance where rapid vision recovery is extremely advantageous is in the monocular patient having surgery on their better seeing eye. This is very satisfying to both the patient and the clinical staff. Because it is an ester anesthetic, 2-choloroprocaine is quickly hydrolyzed by plasma cholinesterase, which makes it a safe local anesthetic that has a high therapeutic index. Clinicians should avoid 2-choloroprocaine in patients who report allergies to ester local anesthetics.

the time of onset of the local anesthetic solution as well as its duration. In retro or peribulbar anesthesia, the addition of hyaluronidase is presumed to decrease the time of exposure of the local anesthetic to the extraocular muscles, which decreases the incidence of myotoxicity that results in diplopia. In a retrospective chart review, Brown and colleagues [17] postulated that the absence of hyaluronidase was responsible for a cluster of diplopia. In a response to this paper, Miller [18] reported a series of over 7000 cases of periocular injections without hyaluronidase which resulted in no incidence of diplopia. It is important to point out that anesthetic myotoxicity is not the only cause of diplopia after periocular block. The extraocular muscle can be directly injured by the injection or indirectly injured by ischemia secondary to pressure on the muscle from a high volume of injectate. Epinephrine is a common additive to local anesthetic solutions for periocular block. It augments anesthetic duration. In the borderline patient small amounts of epinephrine can cause untoward hemodynamic consequences. Clonidine has also been added to local anesthetic solutions used for periocular block to lengthen the duration of the anesthesia [19]. Vecuronium has been added to periocular local anesthetic solutions to enhance the ocular and eyelid akinesia [20]. Adding these medicines to periocular anesthetic solutions is potentially harmful because these agents have powerful systemic actions.

Summary Use of additives Anesthetic solutions often contain preservatives, enzymes that aid the spread of the local anesthetic, and drugs that increase the duration of action. It is important for clinicians to choose whether or not to use these additives because they can affect local anesthetic toxicity both locally and systemically. Preservatives in local anesthetics are considered to be toxic to the retina. In many ophthalmology practices all local anesthetics used are preservativefree, although in many other practices, with the exception of intracameral administration, topical and injected local anesthetics are used with preservatives and without apparent retinal problems. Hyaluronidase is a proteolytic enzyme which is often added to local anesthetic solutions to aid the spread of the anesthetic. The enzyme hydrolyses hyaluronic acid which limits diffusion by binding cells together. The addition of hyaluronidase shortens There are many choices of local anesthetic solutions and additives for both topical anesthesia and conduction blockade. The differing onset and duration, toxicity, and pharmacology of local anesthetics must be considered when making a choice of which agent to use. Additives to local anesthetic solutions must also be considered. Clinicians should make their ocular anesthetic plan based on the specific requirements of the patient, the surgical procedure, and the properties of the local anesthetic.

References
[1] Patel BCK, Byrnes TA, Crandall A, et al. A comparison of topical and retrobulbar anesthesia for cataract surgery. Opthalmology 1966;103:1196 203. [2] Grant RL, Acosta D. Comparative toxicity of tetracaine, proparacane and cocaine evaluated with primary

local anesthetics cultures of rabbit epithelial cells. Exp Eye Res 1994; 58(4):469 78. Bisla K, Tanelian DL. Concentration-dependent effects of lidocaine on corneal epithelial wound healing. Invest Ophthalmol Vis Sci 1992;33:3029 33. Fanning GL. You asked for it. Ophthalmic Anesthesia Society In-Sight 2005;Summer:7. Karp CL, Cox TA, Wagoner MD, et al. Intracameral anesthesia: a report by the American Academy of Opthalmology. Opthalmology 2001;108(9):1704 10. Lee JJ, Moster MR, Henderer JD, et al. Pupil dilation with intracameral 1% liodocaine during glaucoma filtering surgery. Am J Opthalmol 2003;136(1):201 3. Cionni RJ, Barros MG, Kaufman AH, et al. Cataract surgery without preoperative eyedrops. J Cataract Refract Surg 2003;29(12):2281 3. Allman KG, Barker LL, Werrett GC, et al. Comparison of articaine and bupivacaine/lidocaine for peribulbar anaesthesia by inferotemporal injection. Br J Anaesth 2002;88(5):676 8. Nicholson G, Sutton B, Hall GM. Ropivacaine for peribulbar anesthesia. Reg Anesth Pain Med 2001; 26(5):491 2. Gioa L, Fanelli G, Casati A, et al. A prospective randomized, double- blinded comparison of ropivacaine 0.5%, 0.75%, and 1% ropivacaine for peribulbar block. J Clin Anesth 2004;16(3):184 8. Wells AP, Maslin K. Diplopia from peribulbar ropivacaine. Clin Experiment Ophthalmol 2000;28(1): 32 3.

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[12] McLure HA, Kumar CM, Ahmed S, et al. A comparison of lidocaine 2% with levobupivacaine 0.75% for sub-Tenons block. Eur J Anaesthesiol 2005;22(7): 500 3. [13] Birt DJ, Cummings GC. The efficacy and safety of 0.75% levobupivacaine vs 0.75% bupivacaine for peribulbar anaesthesia. Eye 2003;17(2):200 6. [14] Allman KG, McFadyen JG, Armstrong J, et al. Comparison of articaine and bupivacaine/lidocaine for single medial canthus peribulbar anaesthesia. Br J Anaesth 2001;87(4):584 7. [15] Gouws P, Galloway P, Jacob J, et al. Comparison of articaine and bupivacaine/lidocaine for sub-Tenons anaesthesia in cataract extraction. Br J Anaesth 2004;92(2):228 30. [16] Cass G, Reynolds W, Lorenzen T, et al. Randomized double-blind study of the clinical duration and efficacy of Nesacaine-MPF 2% and 3% in peribulbar anesthesia. J Cataract Refract Surg 1999;25(12):1656 61. [17] Brown SM, Brooks SE, Mazow ML, et al. Cluster of diplopia cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999;25:1245 9. [18] Miller RD. Hyaluronidase and diplopia [letter]. J Cataract Refract Surg 2000;26:478. [19] Bharti N, Madan R, Kaul HL, et al. Effect of addition of clonidine to local anaesthetic mixture for peribulbar block. Anaesth Intensive Care 2002;30(4):438 41. [20] Reah G, Bodenham AR, Braithwaite P, et al. Peribulbar anaesthesia using a mixture of local aneaesthetic and vecuronium. Anaesthesia 1998;53(6):551 4.

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Sub-Tenons Anesthesia
Chandra M. Kumar, MBBS, MSc, FFARCS, FRCAa,b,T, Chris Dodds, MBBch, MRCGP, FRCAa,b
b

School of Health and Social Science, University of Teesside, Middlesbrough, TS4 3BW, UK Department of Anaesthesia, The James Cook University Hospital, Middlesbrough, TS4 3BW, UK

The sub-Tenons anesthesia block was reintroduced as a simple, safe, effective, and versatile alternative to a sharp needle block for orbital anesthesia. After topical anesthesia has been instilled, Tenons capsule is dissected, a blunt cannula is introduced into the sub-Tenons space, and a local anesthetic agent is administered [1]. It is not known how frequently this technique has been used. Seven percent of ophthalmic departments in the United Kingdom used this technique in 1997 [2] but its use appears to have increased [3]. In the United Kingdom, only trained ophthalmologists or anesthesiologists perform needle orbital local anesthetic injections [2], but in some centers nurses have been trained to perform the sub-Tenons block [4]. It is essential for any practitioner to have a comprehensive understanding of the basic sciences and techniques behind regional orbital blocks. Before any technique is used, the knowledge of globe anatomy, especially Tenons capsule and the surrounding structures, must be mastered. The regional orbital block was first described by Turnbull in 1884 [5]. More recently Mein and colleagues [6], Hansen and colleagues [7] and Stevens [8] have popularized this block. The technique is also known as pinpoint anesthesia [9], parabulbar block [10], and episcleral block [11].

Anatomy There are many excellent books on ophthalmic anatomy [12 15] and these are recommended as a source of reference. Globe movements are controlled by both the rectus muscles (inferior, lateral, medial, and superior) and the oblique muscles (superior and inferior). The rectus muscles arise from the annulus of Zinn near the apex of the orbit and insert anterior to the equator of the globe to form an incomplete muscle cone. The optic nerve (II), oculomotor nerve (III, contains both superior and inferior branches), abducens nerve (VI), nasociliary nerve (branch of nerve V), ciliary ganglion, and vessels all lie within the muscle cone. The superior branch of the oculomotor nerve supplies the superior rectus and the levator palpebrae muscles. The inferior branch of the oculomotor nerve supplies the medial rectus, the inferior rectus, and inferior oblique muscles. The abducens nerve supplies the lateral rectus. The trochlear nerve (IV) runs outside and above the annulus, and supplies the superior oblique muscle (the anesthetic agent may fail to block this nerve and the oblique muscle will retain activity). Corneal and perilimbal conjunctival sensation and the superonasal quadrant of the peripheral conjunctival sensation are mediated through the nasociliary nerve. The remainder of the peripheral conjunctival sensation is supplied through the lacrimal, frontal, and infraorbital nerves which run outside the muscle cone. Intraoperative pain may be experienced if these nerves are not blocked. The fascial sheath (Tenons capsule) is a thin membrane that envelops the eyeball and separates it

T Corresponding author. Department of Anaesthesia, The James Cook University Hospital, Middlesbrough, TS4 3BW, UK. E-mail address: Chandra.Kumar@stees.nhs.uk (C.M. Kumar).

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Fig. 1. Sub-Tenons space shows multiple connective tissue bands (From Gray, H. Anatomy of the human body. Philadelphia: Lea & Febiger; 1918; Bartleby.com, 2000. Available at www.bartleby.com/107/. Accessed September 14, 2005; with permission.)

from the orbital fat [14]. It thus forms a socket for the eyeball. The inner surface is smooth and shiny and is separated from the outer surface of the sclera by a potential space, the episcleral space (sub-Tenons space). Numerous delicate bands [15] of connective tissue (Fig. 1) cross the space and attach the fascial sheath to the sclera. Anteriorly, the fascial sheath is firmly attached to the sclera (Fig. 2) about 3 5 mm posterior to the corneoscleral junction [16,17]. Posteriorly, the sheath fuses [13] with the meninges around the optic nerve and with the sclera around the exit of the optic nerve (see Fig. 1). However, the description varies and a major textbook of anatomy [15] suggests that the space under the Tenon capsule

is a lymph space, and this follows the optic nerve and continues with the subarachnoid space. The tendons of all six extrinsic muscles of the eye pierce the sheath as they pass to their insertion on the globe. At the site of perforation, the sheath is reflected back along the tendons of these muscles to form a tubular sleeve. The superior oblique muscle sleeve extends as far as the trochlea, and the inferior oblique muscle sleeve extends to the origin of these muscles. The tubular sleeves for the four recti muscles have expansions. Expansions for the medial and lateral recti are strong, are attached to the lacrimal and zygomatic bones, and are called medial and lateral check ligaments respectively. The superior rectus expansion is thinner, less distinct, and extends from the superior rectus tendon to the levator palpebrae superioris. Similarly, the expansion from the inferior rectus extends to the inferior tarsal plate. The inferior part of the fascial sheath is thickened and is continuous, both medially and laterally, with the medial and lateral check ligaments.

Assessment of patients The preoperative assessment and preparation of patients who have ophthalmic surgery under local anesthesia varies worldwide. There are evidencebased guidelines [18] and reports [19] available on this subject. The Joint Colleges Working Party Report

Fig. 2. Tenons capsule is shown underneath the conjunctiva when dissected 5 mm posterior to limbus.

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Fig. 3. Essential (right) and non-essential (left) equipment which may be required during sub-Tenons anesthesia.

[18] has recommended that patients not be starved but starvation policies vary considerably [20]. Complication rates as a result of starvation or aspiration in ophthalmic regional anesthesia are unknown but dangers remain if a patient vomits while undergoing anesthesia and surgery. According to guidelines and evidence reports, routine investigation of patients who undergo cataract surgery is not essential and does not improve health or outcome of surgery, but tests can be done to improve general health of the patient if required. The preoperative assessment should always include specific enquiry about bleeding disorders and drugs. There is increased risk of hemorrhage in patients receiving anticoagulants and a clotting profile assessment is required before injection. Patients who receive anticoagulants are advised to continue medication [21]. Clotting results should be within the recommended therapeutic range [21,22]. Because of a lack of data, currently there are no recommendations for patients who receive antiplatelet agents [22]. Sub-Tenons block is a favored technique for these patients [21].

venous line has been questioned [23], it is always a good clinical practice to secure an intravenous line, because serious complications can occur regardless of the anesthetic technique being used (eg, anaphylactic reaction to antibiotics).

Standard sub-Tenons technique Access to the space by the inferonasal quadrant is the most commonly described approach, because the placement of the cannula in this quadrant allows good fluid distribution superiorly, avoids the area of surgery, and reduces the risk of damage to the vortex veins [1]. The equipment that may be required during sub-Tenons blocks is shown in Fig. 3. After instillation of local anesthetic eye drops (proxymetacaine

Monitoring during block Once the decision is made to operate, anesthetic and surgical procedures are explained to the patient, and informed consent is obtained and recorded. All monitoring and anesthetic equipment in the operating environment should be fully functional [18]. Blood pressure, oxygen saturation, and ECG leads are connected to the patient, and baseline recordings are obtained [18]. Although, the insertion of an intra-

Fig. 4. Upwards and outwards rotation helps to expose the area of dissection.

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Fig. 5. The place of incision for dissection during inferonasal sub-Tenons anesthesia.

0.5% or tetracaine 1%), the eye is cleaned with specially formulated 5% aqueous povidone iodine solution. An eyelid speculum or an assistants finger is used to keep the eyelids apart. The patient is asked to look upwards and outwards, to expose the inferonasal quadrant (Fig. 4). The conjunctiva and Tenons capsule are gripped with non-toothed forceps 5 10 mm away from the limbus. A small incision is made

through these layers with scissors and sclera is exposed (Fig. 5). A blunt, curved (Fig. 6A), metal sub-Tenon cannula, (19 gauge, 25 mm long, curved, a flat profile with end hole) that is securely mounted onto a 5 mL syringe, which contains the local anesthetic solution, is inserted through the hole along the curvature of the sclera. If resistance is encountered, a gentle pressure is applied and hydro-dissection usually helps to advance the cannula. The resistance felt during insertion of the cannula is caused by the intermuscular septum, but usually the cannula passes into the posterior subTenons space. If the hydro-dissection does not help, or the resistance encountered is too great, it is advisable to reposition or reintroduce the cannula. Muscle insertions vary and the cannula may be tranversing the muscles Tenons sheath rather than following the globe surface. The local anesthetic agent of choice is injected slowly and the cannula is removed. A gentle pressure is applied over the globe to help spread the local anesthetic agent. There are many variations of the sub-Tenons technique that relate to route of access, type of cannula, local anesthetic agent, volume of anesthetic, and the adjuvant used.

Fig. 6. Different types of sub-Tenons cannulas. (A) A standard posterior sub-Tenons cannula, 19 gauge and 2.54 cm long; (B) a mid sub-Tenons cannula, 21 gauge and 1.8 cm long; (C) an anterior sub-Tenons cannula, 14 gauge and 1.2 cm long; (D) an ultra-short cannula, 14 gauge and 0.6 cm long.

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Variations of technique Access to sub-Tenons space Access to all other quadrants has been reported: the superotemporal by Fukasaku [9], the superonasal and inferotemporal by Roman and colleagues [24] and McLure and colleagues [25], and the medial canthal side by Ripart [11]. It is not known how frequently these quadrants are used for access. In addition, there are no comparative data to support the ease of access to any particular quadrant. However, the supernasal route is potentially more hazardous because of the vascular, neuronal, and muscular contents in that area. Varieties of cannulae There are several alternative cannulae available for this block. Some are specifically designed for this purpose while others have a different primary purpose. The specifically designed cannulae may be made of either metal or plastic. The metal cannulae vary in gauge, length, curvature, and the position of the end holes. A plastic cannula advocated by Greenbaum [10] is known as an anterior sub-Tenons cannula and is 15 gauge, 1.2 cm long, blunt, D shaped, and has a flat bottom (see Fig. 6C). The opening on the flat bottom is designed to face the sclera after insertion. Non-specific sub-Tenons cannulae include the metal Southampton cannula [8], metal ophthalmic irrigation cannula [26], plastic intravenous cannula [27], and plastic mid sub-Tenons cannula [28] (see Fig. 6B). Recently an ultrashort metal cannula, (16 gauge, 6 mm with blunt end hole) has been described [29] (see Fig. 6D). The placement of a polyethylene catheter into sub-Tenons space has been described for long surgeries [30]. Additionally, access to the sub-Tenon space through the medial canthal approach has been described using needles without dissection [11,31]. The selection of a cannula or needle depends on the availability, cost, and the skills and expertise of the clinician. However, the commercially manufactured, posterior metal sub-Tenons cannula is the type that is most commonly featured in published studies. Choice of local anesthetic agent Anesthesia and akinesia are determined by the properties of the local anesthetic agent, but more directly, by the proximity to the sensory and motor nerves. Lidocaine 2% is the most commonly used

agent and is considered the gold standard [32]. Various local anesthetic agents such as articaine 2% [33], etidocaine [34], prilocaine [35], mepivacaine [36], levobupivacaine [37], and a mixture of lidocaine and bupivacaine [38], have been used but there are few comparative data available on the relative effectiveness of various agents. Volume of local anesthetic agent There is a wide variation in the volume of local anesthetic used in sub-Tenons block and this has been a subject of debate. The volumes vary from 1 to 11 mL [10,39] but 3 to 5 mL are generally used [40]. Smaller volumes will usually provide globe anesthesia but larger volumes are required if akinesia is desirable [41]. Adjuvant and sub-Tenons block Vasoconstrictor Vasoconstrictors are commonly mixed with local anesthetic solution to increase intensity and duration of the block, and to minimize bleeding from small vessels [32]. Because vasoconstrictors reduce absorption of local anesthetic, a surge in plasma levels is avoided. However, epinephrine may cause vasoconstriction of the ophthalmic artery, which compromises the retinal circulation [32]. The use of solutions that contain epinephrine is usually avoided in elderly patients who suffer from cerebrovascular and cardiovascular diseases. The role of epinephrine in subTenons block has been questioned [42]. This is because ophthalmic surgery does not usually take a long time and the duration of the block achieved by lidocaine without epinephrine suffices for modern minimally invasive cataract surgery. Hyaluronidase Hyaluronidase is an enzyme, which reversibly liquefies the interstitial barrier between cells by depolymerization of hyaluronic acid to a tetrasaccharide, and enhances the diffusion of molecules through tissue planes [32]. The amount of hyaluronidase mixed with the local anesthetic varies from 0.5 to 150 IU/mL. There is conflicting evidence that hyaluronidase (30 IU/mL) improves the effectiveness and the quality of sub-Tenons block [43,44]. If hyaluronidase is to be used, 15 IU/mL is the recommended amount in the United Kingdom [45]. It is an expensive drug [46] and although side effects are rare, allergic reactions [47], orbital cellulites [48], and the formation of pseudotumors [49] have been reported after its use.

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pH alteration Commercial preparations of lidocaine and bupivacaine are acidic solutions in which the basic local anesthetic exists predominantly in the charged ionic form [32]. It is only the non-ionized form of the agent that traverses the lipid membrane of the nerve to produce the conduction block. At higher pH values a greater proportion of local anesthetic molecules exist in the non-ionized form, which facilitates more rapid influx into the neuronal cells. Alkalinisation of the local anesthetic agent has been shown to decrease the onset and prolong the duration of needle blocks [50,51] but no such benefit has been observed in subTenons block [52].

Complications of sub-Tenons anesthesia Minor complications Pain during injection The pain experienced during ophthalmic blocks is multi-factorial. Up to 44% of patients report pain during sub-Tenons injection in which a posterior metal cannula is used [8]. Pain scores on a visual analog scale [0 = no pain, 10 = worst imaginable] have been reported as high as 5, and smaller cannulae offer a marginal benefit [56]. Premedication or sedation of patients during sub-Tenons injection does not seem to be beneficial [57]. To reduce the patients discomfort and anxiety, it is important to give a thorough preoperative explanation of the procedure, use a good surface anesthesia, use gentle technique, slowly inject the warm local anesthetic agent, and provide reassurance.

Passage of local anesthetic agent during injection The passage of the local anesthetic during subTenons block has been studied using different imaging techniques [53 55]. These studies confirm that when the anesthetic agent is injected into the subTenons space, it opens the space to form a characteristic T sign (Fig. 7). As the local anesthetic agent spreads through the sub-Tenons space, it diffuses into intraconal and extraconal areas and results in anesthesia and akinesia of the globe and eyelids. Intense analgesia is produced by blockade of the short ciliary nerves as they pass through the Tenons capsule [53]. Akinesia is caused by a blockade of the motor nerves present in the intraconal and extraconal compartments.

Chemosis Chemosis signifies anterior injection of the anesthetic agent. This usually occurs if a large volume of local anesthetic is injected and if the Tenons capsule is not dissected properly [41]. The incidence of chemosis varies from 25% to 60% [24,58] with posterior cannula and to 100% with shorter cannulae [41]. Chemosis may not be confined to the site of injection and has been known to spread to other quadrants [8,41]. This usually resolves after the application of digital pressure, and no intraoperative problems have been reported. Surgeons who per-

Fig. 7. Ultrasound image shows the opening of the sub-Tenons space and the characterstic T-sign.

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form glaucoma surgery may believe that significant chemosis compromises the surgical procedure. Subconjunctival hemorrhage Fine vessels are inevitably severed during the conjunctival dissection, which causes a degree of subconjunctival hemorrhage. The incidence (and severity) of subconjunctival hemorrhage varies from 20% to 100% and depends on the cannula used [8,41]. This can be minimized by careful dissection that avoids damage to fine vessels. The use of cautery has been advocated [10] but no benefit was seen when a disposable diathermy was used by anesthesiologists [59]. Patients should receive adequate warning about the possibility of subconjunctival hemorrhage. Overspill of anesthetic Overspill of the local anesthetic agent during its administration is commonly observed [8,41]. This is likely to occur if the dissection of the sub-Tenons capsule is not complete or if there is a resistance to injection. Traction during injection may cause enlargement of the initial dissection and large injection volume also cause overspill. Careful dissection and use of diathermy may minimize the loss. Gentle pressure over the insertions site with a surgical sponge might also help [1]. Akinesia and anesthesia Akinesia is volume dependent and if 4 5mL of local anesthetic agent is injected, most patients develop akinesia [41]. However, superior oblique muscle and lid movements may remain active in a small but significant number of patients. Many published studies on the subject report good results when anesthesia accompanies sub-Tenons block. However, akinesia is variable and may not be complete [41,57].

[67] as has one case where central spread of the local anesthetic agent led to cardio-respiratory collapse [68]. The mechanism of central spread is not clear but possible explanations include spread of the injected anesthetic agent into the subarachnoid space (see discussion above) through the optic nerve sheath, or back-tracking of the local anesthetic agent through one of the orbital foramina [1]. The later can happen if there is an unintentional perforation of the Tenons capsule, which leads to the deposition of the local anesthetic agent into the intraconal compartment.

Retained visual sensations Published studies have reported that patients who have phacoemulsification cataract surgery under topical, retrobulbar, peribulbar, and sub-Tenons blocks, experience light and other visual sensations during surgery [69]. Although most of the patients felt comfortable with the visual sensations they experienced, a proportion of patients (up to 16%) found the experience to be unpleasant or frightening [70,71]. Preoperative counseling benefits these patients [69]. Patients who receive sub-Tenons block should be offered preoperative advice which may alleviate fear of this experience.

Intraocular pressure and role of ocular compression The rise in intraocular pressure (IOP) after administration of sub-Tenons block is small or even insignificant [72,73]. There was a numerically significant reduction in intraocular pressure using a Honan balloon, but this did not make a clinical difference in the effectiveness of anesthesia [74].

Serious complications Sight- and life-threatening complications have been reported. These include short-lived muscle paresis [60] as well as orbital and retrobulbar hemorrhage [61,62]. Recently, a scleral perforation during sub-Tenons block was reported in a patient who had previously undergone retinal surgery [63]. Damage to the inferior and medial rectus muscles, caused by trauma from metal cannula, has led to restrictive functions that result in diplopia [64]. Other complications relate to optic neuropathy [65], afferent papillary, and accommodation defects [66]. Retinal and choroidal vascular occlusion has been reported

Pulsatile ocular blood flow during sub-Tenons block It is known that retrobulbar and peribulbar injections decrease pulsatile ocular blood flow, at least for a short time [75]. In a recent study [73], the changes in IOP and ocular pulsatile amplitude (OPA) were compared during peribulbar and sub-Tenons blocks. The IOP remained stable with both blocks throughout the study. One minute after injection of the anesthetic agent, the OPA decreased significantly in the injected eyes in both the sub-Tenons (24%) and peribulbar (25%) groups. The OPA decrease in the sub-Tenons group (14%) was also detectable

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after 10 minutes in the control group. Therefore, caution is required in the management of patients whose ocular circulation may be compromised and an alternative anesthesia, such as general anesthesia, may be desirable.

increased risk of an intraoperative event when sedation is used [77,78]. A means of providing supplemental oxygen must be available when sedation is administered.

Advantages of sub-Tenons block Presence of anesthesiologists The presence of anesthesiologists during subTenons block may not be required [18] but the ability to manage life-threatening cardio-respiratory events must be available from the other staff in theater. A member of the staff whose sole responsibility is to the patient, should be responsible for monitoring and should remain with the patient at all times throughout the monitoring period. This person must be trained to detect and act on any adverse events, and may be an anesthesiologist, nurse, or operating department practitioner who is trained in life support [18]. A sub-Tenons block eliminates the risks of sharp needle techniques, provides reliable anesthesia, can be supplemented for prolonged anesthesia and postoperative pain relief, and can be safely used in patients who have a long globe [1]. There are numerous studies that demonstrate its effectiveness compared with retrobulbar, peribulbar, and topical anesthesia alone [1]. Sub-Tenons block has been used mainly for cataract surgery, but also vitreoretinal surgery [79 81], panretinal photocoagulation [82], strabismus surgery [83], trabeculectomy [42,84], optic nerve sheath fenestration [85], chronic pain management [86], and therapeutic delivery of drugs [87]. Recent reviews suggest that sub-Tenons block may be used safely in patients who receive anticoagulants and antiplatelet agents, as long as clotting results are in the normal therapeutic range [21,22]. Despite reports of a few major complications, sub-Tenons block has one of the highest safety profiles of any regional anesthetic technique.

Intraoperative monitoring The patient should be comfortable and soft pads should be placed under the pressure areas. All patients who experience major eye surgery under local anesthesia should be monitored with pulse oximetry, ECG, non-invasive blood pressure measurement, and verbal contact [18]. Patients should receive an oxygen-enriched breathing atmosphere to prevent hypoxia, and a flow rate high enough to prevent hypercarbia if enclosed in surgical drapes. ECG and pulse oximetry should be continued. Once the patient is under the drapes, verbal and tactile contacts are maintained [18].

Limitations of sub-Tenons block Subconjunctival hemorrhage and chemosis are common. Residual muscle movement or incomplete akinesia do not cause intraoperative difficulties and are generally acceptable to surgeons. The block may be difficult to perform in patients who have had previous sub-Tenons block in the same quadrant, previous retinal detachment and strabismus surgery, eye trauma, and infection to the orbit. Some glaucoma surgeons may dislike sub-Tenons block, although it has been used successfully for glaucoma surgery [1].

Sedation during sub-Tenons block A patient who undergoes ophthalmic surgical procedures, regardless of the type of regional anesthesia used, should be fully conscious; responsive; and free of anxiety, discomfort, and pain [18]. The aim of sedation is to minimize anxiety and provide the maximum degree of safety. Sedation is commonly used during cataract surgery under topical anesthesia [76], but selected patients who receive a sub-Tenons or another type of orbital regional block, may benefit from sedation if explanation and reassurance are inadequate [17]. Short acting benzodiazepines, opioids, or intravenous anesthetic agents in minimum dosages are used. However, there is an

Summary Currently there is no absolutely safe orbital regional block technique. Sub-Tenons block is a simple, effective, safe, and versatile technique, although rare complications can occur. To perform a sub-Tenons block, a thorough knowledge of anatomy and understanding of the underlying principles is essential.

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References
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[39] Li HK, Abouleish A, Grady J, et al. Sub-Tenons injection for local anesthesia in posterior segment surgery. Ophthalmology 2000;107:41 6. [40] Tokuda Y, Oshika T, Amano S, et al. Anesthetic dose and analgesic effects of sub-Tenons anesthesia. J Cataract Reftract Surg 1999;25:1250 3. [41] Kumar CM, Dodds C. Evaluation of Greenbaum subTenons block. Br J Anaesth 2001;87:631 3. [42] Buys YM, Trope GE. Prospective study of sub-Tenons versus retrobulbar anaesthesia for inpatient and daysurgery trabeculectomy. Ophthalmolgy 1993;100: 1585 9. [43] Guise P, Laurent S. Sub-tenons block: the effect of hyaluronidase on speed of onset and block quality. Anaesth Intensive Care 1999;27:179 81. [44] Rowley SA, Hale JE, Finlay RD. Sub-Tenons local anaesthesia: the effect of hyaluronidase. Br J Ophthalmol 2000;84:435 6. [45] Joint Formulary Committee. British National Formulary, Volume 50. London7 British Medical Association and Royal Pharmaceutical Society of Great Britain; 2005. [46] Radhakrishna S, Shekawat F, Furlong G. Sub-Tenons block without hyaluronidase. Anaesthesia 2004; 59:411. [47] Agrawal A, McLure HA, Dabbs TR. Allergic reaction to hyaluronidase after a peribulbar injection. Anaesthesia 2003;58:493 4. [48] Kumar CM, Dowd TC, Dodds C, et al. Orbital swelling following peribulbar and sub-Tenons anaesthesia. Eye 2004;18:418 20. [49] Kempeneers A, Dralands L, Ceuppens J. Hyaluronidase induced orbital pseudotumour as a complication of retrobulbar anesthesia. Bull Soc Belge Ophthalmol 1992;243:159 66. [50] Zahl K, Jordan A, Soresen B. Gotta. pH-adjusted lidocaine/bupivacaine mixture are superior for peribulbar block. Anesthesiology 1988;69:A368. [51] Zahl K, Jordan A, McGroarty J, et al. pH-adjusted bupivacaine and hyaluronidase for peribulbar block. Anesthesiology 1990;72:230 2. [52] Moharib MM, Anaesth M, Mitra S. Alkalinized lidocaine and bupivacaine with hyaluronidase for subTenons ophthalmic block. Reg Anesth Pain Med 2000; 25:514 7. [53] Winder S, Walker SB, Atta HR. Ultrasonic localization of anesthetic fluid in sub-Tenons, peribulbar, and retrobulbar techniques. J Cataract Reftract Surg 1999;25: 56 9. [54] Kumar CM, McNeela BJ. Ultrasonic localization of anaesthetic fluid using sub-Tenons cannulae of three different lengths. Eye 2003;17:1003 7. [55] Niemi-Murola L, Krootila K, Kivisaari R, et al. Localization of local anesthetic solution by magnetic resonance imaging. Ophthalmology 2004;111:342 7. [56] Kumar CM, Dodds C, McLure H, et al. A comparison of three sub-Tenons cannulae. Eye 2004;18:873 6. [57] Guise PA. Sub-Tenon anesthesia: a prospective study of 6,000 blocks. Anesthesiology 2003;98:964 8.

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Orbital Regional Anesthesia

Gary L. Fanning, MD
Hauser-Ross Eye Institute, P.O. Box 406, Sycamore, IL 60178-0406, USA

Topical and sub-Tenons local anesthetic techniques have rapidly gained popularity for cataract [1] and other ophthalmic surgical procedures (ie, strabismus and retinal surgery) both here and abroad, largely because of their perceived margins of safety. In Great Britain, sub-Tenons anesthesia in particular has risen in popularity and now is used for a large percentage of cataract surgeries. However, there remains a place for orbital regional anesthesia or general anesthesia in ophthalmic surgery, because topical and sub-Tenons techniques are not suitable for every patient, every procedure, nor every surgeon. The goals of this article are to examine the nomenclature of orbital blocks, to review orbital anatomy as it relates to the safe performance of orbital regional anesthesia, and to describe two specific block techniques and contrast them with others.

This seems reasonable, because parabulbar has the connotation of being next to and close to the globe. Use of the terms retrobulbar and peribulbar to describe different block techniques seems unsuitable on at least two grounds: they are imprecise and they do not actually describe the anatomical spaces they are meant to describe. It would be more precise and anatomically correct to substitute the term intraconal for retrobulbar, because the block is designed to go into the muscle cone. Instead of peribulbar, the term extraconal better describes the type of block intended to inject anesthetic into the extraconal space. In this article, therefore, the terms intraconal and extraconal will be used instead of the more widely used expressions retrobulbar and peribulbar, respectively.

Anatomy for orbital regional anesthesia Nomenclature Nomenclature for orbital blocks is imprecise and can be confusing [2]. Currently, the term retrobulbar is applied to a block for which a long, apically directed needle is used. Actually, all orbital blocks are retrobulbar because the term simply means behind the globe. In many patients it is possible to be behind the globe with a 0.5-in needle. Similarly, the term peribulbar is used to describe a block in which the intent is to stay out of the muscle cone with the needle. In fact, all blocks should be peribulbar (ie, around the globe), because the only alternative is transbulbar, something to avoid. More recently, the term parabulbar has been used to describe sub-Tenons blocks. To best understand the anatomy of the orbit for the purpose of doing blocks, one should have a thorough knowledge of the frontal anatomy of the orbit at various depths from the orbital rim back to the optic canal. This anatomy is best illustrated in the works of Leo Koornneef [3] and Jonathan Dutton [4]. The orbit is an irregularly shaped pyramid; the base faces anteriorly, roughly on the frontal plane. The apex (the optic canal) lies at the posterior end of the medial wall. Because of the irregular shape of the orbit, the lateral wall is longer than the medial wall. As a result, a long (1.5 in) needle that is inserted along the medial wall can easily reach the optic canal in most patients. The globe is situated in the orbit such that it is slightly closer to the roof and lateral wall than to the floor and medial wall. The lateral rectus muscle lies against the orbital wall until quite far anteriorly

E-mail address: glfanning@aol.com

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Fig. 1. A frontal section through the posterior half of the globe. The open star indicates the fat-filled space at the extreme inferotemporal corner of the orbit. The inferior rectus muscle is located at the junction of the lateral onethird and medial two-thirds of the inferior orbital rim. The neurovascular bundle to the inferior oblique lies just lateral to it. The filled star lies in the medial canthal fat-filled space, another relatively safe entry point for an orbital block. IRM, inferior rectus muscle; LPM, levator palpebrae muscle; LRM, lateral rectus muscle; MRM, medial rectus muscle; SOM, superior oblique muscle; SRM, superior rectus muscle. (Adapted from Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: W.B. Saunders Company; 1994; with permission.)

be seen by looking at the junction of the lateral third and medial two-thirds of the lower orbital rim. For decades, this point has been recommended as the needle entry point for an orbital block. Atkinson [5] is often credited with suggesting this entry point, but in his original 1936 paper, he recommended . . .the inferior temporal margin of the orbit. An illustration in his paper shows a skin wheal at the inferotemporal margin of the orbit. It is not surprising that the inferior rectus commonly suffers dysfunction after orbital regional anesthesia. This point is significantly closer to the globe than a point at the inferotemporal corner of the orbit. Thus, for clear anatomical reasons, the classic insertion point for orbital regional anesthesia (junction of the lateral third and medial two-thirds of the lower orbital rim) would seem to be a less desirable entry point than the extreme inferotemporal corner of the orbit. A frontal section of the orbit 5 10 mm behind the hind surface of the eye (Fig. 2) shows a fat-filled, intraconal space that is relatively devoid of structures other than the optic nerve; the bellies of the extraocular muscles are close to the orbital walls at this level. Vascular structures are small and widely spread. The space between the lateral rectus and

where its tendon then passes medially to insert on the globe. The medial rectus muscle, in contrast, begins to angle laterally to join the globe relatively close to its origin at the annulus of Zinn. As a result, there is a sizable fat-filled space between the medial rectus muscle and the medial orbital wall for most of its length, especially in the anterior half of the orbit (Fig. 1). This extraconal space is an excellent site for the injection of local anesthetic, as it communicates freely with the intraconal space and is virtually devoid of easily damaged structures if appropriately approached. Some practitioners use this as the site of their primary orbital block. At the extreme inferotemporal corner of the orbit there is another extraconal, fat-filled space that is easily entered and is devoid of other structures. It, too, communicates with the intraconal space between the lateral rectus muscle and inferior rectus muscle. A frontal section just posterior to the equator of the globe (see Fig 1) invariably shows this space to be large and filled with fat. Actually, both the inferior rectus muscle and the neurovascular bundle to the inferior oblique are quite close to this spot. This can

Fig. 2. Frontal section at a level about 5 10 mm behind the hind surface of the eye. The tip of a 1-in needle should just reach this level and lie in the fat medial to the lateral rectus, and lateral and inferior to the optic nerve. It is unnecessary to be deeper than this in the orbit to achieve an excellent block. IRM, inferior rectus muscle; LRM, lateral rectus muscle; MRM, medial rectus muscle; OA, ophthalmic artery; ON, optic nerve; SOM, superior oblique muscle; SRM, superior rectus muscle. (Adapted from Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: W.B. Saunders Company; 1994; with permission).

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Fig. 3. Frontal section 15 20 mm behind the hind surface of the eye shows how closely packed structures become as the apex of the orbit is approached. There is little room for error here and a needle can damage any of the structures seen in this section. A 1.5-in needle can reach this level in at least 20% of patients. There is no need to be this deep in the orbit when doing orbital regional anesthesia. IRM, inferior rectus muscle; LPM, levator palpebrae muscle; LRM, lateral rectus muscle; MRM, medial rectus muscle; ON, optic nerve; SOM, superior oblique muscle; SRM, superior rectus muscle. (Adapted from Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: W.B. Saunders Company; 1994; with permission.)

traocular muscles, the arteries and veins to those muscles, and the optic nerve. The subarachnoid space between the dural sheath and optic nerve is impressive in this section. The bellies of the extraocular muscles are also much larger at this level. Myotoxicity, which is often irreversible, may occur when local anesthetic is injected directly into a muscle belly [7,8]. The part of the orbit where the structures are closely packed and easily impaled is reached by a 1.5-in needle in at least 15% 20% of eyes, as demonstrated by Katsev and colleagues [9]. To avoid damage to any of the structures seen in the frontal section, it would seem wise to use a shorter needle. Three special anatomical details are worth discussion. First is the vascular tree of the orbit. Both the largest arteries (Fig. 4) and largest veins (Fig. 5) lie in the superior half of the orbit. In addition, the vessels that have the largest diameter lie in the deep portion of the orbit. To avoid a major retrobulbar hemorrhage or intravascular injection, the needle tip should be kept out of the upper half and out of the deep portion of the orbit. Second is the superonasal quadrant of the orbit, which is an especially dangerous place to put a needle. The terminal branches of the ophthalmic artery are here, an artery that is often large and tortuous in elderly, hypertensive individuals. A needle placed in this artery may result in a sight-threatening

inferior rectus muscles is fairly large, but the space between the medial rectus muscle and the medial orbital wall is narrower than in the previous section. These spaces behind the globe are reachable with a 1-in needle. If a sufficient volume of anesthetic is injected, it is unnecessary to place a needle any further back into the orbit to achieve a good block. There is no intermuscular septum between the rectus muscles to define the intraconal from the extraconal space. In fact, anesthetic injected into either space flows readily into the other, as clearly demonstrated by Ripart and coworkers [6]. Some practitioners rely on feeling a pop when the needle is inserted, and believe that they have traversed the (non-existent) septum. When a sharp needle is inserted into a fatfilled space, little, if any, sensation will be felt. A popping sensation may mean that one of the tiny connective tissue septa described by Koornneef [3] and that are found throughout the orbit, has been punctured. It may also indicate, however, a punctured vessel, nerve, muscle, optic nerve, or globe. A frontal section, about 20 mm behind the hind surface of the globe (Fig. 3), shows that the amount of fat in the intraconal space is now much less and there are other structures that fill it. These include the branches of the motor nerves that supply the ex-

Fig. 4. The white line in this drawing divides the orbit into superior and inferior halves. Most large arterial vessels are seen in the superior and deep areas of the orbit. To avoid injuring them, keep needles out of these areas. Note the course of the ophthalmic artery that leaves the optic canal and goes into the superonasal quadrant. (Adapted from Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: W.B. Saunders Company; 1994; with permission.)

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Fig. 5. This figure shows the venous drainage of the orbit. The major vessels are in the superior and deep portions of the orbit. The superior ophthalmic vein begins in the superonasal quadrant. Needles should not enter that quadrant. (Adapted from Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: W.B. Saunders Company; 1994; with permission.)

hematoma or intravascular injection of anesthetic that causes immediate seizure activity. In addition, the terminal branches of the nasociliary nerve lay in the superonasal quadrant and can be damaged. The superior oblique muscle and its trochlear mechanism are also located in the superonasal quadrant. Third is the dural sheath that surrounds the optic nerve. A needle tip placed within that sheath will result in local anesthetic being injected retrograde into the cerebrospinal fluid surrounding the brainstem, causing brainstem anesthesia. This complication may largely be avoided by the use of short needles that are not apically directed.

105 mm Hg diastolic. Judicious doses of intravenous labetalol (10 20 mg) are commonly used, but other agents are available to patients who must avoid betablockers. Great care is taken to avoid suddenly lowering the blood pressure in patients who have angina, aortic stenosis, renal vascular disease, or carotid stenosis. In order to prevent hypotension, administer small, divided doses and monitor carefully. It is also important to examine the eyes for infectious, traumatic, or even malignant lesions. The patients record should be examined for evidence of the length of the eye. In the case of cataract surgery, each patient should have had an axial length measurement and this should be noted and recorded by the person who performs the orbital block. If the anesthesia provider is performing the block, the ophthalmologist should be certain that they know the axial length. If the axial length is not available, the spherical equivalent in the patients eyeglass prescription should be reviewed. High myopes tend to have exceptionally long eyes, so when the spherical equivalent is as high as 6.00 or 7.00, it is advisable to measure the axial length before performing an orbital block. Fig. 6 demonstrates the relationship between axial length and spherical equivalent as measured in 1325 eyes. Patients who have axial lengths ! 27 mm are at risk for posterior staphylomata [10] and should have been carefully examined for their presence preoperatively. After the patients eye length has been determined or estimated, the relationship of the eye within the orbit should be examined. Is it a long eye sunk deeply into a very tight orbit? Is it a short, proptotic eye in a large but potentially shallow orbit? Knowledge of this relationship is used to determine the angle of the block needle as it enters the desired orbital space in order to avoid penetrating the sclera.

Sedation An orbital block can result in a great deal of pain and many practitioners use deep sedation, equivalent to a brief period of general anesthesia, when they perform a block. Pain on injection is likely to occur when a needle is placed deeply into the orbit, because pressure is generated when the anesthetic is injected rapidly into a tight space that is filled with delicate structures. Deep sedation is not without its risks, and a number of unwanted events can occur, including apnea, hypoxemia, uncontrolled movements, and even vomiting or aspiration. Some practitioners believe that it is important not to sedate the patient deeply for an orbital block, because they want the patient to be

Patient preparation Before performing an orbital block, it is wise to review the patients medical history and conduct a directed physical examination to be sure that the patient is a suitable candidate on the day of surgery. Routine assessment of vital signs and an ECG monitor will help determine if patients have fevers, arrhythmias, or hypertension, conditions that may require the procedure to be cancelled. At the HauserRoss Eye Institute patients are routinely treated who have blood pressures > 170 mm Hg systolic and/or

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Fig. 6. Axial length versus spherical equivalent in 1325 eyes. Patients who are highly myopic (and have eyeglass prescriptions with large negative spherical equivalents), tend to have very long eyes. Axial length is plotted against spherical equivalent. The bars represent two standard deviations from the averages. When performing a block on a patient who has not had an their axial length measured, it is useful to look at the spherical equivalent in the eyeglass prescription to estimate the length of the eye. (Gary L. Fanning, MD, unpublished data, 2000.)

able to give notice if excessive pain occurs. Such pain might indicate that the anesthetic is not being injected into a fat-filled space but rather into an extraocular muscle, the globe, a nerve, or under the periosteum. It is possible to have a patient who is sedated to the point of anxiolysis and still remain cooperative. Small intravenous doses of midazolam (1 2 mg) coupled with small, divided doses of a short-acting barbiturate (thiopental [Pentothal] 25 75 mg or methohexital [Brevital] 10 30 mg) or with a rapid, short-acting opioid (remifentanil [Ultiva] 20 40 mcg, alfentanil [Alfenta] 250 500 mcg, or fentanyl [Sublimase] 50 100 mcg) can produce a patient who is relaxed, submissive, and cooperative. Sedative doses of propofol are preferred by many, but it can be difficult to titrate due to its slow onset of action, and in some patients it results in a great deal of unwanted movement unless sleep doses are given. Nonetheless, it is an appropriate agent for many patients when administered by those skilled in its use. Strict attention to the patients reaction to the sedatives is important to avoid over-sedation. The patients response to sedation for the block provides advanced knowledge of their reaction to the sedatives before the onset of surgery. If additional sedation is believed to be required during surgery, the practitioner will be able to avoid excessive sedation and its attendant dangers. To render the injection of a block virtually painless in a patient who

is awake, three precautions must be taken: (1) use a fine, short needle (ie, 25 gauge, 1 in), (2) use an anesthetic solution that has been heated to about 35C, and (3) inject the anesthetic at a slow rate (15 20 s/mL). Studies [11,12] that have examined warming the anesthetic solution have often failed to include the other two precautions, and over-warming the solution often produces increased pain. Any solution injected deeply and rapidly into the orbit will cause intense pain. Warmed solutions injected slowly and more anteriorly do not. Conscious sedation along with a painless injection technique has another benefit: patients may be allowed to have a light breakfast before cataract surgery. The author has used this technique in more than 22,000 patients without a single instance of regurgitation or aspiration. When a painless injection technique is used, only small amounts of sedation, if any, are necessary.

Needles Before discussing the details of block techniques, it is necessary to examine what kind of needle should be used to perform a block. Many, if not most, practitioners still use the 23-gauge, 1.5-in needle that has been used for decades. In 1989, Katsev and

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coworkers [9] published an anatomical study of the orbit with regard to needle length. They measured the distance from the junction of the lateral third and medial two-thirds of the inferior orbital rim to the optic canal. In the 120 skulls that were examined, this measurement varied from about 42 mm to 54 mm (Fig. 7). They postulated that the most dangerous part of the orbit, where structures are densely packed and vulnerable to damage, is the portion within 7 mm of the annulus of Zinn. Thus, the tip of a 1.5-in needle (38 mm) would reach this dangerous portion in any orbit shorter than 45 mm. In their specimens this would be about 15% 20% of the total. If a needle 1.25-in (32 mm) in length is used, the danger area would not be reached in any of the skulls examined by Katsev and coworkers. Although the study was published in a prominent journal, many practitioners still use a long needle. Having used a 1-in needle for 2 years with great success and having used a 1.25-in needle for 12 years before that, it is the authors opinion that the incidence of all of the following complications of orbital regional anesthesia would be significantly reduced by using a shorter needle: retrobulbar hemorrhage, brainstem anesthesia, optic nerve damage, intravascular injection, and extraocular muscle dysfunction. With regard to needle gauge, the needle should be 25 gauge, no bigger. Some prefer a 30-gauge, 1-in needle although others find it too flexible. Many would prefer a 27- or

28-gauge, 1-in needle, but these are no longer available commercially in the United States; a 25-gauge, 1-in needle is a compromise. There is a great debate about whether the bevel of the needle should be sharp or blunt. Some of this discussion revolves around feel: many practitioners believe that a blunt-beveled needle offers a better tactile signal than the sharp-beveled one; others believe just the opposite. Proponents of the blunt-beveled needle believe that it is less likely to inadvertently puncture the sclera than is the sharp-beveled needle. Although this may be true, it is also true that any needle that is capable of going through the intact skin is also able to go through the sclera of the eye in situ (as opposed to an enucleated eye, where it can be demonstrated that a blunt-beveled needle requires more force than a sharp one to penetrate the globe). There is some evidence that scleral puncture with a blunt-beveled needle results in more retinal damage than puncture with a sharp-beveled one [13]. One group has suggested that in patients with a long eye, the blunt-beveled needle should always be used because it is less likely to puncture the sclera [14]. However, the longest eyes have the most delicate sclera, which makes it easy for any needle to penetrate. If penetration did occur, it would seem preferable to have used a needle that would result in less retinal damage. Furthermore, it is not rational to rely on the shape of the needle to avoid penetration of

Fig. 7. Orbital length in 120 skulls. Orbital length is plotted against the percentage of orbits that have specific lengths. About 20% of orbits are short enough that a 1.5-in needle can reach within 7mm of the optic canal where structures are tightly packed. (Adapted from Katsev DA, Drews RC, Rose BT. An anatomical study of retrobulbar needle path length. Ophthalmology 1989; 96:1221 4; with permission.)

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the sclera. Instead, thorough knowledge of orbital anatomy and examination of the patients globe-orbit relationship should prevent this complication. One thing that is not disputed is that the sharp needle enters the skin more easily and with less pain. No matter what needle the practitioner uses, the length, gauge, and bevel shape must be documented in the patients record.

Technique Intraconal block For an intrconal block, the patient should be in the supine position, the chin held up, and the eyes in a neutral gaze. A skin wheal is made with a 0.5-in, 30-gauge needle using 0.1% lidocaine solution injected at the extreme inferotemporal corner of the orbit (Fig. 8). The lidocaine solution is prepared by adding 1.5 mL 2% lidocaine with preservative to a 30 mL bottle of 0.9% saline solution with preservative. The final solution contains about 0.1% lidocaine, which provides excellent anesthesia for about 5 10 min but is virtually painless to inject. This solution given through a 30-gauge 0.5-in needle is also used to anesthetize the intravenous catheters insertion site, which makes starting the intravenous line painless as well. In many patients a distinct notch is felt in the lower orbital rim at the inferotemporal corner. It is worthwhile to search for this notch,
Fig. 9. Line A represents the diagonal of the orbit from the superotemporal to the inferotemporal corner. The block needle is aligned with line A and is inserted at the inferotemporal corner. Dotted line B represents a sagittal plane that goes through the lateral limbus. The block needle is angled (angle C) so that the tip will just intersect plane B about 5 10 mm behind the hind surface of the eye when inserted. The value of this angle is different for each patient.

Fig. 8. A skin wheal is raised at the inferotemporal corner of the orbit. A 30-gauge needle is used to inject 0.1% lidocaine solution, which is virtually painless on injection. The same solution also is used before starting an intravenous to render it painless.

because inserting the needle here increases ones chances of entering into the intraconal space keeping well away from the extraocular muscles and the globe. While an assistant steadies the patients head and holds the upper lid open, a 25-gauge 1-in needle is inserted through the skin wheal at the inferotemporal corner (notch) of the orbit on a line that connects the inferotemporal corner with the superonasal corner (line A, Fig. 9) and is aimed posteriorly to pass tangential to the globe and intersect a sagittal plane (line B, Fig. 9) to pass through the lateral limbus. The angle formed by the needle shaft and the frontal plane on which line A lies (angle C, Fig. 9) will vary in each patient. The degree of angulation is determined by the eyes axial length and how deeply set or proptotic the eye is. In Fig. 10, the two deep-set eyes can be compared with two more proptotic eyes. The angulation necessary to pass tangentially to the globe will differ in each of these patients. The patients eye should be watched constantly during the initial insertion, at which time it should not move at all as the needle passes the globe. Although the patients eye should be in neutral gaze during the initial insertion and should not move, it is helpful to have the patient gaze toward the ipsilateral side once the needle is slightly beyond the equator. This insures that the globe is free and also moves the posterior pole of the eye away from the needle tip. Some practitioners prefer to have the patient continue in neutral gaze, which is also acceptable. It is not ac-

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Fig. 10. The depth of the eye with respect to the lower orbital rim varies from patient to patient. The length of the eye, how deeply it is set, and how tightly it is placed within the orbit constitute the globe-orbit relationship. This relationship must be carefully considered for each patient in order to angle the needle safely to pass tangentially to the globe.

ceptable to move the needle back and forth in order to see if it is in the globe or not. This has been termed by some as stirring the orbital contents, a practice to be avoided. For most patients, the tip of the fully inserted 1-in needle will lie just behind the posterior surface of the globe and no deeper than 5 10 mm behind it. The bevel of the needle should at first be pointing toward the globe so that during insertion the tip of the needle will tend to move away from the globe. After the tip of the needle is well beyond the equator of the globe (about half inserted), the needle can be spun 180 so that the bevel faces away from the globe. This will tend to move the tip medially into the intraconal space behind the globe. Properly placed, the tip of the needle should now be in the intraconal space of the inferotemporal quadrant of the orbit, just behind the globe. Before injecting, the assistant places two fingertips along the lower orbital rim to bolster the inferior orbital septum (Fig. 11). Gentle pressure applied here during injection promotes flow of anesthetic upward and posteriorly instead of retrograde into the lower lid through the ever-present gaps in the orbital septum. Local anesthetic is injected slowly (1 mL every 15 20 seconds) and the globe is periodically palpated to insure that there is no excessive pressure. In most patients 7 mL can be injected safely, a volume that will provide total akinesia and anesthesia in well over 90% of patients. After injection, an orbital compression device is ap-

plied for 10 min. This can be a soft plastic ball or a Honan balloon [15]. This compression helps to disperse the anesthetic throughout the orbit and helps to prevent excessive intraocular pressure caused by the presence of the anesthetic within the orbit.

Fig. 11. The tip is more anterior when a short needle is used and injection may cause anesthetic solution to pass retrograde into the lower eyelid instead of behind the eye. To lessen this tendency, the assistant is directed to place two fingers along the lower orbital rim and to apply gentle pressure to encourage flow of the injectate behind the globe. It is an easy and harmless maneuver that results in a higher rate of successful blocks.

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It is important to emphasize the insertion point described in this technique. For decades, common practice has been to insert the needle at the junction of the lateral third and medial two-thirds of the lower orbital rim (the classic point). As explained above, this insertion site is nearer the globe, is close to the inferior rectus muscle, and is also close to the neurovascular bundle of the inferior oblique. Because it is so close to the globe, it is also difficult from this point to place the needle tip within the muscle cone without trying to redirect it after insertion. From the extreme corner, it is easier to stay far away from the globe and the angle of insertion does not have to change to enter the intraconal space. In fact, a needle only has to be angled 10 medial to a sagittal plane tangential to the globe (ie, to the optic axis) to enter the intraconal space [16]. If the needle is angled as described in the paragraph above, this should happen virtually every time. When performing an extraconal block, it is acceptable to enter at the classic point if the needle remains low and parallel to the orbital floor and is not redirected once inserted. A large volume of anesthetic injected through a short needle in this way will often provide a satisfactory block. Some practitioners prefer to insert the needle into the orbit through the inferior conjunctiva instead of transcutaneously as described above. This is an acceptable technique, especially since the conjunctiva can be anesthetized with topical anesthetic, which avoids the need to inject a skin wheal. Transconjunctival injection can be difficult for some patients, however, especially for those who are very protective, have short palpebral fissures, or have exceptionally deep-set eyes. In these patients, the transcutaneous approach may be easier and perhaps safer. The block technique described above should be contrasted with the classic technique that has been taught, practiced, and described in the literature [17]. In the older technique, the needle enters more medially, as has been mentioned, and is redirected to be aimed toward the apex of the orbit when it is an inch or so into the orbit. It is during this redirection of the needle, especially in patients with long eyes (26 27 mm or longer), that perforation of the globe probably occurs. Perforation is less likely to occur if the needle is inserted further away from the globe, not aimed at the apex, and not redirected. In the apex, structures are tightly packed together, and a long needle aggressively aimed in that direction has a real chance of causing a major complication. The complication rate is, in fact, relatively low, but it could be even lower with the use of improved techniques.

Extraconal block After 10 min, the patients eye should be evaluated for movement. When significant movement occurs, it is most often medial, torsional, or superior. If there is a lot of movement, it may be wise to repeat the inferotemporal, intraconal injection, which is often necessary in patients with large orbits. If there is less movement, a supplement in the medial canthal extraconal space is recommended. The purpose of this injection is to deposit anesthetic into the fat-filled space between the medial rectus muscle and the medial orbital wall (see Fig. 1). Anesthetics placed here flow unimpeded into the posteromedial aspect of the intraconal space as well as into the posterosuperior extraconal space. This block, described by Hustead and colleagues [18], is preferred by some for the primary block. For this procedure, a 25-gauge, 1-in needle (some practitioners use a 30-gauge 0.5-in needle) is inserted into the tunnel that lies between the caruncle and the medial canthus (Fig. 12). This is usually painless because of the inferotemporal block. The needle tip is directed at first toward the medial wall (Fig. 13). The orbital wall is extremely thin here and is called the lamina papyracea (paper layer). If inserted too aggressively, the needle tip ends up in the ethmoid sinus and after injection the patient will feel the anesthetic running down the back of the nose and into the throat. After touching the wall, the needle is withdrawn slightly (1 mm) and is redirected so that it can be inserted into the orbit parallel to the medial wall and the floor (Fig. 14). The needle should be

Fig. 12. If a supplemental block is required to achieve complete akinesia, a medial canthal block is performed. First, identify the small tunnel or dimple that lies anterior to the caruncle and just behind the medial canthus. The tip of the needle is placed in that tunnel.

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longer needles are used, the needle probably enters the medial canthal space [21]. Ripart and colleagues have reported excellent results with their blocks, and their technique should be respected and considered. Block mixtures A variety of anesthetic agents are acceptable for performing orbital regional anesthesia; they range from 1% lidocaine for short procedures that do not require complete akinesia to 0.75% bupivacaine for long procedures that do. The higher concentrations of local anesthetics are known to be significantly myotoxic in laboratory investigations [7,8] and may be so in selected patients [22]. They will certainly be toxic if injected directly into a muscle. In addition, bupivacaine may exhibit significant neurotoxicity and cardiotoxicity when injected intravascularly. Although 4% lidocaine has been marketed and used for deep intraconal blocks for many years, some [23] believe that it is too myotoxic and should be avoided when doing orbital regional anesthesia. For the most part, however, the choice of anesthetic agent is only critical when deciding how long the patient needs to be anesthetized. Hyaluronidase has been used for years in orbital regional anesthesia, perhaps the only regional block where it has been shown to be beneficial, although not all investigators agree regarding its effectiveness [24 26]. Hyaluronidase does slightly speed the onset of block and perhaps improves the quality of the

Fig. 13. The tip of a 1-in needle is inserted into the tunnel until it just touches the periosteum of the medial wall (lamina papyracea). The tip is then withdrawn just 1 2 mm, and the needle is redirected.

aimed straight posteriorly to stay in the fat-filled, avascular space medial to the medial rectus muscle. A needle longer than 1 inch should never be used here, because the optic canal lies directly posterior and can be impacted by overly aggressive insertion. The shoulder (where the hub and shaft join) of a 1-in needle should not go deeper than the plane of the iris. The bevel of the needle during insertion should face the orbital wall to keep the tip of the needle away from the wall. It is not unusual to see the globe move medially and then move back to neutral gaze during insertion of the needle. This is because the needle will pass through the medial check ligament, and, in some patients, the globe will turn. Properly placed, however, the needle is safely medial to the globe in spite of the movement. After aspirating, 2 5 mL is injected while the globe is frequently palpated to insure that excessive pressure does not develop. The orbital compression device is reapplied for another 5 10 min. It is rare to have to give more than one supplement and then only when absolute akinesia is required. As mentioned, some practitioners use this approach for their primary block, inject up to 10 mL, and are happy with their results. An alternative approach to the medial canthal block has been suggested by Jacques Ripart and his colleagues in Nimes, France [19,20]. Instead of inserting the needle in front of the caruncle, they insert it between the caruncle and the globe. The globe turns severely medially during insertion and then pops suddenly back to neutral gaze as the needle goes back further. They have promoted this technique as a way of entering the sub-Tenons space, which they undoubtedly do when short needles (0.5 in) are used. If

Fig. 14. The needle has been redirected and inserted into the fat-filled space medial to the medial rectus. The shaft of the needle should be parallel to the medial wall and to the floor of the orbit. No attempt should be made to angle it superiorly or inferiorly. No needle longer than 1 in should be used, and the shoulder (where hub and shaft meet) of the needle should not go deeper than the plane of the iris.

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block, but it also facilitates more rapid diffusion of the anesthetic bolus within the orbit, which reduces vitreal pressure during cataract and other intraocular procedures [27]. In addition, during a recent lack of hyaluronidase in the commercial market in America, a rise in extraocular muscle dysfunction was noted in some institutions [28,29]. Lack of the agent may have caused high concentrations of anesthetic to remain close to a muscle for a longer period, which resulted in toxicity, although such a mechanism is hypothetical. Nonetheless, the question remains as to whether or not myotoxicity is seen more frequently when hyaluronidase is not added to orbital block mixtures. The amount of hyaluronidase needed has been the subject of clinical investigations. Many practitioners use large amounts of the agent: 150 units per 510 mL of anesthetic mixture (15 30 units per mL). A study from Finland [30] showed that a mixture containing 3.5 units per mL is quite effective. This author has used 1 unit per mL for many years [31]. Hyaluronidase is also an expensive agent and 150 units is more than sufficient for a dozen patients, a significant savings compared with giving 150 units to each patient. The use of epinephrine in the block mixture is controversial. Some believe that it is dangerous and results in retinal vascular problems [23,32]. High concentrations (! 1:200,000) are to be avoided and it should probably not be used for patients who have known severe, generalized peripheral vascular disease. The reasons to add epinephrine are to prolong the block and to improve its quality. In the authors experience, small quantities of epinephrine (1:300,000 or 1:400,000 concentrations) have not resulted in retinal vascular problems in over 22,000 patients and have added significant duration to the block. Epinephrine, however, is not absolutely necessary to obtain a good block, and high concentrations should not be used.

where structures are tightly packed and thus more easily harmed. Thorough knowledge of orbital anatomy and understanding of the globe-orbit relationship of every patient are necessary to perform this form of regional anesthesia. In addition, knowledge of the effects and side effects of the anesthetics and adjuvants is also required.

References
[1] Leaming DV. Practice styles and preferences of ASCRS members2003 survey. J Cataract Refract Surg 2004;30:892 900. [2] Fanning GL. Orbital regional anesthesia: lets be precise. J Cataract Refract Surg 2003;29:1846 7. [3] Koornneef L. Spatial aspects of the orbital musculofibrous tissue in man. Amsterdam and Lisse, The Netherlands7 Swets and Zeitlinger; 1977. [4] Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia7 W.B. Saunders Company; 1994. [5] Atkinson WS. Retrobulbar injection of anesthetic within the muscular cone. Arch Ophthalmol 1936;16: 494 503. [6] Ripart J, Lefrant J, de la Coussaye J, et al. Peribulbar versus retrobulbar anesthesia for ophthalmic surgery. Anesthesiology 2001;94:56 62. [7] Foster AH, Carlson BM. Myotoxicity of local anesthetics and regeneration of the damaged muscle fibers. Anesth Analg 1980;59:727 36. [8] Rainin EA, Carlson BM. Postoperative diplopia and ptosis; a clinical hypothesis on the myotoxicity of local anesthetics. Arch Ophthalmol 1985;103:13379. [9] Katsev DA, Drews RC, Rose BT. An anatomical study of retrobulbar needle path length. Ophthalmology 1989;96:1221 4. [10] Edge R, Navon S. Axial length and posterior staphyloma in Saudi Arabian cataract patients. J Cataract Refract Surg 1999;25:91 5. [11] Martin S, Jones JS, Wynn BN. Does warming local anesthetic reduce the pain of subcutaneous injection? Am J Emerg Med 1996;14:10 2. [12] Jones JS, Plzak C, Wynn BN, et al. Effect of temperature and pH adjustment of bupivacaine for intradermal anesthesia. Am J Emerg Med 1998;16:117 20. [13] Grizzard WS, Kirk NM, Pavan PR, et al. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991;98:1011 6. [14] Waller SG, Taboada J, OConnor P. Retrobulbar anesthesia risk: do sharp needles really penetrate the eye more easily than blunt needles? Ophthalmology 1993; 100:506 10. [15] Honan PR. New safety valve for Honan balloon. J Am Intraocul Implant Soc 1982;8:163. [16] Hustead R, Koornneef L, Zonneveld FK. Anatomy. In: Gills JP, Hustead RF, Sanders DR, editors. Ophthalmic anesthesia. Thorofare (NJ)7 Slack Incorporated; 1993. p. 33.

Summary Orbital regional anesthesia is a useful and safe modality to provide excellent operating conditions for the surgeon and painless, pleasant circumstances for the patient. It is especially suited for patients who are extremely sensitive and who could not tolerate topical anesthesia or a sub-Tenons block without deep sedation. Both intraconal and extraconal techniques can be used safely and effectively if proper precautions are taken to enter the safest areas of the orbit in order to avoid the vascular areas and the deep orbit

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fanning thesia. A clinical evaluation of four different anaesthetic mixtures. Acta Ophthalmol (Copenh) 1993;71:787 90. Crawford M, Kerr W. The effect of hyaluronidase on peribulbar block. Anaesthesia 1994;49:907 8. Bowman R, Newman D, Richardson E, et al. Is hyaluronidase helpful for peribulbar anaesthesia? Eye 1997; 11:385 8. Ripart J, Nouvellon E, Chaumeron A. Regional anesthesia for eye surgery. Reg Anesth Pain Med 2005;30: 72 82. Brown SM, Brooks SE, Mazow ML, et al. Cluster of diplopia cases after Periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999;25:12459. Troll G, Borodic G. Diplopia after cataract surgery using 4% lidocaine in the absence of Wydase (sodium hyaluronidase) [Letter]. J Clin Anesth 1999;11:615 6. Kallio H, Paloheimo M, Maunuksela EL. Hyaluronidase as an adjuvant in bupivacaine-lidocaine mixture for retrobulbar/peribulbar block. Anesth Analg 2000; 91:934 7. Fanning G. Hyaluronidase in ophthalmic anesthesia [Letter]. Anesth Analg 2001;92:560. Ahmad S, Ahmad A. Complications of ophthalmologic nerve blocks: a review. J Clin Anesth 2003;15:564 9.

[17] Lai MM, Lai JC, Lee WH, et al. Comparison of retrobulbar and sub-Tenons capsule injection of local anesthetic in vitreoretinal surgery. Ophthalmology 2005;112:574 9. [18] Hustead RF, Hamilton RC, Loken RG. Periocular anesthesia: medial orbital as an alternative to superior nasal injection. J Cataract Refract Surg 1994;20:197 201. [19] Ripart J, Metge L, Prat-Pradal D, et al. Medial canthus single-injection episcleral (sub-tenon) anesthesia: computed tomography imaging. Anesth Analg 1998;87: 42 5. [20] Nouvellon E, LHermite J, Chaumeron A, et al. Ophthalmic regional anesthesia: medial canthus episcleral (sub-Tenon) single injection block. Anesthesiology 2004;100:370 4. [21] Fanning GL. Is it in the episcleral space or in the medial canthal extraconal space? [Letter]. Anesthesiology 2004;101:1045. [22] Salama H, Farr AK, Guyton DL. Anesthetic myotoxicity as a cause of restrictive strabismus after scleral buckling surgery. Retina 2000;20:478 82. [23] Hamilton RC. Complications of ophthalmic regional anesthesia. Ophthalmol Clin North Am 1998;11:99 114. [24] Johansen J, Kjelgard M, Corydon L. Retrobulbar anaes-

[25] [26]

[27]

[28]

[29]

[30]

[31] [32]

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Choosing Anesthesia for Cataract Surgery

Joselito S. Navaleza, MDa, Sagun J. Pendse, MDa, Mark H. Blecher, MDb,T
b a Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA Cataract and Primary Eye Care Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA

Advances in cataract surgery techniques have presented surgeons with new options for ocular anesthesia. As cataract removal has become faster, safer, and less traumatic, the need for akinesia and anesthesia has declined significantly. The use of general anesthesia or retrobulbar block has largely been replaced with other safer and equally effective means of local anesthesia, including peribulbar, sub-Tenons, and topical. These newer and less invasive methods have not only reduced the potential for catastrophic surgical complications, but also increased the efficiency of cataract surgery and hastened the process of visual rehabilitation. Today there are numerous modes of anesthesia from which a surgeon can choose. There is not one type of anesthesia right for all cases. The best choice varies from surgeon to surgeon, and patient to patient. The goal of this article is to review the current choices for ocular anesthesia, compare their efficacies, and provide a framework, helping to select the most appropriate type of anesthesia for each patient. Although general anesthesia was first used in surgery in 1846 by William Morton, it was not used for cataract surgery until 1954 [1]. Retrobulbar block was first described in 1884 by Knapp who injected 4% cocaine before enucleation surgery [2]. The modern technique used by most ophthalmologists today was described by Atkinson in 1948, and until recently served as the most commonly used technique for intraocular surgery [3]. Davis and Mandel are credited with introducing the peribulbar block in

T Corresponding author. Cataract and Primary Eye Care Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107. E-mail address: mhbmd@earthlink.net (M.H. Blecher).

1986 as a less dangerous alternative to retrobulbar anesthesia [4]. The decision between retrobulbar anesthesia and peribulbar anesthesia presents the surgeon with a choice between speed and safety. With a retrobulbar block a surgeon can ensure that adequate akinesia and anesthesia will result for cataract surgery; however, a blind injection into the orbit poses several potential complications, including, but not limited to retrobulbar hemorrhage, globe perforation, optic nerve damage, and brainstem anesthesia. Peribulbar anesthesia, involving the injection of local anesthetic external to the muscle cone, is thought to decrease the likelihood of optic nerve and globe perforation while maintaining the desirable qualities of excellent akinesia and anesthesia. However, the potential need for reinjection, the higher volume of injectate required, and the longer duration of onset associated with peribulbar blocks may make it a less attractive alternative. In a prospective, randomized controlled trial involving 100 patients undergoing elective cataract surgery, Whitsett and colleagues compared retrobulbar anesthesia with one injection site peribulbar anesthesia [5]. They evaluated the two methods based on three criteria that were considered critical to intraocular surgery: lid akinesia, globe akinesia, and ocular anesthesia. Following administration of the block, an independent observer rated each of these. The authors concluded that one injection site peribulbar anesthesia appeared to have a similar range of efficacy in all three categories as compared with standard retrobulbar anesthesia. There were no anesthetic-related complications in either group. As documented by Leaming [6] in his annual surveys of ASCRS members, the current trend for cataract surgery has shifted away from retrobulbar and peribulbar anesthesia toward topical anesthesia.

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Karl Koller was the first to describe the use of cocaine as a topical anesthetic for ocular surgery in 1884 [7]. Topical anesthesia, however, did not gain popularity until recently when it was reintroduced in the early 1990s by groups that used topical medications. Subsequently, topical anesthesia was modified by Gills and colleagues in 1997 with the introduction of nonpreserved intracameral lidocaine [8,9] and by Barequet et al [10] with the introduction of lidocaine gel. Given the recent trend toward the use of topical anesthesia, perhaps of more significance would be a comparison of retrobulbar and topical anesthesia for cataract surgery. In 1993, Kershner evaluated 100 patents undergoing cataract surgery with topical anesthesia and concluded that topical anesthesia was safe, decreased complication rates, and hastened patients return to normal vision [11]. However, the following year, however, Fukasaku and Marron [12] compared topical and retrobulbar anesthesia and found that patients had unacceptable amounts of intraoperative pain with the topical technique and abandoned its use altogether. They, however, did not mention the use of preoperative counseling or IV sedation. Patel and collegaues completed a randomized controlled trial comparing the clinical efficacy of retrobulbar versus topical anesthesia in patients undergoing temporal clear corneal cataract extraction [13]. Patients were given IV sedation (Midazolam) in this study. They used a visual pain analog scale to evaluate patient discomfort preoperatively, intraoperatively, and postoperatively, and concluded that the degree to which patients experience pain is only marginally higher for the topical group during the administration of the anesthetic, intraoperatively, and postoperatively. There was no statistically significant difference in pain scores ( P = .35). They also concluded that no statistically significant ( P = .5) difference in operative conditions were experienced by the surgeon because of lack of globe akinesia. The importance of careful patient selection with regard to patient anxiety and cooperation was emphasized. In a follow-up study by Crandall and colleagues, the efficacy of topical anesthesia with and without intracameral lidocaine was assessed [14]. In this study no intravenous sedation was used. The authors found that there was no statistically significant difference in patients assessments of pain preoperatively, intraoperatively or postoperatively between those who received intracameral lidocaine and those in the control group. There did exist, however, a statistically significant difference in patients perception of tissue handling ( P = .021). This outcome measure did not incorporate pain, but rather the

sensation that the eye or surrounding tissue is being manipulated. Of perhaps greatest importance was the finding of a statistically significant difference in the surgeons assessment of patient cooperation (P = .043) between the two groups. Those patients who received intracameral lidocaine more readily followed surgeon commands. It was postulated that this ability to cooperate was a result of the patient being less bothered by tissue manipulation. The authors argue that this finding alone justifies the use of intracameral lidocaine to enhance topical anesthesia given the importance of patient cooperation to successful topical cataract surgery. And to take the current trend of less anesthesia to its most absolute, Pandey and associates compared no anesthesia to topical and topical with intracameral and found that for a highly experienced surgeon, with a carefully selected patient population, the pain scores for all three groups were the same. The only difference was the discomfort level of the surgeon [15]. In the most recent published study of the practice styles and preferences of ASCRS members [6], it was found that retrobulbar block without facial block was used by 11% of surgeons and retrobulbar injection with facial block by 9% (down from 76% in 1985, 32% in 1995, and 14% in 2000). The peribulbar block was used by 17% of surgeons (down from 38% in 1995). Topical anesthesia was used by 61% (up from 8% in 1995 and 51% in 2000). Of those surgeons electing to use topical, 73% of surgeons also used concomitant intracameral lidocaine. The use of topical also varied with surgical volume. Those performing 1 to 5 cataract procedures per month used topical 38% of the time and those doing more than 75 procedures used it in 76% of cases. Clearly the trend has been to transition from retrobulbar anesthesia to topical, and this pattern parallels the increase in the use of temporal clear corneal incisions. Given the choices for ocular anesthesia today, one thing remains clear: no single mode of anesthesia can serve as a universal choice for all patients and all surgeons. The literature reveals that each of the major modes of ocular anesthesiaretrobulbar, peribulbar, and topicalare essentially equally effective in controlling patient pain and allowing a surgeon to have a successful surgical outcome. The decision to choose one of these methods ultimately falls on the surgeon, and the surgeon should carefully tailor his or her approach to each individual patient. The decision of which type of anesthesia to use is not only dependent on a number of patient factors, but is also dependent on the surgeon and the surgeons level of expertise and facility with the surgery to be performed. With this in mind, we present a short discussion that

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addresses the decisions involved in choosing the mode of anesthesia best suited for each patient. The ideal surgery is conducted under the safest conditions, is cost- and time-efficient, and ultimately results in excellent outcomes as well as patient satisfaction. These are our goals with regard to the use of anesthesia for cataract surgery as well. We group anesthesia into three categories: general, regional (retrobulbar, peribulbar, and sub-Tenons), and topical (with and without intraocular anesthetics).

Risks and benefits General anesthesia provides excellent anesthesia, analgesia, and akinesia. In addition, the duration of anesthesia can be varied to accommodate the length of surgery. This provides the most controlled environment for surgery and may result in fewer ocular complications and, ultimately, a satisfied patient. Systemic risks include malignant hyperthermia, hemodynamic fluctuation, postoperative nausea and vomiting, and allergic reactions. There may also be increased risk of cardiac complications under general anesthesia. In 1980, Backer and colleagues [16] published a study suggesting elderly patients with a history of myocardial infarction were at a higher risk for another myocardial infarction under general anesthesia. Lang [17] did not find similar results in their review of 15,000 cases between 1977 and 1979 comparing regional with general anesthesia. There was one death in each group and the only two myocardial infarctions occurred in the regional group. Lynch and colleagues [18] found similar rates of mortality and major complications including vitreous loss with general and regional anesthesia in 2217 consecutive patients. Ocular complications such as intraocular pressure fluctuation, Valsalva retinopathy, corneal abrasions, and chemical injury also occur more frequently. General anesthesia requires more medication, equipment, and personnel than topical anesthesia. As a result, it is the most costly form of anesthesia. The time required for induction, intubation, and extubation also contributes to its inefficiency. Modern health care, where time and cost efficiency are significant factors, renders general anesthesia unlikely for the bulk of cataract surgeries. Regional anesthesia also provides excellent anesthesia, analgesia, and akinesia. The duration of effect varies with the anesthetic mixture used but can easily last for most cataract surgeries. While the eye is not able to move, the patient may still move, as a result, it is not quite as controlled as general anesthesia. The

cost of the medications and equipment are much less than with general anesthesia. Injections themselves take very little time, making this method more time and cost efficient than general anesthesia. There are systemic risks such as allergic reactions, brainstem anesthesia, and oculocardiac reflex. In addition, the complications of a blind injection into the orbit present additional risks discussed earlier. The incidence of retrobulbar hemorrhage has been reported as low as 0.44% of cases [19], up to 3% of cases [20]. Peribulbar anesthesia, involving the injection of local anesthetic external to the muscle cone, is thought to decrease the likelihood of optic nerve and globe perforation while maintaining the desirable qualities of excellent akinesia and anesthesia. However, the higher volume of injectate required and the longer duration of onset may make it a less attractive alternative. Sub-Tenons injections with blunt cannulas have an even lower risk of local complications [21]. With all orbital block anesthesia, cosmetic complications such as localized swelling, bruising, and subconjuctival hemorrhage may lead to reduced patient satisfaction. In addition, eye movement and vision are affected for some time after surgery. Topical anesthesia is the most cost and time efficient. Topical does not affect vision or motility, so patients may have improved and useful vision almost immediately after surgery. There are also minimal cosmetic changes. As a result, if patients have no pain or discomfort during surgery, patient satisfaction may be improved. Topical also avoids the systemic risks of general anesthesia and the risk of local trauma that occurs with regional blocks. Rare local allergic reactions do occur. The disadvantage to topical anesthesia is that it provides the least controlled environment for cataract surgery. Patients are able to move their eyes as well as any other part of their bodies. They perceive visual phenomena as the case proceeds. Pain and pressure may be experienced with intraocular pressure changes as the lens iris diaphragm move. These sensations may be reduced with intravenous sedation or analgesia, maneuvers such as entering the eye with low bottle height, or with the use of intracameral anesthetics [22]. However, even with all of the above, patients may still experience some discomfort. In addition, the duration of anesthetic effect is typically less than an hour. Even in uncomplicated cases there may be a loss of effect by the end of a case.

Choosing anesthesia It is essential that the surgeon, patient, and anesthesia staff work together and be involved in

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the selection and execution of anesthesia during the surgery. Involving the patient in this decision by describing the patient experience before and during surgery is critical. Fear and anxiety result when things are unknown or unexpected. If patients are prepared, they are better equipped to cope with the sensations they may feel during and after surgery. Anesthesia staff, whether a physician or nurse anesthetist should also be involved and know the patient. Modulation of intravenous sedation can play a key role during surgery. Increasing sedation as needed during surgery can reduce discomfort, provide akinesia, and ultimately may result in some amnesia that can result in better outcomes. This may be particularly important with topical anesthesia, and the degree of intravenous sedation may vary widely from surgeon to surgeon, and from case to case. Some of the indications for general anesthesia for cataract surgery include pediatric patients, patients who are unable to cooperate, lengthy procedures (> 3 hours), and patient or surgeon preference. Most surgery in children is performed under general anesthesia. Patients with psychiatric disorders, dementia, tremor, and inability to lie flat are at risk to move or even attempt to sit up during surgery. Longer procedures may exceed the duration of action of regional blocks; some complex anterior segment surgeries such as suturing lenses can take hours in some hands. Patients may ultimately feel that they will not be able to cooperate during surgery and request general anesthesia. Finally, the surgeon may choose general anesthesia for certain patients. Again, general does provide the most controlled environment. This may be ideal for the beginning surgeon. In teaching institutions, it would also allow the attending surgeon and the resident surgeon to communicate more freely during surgery. General and topical anesthesia should also be considered in patients on anticoagulation treatment; general is preferable when complete ocular akinesia is desired. Patients with nystagmus may not be able to fixate and ocular akinesia can only be attained with regional or general anesthesia. Anatomic abnormalities such as an abnormally long axial length may make topical or general anesthesia a safer alternative. There are patients in which general anesthesia is contraindicated or should be undertaken with caution. Myotonic dystrophy patients develop cataracts at a younger age; these patients are at risk of cardiac and respiratory complications under general anesthesia [23,24]. Marfans patients are subject to lens subluxation and dislocation; they are also at increased risk of cardiac and pulmonary complications under general anesthesia [25,26]. Other modes of anesthesia

should be considered in patients with a family history of malignant hypertension. Thorough review of medications is necessary, because some ocular medications may interfere with general anesthesia. Topical epinephrine used to treat glaucoma may interact with halogenated hydrocarbon anesthetics leading to ventricular fibrillation [27]. Echothiophate, which in the past was used to treat glaucoma, inhibits plasma pseudocholinesterase, which also metabolizes anesthetics including succinylcholine leading to overdosing [28]. Regional blocks provide some benefit over topical for patients who are unable to follow directions, such as when the patient is hearing impaired or there is a language barrier. It obviously does not prevent patient movement. The ocular akinesia and longer duration of effect make it a more ideal mode of anesthesia in cases in which the primary surgeon is a physician in training. Topical anesthesia provides the least controlled environment for cataract surgery. The surgeon must be able to tolerate some ocular motility, the patient should be able to follow directions, and the anesthesia staff must be willing to modulate intravenous sedation. Topical has the shortest duration of action. If the surgeon anticipates that he or she can complete the case in a reasonable time frame and the other conditions are met, topical anesthesia may ultimately be the safest mode of anesthesia as it avoids the systemic risks of general anesthesia and the risk of local trauma that accompanies regional blocks. For many patients and surgeons this mode of anesthesia fulfills all of the goals of anesthesia in cataract surgery. This is perhaps the reason that it has become the most popular form of anesthesia. It seems every few years we further perfect the cataract operation. We make it safer, faster, better, and more atraumatic. And just when we think we cannot improve it any more, we do. Hand in hand with our evolving surgical technique has come concepts in ocular anesthesia that bring these surgical advances to our patients in the safest and most efficient manner. While it seems unbelievable that we can further reduce the stress of cataract surgery and cataract surgery anesthesia any further, our history should tell us otherwise.

References
[1] Esser A. The first cataract surgery under general anesthesia. Klin Monatsbl Augenheilkd 1954;125(5): 610 4. [2] Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol 1884;18:402 48.

choosing anesthesia for cataract surgery [3] Atkinson WS. Local anesthesia in ophthalmology. Am J Ophthalmol 1948;31:1607 18. [4] Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986;12:182 4. [5] Whitsett J, Baleyat H, McClure B. Comparison of oneinjection-site peribulbar anesthesia and retrobulbar anesthesia. J Cataract Refract Surg 1990;16:243 5. [6] Leaming D. Practice styles and preferences of ASCRS members2003 survey. J Cataract Refract Surg 2004; 30:892 900. [7] Koller C. On the use of cocaine for producing anaesthesia on the eye. Lancet 1884;2:990 2. [8] Fichman R. Use of topical anesthesia alone in cataract surgery. J Cataract Refract Surg 1996;22:612 4. [9] Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine to control discomfort during cataract surgery using topical anesthesia. J Cataract Refract Surg 1997; 23:545 50. [10] Barequet IS, Soriano ES, Green WR, et al. Provision of anesthesia with single application of lidocaine 2% gel. J Cataract and Refract Surg 1999;25:626 31. [11] Kershner R. Topical anesthesia for small incision selfsealing cataract surgery. A prospective evaluation of the first 100 patients. J Cataract Refract Surg 1993;18: 290 2. [12] Fukasaku H, Marron J. Pinpoint anesthesia: a new approach to local ocular anesthesia. J Cataract Refract Surg 1994;20:468 71. [13] Patel B, Burns T, Crandall A, et al. A Comparison of topical and retrobulbar anesthesia for cataract surgery. Ophthalmology 1996;103:1196 203. [14] Crandall A, Zabriskie N, Patel B. A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine. Ophthalmology 1999;6:60 6. [15] Pandey SK, Werner L, Apple DJ, et al. No-anesthesia clear corneal phacoemulsification versus topical and topical plus intracameral anesthesia: randomized

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clinical trial. J Cataract Refract Surg 2001;27(10): 1643 50. Backer CL, Tinker JH, Robertson DM, et al. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth Analg 1980;59:256 62. Lang DW. Morbitity and mortality in ophthalmology. In: Bruce RA, McGoldrick KE, Oppenheimer P, editors. Anesthesia for ophthalmology. Birmingham (AL)7 Aesculapius Publishing; 1982. p. 195. Lynch S, Wolf GL, Berlin I. General anesthesia for cataract surgery: a comparative review of 2217 consecutive cases. Anesth Analg 1974;53:909 13. Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. Anesth Analg 1993;76(5): 1019 22. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology 1988;95:660 5. Greenbaum S. Ocular anesthesia. Philadephia7 W B Saunders Company; 1997. p. 1 57. Fichman RA. Topical anesthesia. Ophthalmol Clin North Am 1998;11:60. Luntz MH. Clinical types of cataracts. In: Duane TD, editor. Clinical ophthalmology. Philadelphia7 JB Lippincott; 1988. p. 14. Aldridge LM. Anaesthetic problems in myotonic dystrophy: a case report and review of the Aberdeen experience comprising 48 general anesthetics in a further 16 patients. Br J Anaesth 1985;57:1119 30. Wells DG, Podolakin W. Anesthesia and Marfans syndrome: case report. Can J Anesth 1987;34:311 4. Mostafa SM. Anaesthesia for ophthalmic surgery. Oxford7 Oxford University Press; 1991. Janssens ML, Cockx F. A case of ventricular fibrillation during halothane anesthesia caused by eye drops. Acta Anaesthesiol Belg 1979;30(4):273 5. DeRoeth A, Dettbar WD, Rosenberg P. Effect of phospholine iodide on blood cholinesterase levels. Am J Ophthalmol 1963;59:586 92.

Ophthalmol Clin N Am 19 (2006) 239 243

Anesthesia Considerations for Vitreoretinal Surgery

Steve Charles, MDa,b,T, Gary L. Fanning, MDc
a

University of Tennessee, College of Medicine, 6401 Poplar Avenue, Suite 190, Charles Retina Institute, Memphis, TN 38119, USA b Columbia University, New York, NY, USA c Hauser-Ross Eye Institute, 2240 Gateway Drive, Sycamore, IL 60178, USA

Regardless of the type of anesthesia contemplated for vitreoretinal (VR) surgery, the patient should undergo a thorough preoperative evaluation before the procedure. Under most circumstances this evaluation should occur well before the day of surgery so that required adjustments can be performed in advance to help ensure that the patient is in optimal condition before surgery. Specific investigations, such as chest radiography, electrocardiogram, and blood chemistries, should be performed only when dictated by the findings of thorough history and physical examinations. So-called screening labs are not indicated when the appropriate history and physical examinations are negative [1].

General versus local anesthesia Both general and local anesthetic techniques are acceptable for VR surgery; however, many retinal surgeons prefer to do the vast majority of these cases using monitored local anesthesia for the following reasons: (1) local anesthesia offers increased safety for patients, especially those in high-risk categories; (2) local anesthesia saves time and reduces cost; and (3) local anesthesia provides rapid recovery and prolonged analgesia, both of which are especially important in the outpatient population.

Not all patients are appropriate candidates for VR surgery under local anesthesia. Immature, mentally deficient, claustrophobic, and uncooperative patients are best managed with general anesthesia. Patients with language barriers, however, can frequently be managed extremely well with local anesthesia if a competent translator can be found. Estimated surgical time is an additional consideration when choosing general versus local anesthesia. Surgeons requiring more than 90 minutes for a given VR procedure should consider general anesthesia over local anesthesia, because patients may become restless and uncomfortable when asked to lie completely still for such long periods. An additional indication for general anesthesia is the patient who insists on it, although these patients will be rare if properly informed and reassured by a sympathetic surgical team.

Monitoring during surgery Regardless of the type of anesthesia used, the patient must be carefully monitored during surgery. Appropriate monitoring begins with the continuous presence of an anesthesiologist or certified registered nurse anesthetist (CRNA) during the entire procedure. If sedation is being given, it is not in the patients best interest to have the surgeon or circulating nurse monitoring the patient, as may be the case in a brief procedure performed under strictly local anesthesia without sedation. Basic monitoring includes continuous electrocardiogram, noninvasive blood pressure (NIBP), and pulse oximetry. End-tidal CO2 monitoring is additionally essential during

T Corresponding author. University of Tennessee, College of Medicine, 6401 Poplar Avenue, Suite 190, Charles Retina Institute, Memphis, TN 38119. E-mail address: scharles@att.net (S. Charles).

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general anesthesia and can also be helpful during local anesthesia, especially when continuous sedation techniques are used. Core temperature monitoring is indicated during longer procedures under general anesthesia to help ensure that thermal preservation procedures are successful and to help in monitoring for the rare occurrence of malignant hyperthermia. In diabetic patients, the ability to monitor blood glucose in the intra- and perioperative periods is also important to recognize and treat extremes of both hyper-and hypoglycemia.

Blood pressure considerations during general anesthesia It is common for VR surgeons to become angry if the patient moves at all during surgery. An unintended consequence of this tendency is for the anesthesia provider to maintain deeper levels of anesthesia to prevent movements, which may result in systemic blood pressures that are low enough to compromise cerebral, myocardial, and retinal perfusion. During VR surgery, intraocular pressure (IOP) should be controlled in the 35-45 mm Hg range. Ocular ischemia and central retinal artery occlusion can occur if low systemic blood pressures are allowed to persist during the procedure. To ensure adequate levels of general anesthesia and immobility of the patient, adequate, monitored muscular paralysis combined with processed electroencephalogram (ie, bispectral analysis) monitoring should be considered so that excessively deep levels of general anesthesia can be avoided.

admonitions to do so. The only way to manage these patients is to stop all sedation completely or to convert to general anesthesia. Finally, patients who are asleep or nearly asleep are prone to awakening suddenly and completely unpredictably and being totally disoriented, resulting in movements that can be devastating, even in the hands of the finest surgeon. Judicious amounts of sedatives or opioid agents can be helpful during local anesthesia for VR surgery, especially in the patient who is very apprehensive or slightly claustrophobic. Methohexital, thiopental, midazolam, propofol, alfentanil, remifentanil, ketamine, and others have been promoted to provide good operating conditions and acceptable patient satisfaction for a variety of procedures performed under local anesthesia. For VR surgery, the emphasis must be placed on balancing patient comfort and satisfaction while providing the most stable conditions for surgery. In general this means using small doses of rapid- and short-acting drugs given continuously with very careful monitoring of effect. The goals are to assist the patient in lying perfectly still for 60 to 90 minutes without falling asleep, to enhance analgesia, and to provide a measure of amnesia. These goals are not easily achieved, but they can be accomplished in most patients by an experienced and knowledgeable anesthesia team.

Psychological preparation for local anesthesia In preparing patients for VR surgery under some form of local anesthesia, it is important to give them specific details about the experience so that they will suffer no surprises. They need to know about the drape and about not being able to see during the procedure. They also need to know that plenty of fresh air will be provided for them under the drape and that breathing under the drape will not be a problem. This is the perfect opportunity to discuss the patients fears, such as claustrophobia, positional dyspnea, positional pain, and similar concerns. One may discover during these discussions that a particular patient might be better managed with general anesthesia. The patient should also be given a realistic estimate of the length of time for the procedure and the need for lying extremely still. Almost anyone can lie still for 30 to 45 minutes, but for longer procedures the patient must be reassured that short time outs can be arranged to allow for some movement. Patients must also be aware that an anesthesia provider will be constantly present and dedicated to monitoring their condition and to act as liaison with the rest of the team. It is extremely important for the

Sedation during local anesthesia In general, patients having VR surgery under local anesthesia should have minimal sedation, most of which should be given at the time of the block. Patients should not be sedated too deeply during VR surgery for a number of reasons. In the first place, airway obstruction may occur, requiring manual support and interruption of the procedure. This has been described as AWAC (anesthesia without airway control). Second, respiratory movements during sleep or near sleep often result in magnified movements of the head, which greatly hinder the progress of the surgeon who is seeing these movements magnified 20 to 40 times through the operating microscope. Third, some patients become quite talkative and social when overly sedated. It may be impossible for them to quit talking and moving despite the most vigorous

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anesthesia provider and surgeon to communicate freely during the procedure, both with each other and with the patient. Simple means for communication with minimal movement, such as hand-holding or hand-held signaling devices, give the patient a feeling of comfort in knowing that it is possible to alert the team to a problem while not jeopardizing the surgical field. If the patient cannot speak English, it is imperative to have a translator in the room who is fluent in the patients native language.

Choice of local anesthesia There are essentially four types of local anesthesia commonly used in ophthalmic surgery: topical, retrobulbar, peribulbar, and sub-Tenons. Topical anesthesia is useful in a variety of operations, but it has limitations in VR surgery because of the need for complete akinesia during many VR procedures, such as macular surgery and membrane peeling. The terms retrobulbar and peribulbar are confusing and imprecise, and they should perhaps be replaced by the terms intraconal and extraconal, which more accurately describe the intended location of the needle in the orbit. These techniques carry a risk, albeit small, of major complications, such as ocular perforation, bleeding, and brainstem anesthesia, but both are very useful for VR surgery, providing excellent akinesia, anesthesia, and prolonged postoperative analgesia. Sub-Tenons anesthesia offers an increased level of safety over intraconal and extraconal techniques. Sub-Tenons may not be appropriate for patients who have had previous scleral buckling, as scleral perforation with a sub-Tenons cannula has been reported in such a patient [2]. A recent report by Lai et al [3] compared the use of orbital regional anesthesia with sub-Tenons anesthesia for retinal surgery and found that both had similar efficacy profiles.

third, inner two thirds junction to reduce potential damage to the eye and inferior oblique muscle. The needle should not be directed apically but rather posteromedially to intersect a sagittal plane through the lateral limbus about 5 to 10 mm behind the posterior surface of the eye [4]. The authors use 2% plain lidocaine without epinephrine to reduce the risk of arrhythmias and hypertension and avoid using bicarbonate because of reports and personal experience with lateral rectus paralysis for months after surgery. The author recommends applying pressure on the entire orbit with the palm of the hand immediately after withdrawing the needle to reduce bleeding and disperse the anesthetic agent. If hyaluronidase is used in the block mixture, its concentration should be limited to 1 unit per milliliter, as higher concentrations are not necessary [5].

Reblocking during the procedure Sometimes local anesthesia must be supplemented during surgery. This can occasionally be accomplished with topical anesthesia, but we most commonly supplement intraoperatively by placing a flexible cannula into Tenons space and injecting additional local anesthetic. An additional intraconal injection can also be performed by placing the needle between Tenons capsule and the sclera to enter the intraconal space. Most often reblocking is necessary when the block has been inadequate, when the patient is a reoperation, and when the procedure is prolonged.

Facial nerve blocks Separate facial nerve blocks are rarely indicated, especially if a well-performed extraconal or highvolume intraconal block is used. Avoiding a facial nerve block spares the patient a painful injection and prevents the bleeding, swelling, and other complications that occasionally accompany these blocks. If the patient is a marked squeezer, the orbicularis oculi can be easily and effectively blocked by inserting a one-half-inch 30-gauge needle transconjunctivally into the lower lid just beneath the orbicularis and injecting about 1.5 mL of local anesthetic.

Technique for intraconal anesthesia A 25- or preferably a 27-gauge sharp needle is preferred over larger needles and blunt so-called retrobulbar needles, which cause much more pain when entering the orbit. [4] In addition, retrobulbar needles often penetrate the septum abruptly after considerable force is applied and may then perforate the eye. The conventional 1.5-inch needle is too long for many orbits and should be replaced by a 1- to 1.25-inch needle to avoid impaling the optic nerve in the orbital apex. The entry point should be at the outer corner of the orbital rim, not at the outer one

Sources of pain during VR surgery Local anesthesia needs to be quite complete if the experience is to be pain-free. Manipulation of the iris, ciliary body, and sclera can all be painful, especially

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if blunt instruments are being used. Thermal stimulation is also an important source of discomfort. Cryopexy is very painful, more so than laser or even radiofrequency cautery (bipolar diathermy). Lasers in the near-infrared range are more painful than the argon laser at 514 nm or the diode-pumped, frequencydoubled CW YAG laser at 532 nm. As one or more of these modalities may be used during VR surgery, it is important that the patient receives adequate anesthesia.

dangers of air travel for as long as the bubble is present [6].

Anesthetic considerations for specific procedures Endophthalmitis Endophthalmitis is an acute situation in which cultures must be taken and therapy instituted as quickly as possible. In many situations, cultures and even core vitrectomy can be performed under topical anesthesia. If general anesthesia is required, surgery cannot be delayed to allow the stomach to empty. The open globe Each patient must be thoroughly evaluated, as choice of anesthesia will depend on the extent of the injury and the ability of the patient to cooperate. Often initial wound closure can be accomplished under topical and intracameral anesthesia. In cooperative patients with limited damage, orbital regional anesthesia can be safely used [7], provided that the person performing the block has had sufficient experience, uses limited volumes of anesthetic, and injects very slowly (ie, 1 mL every 30 to 60 seconds) while closely watching the eye. When general anesthesia is required, the issue of whether or not to use a depolarizing muscle relaxant arises. Because there are advocates on both sides of this issue, the choice must be left to the anesthesia provider who will make a decision based on the total clinical picture. If general anesthesia is required, allowing sufficient time (6 to 8 hours) for the stomach to empty should be seriously considered. Scleral buckles

Carbon dioxide issues Patients lying awake under the drape frequently complain that they cannot get enough air. Because pulse oximetry routinely records normal oxygen saturation in these patients, their complaints are frequently attributed to anxiety. In fact, CO2 often builds up under the drape, resulting in hypercarbia and a feeling of air hunger. This may be noted by a rise in the baseline if capnography is being used, even though the peak expired CO2 may be normal or only slightly elevated. An easy solution to this problem is to ensure adequate air/oxygen supplementation near the patients nose and mouth as well as active evacuation of the exhaled gases by way of a large bore vacuum line placed under the drapes. The vacuum line also facilitates cooling, which can be an issue as well. If laser or electrocautery are to be used, it is important to use only air under the drape to avoid the dangers of fires attended by an oxygenenriched atmosphere.

Air/gas and general anesthesia If gas or air are introduced into the eye during VR surgery, nitrous oxide should be turned off at least 10 minutes beforehand and fresh gas flow into the anesthesia machine should be increased to ensure adequate washing out before introduction of the gas. Failure to do so results in a smaller-than-desired gas bubble within the eye and lower-than-desired IOP postoperatively when nitrous oxide diffuses out of the bubble. Conversely, if a patient has a bubble in the eye from a previous procedure, nitrous oxide should be avoided from the beginning to prevent expansion of the bubble by diffusion of nitrous oxide into it, thus raising IOP. In fact, patients must be warned both verbally and in writing to alert physicians to the presence of the bubble should they require emergency surgery for a nonophthalmic condition and of the

Many presenting for scleral buckling procedures will be high myopes. These patients have long axial lengths, often accompanied by posterior staphylomata and scleral thinning. Sub-Tenons cannula techniques might be considered in these patients to lessen the risk of perforation, provided that long cannulae approaching the posterior half of the globe are avoided. Regional anesthesia for scleral buckling procedures may be complicated by the fact that the orbital retractor can cause significant orbital rim pain even in the presence of complete ocular anesthesia. Additionally, with traction of the extraocular muscles the oculocardiac reflex may occur. Most commonly the resulting bradycardia will return to normal when traction is released, and the reflex will diminish over

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time. Intravenous atropine is more effective than glycopyrrolate in blocking the reflex, but its use is associated with the higher incidence of subsequent tachyarrhythmias. Local anesthetic injection may block the bradycardia, but the reflex is also seen in the presence of a complete block. Patients who have had previous scleral buckles and present for another procedure may be difficult to block. Because the buckling may slightly elongate the eye, one must be aware of an increased danger for perforation. Because scarring occurs, normally safe procedures may be come less safe, and ocular perforation has been reported with sub-Tenons anesthesia in a patient with a previous scleral buckle [2].

end of the procedure with a flexible cannula can greatly reduce postoperative pain. This is especially important in the occasional patient who requires general anesthesia for VR surgery and those undergoing scleral buckles.

Summary The vast majority of VR procedures can be safely, comfortably, and efficiently performed under local anesthesia with minimal sedation. Compared with general anesthesia, properly performed monitored local anesthesia offers the patient an increased level of safety, reduced recovery times, and prolonged postoperative pain relief. Nonetheless, the choice of anesthesia technique must be based on the needs of the patient, the requirements of the surgeon, and the skills of the anesthesia provider, ever keeping in mind that our ultimate goal is a satisfied patient with a good visual outcome.

Anticoagulation issues In our practice we virtually never stop anticoagulation before VR surgery, although it is wise to ensure that the patient taking warfarin compounds has an International Normalized Ratio in the therapeutic range (generally 2 to 3). Stopping anticoagulants risks causing morbidity or mortality from a variety of causes, including stroke, myocardial infarction, pulmonary embolism, and deep venous thrombosis. In our opinions the dangers of intraoperative hemorrhage are grossly overemphasized when compared with the dangers of stopping therapeutic anticoagulation. Use of cannula techniques for local anesthesia greatly reduces the risk of hemorrhage in these patients, as does the use of short needles (1 to 1.25 inches) placed in the less vascular areas of the orbit (ie, avoiding the superior half of the orbit in general and especially the superonasal quadrant) for orbital blocks.

References
[1] Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. Study of medical testing for cataract surgery. N Engl J Med 2000;342:168 75. [2] Frieman BJ, Friedberg MA. Globe perforation associated with subtenons anesthesia. Am J Ophthalmol 2001;131:520 1. [3] Lai MM, Lai JC, Lee WH, et al. Comparison of retrobulbar and sub-Tenons capsule injection of local anesthetic in vitreoretinal surgery. Ophthalmology 2005;112: 574 9. [4] Kumar CM, Fanning GL. Orbital regional anaesthesia. In: Kumar CM, Dodds C, Fanning GL, editors. Ophthalmic anaesthesia. Lisse (The Netherlands)7 Swets & Zeitlinger B.V.; 2002. p. 61 88. [5] Fanning GL. Hyaluronidase in ophthalmic anesthesia [letter]. Anesth Analg 2001;92:560. [6] Seaberg RR, Freeman WR, Goldbaum MH, et al. Permanent postoperative vision loss associated with expansion of intraocular gas in the presence of a nitrous oxidecontaining anesthetic. Anesthesiology 2002;97:1309 10. [7] Scott IU, Gayer S, Voo I, et al. Regional anesthesia with monitored anesthesia care for surgical repair of selected open globe injuries. Ophthalmic Surg Lasers Imagining 2005;36:122 8.

Postoperative pain One source of postoperative pain is the injection of antibiotics and steroids into the periocular tissues at the end of the procedure. This pain can be reduced by injecting these substances into the sub-Tenons space with a cannula if conjunctival incisions have been made, which is not the case with 25-gauge, sutureless surgery. In addition, injection of a longacting local anesthetic, such as bupivacaine, at the

Ophthalmol Clin N Am 19 (2006) 245 255

Anesthesia for Glaucoma Surgery

Tom Eke, MA (Cantab), MD, FRCOphth
Norfolk & Norwich University Hospitals NHS Trust, Colney Lane, Norwich NR4 7UY, UK

Glaucoma surgery can be done using any of the established anesthesia techniques. Each technique has its advantages and disadvantages, as outlined in Tables 1 and 2. Retrobulbar and peribulbar injections are particularly associated with the risk of sightthreatening and life-threatening complications, in any patient. Glaucoma patients may be at increased risk of sight-threatening complications from orbital injections because the optic nerve is already compromised and vulnerable to pressure/ischemic damage (Table 3). Therefore, there has been much interest in the less invasive techniques of local anesthesia for glaucoma patients, with anterior placement of local anesthesia (anterior sub-Tenon, subconjunctival, topical, and intracameral techniques) [1]. These newer techniques appear to be successful in terms of safety and patient acceptability. However, there is some uncertainty regarding the effect of different anesthesia techniques on complication and failure rates for glaucoma surgery.

Factors influencing the choice of anesthesia In planning any ocular surgery, it is appropriate to ask which is the most appropriate anesthetic, for this operation, for this patient? Numerous factors must be considered, including nature of the operation to be done; efficacy of the various anesthetic techniques; acceptability to both patient and surgeon; safety issues (ocular, orbital, and systemic complications of anesthesia or per-operative and later surgical complications associated with each anesthetic technique); demand on staff, hospital beds, and other resources; speed, efficiency, and throughput of patients in the

operating room; and financial issues (Tables 1 and 2). The patients general health may influence the choice of anesthesia, particularly the choice between general anesthesia (GA) and local anesthesia (LA). Ocular conditions themselves may also influence the choice of anesthetic technique, and this is especially true in the case of glaucoma (Table 3). Glaucoma is a chronic condition characterized by progressive pressure/ischemic damage to the optic nerve head, so it would be logical to choose an anesthetic technique that has a low risk of causing further damage to the optic nerve. It is common for glaucoma patients to require filtering surgery (eg, trabeculectomy) and also cataract surgery, and many eyes with glaucoma will require two or more operations. Therefore, the long-term functioning of any previous or future filtering surgery should also be considered when deciding on the appropriate anesthesia technique for a glaucoma patient. In this article, the issues specific to glaucoma patients are discussed. Other articles have discussed the generic problems associated with each of the LA techniques, which can be briefly summarized as sight-threatening complications, life-threatening complications, and surgical complications related to the LA technique used (Table 2). General anesthesia has the potential for various life-threatening complications, as discussed in any textbook of anesthesia. Table 3 summarizes the concerns related to anesthesia and glaucoma surgery, and the relative merits and demerits of the various anesthesia techniques.

Optic nerve damage from anesthesia If anesthetic agents are placed into the orbit behind the globe, there is potential for damage to the optic nerve. This damage could occur as a result of

E-mail address: tom.eke@nnuh.nhs.uk

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ophthalmology.theclinics.com

246 Table 1 Factors influencing the choice of anesthesia technique for any ocular surgery How much of the eye/orbit needs to be anesthetised? Is total akinesia needed? Any specific anesthetic requirements for this operation? (see Tables 2, 3) Patient factors General (eg, child; adult with very and comorbidity poor general health) Ocular (eg, glaucoma (see Table 3), severe nystagmus) Acceptability To patient of technique To surgeon To managers/providers Use of Staff (eg, anesthetist, trained resources assistants) Efficiency Hospital accommodation (eg, beds for GA patients) Back-up facilities required (eg, cardiac arrest team, intensive care) Cost (consumables, staffing costs, and so forth) Time taken per case Number of cases done per operating list Safety Ocular/orbital complications of LA/GA technique Systemic complications of LA/GA technique Surgical complications related to LA/GA technique Late complications related to LA/GA technique Abbreviations: GA, general anesthesia; LA, local anesthesia. Operation to be done

eke

direct trauma from a retrobulbar or peribulbar needle, pressure on the nerve, or ischemia [2]. Potential mechanisms are summarized in Table 3. For patients whose optic nerve is already damaged by glaucoma, this could result in further loss of vision. The phenomenon of severe visual loss after surgery, with no obvious cause, is known as wipe-out or snuff syndrome. Wipe-out is generally seen in patients who already have a severe glaucomatous visual field defect [3,4]. Local anesthetic injections into the orbit have been postulated as a likely cause for many cases of wipe-out [4]. Possible mechanisms include unnoticed trauma to the optic nerve from the anesthetic needle, or pressure on the optic nerve owing to either a hematoma in the optic nerve sheath, a retrobulbar hematoma, or simply from the volume of anesthetic injected. High pressure around the nerve could potentially occur even with a low volume of LA, if the LA were to become trapped between fascial layers to give a compartment syndrome. This pres-

sure may also induce ischemia of the nerve, as may epinephrine (adrenaline) in the LA mixture. While the term wipe-out is reserved for severe loss of vision after surgery, glaucoma patients are also at risk of suffering a milder form of this condition. There is a wealth of indirect evidence to support the concept of orbital LA as a cause for wipe-out syndrome. There have been numerous case-reports of visual loss as a result of direct needle trauma to the optic nerve, or secondary to high orbital pressure from LA-induced orbital hemorrhage [2]. In a series of 3 cases of hyaluronidase-associated orbitopathy, the most severe and long-lasting visual loss occurred in the one patient who had glaucoma [5]. Doppler imaging studies have shown that retrobulbar injections can cause a marked reduction in blood flow in the arteries supplying the anterior optic nerve, particularly if epinephrine is included in the LA mixture [6,7]. This effect is not seen with anterior placement of LA, for example by subconjunctival anesthesia [8]. A retrospective study of 508 trabeculectomies identified four cases of wipe-out, all of which had retrobulbar anesthesia [3]. The problems described above could potentially occur with retrobulbar, peribulbar, or posterior subTenons LA. It would be very difficult to prove a definite association between LA technique and wipeout or increasing field defects, because of difficulties in case definition, the rarity of the condition, and the problems encountered with any large randomized prospective trial. However, the high index of suspicion means that many glaucoma specialists now try to avoid using these LA techniques for any surgery on glaucoma patients [1]. Preferred techniques are GA, anterior sub-Tenons, subconjunctival, topical, and intracameral anesthesia. Small case-series indicate that these techniques are acceptable to patients and surgeons, but data are lacking as regards long-term pressure control, complications, and visual field.

Effect of LA on the conjunctiva, and outcome of filtering surgery Conjunctival scarring, as a result of previous surgery or topical medication, may significantly increase the risk of trabeculectomy failure [9,10]. These insults initiate an inflammatory response in the conjunctiva and Tenons capsule, making a trabeculectomy more likely to fail because of further scarring. It would be logical to infer that any LA technique that induces chemosis or subconjunctival hemorrhage could increase the risk for failure for any future trabeculectomy. Chemosis and hemorrhage are fre-

Table 2 Safety factors to be considered when choosing an anesthesia technique for any patient undergoing intraocular surgery, and relative risk of each anaesthesia technique General anesthesia (GA) Sight-threatening complications Globe penetration or perforation Optic nerve penetration or perforation Severe orbital hemorrhage Hyaluronidase orbitopathy Brainstem anesthesia Oculo-cardiac reflex Other life-threatening adverse event + ++ Peribulbar local anesthesia (LA) ++ ++ ++ + ++ ? Retrobulbar LA ++ ++ ++ + ++ ? Sub-Tenons LA +/ +/ + ? Subconjunctival LA + +? Topical LA +? Topical-intracameral LA +?

anesthesia for glaucoma surgery

Life-threatening complications

See text for fuller discussion. Abbreviations: ++, significant potential risk of sight-threatening or life-threatening adverse event; +, lower potential risk; +/, this adverse event is very rare with this technique, or theoretical risk only; , no risk of this event occurring.

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Table 3 Additional safety concerns for the glaucoma patient when choosing anesthesia techniques for ocular surgery, and relative risk for each anesthesia technique General Peribulbar local Retrobulbar Sub-Tenons Sub-conjunctival Topical Topical-intracameral anesthesia anesthesia (LA) LA LA LA LA LA Avoid risk of further damage to optic nerve Inadvertent trauma from LA needle Pressure damage Volume effect of periocular LA compartment syndrome (esp. if no hyaluronidase) Hyaluronidase orbitopathy Severe orbital haemorrhage Ischemic damage Pressure (see above) Epinephrine Systemic hypotension Consider functioning Future filter Induction of conjunctival of filtering surgery scarring Previous filter Re-activation of conjunctival scarring Filtering surgery Induced scarring? (controversial, today see text) Direct trauma ++ ++ ++ + + ++ ++ + +/ +/ ? ++ + + + ++ ++ + +/ +/ ? +/ +/ + +/ +/ + +? +? ? +? +? +? ? eke

See text for fuller discussion, and see also Table 2. Abbreviations: ++, significant potential risk of sight-threatening adverse event; +, lower potential risk; +/, very rare, or theoretical risk only; , no risk of this event occurring.

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quently seen with peribulbar, retrobulbar, and subTenons injections [2], particularly if the sub-Tenons injection is more anterior or of larger volume [11]. For this reason, many glaucoma specialists prefer to avoid these LA techniques for any surgery in patients who may need filtering surgery in the future. Some studies have suggested that the outcome of trabeculectomy surgery itself may be influenced by the anesthetic technique used, although published evidence is inadequate at present. Observational studies have suggested that subconjunctival LA may be associated with an increased risk of bleb failure or leakage, although there is no definite evidence to support this and some of the evidence is contradictory. Noureddin and colleagues [12] published a study that appeared to show a link between subconjunctival anesthesia and thin-walled, leaking trabeculectomy blebs. In a retrospective, nonrandomized observational study, they looked at 29 patients who had undergone trabeculectomy with GA approximately 1 year previously, and compared them with 19 patients who had LA with 2 mL of subconjunctival 2% lidocaine. Intraocular pressure (IOP) control was good in both groups, with better IOP in the subconjunctival anesthesia group. However, the incidence of thin-walled, leaky (Seidel-positive) blebs was higher, at 77% in the subconjunctival lidocaine group as opposed to 25% in the GA group. Leaky blebs are undesirable, because they predispose the eye to bleb-related infection and potential blindness. The authors postulated that lidocaine might have an inhibitory effect on fibroblasts. Edmunds and colleagues [13 16] found a possible link between subconjunctival anesthesia and poor IOP control, although they did not report any problems with late bleb leakage. They performed a large prospective observational study of routine practice, which looked at 1450 primary trabeculectomies performed by 382 surgeons [13]. Success was defined as a one-third reduction in IOP, without the use of antiglaucoma medications. At 1 year, success rate was 65.6% for the 555 peribulbar LA cases, 69.5% for the 424 GA cases, 65.7% for the 105 retrobulbar LA cases, 69.0% for the 59 sub-Tenons cases, 39.5% for the 38 subconjunctival LA cases, and 100% for the 6 topical LA cases. Multiple logistic regression compared success rates for subconjunctival and peribulbar LA, and indicated an odds ratio of 0.172 (95% confidence interval: 0.065 0.459, P<.0001) [16], suggesting that subconjunctival anesthesia is associated with worse surgical outcome. There was no further detail on the number of surgeons who did the 38 cases (possibly as few as 10 surgeons), or the specific techniques used for subconjunctival

LA. The authors speculated that subconjunctival LA could possibly stimulate conjunctival fibroblasts or cause hemorrhage, thus predisposing to a higher failure rate. They concluded that the association deserved further examination, and suggested a prospective randomized trial of the type of LA in trabeculectomy [16]. Edmunds and colleagues series appears to have a much lower rate of bleb leak than Noureddin and colleagues. The actual rate of bleb leakage at 1 year is not given, although the paper implies that the overall rate was below 3% [15]. In another study, Vicary and colleagues [17] looked at 1-year outcomes for phaco-trabeculectomy using small volume (0.1- to 0.2-mL) subconjunctival 2% lidocaine with epinephrine: IOP control was described as excellent, with 72% of patients requiring no glaucoma medication at 1 year. Thus, there appears to be no agreement between these studies that looked at anesthesia technique and trabeculectomy outcomes. Each of these studies is observational in nature with small numbers of subconjunctival anesthesia cases, so these results should be interpreted with caution. In a recent clinical audit, my colleagues and I looked at results of primary trabeculectomy, using the same criteria as Edmunds and colleagues study. We looked retrospectively at the 1-year outcomes for two glaucoma surgeons at the same institution, one of whom routinely used peribulbar anesthesia, the other subconjunctival lidocaine 0.5% (Rai C et al, submitted for publication). Both techniques showed 1-year success rates that were better than Edmunds series. There was no bleb leakage at 1 year, but the subconjunctival anesthesia group did appear to have a higher rate of early leakage. We will be conducting a prospective audit to see if this is a genuine phenomenon, or simply reflects a higher degree of concern about bleb leakage in patients who have had subconjunctival anesthesia. There is some evidence that subconjunctival lidocaine may indeed have an inhibitory effect on conjunctival healing, as suggested by Noureddin and coworkers. Studies on other tissues have found a dose-dependent effect of lidocaine on wound strength. The tensile strength of skin wounds has been studied, following infiltration of the wound with lidocaine 2%, 1%, 0.5%, and saline. Wound strength was the same when 0.5% lidocaine or saline was used, but 1% and 2% lidocaine gave significantly weaker wounds [18,19]. Lidocaine 1% infiltration was associated with decreased vascularity and fewer collagen fibers, when compared with saline [18]. These findings could possibly explain Noureddin and colleagues high rate of bleb leakage with large volumes (2 mL) of strong (2%) lidocaine [12]. It may

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be that lidocaine exhibits a dose-dependent inhibitory effect on conjunctival healing, analogous to the antimetabolites.

Data on specific LA techniques Since the early 1990s, there have been numerous papers describing less invasive LA techniques for glaucoma surgery. Most have been either case-series or small randomized trials of a few dozen patients. Numerous techniques have been described, mainly for trabeculectomy or combined cataract and trabeculectomy (phaco-trabeculectomy) surgery. They include various methods of administering topical, subconjunctival, anterior sub-Tenons, and intracameral anesthesia. Most publications concentrate on per-operative complication rates and acceptability to patient and surgeon. Studies on patient/surgeon acceptability should be interpreted with caution, because it is difficult to avoid bias. Even in prospective randomized studies, both patient and surgeon are likely to be aware whether they are using a periocular injection or one of the newer techniques. This lack of masking may influence acceptability scores. It is best if pain/ acceptability data are collected by an independent person, who is unaware of the LA technique used and without the presence of the surgeon or other personnel connected with the surgery. This means that pain scores collected at the time of surgery may be biased by the patient not wanting to displease the surgical team, and pain scores collected after surgery may be subject to recall bias. Most or all published studies show good acceptability to the surgeon, but this may simply reflect that the authors want to prove the effectiveness of their favored technique, and tend to recruit surgeons who feel likewise. In addition, there is publication bias in that unfavorable studies are less likely to be submitted and published. Despite these caveats, it does appear that the newer LA techniques are acceptable to most patients, and to many surgeons. The current literature should be considered inadequate, for several reasons. Terminology is not consistent, with some authors using the terms subconjunctival and sub-Tenons for what appears to be the same technique, and others creating new terms for minor variations on established techniques (perilimbal, contact, and so forth). Most of the safety concerns outlined in Tables 2 and 3 cannot be addressed by these small studies, although it is possible to infer from the larger studies of cataract patients that

these newer techniques ought to be safer than periocular injections [20,21]. Most studies have looked at LA for trabeculectomy, with very few studies looking at other glaucoma procedures such as cycloablation, glaucoma drainage devices, or nonpenetrating surgery. There is no direct evidence regarding the possible effect of LA technique on the visual field, as discussed in the section Optic nerve damage from anesthesia. There is a definite need for studies that look at success rates for filtering surgery and late complication rates.

Subconjunctival anesthesia and anterior sub-Tenons anesthesia These two techniques will be considered together, because of confusing use of terminology in the glaucoma literature. In the literature related to cataract surgery, there is a clear difference between the two techniques, but the terms sub-conjunctival and sub-Tenons appear to be used interchangeably by some authors in the glaucoma literature. Both techniques were popularized by publications in the early 1990s. Sub-Tenons LA for cataract surgery was described by several authors, all of whom used similar techniques [22 24]. A small cut is made through conjunctiva and Tenons capsule, so that a blunt cannula can be passed into the subTenons space, between Tenons capsule and sclera. The LA agent can easily reach the back of the globe, even with an anterior injection [25], and chemosis is unlikely if small volumes are injected posteriorly via a long cannula [11]. By contrast, subconjunctival LA [26,27] is administered by means of a sharp needle, the aim being to infiltrate the conjunctiva/Tenons layer with the anesthetic agent. Therefore, subconjunctival LA will always induce chemosis in the area where the LA is injected, and the LA is not expected to reach the back of the globe. A sharp-needle subTenons (episcleral) LA technique has been described [28], although some have raised concerns about the risk of globe penetration by the needle. Many of the descriptions of sub-Tenons anesthesia in the glaucoma literature would be more accurately described as sub-conjunctival anesthesia. Ritch and Liebmann [29] were among the earliest to describe this technique for glaucoma surgery. Their original report was entitled Sub-Tenons anesthesia for trabeculectomy, although they later referred to it as a subconjunctival technique [30]. They used a lid block, topical tetracaine, and then injected about 1 mL of 2% lidocaine or 2% mepivacaine via a

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30-gauge needle, beneath Tenons capsule over the anterior portion of the superior rectus muscle, with smaller injections over the medial and lateral recti. They wrote that concerns regarding sensation during iridectomy have proven to be unfounded, and only rarely do patients complain of pain at the time. Buys and Trope [31] used a similar technique to that of Ritch and Liebmann, and performed a prospective randomized comparison with retrobulbar anesthesia. All 39 patients had sedation using a standard technique. Pain scores collected during and after surgery were similar, and creation of an iridectomy was not associated with discomfort or a response in the sub-Tenons group. The subTenons group was less likely to require additional LA during surgery (9% versus 60%), or analgesia after surgery (32% versus 71%), and these differences were both statistically significant. Azuara-Blanco and colleagues [32] reported a prospective randomized trial of sub-conjunctival versus peribulbar anesthesia in trabeculectomy. All patients had intravenous sedation and a facial nerve block, using an identical technique. The LA agent was the same for the 30 peribulbar and 30 subconjunctival injections (2% mepivacaine with 0.75% bupivacaine), except for the omission of hyaluronidase from the subconjunctival group. Subconjunctival injections were given in the supero-temporal quadrant, 8 to 10 mm posterior to the limbus, ballooning the superior conjunctiva. During surgery, patients were asked to grade their pain as none, mild, moderate, or severe. There was a low pain score for both groups, with all episodes of pain (20% in the subconjunctival group and 7% in the peribulbar group) rated as mild. This difference did not reach statistical significance. The authors concluded that their technique was well tolerated, although mild intra-operative discomfort and eye movements should be expected. Anderson [33] described a modification of the subconjunctival LA technique, which he called circumferential perilimbal anesthesia. A small injection of 0.25 mL lidocaine 4% was injected through the inferior conjunctiva, to avoid the possibility of a button-hole in the superior conjunctiva. The anesthetic was then spread subconjunctivally around the limbus for 360 degrees, using smooth forceps. All patients were sedated, and 1 of 34 phaco-trabeculectomy patients complained of pain during surgery. Vicary and colleagues [17] looked at surgical outcomes 1 year after phaco-trabeculectomy using subconjunctival anesthesia. They used topical lidocaine 4% and a small volume (0.1 to 0.2 mL) of

subconjunctival 2% lidocaine with 1:200,000 epinephrine. Charts were reviewed retrospectively for 38 consecutive cases. At 1 year, 72% of patients had controlled IOP without additional medication and overall IOP control was described as excellent. Bleb leak is not mentioned. Bellucci and colleagues [34] described a true sub-Tenons anesthesia technique for phacotrabeculectomy. A conjunctival limbal incision was commenced as for a standard fornix-based trabeculectomy using topical lidocaine 4% anesthesia. A plastic cannula was then passed into the sub-Tenons space near to the superior rectus, to inject 1.5 mL of mepivacaine 2%. Retrospective review of 50 cases showed that only one patient required supplementary sub-Tenons anesthesia, and the per-operative and early complication rates were similar to a cohort of 50 patients who had peribulbar anesthesia. Kansal and colleagues [35] describe a similar technique in which true sub-Tenons anesthesia is augmented with intracameral anesthesia. This is discussed in the Combined LA techniques section later in this article.

Topical anesthesia techniques Several studies have described using topical anesthesia for trabeculectomy, with or without the use of sedation. Techniques include LA drops alone, application of LA in gel form, or via an applicator made of spongelike material. Topical anesthesia may be combined with any of the other LA techniques discussed below. Jonas [36] describes using topical oxybuprocaine 0.4% (Benoxinate) eyedrops, followed by topical cocaine 10%, for all of his routine trabeculectomy surgery. Patients are instructed to gaze in the desired direction, so that superior rectus or corneal traction sutures are not used. An earlier study compared this technique with retrobulbar anesthesia in a prospective randomized study of 20 patients [37]. Intravenous infusion was set up, but the authors do not state whether the patients had any sedation. Pain scores were similarly low in both groups, and none of the topical anesthesia patients thought that the surgery was more painful than having the intravenous needle put into the back of their hand. In a subsequent series of 69 consecutive cases, there were no per-operative complications that could be attributed to a mobile eye, and when asked which type of anesthesia they would prefer if the same type of surgery would have to be repeated, the patients answered they preferred topical anesthesia [36].

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Ahmed and colleagues published randomized trials comparing topical bupivacaine drops with retrobulbar anesthesia, for trabeculectomy [38] and for phaco-trabeculectomy [39]. All patients were sedated. Different sedative agents were used for each group and pain scores were collected postoperatively, therefore the results are difficult to interpret. The authors felt that both techniques were similarly well tolerated by patients. Pablo and colleagues [40] described a technique of contact-topical LA for trabeculectomy. An absorbable gelatin sponge was soaked in lidocaine 2% solution, and inserted into the superior fornix for 5 minutes before surgery. Intravenous sedation was given as required, and the technique was compared with peribulbar LA in a randomized trial of 100 cases. Pain scores and use of sedation were similarly low in both groups. Lai and colleagues [41] looked at using 2% lidocaine gel without sedation. They prospectively evaluated 22 consecutive cases of phaco-trabeculectomy, all of whom had surgery under topical anesthesia without sedation. Lidocaine 2% gel was applied to the conjunctival fornices for 5 minutes before surgery. They looked at patients pulse rate and blood pressure, and per-operative pain scores were recorded immediately after surgery. Using a pain scale of 0 to 10, mean reported pain was 0.9, with a range of 0 to 3, and only three patients reported having pain or discomfort during surgery. They concluded that the technique provided adequate analgesia for the surgery. Carrillo and colleagues [42] reported a prospective randomized trial comparing topical lidocaine 2% gel with sub-Tenons LA for trabeculectomy. As discussed in the previous section, the LA technique for the control group would be described as subconjunctival by some other authors. All 59 cases received a standardized sedative, and the topical group received about 1 mL of nonpreserved lidocaine 2% gel to the conjunctival fornices 5 minutes before surgery commenced. The control group LA was similar to the sub-conjunctival technique described by Azuara-Blanco and colleagues [32] (see previous section). Mean pain scores (recorded postoperatively) and surgeon satisfaction scores were similar in the two groups. Supplemental anesthesia (as determined by the surgeon) was required in 4 of the 29 subTenons cases, and none of the lidocaine gel cases. The authors concluded that topical 2% lidocaine gel was as effective as the sub-Tenons (subconjunctival) technique. Lidocaine 2% gel has also been used for implantation of glaucoma drainage devices. Rebolleda and

colleagues [43] describe using lidocaine 2% gel without sedation for implanting Ahmed valves. In a prospective randomized trial, the technique was compared with retrobulbar anesthesia. Pain scores were similarly low, although surgical times were longer in the topical group and the authors concluded that lidocaine 2% gel offered a reasonably safe and comfortable surgical environment for experienced surgeons and selected patients.

Topical-intracameral anesthesia Rebolleda and colleagues [44] described topicalintracameral LA for phaco-trabeculectomy. Tetracaineoxybuprocaine drops were supplemented with 1% nonpreserved intracameral lidocaine; sedation was not used. The technique was compared with retrobulbar anesthesia in a prospective randomized study of 60 patients. Pain scores were significantly higher in the topical-intracameral group, in that 93% of the topical-intracameral anesthesia patients required further LA in the form of extra drops or application of a sponge soaked in 1% lidocaine. By contrast, only 17% of the retrobulbar LA group needed any additional LA. Pain scores showed that discomfort was rated as none/mild by 67% of the topical group and 93% of the retrobulbar group. Four patients had retrobulbar anesthesia for their first eye and topicalintracameral for the second; three of these patients stated that they preferred topical-intracameral anesthesia. The authors concluded that, despite the higher levels of per-operative discomfort, the technique was well tolerated and provides a safe and comfortable surgical environment for experienced surgeons. Pablo and colleagues [45] described a technique of contact-topical plus intracameral LA for phacotrabeculectomy. An absorbable gelatin sponge was soaked in lidocaine 2% and inserted into the superior fornix for 5 minutes before surgery, and intracameral lidocaine 1% was used for phaco-emulsification. No sedation was used. In a prospective trial, 80 patients were randomized to topical-intracameral or peribulbar LA. During surgery, there were no significant differences in vital signs, patients pain evaluation, or surgeon stress. If intracameral anesthesia is used for trabeculectomy surgery, it may cause the pupil to dilate in many patients [46]. This may make it difficult to do the peripheral iridectomy, but the phenomenon can be prevented by using pilocarpine drops preoperatively.

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Combined LA techniques Kansal and colleagues [35] described a combined sub-Tenons (subconjunctival), topical, and intracameral LA with intravenous sedation. The technique, referred to as blitz anesthesia, involved topical bupivacaine or mepivacaine, intracameral 1% lidocaine, and a sub-Tenons injection of 1% lidocaine via a 30-gauge needle (for limbus-based filters) or via a cannula in fornix-based filters. Acceptability was assessed in a prospective series of 139 consecutive cases of trabeculectomy, phaco-trabeculectomy, and aqueous shunt surgery. Results were compared with a parallel case-series of 139 patients who had similar surgery by different surgeons using retrobulbar anesthesia and sedation. Pain scores were similarly low in both groups, with no intraoperative complications. The authors concluded that the technique was a safe and effective alternative to retrobulbar anesthesia for glaucoma surgery. This authors favored technique for trabeculectomy surgery is a combined subconjunctivalintracameral anesthesia without sedation (Burnett and Eke, submitted for publication). After instilling topical oxybuprocaine or tetracaine, around 0.5 mL of 0.5% lidocaine is infiltrated subconjunctivally in the area of the proposed drainage bleb. The bleb of anesthetic is then massaged (through the lid), so that it covers the entire surgical area. Additional tetracaine drops are instilled onto the sclera before cautery, and intracameral 0.5% lidocaine is used before the peripheral iridectomy. Patients acceptability is good, with low pain scores for the surgery. Average pain scores for surgery are lower than the average pain scores for removing the sticky surgical drape at the end of the procedure. When asked, all patients stated they would have the same LA technique again if further surgery was required.

become popular, using combinations of topical, subconjunctival, anterior sub-Tenons, and intracameral LA. These newer LA techniques should avoid the potential for optic nerve damage, and they have been shown to be acceptable to patients and surgeons. However, there have been some concerns regarding long-term outcomes of trabeculectomy surgery, particularly with subconjunctival anesthesia. There is little evidence in the literature regarding this, and further research is needed. The authors personal practice is to use LA without sedation for virtually all patients. Filtering surgery is performed using a combined subconjunctival/ intracameral technique, with 0.5% nonpreserved lidocaine as described in Combined LA techniques. Cyclo-ablation (cyclo-diode laser) is performed using a small volume posterior sub-Tenons LA. Cataract surgery is performed using topical-intracameral LA and a clear-corneal incision. This approach is designed to give a good balance of safety and patient acceptability. The doctor-patient relationship is particularly important in glaucoma. Treatment goals are, first, lifelong maintenance of normal vision, and second, freedom from concern regarding eyes and vision. A painful operation could result in a breakdown in trust between the patient and his or her ophthalmologist, so it is important to use an appropriate mode of anesthesia for each individual patient. Preoperative counseling should therefore include an explanation of the degree of awareness that the patient should expect.

References
[1] Jones E, Clarke J, Khaw PT. Recent advances in trabeculectomy technique. Curr Opin Ophthalmol 2005; 16(2):107 13. [2] Hamilton RC. Complications of ophthalmic regional anesthesia. In: Finucaine BT, editor. Complications of regional anesthesia. Philadelphia7 Churchill Livingstone; 1999. p. 39 55. [3] Costa VP, Smith M, Spaeth GL, et al. Loss of visual acuity after trabeculectomy. Ophthalmology 1993; 100(5):599 612. [4] Henry JC. Snuff syndrome. J Glaucoma 1994;3:92 5. [5] Kumar CM, Dowd TC, Dodds C, et al. Orbital swelling following peribulbar and sub-Tenons anaesthesia. Eye 2004;18(4):418 20. [6] Hessemer V. [Anesthesia effects on ocular circulation. Synopsis of a study]. Fortschr Ophthalmol 1991;88(5): 577 87 [in German]. [7] Hulbert MF, Yang YC, Pennefather PM, et al. Pulsatile ocular blood flow and intraocular pressure during

Summary While glaucoma surgery can be done using any of the established anesthesia techniques, many glaucoma specialists prefer to avoid using retro-ocular injections (peribulbar, retrobulbar, posterior subTenons) for their glaucoma patients. Peribulbar and retrobulbar injections can have sight-threatening or life-threatening complications in any patient (Table 2), and glaucoma patients may be at further risk of vision loss because of more subtle pressure/ischemic effects of LA injected around the optic nerve (Table 3). For this reason, anterior application of LA agents has

254 retrobulbar injection of lignocaine: influence of additives. J Glaucoma 1998;7(6):413 6. Huber KK, Remky A. Effect of retrobulbar versus subconjunctival anaesthesia on retrobulbar haemodynamics. Br J Ophthalmol 2005;89(6):719 23. Broadway DC, Chang LP. Trabeculectomy, risk factors for failure and the preoperative state of the conjunctiva. J Glaucoma 2001;10(3):237 49. Flach AJ. Does medical treatment influence the success of trabeculectomy? Trans Am Ophthalmol Soc 2004;102:219 23. Kumar CM, Dodds C, McLure H, et al. A comparison of three sub-Tenons cannulae. Eye 2004;18(9):873 6. Noureddin BN, Jeffrey M, Franks WA, et al. Conjunctival changes after subconjunctival lignocaine. Eye 1993;7:457 60. Edmunds B, Thompson JR, Salmon JF, et al. The National Survey of Trabeculectomy. I. Sample and methods. Eye 1999;13(Pt 4):524 30. Edmunds B, Thompson JR, Salmon JF, et al. The National Survey of Trabeculectomy. II. Variations in operative technique and outcome. Eye 2001;15(Pt 4): 441 8. Edmunds B, Thompson JR, Salmon JF, et al. The National Survey of Trabeculectomy. III. Early and late complications. Eye 2002;16(3):297 303. Edmunds B, Bunce CV, Thompson JR, et al. Factors associated with success in first-time trabeculectomy for patients at low risk of failure with chronic open-angle glaucoma. Ophthalmology 2004;111(1):97 103. Vicary D, McLennan S, Sun XY. Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up. J Cataract Refract Surg 1998;24(9): 1247 51. Drucker M, Cardenas E, Arizti P, et al. Experimental studies on the effect of lidocaine on wound healing. World J Surg 1998;22(4):394 7 [discussion 397 398]. Morris T, Tracey J. Lignocaine: its effects on wound healing. Br J Surg 1977;64:902 3. Friedman DS, Bass EB, Lubomski LH, et al. The methodologic quality of clinical trials on regional anesthesia for cataract surgery. Ophthalmology 2001; 108(3):530 41. Naor J, Slomovic AR. Anesthesia modalities for cataract surgery. Curr Opin Ophthalmol 2000;11(1):7 11. Stevens JD. A new local anaesthesia technique for cataract extraction by one quadrant sub-Tenons infiltration. Br J Ophthalmol 1992;76:670 4. Greenbaum S. Parabulbar anesthesia. Am J Ophthalmol 1992;114:776. Fukasaku H, Marron JA. Pinpoint anesthesia: a new approach to local ocular anesthesia. J Cataract Refract Surg 1994;20:468 71. Kumar CM, McNeela BJ. Ultrasonic localization of anaesthetic fluid using sub-Tenons cannulae of three different lengths. Eye 2003;17(9):1003 7. Smith R. Cataract extraction without retrobulbar anaesthetic injection. Br J Ophthalmol 1990;74:205 7. Petersen WC, Yanoff M. Subconjunctival anesthesia:

eke an alternative to retrobulbar and peribulbar techniques. Ophthalmic Surg 1991;22:199 201. Ripart J, Lefrant JY, Vivien B, et al. Ophthalmic regional anesthesia: medial canthus episcleral (subtenon) anesthesia is more efficient than peribulbar anesthesia: a double-blind randomized study. Anesthesiology 2000;92(5):1278 85. Ritch R, Liebmann JM. Sub-Tenons anesthesia for trabeculectomy. Ophthalmic Surg 1992;23(7):502 4. Pinhas DJ, Liebmann JM, Ritch R. Anesthesia for glaucoma surgery. In: Greenbaum S, editor. Ocular anesthesia. Philadelphia7 WB Saunders; 1997. p. 109 23. Buys YM, Trope GE. Prospective study of sub-Tenons versus retrobulbar anesthesia for inpatient and daysurgery trabeculectomy. Ophthalmology 1993;100(10): 1585 9. Azuara-Blanco A, Moster MR, Marr BP. Subconjunctival versus peribulbar anesthesia in trabeculectomy: a prospective, randomized study. Ophthalmic Surg Lasers 1997;28(11):896 9. Anderson CJ. Circumferential perilimbal anesthesia for combined cataract glaucoma surgery. Ophthalmic Surg Lasers 1999;30(3):205 7. Bellucci R, Morselli S, Pucci V, et al. Sub-Tenons anesthesia for combined cataract and glaucoma surgery. J Cataract Refract Surg 1999;25(5):606 7. Kansal S, Moster MR, Gomes MC, et al. Patient comfort with combined anterior sub-Tenons, topical, and intracameral anesthesia versus retrobulbar anesthesia in trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery. Ophthalmic Surg Lasers 2002;33(6):456 62. Jonas J. Penetrating trabeculectomy in topical anesthesia. J Glaucoma 2005;14(1):88. Sauder G, Jonas JB. Topical anesthesia for penetrating trabeculectomy. Graefes Arch Clin Exp Ophthalmol 2002;240(9):739 42. Zabriskie NA, Ahmed II, Crandall AS, et al. A comparison of topical and retrobulbar anesthesia for trabeculectomy. J Glaucoma 2002;11(4):306 14. Ahmed II, Zabriskie NA, Crandall AS, et al. Topical versus retrobulbar anesthesia for combined phacotrabeculectomy: prospective randomized study. J Cataract Refract Surg 2002;28(4):631 8. Pablo LE, Perez-Olivan S, Ferreras A, et al. Contact versus peribulbar anaesthesia in trabeculectomy: a prospective randomized clinical study. Acta Ophthalmol Scand 2003;81(5):486 90. Lai JS, Tham CC, Lam DS. Topical anesthesia in phacotrabeculectomy. J Glaucoma 2002;11(3):271 4. Carrillo MM, Buys YM, Faingold D, et al. Prospective study comparing lidocaine 2% jelly versus sub-Tenons anaesthesia for trabeculectomy surgery. Br J Ophthalmol 2004;88(8):1004 7. Rebolleda G, Munoz-Negrete FJ, Benatar J, et al. Comparison of lidocaine 2% gel versus retrobulbar anaesthesia for implantation of Ahmed glaucoma drainage. Acta Ophthalmol Scand 2005;83(2):201 5. Rebolleda G, Munoz-Negrete FJ, Gutierrez-Ortiz C.

[8]

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[41] [42]

[25]

[43]

[26] [27]

[44]

anesthesia for glaucoma surgery Topical plus intracameral lidocaine versus retrobulbar anesthesia in phacotrabeculectomy: prospective randomized study. J Cataract Refract Surg 2001;27(8): 1214 20. [45] Pablo LE, Ferreras A, Perez-Olivan S, et al. Contacttopical plus intracameral lidocaine versus peribulbar

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anesthesia in combined surgery: a randomized clinical trial. J Glaucoma 2004;13(6):510 5. [46] Lee JJ, Moster MR, Henderer JD, et al. Pupil dilation with intracameral 1% lidocaine during glaucoma filtering surgery. Am J Ophthalmol 2003;136(1): 201 3.

Ophthalmol Clin N Am 19 (2006) 257 267

Oculoplastic and Orbital Surgery

Adam J. Cohen, MDT
Eyelid and Facial Aesthetic and Reconstructive Surgery, Craniofacial Surgery, Elmhurst Hospital, Elmhurst, IL 60126, USA

Successful surgical outcomes are not based solely on the knowledge and skill level of a surgeon. Patient comfort and cooperation along with minimizing bleeding are paramount to achieving successful surgical outcomes. Few things in a surgeons life can be more frustrating than a patient who is not adequately anesthetized and is uncooperative during an operation. The majority of oculoplastic and facial surgical procedures are performed in outpatient settings under local or regional anesthesia with sedation via oral or intravenous routes. To achieve maximal patient comfort, familiarity with regional neuroanatomy, anesthetic agents, and techniques of delivery are salutary. Because large numbers of these procedures are performed with an anesthesiologist, this article will be geared toward delivery of anesthesia from the surgeons standpoint.

Anatomy Sensory innervation of the craniofacial region is most easily broken down by the well-recognized dermatomes [1]. The major sensory innervation of the face; a large portion of the scalp, teeth, and oral and nasal regions; and dura mater is the trigeminal or fifth cranial nerve. This nerve transmits information on light touch, pain, temperature, and propioception to the ventral, mid-lateral pons. After leaving its nucleus the nerve divides into three branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3) (Fig. 1).

T 2720 S. Highland Avenue, Lombard, IL 60148. E-mail address: ajcohenmd@comcast.net

The ophthalmic nerve (V1) is the smallest branch of the trigeminal nerve and is a purely sensory nerve. After traversing the lateral wall of the cavernous sinus the ophthalmic nerve divides into the lacrimal, frontal, and nasociliary nerves just before entering the orbit through the superior orbital fissure (Fig. 2). The lacrimal nerve enters the orbit laterally via the superior orbital fissure and travels in proximity to the lacrimal artery to supply the lacrimal gland and surrounding conjunctiva, terminating in the upper eyelid septum. The frontal nerve enters the orbit through the superior orbital fissure and continues anteriorly. It lies between the periosteum of the orbital roof and the levator palpebralis superioris and divides into the supraorbital and supratrochlear bundles. The supraorbital branch of the frontal nerve continues along the orbital roof exiting from the supraorbital notch radiating branches to the upper eyelid and conjunctiva. The supraorbital notch can usually be palpated at the medial one third of supraorbital rim. Moving cephalad it ascends with the supraorbital artery to a level in the vicinity of the lambdoid suture supplying sensation to the forehead and a large portion of the scalp (Fig. 3). An in-depth study of this nerve by Knize [2], found two distinct branches after it exits the supraorbital foramen: a superficial (medial) branch, which supplies the anterior scalp margin and forehead skin, and a deep (lateral) branch supplying the frontoparietal scalp. In addition, this nerve also supplies the mucosa of the frontal sinus. The supratrochlear nerve exits the orbit medial to the supraorbital notch and travels along the frontal bone to supply the upper eyelid skin and conjunctiva. Moving superiorly below the corrugator supercilii and frontalis muscles it terminates to innervate the glabelar region.

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.016

ophthalmology.theclinics.com

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cohen

Fig. 1. The distribution of ophthalmic and maxillary nerves. The mandibular nerve is not shown because it is usually not of consequence during oculoplastic procedures. (Courtesy of Mark R. Levine.)

Fig. 3. Deep branch of supraorbital nerve with artery.

The nasociliary branch of the ophthalmic nerve (V1) enters the orbit through the annulus of Zinn and travels to the medial orbital wall. Here it enters the cranium via the anterior ethmoidal foramen and canal as the anterior ethmoidal nerve. Before entering the anterior ethmoidal foramen, the infratrochlear nerve offshoots to supply the skin of the medial canthal region including the caruncle and nasal skin superior to the medial canthal tendon along with nasolacrimal sac. Moving extracranially it then enters the nasal cavity innervating the mucosa and upper lateral nasal sidewall terminating as the external nasal nerve to partially supply the skin of nasal columella, ala, and tip. Before leaving the orbit this nerve provides several branches of the long ciliary nerves that supply the ciliary body, iris, cornea and post-ganglionic sympathetic fibers of the dilator pupillae. The posterior ethmoidal nerve innervates the mucosa of ethmoidal and sphenoid sinuses.

Fig. 2. The ophthalmic nerve exiting the superior orbital fissure and its branches. (Courtesy of Mark R. Levine.)

The maxillary nerve (V2) provides sensory neural branches emanating at four distinct craniofacial sites: the cranial cavity, pterygopalatine fossa, infraorbital canal, and face. Because the oculoplastic surgeon rarely performs intracranial surgery I will limit my description to the latter three. At the pterygopalatine fossa the maxillary nerve gives off the zygomatic nerve, which enters the orbit through the inferior orbital fissure. Before leaving the orbit it divides into the zygomaticotemporal and zygomaticofacial nerves. Both of these nerves emerge through their respective foramina with the zygomaticotemporal nerve supplying the skin of the temporal region and the zygomaticofacial supplying the skin of malar region. Within the infraorbital canal the superior alveolar nerves (anterior, middle, and posterior) arise before the infraorbital nerve and its accompanying vessels exit the infraorbital foramen located approximately 6 mm below the inferior orbital rim and parallel to the mid-pupillary axis. They supply the lower eyelid and lateral canthal region; the skin of the nasal sidewall and anterior portion of its mucosa; the nasal septum; maxillary sinus; upper gingiva and teeth; and the skin of the anterior cheek, upper lip, and oral mucosa (Fig. 4). The palatine branch of the maxillary nerve is of importance to the oculoplastic surgeon when harvesting hard palate grafts for eyelid reconstruction. It should be recognized that there is overlap of the ophthalmic and maxillary nerve branches in the medial and lateral canthal regions. This overlap may explain patients discomfort when operating in these areas after local anesthetic infiltration. The mandibular nerve (V3), the largest division of the trigeminal nerve, is composed of a large sensory and smaller motor root. The sensory branch supplies

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of the upper and back part of auricle. The posterior branch of the greater auricular nerve can be damaged during elevation of the retroauricular flap during rhytidectomy.

Pharmacology
Fig. 4. The infraorbital and zygomaticofacial nerves exiting the infraorbital and zygomaticofacial foramina respectively. (Courtesy of Mark R. Levine.)

Topical anesthetic agents Commonly used topical ocular anesthetic agents include proparacaine hydrochloride, tetracaine hydrochloride, and lidocaine hydrochloride jelly. Their side effects include ocular discomfort before onset of action and punctate keratopathy [3] (Table 1). EMLA (Astra Zeneca Pharmaceuticals, Wilmington, Delaware) (lidocaine 2.5% and prilocaine 2.5%) and ELA-Max (Ferndale Laboratories, Inc., Ferndale, Michigan) (4% lidocaine) are topical skin anesthetics. These creams can lessen the discomfort associated with needle insertions and superficial cutaneous surgery when applied approximately 15 to 60 minutes before the procedure. Corneal or conjunctival contact should be avoided with these agents. Ramos-Zabala and colleagues [4] reported adequate anesthesia with EMLA cream and remifentanil during full face laser resurfacing with the Erbium:yttrium-aluminumgarnet (Er:YAG) laser. Reducing the temperature of the skin with ice or cool compresses often provides adequate anesthesia to reduce discomfort associated with needle insertion and removal of small acrochordons. Placement of ice for 5 minutes before injection of botulinum toxin to the lateral orbital region resulted in a statistically significant decrease in pain when compared with noniced regions [5]. Infiltrative anesthetic agents Local anesthetic agents are usually of the amino amide class and have a relatively rapid onset of action. Commonly used agents include lidocaine, bupi-

the teeth and gums of the mandible, the skin of the temporal region, the otic auricle, the lower lip, and the lower part of the face. The smaller motor branch innervates the muscles of mastication. Branches of the mandibular nerve pertinent to the oculoplastic and facial surgeon include the inferior alveolar nerve and its branch the mental nerve. The largest branch of the mandibular nerve is the inferior alveolar nerve. Descending with the inferior alveolar artery, it passes between the sphenomandibular ligament and the ramus of the mandible into the mandibular foramen. It then passes forward in the mandibular canal, beneath the teeth, as far as the mental foramen, where it divides into two terminal branches, the incisive and mental nerves. The mental nerve exits at the mental foramen, and divides into three branches. These branches provide sensation to the skin of the chin and the skin and mucous membrane of the lower lip. Inferior alveolar nerve injury can occur during a sagittal split osteotomy while dissections for alloplastic chin implantation or mandibular protuberance reshaping can insult the mental nerves. The cervical plexus is formed by the anterior divisions of the upper four cervical nerves. Each nerve, except the first, divides into an upper and a lower branch, and the branches unite to form three loops. These branches are divided into superficial and deep groups. The great auricular nerve is the largest of the superficial ascending branches. It arises from the second and third cervical nerves and divides into an anterior and a posterior branch. The anterior branch supplies the skin of the face over the parotid gland and communicates in the substance of the gland with the facial nerve. The posterior branch supplies the skin over the mastoid process and the posterior auricle, except at its superior most aspect. The posterior branch communicates with the smaller occipital nerve and the auricular branch, which also supplies the skin

Table 1 Commonly used ophthalmic topical anesthetic agents Anesthetic agent Proparacaine HCL Tetracaine HCL Lidocaine HCL Available strengths, % 0.5 0.5 2.0 2.0 or 5.0 Duration of action, min 5 20 15 20 20 30

Abbreviation: HCL, hydrochloride.

260 Table 2 Commonly used infiltrative anesthetic agents Anesthetic agent Lidocaine Bupivacaine Prilocaine Mepivacaine Etidocaine Cocaine Abbreviation: EPI, epinephrine. Onset of action Rapid Slow Moderate Rapid Rapid Rapid

cohen

Dosage ceiling 7.0 4.5 3.0 2.5 7.5 5.0 7.0 5.0 8.0 6.0 2.8 mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg with EPI without EPI with EPI without EPI with EPI without EPI with EPI without EPI with EPI without EPI without EPI

Duration of action 2 4 h with EPI 1 2 h without EPI 8 h with EPI 4 h without EPI 6 h with EPI 90 min without EPI 6 h with EPI 3 h without EPI 8 h with EPI 4 h without EPI 45 min without EPI

vacaine, prilocaine, mepivacaine, and etidocaine. The potency, onset, toxicity level, and duration of action of these agents vary (see Table 2) [6]. Local anesthetic agents of the amino ester class include procaine, chloroprocaine, cocaine, and tetracaine. This class of agents is uncommonly used except for cocaine during surgery of the lacrimal system. Toxicity of infiltrative anesthetics is related to systemic absorption, distribution, and metabolism that vary considerably among individual compounds and patients. Infiltrative anesthetic adverse reactions are almost always the result of an excessively large dose or oversight of an intravascular injection [7]. Toxic signs and symptoms of local anesthetic are usually limited to cardiovascular and central nervous system dysfunction. Cardiac dysfunction is related to direct myocardial depression, which may lead to arrthymia, hypotension, and asystole. Intravascular injection of bupivicaine and etidocaine has been reported to result in cardiovascular collapse unresponsive to resuscitative attempts [8]. Central nervous system signs and symptoms include circumoral paresthesias, light-headedness, tinnitus, metallic taste, auditory or visual hallucinations, dysarthria, nystagmus, and tremors. At higher toxicity levels grand mal seizures, apnea, and loss of consciousness may result [8]. Allergic reactions may occur with infiltrative anesthetics [9]. Para aminobenzoic acid (PABA) is thought to play a role in hypersensitivity [10]. Because ester amides produce a PABA metabolite the incidence of hypersensitivity is greater versus amino amides [11], albeit the overall frequency of these reactions is uncommon in either class. Preservatives such as methylparaben are found in the amino amide class of agents and are metabolized to PABA [10]. One should use preservative-free amino amide agents

when anesthetizing a patient with a known allergy to ester amide agents to avoid indirect patient exposure to PABA. Hypersensitivity reactions can manifest as mild rashes, hives, angioedema, dyspnea, tachycardia, hypotension, or anaphylactia. Antihistamines and corticosteroids are usual treatment options in mild cases, while cardiopulmonary compromise necessitates ACLS measures [11].

Additives to infiltrative anesthetics Epinephrines vasoconstrictive properties provide hemostatis and impede the systemic absorption of infiltrative agents by one third [10], prolonging their effect. This reduced systemic absorption allows for a greater maximal safe dose. Most commercially available injectable agents contain 1:100,000 or 1:200,000 strengths. Care should be taken to avoid use of epinephrine in patients with thyroid storm or advanced cardiac disease. Sodium bicarbonate has been used to reduce the acidic pH of infiltrative anesthetics. This is thought to improve patient comfort associated with irritation of infiltration of low pH solutions. Risks of alkalinization include precipitation of anesthetics [12]. Addition of 1 cc of a 1 mEq/mL solution of bicarbonate for every 9 cm3 of local anesthetic can alleviate burning and improve patient comfort [13]. It should be remembered that increasing the pH reduces the shelf life of infiltrative anesthetic agents [14]. Ovine testicular hyaluronidase (Vitrase, Irvine, CA, USA) increases the permeability of connective tissue by the hydrolysis of hyaluronic acid [15]. This allows for more rapid diffusion of injectable solutions

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thereby reducing the amount of anesthetic needed and increasing the rate of onset. Symptoms of overdose include edema, urticaria, nausea, chills, and tachycardia [15].

Intravenous sedative and anesthetic agents Because profound cardiovascular and pulmonary effects are avoided with intravenous sedatives in most cases, this class of agents is extremely popular. They produce excellent analgesia and amnesia without the need for laryngeal mask or general endotracheal anesthesia. Several are discussed below. Propofol (Diprivan, AstraZeneca Pharmaceuticals LP, Wilmington, DE, USA) is a widely used sedativehypnotic agent [21]. Its rapid onset of action and superlative level of hypnosis make for an excellent choice when coupled with an opioid before local anesthetic infiltration or as maintenance of monitored anesthesia care sedation during prolonged procedures. The author has found this agent to be of excellent value when repairing traumatic eyelid and facial lacerations in the pediatric population in an emergency department setting. Midazolam is a benzodiazepine with a short halflife. Given in slow, incremental 1-mg doses this agent produces deep semiconscious sedation [22]. Intravenous use of this agent has been described to cause impairment of memory for several hours [23]. Another useful attribute is its antianxiolytic effect. Morphine sulfate, alfentanil hydrochloride, and remifentanil hydrochloride (Ultiva, GlaxoWellcome, Inc., Research Triangle, NC, USA) can provide outstanding analgesia. The author has found alfentanil hydrochloride (Alfenta, Taylor Pharmaceutical, Decatur, IL, USA) at an induction dose of 3 to 8 mg/kg provides effective pain control when used in a monitored anesthesia care setting. Maintenance dosing of 0.25 to 1 mcg/kg/min may be required during protracted procedures. Care should be taken in patients with respiratory compromise because decreased respiratory drive and increased airway resistance occur with increasing doses of alfentanil. Avramov and White suggested healthy outpatients premedicated with 2 mg of intravenous midazolam, receive a propofol and alfentanil infusion dose as calculated by their formula for sedation and analgesia during monitored anesthesia care (MAC) in the ambulatory setting [24]. Remifentanil hydrochloride is a rapid onset, shortacting m-opioid. Philip and colleagues [25] compared this agent to alfentanil. They found remifentanil may be used in a 1:4 ratio compared with alfentanil for total IV anesthesia in ambulatory surgery patients premedicated with midazolam. Remifentanil was more effective in suppression of intraoperative responses and did not result in prolonged awakening or discharge times. Another study compared propofol and remifentanil in patients who received 2 mg of

Tumescent anesthesia Tumescent anesthesia has been well described to provide excellent anesthesia of superficial and deep tissue structures and vasoconstriction [16]. This modality allows for the use of large amounts of anesthetic solution because of the extremely low concentration of lidocaine. Kleins solution is a well- recognized mixture that includes 50 mL of lidocaine hydrochloride, 1 mL of 1:1000 epinephrine, 12.5 mL of 8.4% sodium bicarbonate, and 1000 mL of normal saline with a final concentration of 0.05% lidocaine hydrochloride and 1:100,000 epinephrine [17]. Klein reported a safe upper limit of 35 mg/kg when using tumescent solution and postoperative analgesia for up to 18 hours obviating the need for postoperative analgesic medications [18]. Tumescent solutions are infused into the subcutaneous adiposity via a cannula in a subcutaneous plane. This is especially useful with facial procedures such as rhytidectomy or liposuction because of the creation of a tissue plane that aids in dissection and a relatively bloodless field provided by vasoconstriction. Tumescence may also be used when performing laser or chemical skin resurfacing. Because of skin creep, optimal exposure to laser energy or chemical agents can be achieved. Although some support the use of tumescent solution for facial reconstruction with flaps, I personally do not use this technique [19]. Use of injectable anesthetic agents has yielded excellent results in my experience without compromise of flap vascularity.

Oral sedatives The use of and selection of these agents are based on the comfort level of the surgeon. A commonly used class of medication is the benzodiazepines, which provide excellent sedative and antianxiety affects. One must use caution when prescribing these since age, weight, and history of patient use of these medications and drug interactions can alter metabolism of these drugs. Diazepam, 5 to 20 mg and alprozolam 0.25 to 0.50 mg [20] are two commonly used drugs and can be given to patients on arrival for their procedure.

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Fig. 5. Cornwall syringe system.

midazolam before the procedure [26]. It found remifentanil to provide comparable intraoperative conditions and patient comfort at a lower sedation level compared with propofol. Remifentanil did result in increased respiratory depression and longer discharge times in these patients.

constriction, especially advantageous in this highly vascular region. A Cornwall syringe system (Becton Dickinson and Co, Franklin Lakes, NJ) system can assist in delivering anesthetic agents to large areas such as the scalp and forehead (Fig. 5). Usually the supraorbital foramen can be palpated approximately parallel to the midpupillary axis, although others have described it to be parallel to the medial iris [27]. Once this landmark is found, a 30-gauage, one-half-inch needle is advanced to a level beneath the periosteum just lateral to the foramen. The foramen itself should not be entered. One should remember to draw back on the syringe before injection because inadvertent intravascular placement of the needle may occur. One to 2 mL of solution is injected and the needle withdrawn followed by digital pressure. The supratrochlear nerve may be anesthetized by inserting a needle in a perpendicular fashion at the junction of the nasal root, medial orbital wall, and roof. A similar injection technique as described above should be used.

General anesthetic agents Familiarity and administration of general inhalation anesthetic agents is not usual practice for the vast majority of oculoplastic surgeons and is beyond the scope of this manuscript.

Upper eyelid surgery Anesthetizing the upper eyelid is achieved with direct infiltration in most cases. The solution should be injected in a subcuticular plane and unhurriedly to reduce patient discomfort (Fig. 6). If possible, the needle should pierce the skin in an avascular region to avoid hematoma formation, which can lead to perioperative eyelid distortion. Application of digital pressure following injection can help to evenly dis-

Applied anatomy The vast majority of oculoplastic procedures are performed with direct infiltration or regional blocks in conjunction with conscious sedation. This section will deal with these direct infiltrative and regional block techniques in a structured anatomical fashion. Although many commercially available injectable anesthetics are available, I prefer a mixture of 0.75% bupivicaine, 1:400,000 epinephrine, and hyaluronidase (Vitrase, Ista Pharmaceuticals, Irvine, CA) (1 unit/mL). In my experience this melange offers excellent and prolonged analgesia, hemostatis, and tissue diffusion.

Scalp, forehead, and eyebrow surgery Anesthesia of this region can be achieved by direct infiltration alone or in combination with supratrochlear and supraorbital nerve blocks. Direct infiltration provides the additional advantage of vaso-

Fig. 6. Local infiltration in a subcutaneous, avascular plane.

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Fig. 7. Insertion of needle with bevel facing orbital periosteum. Eyelid crease has been exaggerated to better define the needle placement site.

tribute the solution and reduce focal swelling. Local anesthetic agents should be used sparingly to minimize Mullers muscle overactivity and levator palpe bralis superioris underactivity due to epinephrine and bupivicaine respectively. Focal swelling and muscle under- or overactivity may result in imprecise results during repair of blepharoptosis. If medial fat extirpation is planned one should be cognizant that both the supratrochlear and infratrochlear nerves may supply this area necessitating additional anesthetic. Oliva and colleagues [28] reported a case of transient visual impairment and internal and external ophthalmoplegia following injection for blepharoplasty reaffirming the need for gentle infiltration and minimal anesthetic doses. In addition, central retinal artery occlusion has been reported following local anesthesia for blepharoplasty [29]. A frontal nerve block is usually performed during Mullers muscle-conjunctival resection for blepharo ptosis. A 25-gauge, 1.5-inch sharp needle is used. It is passed below the midsuperior orbital rim with the needle lumen facing the orbital roof (Fig. 7). One should feel the needle passing along the orbital roof to a depth of 1.5 inches. Then, 1.5 to 2 mL of anesthetic solution is infiltrated followed by gentle digital pressure. If the patient is adequately blocked, a complete ptosis will result with the inability to open his or her eye.

lid and upper midface analgesia. After instillation of a topical anesthetic onto the patients eye, a corneoscleral shield should be placed over the globe. The lower eyelid should be retracted away from the globe exposing the tarsal conjunctiva. A 30-gauge 0.5-inch or 25-gauge 5/8-inch needle should be directed at a 45 degree angle directly below the inferior tarsal border to a point just anterior to the inferior orbital rim. Once the initial injection is performed the needle may be slightly withdrawn and directed laterally and medially to further anesthetize the entire eyelid. Infraorbital nerve blocks provide excellent anesthesia when operating on the lower eyelid, central and medial midface, lateral aspect of the nose, and upper lip. Blocking of this nerve may be approached via a cutaneous or intraoral route. Whichever route is chosen, one should be certain the needle is placed beneath the periosteum to achieve the maximum distribution of the anesthetic. If a cutaneous route is taken, the infraorbital foramen is palpated approximately 6 mm below the inferior orbital rim and parallel to the mid-pupillary axis. A 30-gauge 0.5-inch or 25-gauge 5/8-inch needle should be directed perpendicular to, without entering, the foramen. Several boluses of 0.5- to 1.0-mL injections can be placed around the foramen by repositioning the needle. Care should be taken to avoid entering the orbit, which can lead to diplopia, hemorrhage, and loss of vision. The intraoral approach begins with palpation of the infraorbital foramen with the middle finger and elevation of the lip with the thumb and index finger of the same hand. A 30-gauge 0.5-inch or 25-gauge 5/8-inch needle should be introduced into the gingival sulcus above at the superior aspect of the canine fossa. One to 2.0 mL of anesthetic solution should be placed around the foramen.

Lower facial and mandibular surgery Excellent analgesia can be achieved with mental nerve blocking. The mental nerve exits the mandible via the mental foramen, which is located approximately within the midpupillary line. This nerve may be blocked by a cutaneous or intraoral route. Whichever route is chosen, one should be certain the needle is placed beneath the periosteum to achieve the maximum distribution of the anesthetic as described with the infraorbital block. After palpating the mentalis foramen the needle should be advanced without entering the foramen.

Lower eyelid and midface surgery Direct anesthetic technique for the lower eyelids is similar to that for the upper eyelids. If desired, this direct infiltration of subcutaneous structures can be combined with a conjunctival approach for lower eye-

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Then 1.5 to 2.0 mL of solution anesthetic solution should be infiltrated. When an intraoral route is taken a similar technique as describe for the infraorbital block is used for exposing the injection site. The needle then pierces the inferior labial sulcus at the top of the first bicuspid followed by anesthetic infiltration.

Lacrimal system surgery Innervation of this system stems from the ophthalmic and maxillary divisions of the trigeminal nerve [30]. Achieving adequate anesthesia of medial canthal and intranasal structures is essential for optimal patient comfort during dacryocystorhinostomy, conjunctivodacryocystorhinostomy, dacryocystectomy, balloon dacryoplasty, or lacrimal system intubation. Nasal passageway anesthesia has typically been described to consist of preoperative packing of the middle turbinate region with neurosurgical cottonoids soaked in a 4% cocaine solution (Fig. 8). Others espouse the use of a mixture of phenylephrine and cocaine [31] to reduce untoward side effects while others support the use of oxymetazoline and lidocaine [32] for intranasal anesthesia. Pelletier and colleagues [33] suggest coating the nasal vault with 2% lidocaine hydrochloride jelly via a 22-gauge angiocatheter to reduce the discomfort of placement of the nasal packing and to aid passage of the cottonoids into the nose. Blocking of the nasolacrimal sac and duct and medial canthal and external nasal regions can be achieved by the elegant technique described by Fanning [31]. Fannings technique is composed of

Fig. 9. Infraorbital nerve block.

four blocks. The first block is a standard cutaneous infraorbital block as described previously using a 27-gauage, 1-inch needle (Fig. 9). Following the infraorbital block the needle is withdrawn completely and is directed toward the medial canthus and placed beneath the periosteum (Fig. 10). One to 1.5 mL of anesthetic is instilled and the needle withdrawn completely. The needle should then be reinserted below the periosteum at a point midway between the original injection site and the medial canthus, directed at the medial canthus. Injection at this site results in a subperiosteal tumescent effect moving toward the medial canthus (Fig. 11). Once this effect is seen the injection is stopped. Gentle massage for 1 minute allows for further anesthetic dissemination and reduction of edema at the injection site. The second block is a medial compartment block. The same caliber and length needle is used as before and is directed at a 30-degree angle to the coronal plane between the caruncle and medial canthus toward the medial wall stopping just at the perios-

Fig. 8. Packing of the nasal vault with neurosurgical cottonoids.

Fig. 10. Reinsertion of the needle toward the medial canthus followed following infraorbital nerve blocking.

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Fig. 11. Reinsertion of the needle at a point half way between the medial canthus and insertion site depicted in Fig. 10.

teum (Fig. 12A). Once this point is reached the needle is withdrawn 1 or 2 mm and then redirected becoming parallel with the medial orbital wall. The bevel of the needle should be facing the orbital bone and the needle should be inserted until the shoulder (hub-needle junction) of the needle meets the iris plane (Fig. 12B). The needle should remain medial to the medial rectus at all times. Slowly inject 2 to 4 mL of anesthetic while monitoring the tension of the globe with your fingertip. This technique will produce transient extraocular and orbicularis muscle weakness necessitating gentle patching for several hours postoperatively. The third block is an optional lacrimal canal block. A 30-gauge 0.5-inch needle is inserted perpendicular to the coronal plane entering the medial aspect of the lower eyelid stopping at the level of the infraorbital rim periosteum. The needle should be gently rolled until it falls off the posterior aspect

Fig. 13. Intranasal injection.

of the infraorbital rim. The needle is now within the lacrimal canal and 2 mL of anesthetic should be injected. If reflux is noted from the punctum the needle should be slightly withdrawn, removing it from the lacrimal sac, and the area re-infiltrated. The fourth block is performed after temporarily removing the previously placed nasal packing. A 27-gauge 1-inch needle is used to directly infiltrate anterior to the middle turbinate in a submucosal plane (Fig. 13). Slow instillation of anesthetic results in a spreading effect posteriorly along the middle turbinate and lateral nasal wall. The nasal packing is then replaced and left until intranasal access is needed during the procedure. Adequate anesthesia for less invasive procedures involving the puncta or canaliculi can be realized with topical and local infiltration in most instances.

Fig. 12. (A) Insertion of the needle between the medial canthus and caruncle at a 30-degree angle with respect to the coronal plane. (B) Redirection of the needle in a plane parallel to the medial orbital wall.

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cohen [7] Thorne AC. Local anesthetics. In: Aston SJ, Beasley RW, Thorne CHM, editors. Grabb and Smiths plastic surgery. Philadelphia7 Lippencott-Raven; 1997. p. 99 103. [8] Covino BG. Pharmacology of local anesthetic agents. Ration Drug Ther 1987;21(8):1 9. [9] Eggleston ST, Lush LW. Understanding allergic reactions to local anesthetics. Ann Pharmacother 1996; 30(7 8):851 7. [10] Covino BG. Pharmacology of local anaesthetic agents. Br J Anaesth 1986;58:701 16. [11] Ehlert TK, Arnold DE. Local anesthesia for soft-tissue surgery. Otolaryngologic Clin North Am 1990;23(5): 831 44. [12] Hinshaw KD, Fiscella R, Sugar J. Preparation of pHadjusted local anesthetics. Ophthalmic Surg 1995; 26(3):194 9. [13] Brogan Jr GX, Giarrusso E, Hollander JE, et al. Comparison of plain, warmed, and buffered lidocaine for anesthesia of traumatic wounds. Ann Emerg Med 1995;26:121 5. [14] Bartfield JM, Homer PJ, Ford DT, et al. Buffered lidocaine as a local anesthetic: an investigation of shelf life. Ann Emerg Med 1992;21:16 9. [15] Ista Pharmaceuticals. Vitrase. Available at: www. istavision.com/products/products_vitrase.asp. Accessed September 1, 2005. [16] Namias A, Kaplan B. Tumescent anesthesia for dermatologic surgery. Dermatol Surg 1998;24:755 8. [17] Klein JA. The tumescent technique. Dermatol Clin 1990;8(3):425 37. [18] Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16(3):248 63. [19] Coleman 3rd WP, Klein JA. Use of tumescent technique for scalp surgery, Dermabrasion and soft tissue reconstruction. Dermatol Surg Oncol 1992;18(2):130 5. [20] Moody BR, Holds JB. Anesthesia for office-based oculoplastic surgery. Dermatol Surg 2005;31(7):767 9. [21] Hickey KS, Martin DF, Chuidian FX. Propofolinduced seizure-like phenomena. J Emerg Med 2005; 29(4):447 9. [22] Biswas S, Bhatnagar M, Rhatigan M, et al. Low-dose midazolam for oculoplastic surgery under local anesthesia. Eye 1999;13(Pt. 4):537 40. [23] Baker TJ, Gordon HL. Midazolam (Versad) in ambulatory surgery. Plas Reconstr Surg 1988;82:224 6. [24] Avramov MN, White PF. Use of alfentanil and propofol for outpatient monitored anesthesia care: determining the optimal dosing regimen. Anesth Analg 1997; 85(3):566 72. [25] Philip BK, Scuderi PE, Chung F, et al. Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. The Remifentanil/ Alfentanil Outpatient TIVA Group. Anesth Analg 1997; 84(3):515 21. [26] Smith I, Avramov MN, White PF. A comparison of propofol and remifentanil during monitored anesthesia care. J Clin Anesth 1997;9(2):148 54.

Orbital surgery Although most orbital surgery is performed with general anesthesia, several authors have reported successful outcomes with regional anesthetic blocks. Burroughs and colleagues [34]described successful outcomes in 158 patients when performing enucleation and evisceration with retrobulbar blocks and monitored anesthesia care . In addition, Kezirian and colleagues [35] reported four cases of successful orbital floor repair with peribulbar and infratrochlear nerve blocks. Postoperative pain control following enucleation, evisceration and orbital implant placement may be difficult even with narcotics. Several authors have described success in such scenarios with placement of orbital catheters [36,37]. Garg and colleagues [38] reported one case of death of a patient with Sticklers syndrome following placement of a flexible orbital catheter.

Summary A wide variety of anesthetic agents and techniques are available. No one combination of agents or techniques is accepted as dogma. Experience and knowledge with these agents will optimize anesthetic effects, surgical outcomes, and patient satisfaction and will reduce the risk of complications.

References
[1] Gray H. Grays anatomy. 38th edition. London7 Churchill Livingstone; 1999. p. 1230 40. [2] Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg 1995;96(3):564 9. [3] Katzen LB. Anesthesia, analgesia and amnesia. In: Putterman AM, editor. Cosmetic oculoplastic surgery. Philadelphia7 W.B. Saunders Company; 1999. p. 67 74. [4] Ramos-Zabala A, Perez-Mencia MT, FernandezGarcia R, et al. Anesthesia techniques for outpatient laser resurfacing. Lasers Surg Med 2004;34(3):26972. [5] Sarifakioglu N, Sarifakioglu E. Evaluating the effects of ice application on the pain felt during botulinum toxin type-a injections: a prospective randomized, single-blind controlled trial. Ann Plast Surg 2004; 53(6):543 6. [6] Mercandetti M, Cohen AJ, Hern D. Anesthesia, local with sedation. In: Green R, Talavera F, Rahig S, et al, editors. Plastic Surgery/Anesthesia. eMedicine: [serial online] 2002. Available at: http://www.eMedicine.com/ plasticsurgery. Accessed September 1, 2005.

oculoplastic [27] Cuzalina AL, Holmes JD. A simple and reliable landmark for identification of the supraorbital nerve in surgery of the forehead: an in vivo anatomical study. J Oral Maxillofac Surg 2005;63(1):25 7. [28] Oliva MS, Ahmadi AJ, Mudumbai R, et al. Transient impaired vision, external ophthalmoplegia and internal ophthalmoplegiaafter blepharoplasty under local anesthesia. Am J Ophthalmol 2003;135(3):410 2. [29] Brancato R, Pece A, Carassa R. Central retinal artery occlusion after local anesthesia for blepharoplasty. Graefes Arch Clin Exp Ophthalmol 1991;229:593 4. [30] Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia7 Saunders; 1994. [31] Fanning GL. Local anesthesia for dacryocystorhinostomy. Curr Anaesth Crit Care 2000;11:306 9. [32] Meyer DR. Comparison of oxymetazoline and lidocaine versus cocaine for outpatient dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 2000;16(3): 201 5.

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[33] Pelletier CR, Jordan DR, Hamilton PP. Intranasal application of lidocaine jelly preoperatively in patients undergoing dacryocystorhinostomy. Can J Ophthalmol 1996;31(5):245. [34] Burroughs JR, Soprakar CNS, Patrinely JR, et al. Monitored anesthesia care for enucleation and eviscerations. Ophthalmology 2003;110:311 3. [35] Kezirian GM, Hill FD, Hill FJ. Peribulbar anesthesia for the repair of orbital floor fractures. Ophthalmic Surg 1991;22(10):601 5. [36] Fezza JP, Klippenstein KA, Wesley RE. Use of an orbital epidural catheter to control pain after orbital implant surgery. Arch Ophthalmol 1999;117(6):1306 7. [37] Merbs SL, Grant MP, Iliff NT. Simple outpatient postoperative analgesia using an orbital catheter after enucleation. Arch Ophthamol 2004;122(3):349 52. [38] Garg S, Piva A, Sanchez RN, et al. Death associated with an indwelling orbital catheter. Ophthal Plast Reconstr Surg 2003;19(5):398 400.

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Anesthesia for Pediatric Ocular Surgery

Steven Gayer, MD, MBAa,b,T, Jacqueline Tutiven, MDa
b a University of Miami Miller School of Medicine, 900 Northwest 17th Street, Miami, FL 33136, USA Director of Anesthesia Services, Bascom Palmer Eye Institute, 900 Northwest 17th Street, Miami, FL 33136, USA

Ophthalmic pathology in infants and children undergoing eye surgery ranges from the rare and atypical to the commonplace. These pathologies include nasolacrimal duct obstruction, strabismus, congenital or traumatically induced cataracts, penetrating eye injuries, glaucoma, retinopathy of prematurity, intraorbital tumors, and more. Nasolacrimal duct stenosis, cataracts, and traumatic eye injuries often occur in otherwise healthy pediatric patients; however, many ophthalmopathies can be associated with other congenital disorders that may have important anesthesia implications. In this article, we will review pertinent anesthesia issues within the context of various ophthalmic diseases. The vast majority of adult eye surgery patients have regional or topical anesthesia with sedation. Pediatric patients lack the maturity to remain still and are readily traumatized by unfamiliar environments and separation from parents, so general anesthesia is de rigueur. It may be difficult for children up to the age of 5 or 6 to cooperate for the most basic ophthalmic examination. Therefore, general anesthesia is also often used to accomplish simple refraction; measure intraocular pressure (IOP); and obtain photographs, ultrasound examination, or electroretinography. The preoperative anesthesia evaluation is crucial. The timeline is dependent on degree of prematurity and existing comorbidities. Congenital aberrancies and degrees of previously unviable prematurity are now frequently survivable. Additionally, frail and

T Corresponding author. University of Miami Miller School of Medicine, 900 Northwest 17th Street Miami, FL 33136. E-mail address: sgayer@miami.edu (S. Gayer).

sickly neonates often mature to become frail, sickly children [1]. Societal pressures have caused the venue for ophthalmic surgery to migrate from hospital operating room suites to freestanding eye surgery centers. Many such facilities lack depth of services and may perform only a modest amount of pediatric surgery per year. Caring for the infant or child with significant comorbidities puts greater demands on the anesthesiology staff as well as the facility [2]. The preoperative examination is a key point in the continuum of care to assess if the perioperative anesthesia environment will ensure a safe course for the individual patient. Separation anxiety is a well-described concern of pediatric patients (and their parents). A small dose of benzodiazepine may be helpful in transitioning a child into the operating room. Anxiolytics can be administered intramuscularly, intranasally, by mouth or rectum, or intravenously. Older children may acquiesce to placement of an IV, particularly if the cannulation site has been anesthetized with EMLA (eutectic mixture of local anesthetics) cream. For younger children, the oral route is more readily accepted. Because of variability in first-past absorption through the hepatic circulation, timing and extent of response to oral midazolam is less predictable. Intranasal midazolam can be painful and is poorly tolerated [3]. Premedication with midazolam prolongs neither emergence from general anesthesia nor discharge from the hospital [4]. Surgical access is improved with pupil dilation. Because of prolonged latency of onset, drops are often instilled preoperatively, but may be given in the operating room as well. They can migrate through the puncta into the nasolacrimal duct and on to the nasal mucosa with subsequent absorption into the systemic

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.012

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circulation. Sequelae from phenylephrine, an alpha agonist mydriatic, range from transient hypertension to pulmonary edema and cardiac arrest [5]. Over 100 severe or fatal reports have been documented. Additionally, intravenous administration of beta-blockers given in response to iatrogenic hypertension can induce unopposed alpha-adrenergic stimulation, exacerbate symptoms, and produce life-threatening consequences [6]. Therefore, full strength, 10% phenylephrine should be avoided in pediatric patients [7,8]. Ideally, parasympatholytic mydriatic agents should be used instead of phenylephrine. Otherwise judicious instillation of 2.5% phenylephrine with active occlusion of the nasal puncta to minimize unintentional rerouting of drug through the nasolacrimal duct is advisable. Sufficient time for onset of effect is warranted before placing additional drops. The anesthesiologist must be informed so that he or she may monitor for a hypertensive response and react appropriately.

Retinopathy of prematurity Retinopathy of prematurity (ROP), a disease of neovascularization of the retina, is a leading cause of infant blindness. Primary risk factors for ROP are birth weight of less than 1500 g and prematurity with a postconceptual age less than 32 weeks. Together, the least mature, lowest weight infants are at highest risk of developing the disease. Oxygen administration in the first few weeks of life may be associated with ROP; however, there are confounding case reports of newly born infants who have never had exposure to exogenous oxygen yet have evidence of ROP [9 11]. The improved survival rate of very low birth weight and highly premature infants has increased the incidence of ROP surgery in developed countries [12]. These infants have markedly higher incidence of bronchopulmonary dysplasia, cardiac anomalies, episodic bradydysrhythmias, anemia, intraventricular hemorrhage, and necrotizing enterocolitis. In normal development, retinal vessel formation and growth begins at the optic disc and continues concentrically, reaching the periphery by 36 to 40 weeks of gestation. It is a dynamic process vessels develop or resorb as a function of changes in local tissue oxygen availability. ROP results from aberrant formation of blood vessels within the eye in response to fluctuating levels of oxygen. It develops in a two-step manner: During the period of early vascular development, blood vessels in the retina diminish as an autoregulatory response to high oxygen tension. Later, in response to the increased

metabolic demands of the developing retina in a milieu of relative avascularity, endothelial growth factors are secreted that, in turn, induce vasoproliferation [13,14]. This neovascularity causes poor visual acuity, tractional retinal detachment, amblyopia, and ultimately, blindness. Neonatologists attempt to maintain preterm infants oxygen saturation below the level that is usually considered to be physiologically normal to prevent further neovascularization and advancement of ROP [15]. Intraoperatively, anesthesiologists have adhered to this practice as well. The Supplemental Therapeutic Oxygen for Prethreshold Retinopathy (STOP-ROP) multicenter study sought to determine if use of exogenous oxygen during the ischemic phase of ROP could correct local tissue hypoxia, blunt the secretion of vascular endothelial growth factors, and prevent formation of new vessels [16]. Threshold disease, typically stage 3 retinopathy, is the point at which treatment should be administered. Premature infants with prethreshold ROP and oxygen saturation below 94% were randomized to maintain oxygen saturation between 89% and 94% or 96% and 99%. Although the STOP-ROP study did not find clear evidence that staged oxygen administration attenuated development of ROP, it was significant in that it found that provision of supplemental oxygen to saturations up to 99% did not cause greater progression to threshold ROP. During surgery and anesthesia, higher FI O2 reduces the likelihood of severe hypoxemia, lowers pulmonary arterial pressure, and decreases airway resistance in infants with chronic lung disease [17]. Thus, one may consider that if higher oxygenation is warranted because of other patient comorbidities, maintaining a relatively hypoxic state intraoperatively may not be crucial to the management of neonates with ROP. On the other hand, some studies have found that episodic cycling between hypoxia and hyperoxia produces greater retinal neovascularization than exposure to either hypoxic or hyperoxic environments [18,19]. Many neonatal intensive care units (NICUs) have adopted policies that strive to keep oxygen saturation within a restricted, tight range [20]. The anesthesiologist may consider keeping perioperative oxygen saturations within the NICUs proscribed boundary. Thus, since concentration, duration, timing, and fluctuation of oxygen all may have a role in ROP; the optimal intraoperative oxygen saturation for these patients has yet to be clearly elucidated. The same risk factors that predispose a neonate to develop ROP, namely low birth weight, prematurity, and exogenous oxygen, may also promote bronchopulmonary dysplasia. This form of chronic lung

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disease is associated with increased airway resistance and reactivity, diminished lung compliance, and hypoxemia. In the operating room, endotracheal intubation has been the traditional means of obtaining control of premature and ex-premature ROP patients airways; however, barring specific contraindications, supraglottic devices may provide suitable airways, even for those patients with history of mild to moderate bronchopulmonary dysplasia [21,22]. For short procedures, placement of a laryngeal mask airway (LMA) causes less cardiovascular stimulation than laryngoscopy and endotracheal intubation. It does not impede the ophthalmologists access to the eyes, and is associated with a reduced incidence of coughing and Valsalva [23]. Postoperative breath-holding and apnea are potential serious complications for premature and expremature infants undergoing surgery for ROP. It may be associated with episodic bradycardia [24]. Perioperative risk of apnea is dependent on postconceptual age, gestational age, and prior history of apnea at home, with the incidence strongly correlating inversely with postconceptual and gestational age. Combined analysis of several studies has found that at 48 weeks postconceptual age, neonates have an approximately 5% risk of postoperative apnea, whereas those at approximately 55 weeks have a less than 1% probability [25]. Apnea at emergence from anesthesia, periodic breathing in the recovery room, and history of anemia confer moderate additional risk for delayed breath-holding [26]. Intravenous caffeine or theophylline may attenuate the likelihood of postoperative apnea [27]. Ophthalmologists should consider delaying ROP surgery until after 48 to 55 weeks postconceptual age when feasible. Alternatively, examination and minor procedures on extremely premature patients may be performed bedside in the NICU [28]. Preterm infants should be observed after surgery with pulse oximetry and apnea monitoring in an inpatient setting [29]. If the surgical venue is a freestanding ophthalmic specialty center, arrangements for a bed in an inpatient, monitored facility as well as for a pediatric transport team must be coordinated with sufficient time before the day of surgery [30]. Patients may be brought to the operating room for diagnostic or surgical interventions. Advances in photography and ultrasonography now allow for improved imaging of the eyes posterior segment. Cryotherapy, and more recently, laser photocoagulation are common minimally invasive procedures. Retinal detachment is managed with vitrectomy, injection of intravitreal gas, and scleral buckle surgery. General anesthesia with nitrous oxide should

be avoided if use of intravitreal gas is intended [31,32].

Glaucoma Congenital glaucoma is caused by aberrant development of the trabecular mesh network with obstruction of flow of aqueous humor. It may be primary or secondary, infantile or juvenile. Infantile glaucoma has onset within the first 3 years of life and is commonly associated with elevated intraocular pressure (IOP), enlargement of the eyes, and cloudy corneas. Neonates have elastic, immature tissue that stretches in response to increased pressure, so largersized, buphthalmic ox-like eyes and are common, while juvenile glaucoma patients do not have this feature. The classic triad of symptoms for congenital glaucoma includes tearing, photophobia, and blepharospasm [33]. Corrective surgery to establish paths for aqueous humor outflow include goniotomy, trabeculotomy, and implantation of synthetic drainage devices. Aqueous humor production can be abated by destruction of the ciliary body with laser in refractory cases. The key to good outcome is prompt diagnosis because early surgery is highly successful at curtailing progress of disease. On several occasions we have operated on days-old neonates who have been diagnosed by astute parents and pediatricians. Because of immaturity and inability to cooperate, older infants and small children may not tolerate the initial diagnostic ophthalmoscopic examination and IOP measurement, thus general anesthesia to accomplish a meticulous eye assessment is warranted. Concomitant congenital abnormalities such as craniofacial dystoses, various chromosomal trisomies, and other syndromes are not uncommon and may have significant anesthesia implications [34,35]. After definitive surgery, many pediatric patients return to the operating room periodically for examination under anesthesia until they are sufficiently mature to be examined in an office setting. Assessment of IOP is crucial to both diagnosis and determination of response to treatment. Anesthetic intervention introduces variables that may taint the accuracy of IOP measurements. Most anesthetics, including inhalation and induction agents as well as benzodiazepines and narcotics, lower ocular pressure [36]. A number of etiologies, including depression of central nervous system (CNS) activity, induction of extraocular muscle tone relaxation, reduction of aqueous humor production while enhancing aqueous flow, and lowering of venous/arterial blood pressure

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have been postulated. Recent studies have disputed the traditional notion that ketamine raises IOP. Some have found that pretreatment with benzodiazepines or narcotics prevents change in eye pressure with ketamine, while others have determined that ketamine may actually decrease IOP [37,38]. Although nondepolarizing neuromuscular blocking agents do not increase IOP, succinylcholine may transiently do so by as much as 10 mm Hg. Debate exists as to whether or not pretreatment with a small dose of nondepolarizing agent ablates this effect [39]. Compression of the eye by an anesthesia facemask may lead to spuriously high IOP measurement [40]. Laryngoscopy and intubation raise IOP through sympathetic nervous system stimulation; however, this may be attenuated by achieving a deep plane of anesthesia before attempting airway manipulation [41]. Supraglottic airway placement is not accompanied by significant increase of IOP and may have comparable effect on pressure as use of a facemask [42,43]. Both pediatric as well as glaucoma patients experience less change in IOP with placement of a laryngeal mask airway than with laryngoscopy and intubation [44,45]. Because there are a number of confounding intraoperative variables that may affect IOP, we believe that it is important to achieve consistency of technique such that the patients IOP is assessed under similar conditions with each visit to the operating room [46].

Intraocular tumors In adults, orbital tumors most commonly result from secondary metastasis from other areas. The major primary eye cancer is uveal tract melanoma. In children, retinoblastoma is the predominant primary eye neoplasm. It accounts for nearly 3% of all childhood cancers and, in the past, was the cause of almost 1% of all pediatric cancer deaths. Untreated, it is a fatal disease; however, with therapy survival rates exceed 90%. Retinoblastoma is caused by an abnormality in a specific tumor suppressor gene. This defect may occur spontaneously or be inherited. More than half of the children of a parent with bilateral retinoblastoma will develop ocular malignancy. Initial clinical diagnosis is made within the first 2 years of age by observing leukocoria on gross examination or via indirect ophthalmoscopy of the fundus [47,48]. Earlier detection and newer modalities of treatment have led to improved survival and more conservative approaches to retinoblastoma than the traditional enucleation and external beam radiotherapy [49]. Currently, enucleation is reserved for

patients with extensive disease or those who have not responded to other therapeutic interventions. The majority of patients, however, come to the operating room for minimally invasive procedures. Often there is no surgery on the day of surgery. Typical interventions are fundoscopic examination, photography, ultrasound, laser, cryotherapy, and thermotherapy. Owing to the need to document and follow progress/ regress of disease and provide therapy on a continuous basis, patients may return to the operating room regularly over the course of their early childhood. The psychosocial aspect of care for both the patient and parents should not be ignored. Small children tend to begin fearing trips to the hospital and develop white coat syndrome. Providing a relaxed atmosphere with interesting toys along with ageappropriate preoperative tours of the operating room suite and videos for viewing at home can help belay the onset of blue scrubs anxieties. Premedication with benzodiazepines may also be beneficial [50,51]. Atraumatic, smooth induction of anesthesia reduces the incidence of postoperative emotional consequences by half [52]. Parental presence in the operating room at the time of induction is somewhat controversial. Although it has no impact on infant distress during induction of anesthesia, it may allay a small childs anxiety and ease the experience [53]. On the other hand, some children are not calmed by their parents presence and staff and physicians may be uncomfortable. Some parents are distressed by the foreign environment. Each care team and institution needs to develop its own suitable policy [54]. Preoperative labs are generally unnecessary for children with retinoblastoma who return to the operating room episodically for tailored, focused interventions; however, a complete blood count may be indicated for those who have received recent chemotherapy. Inhalation induction of general anesthesia with maintenance of airway patency via a facemask is typical. Access to the eye for the surgeon, photographer, and ultrasonographer can be improved with use of a mask such as a Rendell-Baker mask, tailored to hug the bridge of the nose and taper away from the eyes. If a brief procedure is anticipated, assuming an otherwise healthy child without prolonged fasting, we often forgo intravenous cannulation. If actual surgery is planned or if multiple procedures are foreseen, an IV and supraglottic airway such as an LMA are placed. To avoid laryngospasm or the oculocardiac reflex, particularly without an indwelling IV, sufficient depth of anesthetic should be ensured before any manipulation of the eye. Atropine, epinephrine, and succinylcholine doses are calculated and drawn up before

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induction of anesthesia and are immediately available for intramuscular injection should circumstances require them. Materials for IV access are also placed proximate to the patient. An indicator of insufficient degree of anesthesia is the upward rolling of the eyes in response to pressure on the eyelids by an eye speculum. Normally, a natural protective reflex, this so-called Bells phenomenon, causes the eye to gaze cephalad when the lid begins to close. Since this reflex is lost under deep general anesthesia and the eyelids are open with the eye readily visible throughout the procedure, Belling of the eye may be a useful monitor of anesthetic depth [55,56]. Currently, there is debate as to whether bispectral index data correlate with depth of anesthesia of pediatric patients [57]. Sevoflurane is an ideal inhalation agent for children undergoing examination under anesthesia because of its favorable cardiovascular profile and lack of respiratory irritation. One drawback, however, is emergence delirium, most often encountered in children younger than 6 years of age [58]. Postsevoflurane agitation occurs whether or not actual surgery has occurred and is not caused by postoperative pain [59]. It may, however, be related to a childs level of preoperative anxiety [60]. The child with retinoblastoma presenting for examination under anesthesia is at enhanced risk of post-sevoflurane agitation because his or her general anesthetic primarily consists of high-dose sevoflurane via facemask and little else. Some studies have found that addition of midazolam, propofol, narcotics, or nonsteroidal anti-inflammatory drugs (NSAIDS) to the anesthetic regimen decreases the likelihood of emergence delirium [58,61]. Preoperative narcotics confer no advantage over midazolam, providing further justification for our inclination to use oral benzodiazepines before surgery [62]. Some consider switching to an alternative inhalation agent after induction. Fortunately, while acutely distressing to patient and parents, there are no long-term behavioral ramifications of sevoflurane-induced emergence delirium [63].

procedure. Infants and small children, however, often will not tolerate the procedure and may require anesthesia. Traditionally, bulky electroretinogram (ERG) equipment has been fixed in specialized lightproof suites where patients retinal cells can be darkadapted before the examination. Older inhalational anesthetics such as halothane and isoflurane, as well as newer agents, sevoflurane and desflurane, are known to decrease amplitude and prolong latency of ERG/VEPs when given in high doses typically needed for mask-induction of anesthesia, so their use has been typically avoided for these studies [64 67].While VEPs are exquisitely sensitive to inhalation agents, ERGs may be less so [68]. Methohexital, an ultrashort-acting barbiturate that has a rapid recovery profile, provides effective sedation. It can be administered rectally, obviating need for intravenous access. Onset of effect occurs quickly with 15 to 30 mg/kg of a 10% solution [69]. Owing to potential apnea of variable duration, post-procedure monitoring is requisite [70]. Propofol may have less effect upon the ERG than barbiturates and is associated with a very rapid recovery, but requires cannulation of a vein [71,72]. Although there are multiple techniques for sedation of pediatric patients outside of the operating room setting, customary use of rectally administered barbiturate-based anesthesia for ERG/VEP examinations evolved as a direct consequence of the need to avoid inhalation agents for anesthesia of infants and small children in an artificially darkened area remote from the operating room [73]. Recently there have been acute shortages of methohexital. The manufacture of small portable ERG machines allow for darkadapted pediatric patients to undergo the examination as scheduled cases in the operating room suite.

Strabismus Strabismus is a misalignment disorder of extraocular muscles characterized by amblyopia with or without anisometropia. Surgery, including intramuscular placement of adjustable or semi-adjustable sutures, resections, or direct injection of the paralytic botulinum toxin, often yields immediate rectification of symptoms. Strabismus may be inherited, developmental, or acquired, and can have associated comorbiditiesparticularly other neuromuscular disorders. Children with strabismus or palpebral ptosis may be at increased risk for malignant hyperthermia or harbor an undiagnosed cardiomyopathy, so a thorough preanesthesia examination is warranted [74,75]. The incidence of malignant

Electroretinograms and visual evoked potentials Electroretinography and visual evoked potentials (VEPs) are used to assess the function of the visual cortical axis from the level of the photoreceptors to the visual cortex. The examination is fairly brief and noninvasive, requiring placement of a contact lens electrode on each eye and subsequent exposure to pulses of flashing light. For adults, this is an office

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hyperthermia, intraoperative hyperkalemic arrest, or rhabdomyolysis has decreased with improved identification of highly susceptible patients, avoidance of succinylcholine and other triggering agents, and use of total intravenous anesthesia with nontriggering anesthetics [76]. Usually elicited by traction on extraocular muscles and their adnexa or by sudden pressure applied to the eye or orbit, the oculocardiac reflex (OCR) is not infrequently encountered in infants and children having ophthalmic procedures under general anesthesia. It is fairly commonly experienced during strabismus surgery. The stimulus is initially mediated by the trigeminal nerve, with a vagal efferent response that can produce abrupt changes in heart rate. The cardiac response may be attenuated by a timely prestimulus IV dose of anticholinergics, use of sevoflurane instead of halothane, use of neuromuscular blocking drugs with vagolytic effects, and gentle surgical handling of the extraocular muscles [77]. Since the OCR displays tachyphylaxis, repeated stimuli are often accompanied by attenuated responsesor extinguishment of symptoms. First response should be cessation of the surgical stimulus, allowing the heart rate and rhythm to return to baseline while simultaneously reassuring adequate patient oxygenation, ventilation, and depth of anesthesia. Mild hemodynamic instability of brief duration may not require anticholinergics; however, compromising bradycardia warrants the use of atropine. Atropine, not glycopyrrolate or epinephrine, is the appropriate initial agent for vagalinduced symptomatic bradycardia [78]. Glycopyrrolate may produce a similar cardiac effect with less proarrhythmic consequences and is used prophylactically by some after induction of anesthesia, before surgical stimulation [79]. Strabismus surgery is often accompanied with postoperative nausea and vomiting (PONV). The reported incidence of nausea and emesis ranges widely, no doubt because of differences in patient populations as well as surgical and anesthetic techniques [80]. The increased probability of PONV above baseline may be a result of an oculo-gastric reflex that is a vagally mediated response to surgical manipulation of extraocular muscles. Supporting this notion, an association between the intraoperative occurrence of another vagus nerve-mediated response, the OCR, and PONV has been described [81]. Following surgery, motion sickness because of diplopia may also produce nausea and emesis. While symptoms are usually self-limiting, serious ramifications may occur. Delayed eating and drinking may lead to dehydration, electrolyte imbalance, and

prolonged stay in the recovery room. Unanticipated admission to an inpatient facility may be necessary. PONV is distressing and its curtailment is valued [82]. Avoidance of emesis and nausea after surgery is a greater patient priority than prompt wakefulness, rapid discharge from same-day surgery, cost, or even pain itself [83]. Strategies to minimize PONV include adjustment of the anesthetic plan as well as the use of antiemetics. Preoperative anxiety may contribute to postoperative nausea/vomiting, so benzodiazepines or clonidine may be beneficial [84,85]. Narcotics are highly proemetic and newer agents such as remifentanil may not confer advantage over fentanyl [86]. Conflicting reports regarding nitrous oxide exist. Higher oxygen concentrations allay PONV in adults after gastrointestinal (GI) surgery, however, increased FI O2 has not been found to have similar effect in pediatric and adult strabismus patients [87,88]. Anticholinesterases used for reversal of neuromuscular blocking agents promote nausea, so preintubation use of an ultrashort neuromuscular blocking agent that does not require reversal, such as mivacuronium, is warranted [89]. Supraglottic airways obviate the need for paralysis altogether. Propofol may reduce the incidence of nausea and vomiting, but is associated with the oculo-cardiac reflex and bradydysrythmias [90,91]. Peribulbar or sub-Tenons block before emergence from general anesthesia lessens PONV [92,93]. Nonpharmacologic techniques such as acupressure may be helpful [94]. Postoperatively, premature inducement to eat and drink should be avoided [95]. Antiemetics can be administered during surgery or once symptoms arise after emergence. Since strabismus surgery is, in and of itself, a notable independent risk factor for PONV in children, prophylactic administration of antiemetics is warranted [84]. Surgery in excess of 30 minutes, as well as a family history of PONV confer additional risk and further justify intraoperative antiemetics [96]. Additionally, in this setting, prophylactic antiemetics may be more costeffective than symptomatic treatment of nausea and vomiting [97]. PONV after strabismus surgery has been studied with all classes of antiemetics, including butyrophenones, benzamides, histamine and muscarinic receptor antagonists, steroids, and serotonin 5-HT3 receptor antagonists [98,99]. Use of combinations of antiemetics with differing mechanisms of action may be more effective for those eye muscle surgery patients at highest risk of PONV. One such combination includes droperidol, a 5-HT3 receptor agonist, or steroid. Droperidol has a marked anti-nausea effect

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while the serotonin receptor antagonists are better suppressers of vomiting than nausea, and dexamethasone has a prolonged duration of action [98].

Traumatic eye injuries Traumatic eye injuries are relatively common with small children and adolescents. Reparative surgery occurs more frequently in community-based facilities than trauma centers [100]. Open eye injuries are either ruptures from blunt objects or lacerations from sharp projectiles. Lacerating injuries may be penetrating, with single full-thickness lesions, or perforating, with entrance and exit wounds. An intraocular foreign body may also be present. Anesthesia strategies for management of open-globe patients are described elsewhere in this text. In the otherwise healthy, normovolemic, fasted child, a gentle inhalation-based induction may be considered since squeezing of the eyelids owing to attempted IV access can cause IOP to exceed 70 mm Hg, potentially precipitating extrusion of globe contents [101]. Although general anesthesia remains conventional, anesthesia for select patients with open globe injuries can be accomplished with regional anesthesia [102,103]. In the pediatric population, with the possible exception of older more-mature teenagers, general anesthesia is most appropriate. Nonetheless, an eye block before conclusion of surgery provides effective postoperative analgesia for the child having repair of a traumatic eye injury under general anesthesia. Emergence from anesthesia is more quiescent, with less PONV than encountered with opiates, and the child is less likely to rub or squeeze an eye that has been rendered insensate with local anesthetics [104]. Appropriate dosing can be achieved with proportionally smaller volumes and lower concentrations of local anesthetic. Alternatively, intravenous, but perhaps not topical, ketorolac as well as oral or rectal acetaminophen may also attenuate postoperative pain without enhancing the potential for PONV [105 107].

support, and may also need postoperative transportation from the ophthalmology specialty center to a pediatric intensive care unit for further monitoring. Anesthesia implications for particular ophthalmic pathologies including retinopathy of prematurity, glaucoma, retinoblastoma, strabismus, and traumatic eye injuries were discussed. We reviewed perioperative considerations including the preoperative examination, evaluation of comorbidities and syndromes, preoperative labs, premedication, separation anxiety, systemic effects of ophthalmic medications, emergence delirium, the increasing use of supraglottic airways, IOP, OCR, PONV, and pain management strategies including intraoperative eye block.

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Summary The intent of this article was to shed light on important issues in pediatric ophthalmic anesthesia within the constraints of the space allotted. A timely and detailed history and physical examination complimented with indicated diagnostic tests generally ensures a safe anesthetic course. Preterm and expremature infants as well as syndromic children undergoing eye surgery require proper institutional

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Succinylcholine and the Open Eye

Elie Joseph Chidiac, MDa,b,T, Alex Oleg Raiskin, MDa
a

Department of Anesthesiology, Wayne State University School of Medicine, Anesthesiology Education Office, Room 2901, 2-Hudson, 3990 John R., Detroit, MI 48201, USA b Kresge Eye Institute, 4717 St. Antoine, Detroit, MI 48201, USA

The use of succinylcholine in ocular trauma is controversial. This article reviews the determinants of intraocular pressure (IOP), the effects of succinylcholine on IOP, and the advantages and disadvantages of alternatives to succinylcholine, including regional anesthesia for open globe injuries. We review various methods to attenuate the effect of succinylcholine on IOP, if it is to be used. Finally, we suggest an algorithm for airway management of patients with penetrating eye injuries, highlighting circumstances where succinylcholine may be the safest muscle relaxant.

Intraocular pressure Normal IOP is 10 to 22 mm Hg, with diurnal variations (ie, 2 to 3 mm Hg higher in the daytime) and positional changes (ie, 1 to 6 mm Hg higher if supine).It is physiologically determined by aqueous humor dynamics, changes in choroidal blood volume, central venous pressure, and extraocular muscle tone [1]. The most important determinant of IOP is the balance between production and elimination of aqueous humor, maintaining an average volume of 250 mL. Aqueous humor is formed in the ciliary process from capillaries by diffusion, filtration, and active secretion [2]. It flows through the posterior chamber, around the

T Corresponding author. Department of Anesthesiology, Wayne State University School of Medicine, Anesthesiology Education Office, Room 2901, 2-Hudson, 3990 John R., Detroit, MI 48201. E-mail address: echidiac@med.wayne.edu (E.J. Chidiac).

iris, and into the anterior chamber. It is eliminated through the spaces of Fontana and Schlemms canal at the iridocorneal angle, where it flows into the episcleral venous system. Any increase in venous pressure (eg, cough, strain, head-down position) will increase IOP. Additionally, any decrease in crosssectional area of the spaces of Fontana (eg, mydriatic drugs) will increase IOP. The choroid is a meshwork of arterial anastomoses in the posterior chamber. Autoregulation of choroidal blood flow keeps IOP stable [3]. However, this process is slow, so that sudden increases in systemic blood pressure or central venous pressure (coughing, bucking) will cause a transient increase in choroidal blood volume and thus IOP. Additionally, there is a linear relationship between choroidal blood volume and hyper- and hypoventilation, so that an increase in carbon dioxide tension will raise IOP. A sudden drop in IOP to atmospheric pressure (open eye) can cause rupture of choroidal vessels. Extraocular muscles (EOM) have a unique morphologic structure that enables rapid and precise control with resistance to fatigue. Whereas skeletal muscles have a single nerve axon connected to an endplate at the mid-belly of each fiber, EOM are both singly innervated and multiply innervated. With firing of synapses, the action potential of multiply innervated fibers is not an all-or-none phenomenon; instead, there are tonic focal contractions and the force generated is directly proportional to the membrane depolarization [4]. This may explain differences in the response of EOM to succinylcholine; in the EOM of cats, multiply innervated fibers are more sensitive to succinylcholine than singly innervated fibers [5].

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.015

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Succinylcholine and IOP When first introduced, succinylcholine was seen as an ideal muscle relaxant [6]. Soon thereafter, it was reported that succinylcholine increased IOP [7] and with personal communications from surgeons, concerns were raised regarding possible vitreous extrusion [8]. Others studied intraocular physiology and described loss of vitreous after succinylcholine administration under light anesthesia, suggesting that the use of succinylcholine in intraocular surgeries was hazardous [9]. Anesthesiologists at the Wills Eye Hospital in Philadelphia performed a retrospective review of 100 of 228 open eye trauma cases from 1982. Of those 100 cases, 81 had general anesthesia: 11 had an inhalational induction (all were children) and 70 had an intravenous induction. Of those 70, there were 63 who received succinylcholine, at 60 to 160 mg. Based on the description of the eye on the operative report and in the preoperative progress notes, there was no extrusion of vitreous in any of the cases where succinylcholine had been used. They added that they had no anecdotal reports of loss of ocular content using succinylcholine for eye injury patients in more than 10 years at their institution [10]. This article generated two Letters to the Editor, one with a case report of extrusion of vitreous necessitating an enucleation [11] and the other from the anesthesiologists at the Massachusetts Eye and Ear Infirmary in Boston, MA, citing more than 10 years of using succinylcholine at induction in open globe injuries without vitreous expulsion [12]. IOP increases within 1 minute and peaks at an increase of 9 mm Hg within 6 minutes after succinylcholine administration [13]. The exact mechanism of this increase is unknown. Some feel that tonic contractions of the extraocular muscles may explain this IOP increase. However, in a feline model of anterior and posterior ocular trauma, there was no extrusion of ocular contents after succinylcholine. The only effect was forward displacement of the lens and iris [13]. In a study of 15 patients undergoing elective enucleation, succinylcholine was given after all the extraocular muscles to the diseased eye had been detached. There was no difference in IOP increase between the detached and intact eyes [14]. It is now thought that succinylcholine-induced IOP increase is a vascular event, with choroidal vascular dilatation or a decrease in drainage secondary to elevated central venous pressure, temporarily inhibiting the flow of aqueous humor through the canal of Schlemm [15]. Therefore, it is clear that succinylcholine raises IOP. However, at induction of general anesthesia there are many activities that raise IOP with a much

larger increase than that with succinylcholine, including crying, Valsalva, forceful blinking, and rubbing of the eyes [16] as well as coughing or bucking during poor intubating technique [1]. Therefore, the increase in IOP owing to succinylcholine may be inconsequential if optimal intubating conditions are not provided [17].

Nondepolarizing muscle relaxants There are many nondepolarizing muscle relaxants that can be used to facilitate rapid-sequence induction for open eye injuries. In general, onset time is slower than succinylcholine. Various methods have been proposed to speed this onset: priming, administering the neuromuscular agent before the induction agent, and using high-dose regimens. The priming principle suggests that a small dose of a nondepolarizing muscle relaxant be given 3 minutes before rapid sequence induction, when the induction agent and the rest of the nondepolarizing drug are given. This runs the risk of partial paralysis from the priming dose itself as well as the risk of loss of airway control [18]. Some have proposed administering the neuromuscular agent before the induction agent. With that technique, the concern is a poorly timed disconnection at the site of the intravenous catheter and a longer interval between induction and intubation [19]. Some have proposed using high-dose regimens of nondepolarizing muscle relaxant. High doses of vecuronium, 0.2 to 0.3 mg/kg, can provide good intubating conditions in 90 seconds [20]. Rocuronium 0.6 mg/kg can be a good substitute for rapid sequence induction and intubation [21,22]. When comparing succinylcholine 1.5 mg/kg versus rocuronium 0.6 mg/kg, the intubating conditions were excellent after 60 seconds and the IOP rise with succinylcholine was 21.6 mm Hg as opposed to 13.3 mm Hg with rocuronium [23]. However, others have suggested that as much as 0.9 to 1.2 mg/kg of rocuronium is needed to provide equivalent intubating conditions to succinylcholine, at the expense of prolonged duration of action [24 26]. Therefore, despite various methods to optimize their use, nondepolarizing muscle relaxants can result in nonideal intubating conditions at 60 seconds, a delay in intubation, a prolonged effect, increases in intraocular pressure from mask application, and a longer time with an unprotected airway. Some feel that depolarizing agents will always be faster because, compared with succinylcholine molecules, more receptors have to be occupied by nondepolariz-

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ing muscle relaxant molecules to produce an equivalent degree of paralysis [27].

Regional anesthesia for open globe injuries Regional anesthesia can be a safe, albeit nonroutine anesthesia technique for repair of open eye injuries. It is a reasonable alternative for the management of trauma patients where general anesthesia may expose patients to excessive risk for complications, or for patients with less traumatic globe injuries that pose a lower threat of loss of the eye. There are many techniques for ocular conduction anesthesia: cannula-based sub-Tenon block techniques, topical anesthesia, intracameral injection, and peribulbar and retrobulbar anesthesia. Selection of the appropriate anesthesia technique should consider many factors that pertain to the patient, surgery, surgeon, anesthesia provider, and operative venue. The risks of all ocular block techniques are inversely proportional to education and experience. This is affirmed by several reports of complications by inadequately trained personnel [28 31]. Regional anesthesia has traditionally been considered contraindicated in patients with penetrating eye injuries because of the concerns with potential extrusion of intraocular contents from the force generated by local anesthetics, from needle instrumentation of the orbit, from squeezing of the eyelids because of pain on injection, or from a potential hemorrhage after injection. Nonetheless, there are some anecdotal case reports of successful use of ophthalmic blocks in this setting [32,33]. There is a spectrum of eye injuries based on type (defined by the mechanism of the injury), grade (based on visual acuity), pupillary defect, and zone of injury [34]. This spectrum has been validated in a subsequent study, with a prognostic correlation between initial evaluation and eventual visual outcome [35]. Regional anesthesia can be a reasonable alternative to general anesthesia for selected patients with open globe injuries. Two retrospective studies investigated clinical features and visual acuity outcomes associated with regional anesthesia versus general anesthesia for open globe injuries in adult reparable eyes. With a total of 458 patients with open globe injuries, those who underwent surgery without general anesthesia were more likely to have an intraocular foreign body, better presenting visual acuity, more anterior wound location, shorter wound length, and dehiscence of previous surgical wound, and were

less likely to have a pupillary defect. There were no anesthesia-related complications. The general anesthesia groups had longer operating times. Change in visual acuity between the presenting and final examinations was similar in the general anesthesia and regional anesthesia groups [36,37]. A similar prospective study showed that patients with small anterior penetrating globe injuries may be operated with a combined peri- and retrobulbar anesthetic, with operative conditions as good as those with general anesthesia [38]. Topical anesthesia has been used for an open globe injury in a situation where cardiopulmonary disease prevented the use of general anesthesia and the extensive extrusion of eye contents made periand retrobulbar blocks contraindicated [39]. A prospective study of 10 open globe injuries repaired under topical anesthesia showed that, for less severe eye injuries, surgeons have adequate operative conditions (slight difficulty in 9, moderate difficulty in 1 case) and most patients have minimal pain and discomfort [40].

Blunting the effect of succinylcholine on IOP Various methods have been used to attenuate the effects of succinylcholine on IOP. They include selftaming and pretreatment with lidocaine, narcotics, nifedipine, nondepolarizing muscle relaxants, nitroglycerin, and propranolol. Self-taming is a technique where a small dose of succinylcholine is initially given, before rapidsequence induction. This has been found to be ineffective in reducing the rise in IOP and can, by itself, cause an increase in IOP [41,42]. Pretreatment with lidocaine partially blunts the IOP increase from succinycholine and blunts the further increase from intubation [43]. Pretreatment with narcotics decreases the IOP rise from succinylcholine. After fentanyl or alfentanil, IOP increased significantly following suxamethonium, but mean IOP remained significantly less than control values. Tracheal intubation caused a further significant increase in IOP, and both opioids reduced, but did not abolish the hemodynamic responses to tracheal intubation [44]. The IOP rise from succinylcholine can be obtunded with remifentanil [45,46], sufentanil [47], and alfentanil [48]. This decrease may be related to the effects of opioids on systemic vascular resistance [49]. Pretreatment with nifedipine can blunt the IOP increase from succinylcholine: the IOP increased 7.82 mm Hg in the placebo group and 0.15 mm Hg

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in those who received 10 mg sublingual nifedipine [50]. Pretreatment with a small defasciculating dose of nondepolarizing muscle relaxant has shown mixed results. Some have suggested that mivacurium attenuates the IOP increase from succinylcholine [51]. D-tubocurarine has been shown to be beneficial by some authors [52], while others have shown no significant difference between the IOP increase after succinylcholine alone or after succinylcholine when given 3 minutes after d-tubocurarine [53 55]. Pretreatment with nitroglycerin will cause significantly less increases in IOP after succinylcholine and after tracheal intubation [56]. Pretreatment with propranolol has been shown to prevent significant increases in IOP after succinylcholine, but there was significant cardiovascular depression [57].

After approval by our Institutional Review Board, we retrospectively reviewed all open globe surgeries performed at the Kresge Eye Institute in a 24-month period. There were 59 cases and all were adults receiving general endotracheal anesthesia. One was a planned fiberoptic intubation because of facial injuries. Eight were judged to be possibly difficult intubations (see algorithm, Fig. 1) and therefore received succinylcholine. Five of them were indeed difficult intubations, requiring more than one attempt (one of these five patients required fiberoptic intubation). In all 59 cases, comparing ophthalmologists comments in the preoperative assessment and after induction, similar to the process used by Libonati et al [10], there were no increases in vitreous loss, no lens or uvea extrusion, and no excessive intraocular bleeding causing further extrusion.

A proposed algorithm The practice at the Kresge Eye Institute At our institution, we feel that succinylcholine may be used to facilitate endotracheal intubation during rapid sequence induction, despite its effects on IOP, because it allows intubation within 30 to 60 seconds. Its short half-life also allows fast recovery of muscle power if the airway conditions are difficult. In a full stomach-open eye injury situation, with the need for a rapid-sequence induction with avoidance of IOP increase, there is a balancing act: preventing aspiration and preventing IOP increase. When succinylcholine is chosen, we use various medications to blunt its effect on IOP, such as opioids, lidocaine, nifedipine, and defasciculating doses of nondepolarizing drugs. We feel that two questions need to be asked before the decision about the use or the avoidance of succinylcholine in open globe surgeries: Is this an easy airway? and Is the eye viable? (see Fig. 1). If the airway assessment shows that intubation should be easy, then regardless of the patients aspiration risk and regardless of the viability of the eye, we feel that succinylcholine can be avoided and replaced with the currently available short- or intermediate-acting nondepolarizing muscle relaxants. If the airway assessment, using whatever tools the anesthesiologist prefers, shows that this could be a difficult intubation, regardless of the patients aspiration risk, then a second question becomes important: Is the eye viable? In that setting, the anesthetic induction plan may need to change. If, during the preoperative ophthalmologic examination, it is felt that the eye is not salvageable, and the surgery is to assess the damage and create a cosmetic closure, we prefer to use fiberoptic laryngoscopy. This, we realize, may increase intraocular pressure (gagging from local anesthetic spray, retching from local anesthetic nebulized breathing treatments, bucking from transtracheal injection, hypercarbia from sedation), but this increase should be similar to that from blinking, crying, or rubbing the eye. If the ophthalmologist feels that the eye is viable, then we prefer using succinylcholine over any other modality. In this setting, we start with other drugs that attenuate the intraocular pressure effect of succinylcholine.

Is this an easy airway?

YES NO Is the eye viable? YES NO

Short- or intermediateacting nondepolarizing muscle relaxants.

Fiberoptic laryngoscopy Succinylcholine (after pre-treatments)

Fig. 1. Intubation algorithm for open eye injuries.

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Summary There is still no real case report of extrusion. The witnessed extrusions of the 1950s and 1980s spoke of light anesthesia. Although it is inevitable that the use of succinylcholine will decline with the availability of new drugs [58], the currently available shorteracting nondepolarizing muscle relaxants have yet to replace the fast onset and short duration profile of succinylcholine [59]. A new ideal replacement must work as fast as succinylcholine, wear off as quickly as succinylcholine, and not cause an IOP increase. Choosing or avoiding succinylcholine is a matter of balance of risk. To control IOP at induction, there must be adequate dosing of drugs and adequate timing to coincide with the three potent stimuli: the administration of succinylcholine, the laryngoscopy, and the endotracheal intubation. We know that succinylcholine increases IOP, but this increase can be attenuated with various pretreatments, is less than the increases seen with inadequate paralysis at the time of laryngoscopy and intubation, and is unimportant when weighed against the risk of loss of the airway. Therefore, we feel that in the situation of difficult airway, eye viable, one should use succinylcholine.
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Acknowledgments Many thanks to Dr. Steven Gayer, Associate Professor of Anesthesiology and Ophthalmology at the University of Miami and Director of Anesthesia Services at the Bascom Palmer Eye Institute, for his advice and guidance, particularly in the area of regional anesthesia for open eye injuries.

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iontophoretically labeled fibers contracting in response to succinylcholine. Invest Ophthalmol Vis Sci 1977; 16(6):561 5. Foldes FF, Mcnall PG, Borrego-Hinojosa JM. Succinylcholine: a new approach to muscular relaxation in anesthesiology. N Engl J Med 1952;247:596 600. Hofman H, Holzer H, Bock J, et al. Die Wirkung von Muskelrelaxantien auf den intraokularen Druck [The effect of muscle relaxants on intraocular pressure]. Klin Monatsbl Augenheilk 1953;123:1 15 [in German]. Lincoff HA, Breinin GM, Devoe AG. The effect of succinylcholine on the extraocular muscles. Am J Ophthalmol 1957;43:440 4. Dillon JB, Sabawala P, Taylor DB, et al. Action of succinylcholine muscles and intraocular pressure. Anesthesiology 1957;18:44 9. Libonati MM, Leahy JJ, Ellison N. The use of succinylcholine in open eye surgery. Anesthesiology 1986;62:637 40. Rich AL, Witherspoon CD, Morris RE, et al. Use of nondepolarizing anesthetic agents in penetrating ocular injuries. Anesthesiol 1986;65:108 9. Donlon JV. Succinylcholine and open eye injuries. Anesthesiol 1986;65:526 7. Moreno RJ, Kloess P, Carlson DW. Effect of succinylcholine on the intraocular contents of open globes. Ophthalmology 1991;98:636 8. Kelly RE, Dinner M, Turner LS, et al. Succinylcholine increases intraocular pressure in the human eye with the extraocular muscles detached. Anesthesiol 1993; 79(5):948 52. Metz HS, Venkatesh B. Succinylcholine and intraocular pressure. J Pediatr Ophthalmol Strabismus 1981; 18(1):12 4. Coleman DJ, Trokel S. Direct-recorded intraocular pressure variations in a human subject. Arch Ophthalmol 1969;82:637 40. Mirakhur RK, Shepherd WF, Darrah WC. Propofol or thiopentone: effects on intraocular pressure associated with induction of anaesthesia and tracheal intubation (facilitated with suxamethonium). Br J Anaesth 1987;59:431 6. Jones RM. The priming principle: how does it work and should we be using it? Br J Anaesth 1989;63:1 3. Edmondson L, Lindsay SL, Lanigan LP, et al. Intraocular pressure changes during rapid sequence induction of anaesthesia. A comparison between thiopentone and suxamethonium and thiopentone and atracurium. Anaesthesia 1988;43(12):1005 10. Di Filippo A, Grechi S, Rizzo L, et al. [High-dose vecuronium in open-eye emergency surgery]. Minerva Anestesiol 1995;61(11):457 62 [in Italian]. Puhringer FK, Khuenl-Brady KS, Koller J, et al. Evaluation of the endotracheal intubating conditions of rocuronium (ORG 9426) and succinylcholine in outpatient surgery. Anesth Analg 1993;75:37 40. Vinik HR. Rapid sequence induction and intubation with rocuronium without increasing intraocular pressure. Anesth Analg 1995;80:S531.

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raiskin [39] Auffarth GU, Vargas LG, Klett J, et al. Repair of a ruptured globe using topical anesthesia. J Cataract Refract Surg 2004;30:726 9. [40] Boscia F, La Tegola MG, Columbo G, et al. Combined topical anesthesia and sedation for open globe injuries in selected patients. Ophthalmology 2003;110: 1555 9. [41] Verma RS. Self-taming of succinylcholine-induced fasciculations and intraocular pressure. Anesthesiology 1979;50(3):245 7. [42] Meyers EF, Singer P, Otto A. A controlled study of the effect of succinylcholine self-taming on intraocular pressure. Anesthesiology 1980;53(1):72 4. [43] Mahajan RP, Grover VK, Munjal VP, et al. Doubleblind comparison of lidocaine, tubocurarine and diazepam pretreatment in modifying intraocular pressure increases. Can J Anaesth 1987;34(1):41 5. [44] Sweeney J, Underhill S, Dowd T, et al. Modification by fentanyl and alfentanil of the intraocular pressure response to suxamethonium and tracheal intubation. Br J Anaesth 1989;63:688 91. [45] Alexander R, Hill R, Lipham WJ, et al. Remifentanil prevents an increase in intraocular pressure after succinylcholine and tracheal intubation. Br J Anaesth 1998;81:606 7. [46] Ng HP, Chen FG, Yeong SM, et al. Effect of remifentanil compared with fentanyl on intraocular pressure after succinylcholine and tracheal intubation. Br J Anaesth 2000;85(5):785 7. [47] Georgiou M, Parlapani A, Argiriadou H, et al. Sufentanil or clonidine for blunting the increase in intraocular pressure during rapid-sequence induction. Eur J Anaesthesiol 2002;19(11):819 22. [48] Zimmerman AA, Funk KJ, Tidwell JL. Propofol and alfentanil prevent the increase in intraocular pressure caused by succinylcholine and endotracheal intubation during a rapid sequence induction of anesthesia. Anesth Analg 1996;83(4):814 7. [49] Polarz H, Bohrer H, Fleischer F, et al. Effects of thiopentone/suxamethonium on intraocular pressure after pretreatment with alfentanil. Eur J Clin Pharmacol 1992;43(3):311 3. [50] Indu B, Batra YK, Puri GD, et al. Nifedipine attenuates the intraocular pressure response to intubation following succinylcholine. Can J Anaesth 1989;36: 269 72. [51] Chiu CL, Lang CC, Wong PK, et al. The effect of mivacurium pretreatment on intra-ocular pressure changes induced by suxamethonium. Anaesthesia 1998;53(5):501 5. [52] Miller RD, Way WL, Hickey RF. Inhibition of succinylcholine-induced increased intraocular pressure by non-depolarizing muscle relaxants. Anesthesiology 1968;29:123 6. [53] Cook JH. The effect of suxamethonium on intraocular pressure. Anaesthesia 1981;36(4):359 65. [54] Meyers EF, Krupin T, Johnson M, et al. Failure of nondepolarizing neuromuscular blockers to inhibit succinylcholine-induced increased intraocular

[23] Chiu CL, Jaais F, Wang CY. Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anaesthesia. Br J Anaesth 1999;82(5):757 60. [24] Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Anesthesiology 1993;79:913 8. [25] Weiss JH, Gratz I, Goldberg ME. Double-blind comparison of two doses of rocuronium and succinlycholine for rapid-sequence intubation. J Clin Anesth 1997; 9:379 82. [26] Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg 2000;90:175 9. [27] Feldman S, Fauvel NJ, Harrop-Griffiths AW. Onset of neuromuscular block: an hypothesis. Br J Anaesth 1990;65:585. [28] Olitsky S, Juneja R. Orbital hemorrhage after the administration of sub-Tenons infusion anesthesia. Ophthalmic Surg Lasers 1997;28:145 6. [29] Hay A, Flynn Jr HW, Hoffman JI, et al. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991;98:1017 24. [30] Duker JS, Belmont JB, Benson WE, et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia: patient characteristics, surgical management, and visual outcome. Ophthalmology 1991;98: 519 26. [31] Grizzard WS, Kirk NM, Pavan PR, et al. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991;98:1011 6. [32] Lo MW, Chalfin S. Retrobulbar anesthesia for repair of ruptured globes. Am J Ophthalmol 1997;123(6): 833 5. [33] Lesnoni G, Rossi T, Villa G, et al. Repair of scleral rupture and total retinal detachment in a self-injuring psychotic patient under local anesthesia: a case report. Eur J Ophthalmol 1999;9:248 51. [34] Pieramici DJ, Sternberg Jr P, Aaberg Sr TM, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol 1997;123:820 31. [35] Pieramici DJ, Au-Eong KG, Sternberg Jr P, et al. The prognostic significance of a system for classifying mechanical injuries of the eye (globe) in open-globe injuries. J Trauma 2003;54:750 4. [36] Scott IU, Mccabe CM, Flynn Jr HW, et al. Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries. Am J Ophthalmol 2002;134:707 11. [37] Scott IU, Gayer S, Voo I, et al. Regional anesthesia with monitored anesthesia care for surgical repair of selected open globe injuries. Ophthalmic Surg Lasers Imaging 2005;36:122 8. [38] Niemi-Murola L, Immonen I, Kallio H, et al. Preliminary experience of combined peri- and retrobulbar block in surgery for penetrating eye injuries. Eur J Anaesthesiol 2003;20:478 81.

succinylcholine pressure: a controlled study. Anesthesiology 1978;48: 149 51. [55] Feneck RO, Cook JH. Failure of diazepam to prevent the suxamethonium-induced rise in intra-ocular pressure. Anaesthesia 1983;38(2):120 7. [56] Mahajan RP, Grover VK, Sharma SL, et al. Intranasal nitroglycerin and intraocular pressure during general anesthesia. Anesth Analg 1988;67(7):631 6.

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[57] Cook JH, Feneck RO, Smith MB. Effect of pretreatment with propranolol on intra-ocular pressure changes during induction of anaesthesia. Eur J Anaesthesiol 1986;3(6):449 57. [58] Bevan D. Succinylcholine. Can J Anaesth 1994;41: 465 8. [59] Cook DR. Can succinylcholine be abandoned? Anesth Analg 2000;90:S24 8.

Ophthalmol Clin N Am 19 (2006) 287 292

Management of a Blind Painful Eye

Shannath L. Merbs, MD, PhD
Wilmer Eye Institute, 600 North Wolfe Street, Maumenee 505, Baltimore, MD 21287, USA

Ophthalmologists are often asked to treat patients who have eye pain from a variety of ocular diseases. Topical steroids, cycloplegics, ocular hypotensives, and bandage contact lenses can be effective in many cases. However, when the pain is intractable and the eye has very poor vision and is disfigured, surgical removal of the eye has traditionally been the definitive treatment of choice. In several situations, an alternative to enucleation is warranted, and injection of a neurolytic substance can often induce long-lasting anesthesia for a blind painful eye. One of the most common causes of a blind painful eye is trauma [1,2], but many other ocular conditions, such as retinal detachment, chronic open-angle glaucoma, phthisis, intraocular inflammation, and corneal decompensation can lead to loss of vision and pain. A blind eye can be associated with several types of pain or discomfort. Most common is an aching or sharp pain of the eye or orbit, but the pain may also be referred to the forehead or temple. Photophobia of the contralateral eye is not uncommon, even in patients who have lost all sight in the affected eye [2].

Retrobulbar injection Ethyl alcohol Retrobulbar alcohol injections have been used as an alternative to enucleation since the early 1900s to treat blind painful eyes. Retrobulbar injections may be preferred in cases where the blind painful eye is cosmetically normal and not disfigured, as is often

the case in refractory, or end-stage glaucoma [3,4]. Patients, who cannot proceed with enucleation for medical reasons or who are reluctant to proceed with enucleation for psychological, cultural, or religious reasons, can be temporarily relieved of their eye pain by a retrobulbar alcohol injection in about 85% of cases for at least 1 month [4]. However, the discomfort often returns an average of 6 months after injection [3,4]. The pain is believed to recur because the alcohol, that infiltrates the area surrounding the sensory nerve fibers, damages but does not destroy the nerve fibers. After a few months, the peripheral portion of the nerve fibers regenerate and the pain recurs. Typically, 1 mL of 95% ethyl alcohol is injected after a standard retrobulbar block (see later discussion). Immediately after a retrobulbar alcohol injection, the patient may experience a sharp pain in the orbit or a dull occipital headache [4]. This discomfort can last for several minutes. Other transient complications include eyelid swelling, ptosis, chemosis of the conjunctiva, slight proptosis of the globe, and temporary paralysis of one or more extraocular muscles. In general, these complications last for a few days to two months [4,5]. Neurotrophic keratitis is a rare complication of retrobulbar alcohol injection [4]. Phenol Chemical neurolysis by phenol is frequently used by disciplines other than ophthalmology to provide relief of pain and spasticity. Phenol has several advantages over alcohol, including a less painful injection and a more rapid onset [6]. In the treatment of blind painful eyes, the effectiveness of phenol (80%) is similar to alcohol, although the duration may be longer (mean 15 months) [7]. Using the stan-

E-mail address: smerbs@jhmi.edu

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.010

ophthalmology.theclinics.com

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dard technique described below, injection of local anesthetic is followed by 1.5 mL of a 1:15 (6.7%) aqueous phenol solution [7]. Complications, which include ptosis, ophthalmopelgia, and neurotrophic keratitis, are also similar to retrobulbar alcohol and typically resolve after a few weeks [7]. Chlorpromazine Chlorpromazine is another chemical that has been injected into the retrobulbar space to treat blind painful eyes [8]. The effectiveness of phenol for eliminating pain with one injection (80% 83%) is similar to retrobulbar alcohol and phenol [8,9]. Like phenol, the duration of pain control after a retrobulbar injection of chlorpromazine can exceed that of alcohol and normally lasts more than a year. Mild to moderate chemosis, lid edema, and ptosis can occur but usually resolve within a few weeks [9]. Typically, 1 mL of 25 mg/mL chlorpromazine is injected after retrobulbar anesthesia. Technique Retrobulbar injection of neurolytic agents, especially alcohol, is painful. To minimize discomfort, the injection is preceded by a retrobulbar block which is administered using standard technique [4]. The patient is asked to look up and nasally. A 3.5-cm, 22-gauge needle is inserted into the lateral third of the lower lid just above the rim of the orbit. The needle is passed through Tenons capsule between the lateral and inferior rectus muscles into the muscle cone. The plunger of the syringe is withdrawn slightly to insure that the needle has not entered a blood vessel. An initial injection of 1-2 cc of 2% lidocaine is given into the retrobulbar space. The syringe is removed, and the needle is held in place with a clamp. A second syringe, containing 1 1.5 mL of either 95% ethanol, 6.7% aqueous phenol, or 25 mg/mL chlorpromazine, is attached to the needle, and the solution is injected into the orbit. A patch is applied. A variation on the injection technique uses 95% ethanol and 2% lidocaine in the same syringe [10]. Because the specific gravity of ethanol is less than lidocaine, ethanol drawn first into a syringe remains above the lidocaine if the syringe is held perpendicular to the floor while the lidocaine is drawn into the syringe slowly to avoid turbulence and inadvertent mixture. Use of a single syringe simplifies the procedure. Alternatively, two syringes can be attached to the same retrobulbar needle with a three-way stopcock.

Intravitreal injection Phthisis bulbi is a progressive process in which intraocular fibrosis leads to ciliochoroidal detachment, hypotony, and a blind painful eye. In one report, intravitreal corticosteroid injection into a phthisical eye alleviated pain for at least 2 months [11], and this treatment may be a viable alternative to retrobulbar alcohol injection. The corticosteroid also appeared to reduce ocular inflammation, with decreased conjunctival congestion after injection [11]. After standard retrobulbar anesthesia, 0.3 mL (12 mg) of triamcinolone acetonide (40 mg/mL) is injected intravitreally and the eye is patched. Most patients reported pain relief within 24 hours [11].

Cyclodestruction Cyclodestruction destroys a portion of the ciliary body and reduces aqueous production which decreases intraocular pressure. This form of therapy can be used to relieve pain in patients who have a blind hypertensive eye. Cyclodestruction by transcleral cryotherapy effectively reduces intraocular pressure and pain, but this technique is usually reserved for cases of end-stage glaucoma because of an increased risk of complications such as visual loss and phthisis bulbi [12]. Cyclophotocoagulation by diode laser is more commonly used and also effectively provides pain relief in blind hypertensive eyes and results in fewer complications [12,13]. Under retrobulbar or peribulbar anesthesia, a quartz fiberoptic probe (600 mm diameter) is used to apply the diode laser over the ciliary body. One-half to three-quarters of the ciliary body is treated with 20 40 applications of 1.5 2 seconds duration. Complications of cyclodestruction include post-operative uveitis and hyphema, and persistent hypotony [12,13].

Enucleation One of the leading causes of enucleation, or removal of the eye from the orbit, is a blind painful eye [1,14]. When topical medications or retrobulbar injections fail to control the pain, enucleation can usually provide complete pain relief within 3 months [15]. Painful, and severely traumatized or phthisical blind eyes are usually best treated by enucleation or evisceration (see later discussion). The decision to recommend enucleation must take into account a patients psychological state and general medical condition, the etiology of the pain, the cosmesis of

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the eye, and the potential for complications. Patients who have blind painful eyes that are disfigured from trauma, may more readily agree to enucleation [2]. Enucleation provides pain relief for over 90% of patients [2]. Some patients experience phantom eye pain or visual hallucinations after enucleation [16,17]. Technique Standard enucleation techniques are detailed in a number of oculoplastic surgical textbooks [18 21]. Enucleation is usually performed under general anesthesia [18 20], although it can be performed with a retrobulbar or peribulbar block [22 24]. After an eyelid retractor is placed, a 360 conjunctival peritomy is performed around the corneoscleral limbus. Tenons capsule is opened in all 4 quadrants between the rectus muscles with blunt dissection. Each rectus muscle is isolated, secured with a locking suture, and severed from the globe at its insertion. The superior oblique tendon is isolated and divided. The muscular insertion of the inferior rectus muscle is clamped or cauterized to minimize bleeding and then divided. Remaining fibrous attachments to the globe are divided. The optic nerve is clamped behind the eye and enucleation scissors are used to cut the optic nerve between the clamp and the back of the eye. Alternatively, a snare can be used to isolate and cut the optic nerve. Hemostasis is achieved with digital pressure for several minutes. In most cases, the orbital volume lost by removing the eye is replaced with an alloplastic orbital implant. Many implant materials have been advocated in the past, but integrated implants that allow for fibrovascular tissue ingrowth into the inorganic material are currently favored. Two of the most commonly used materials are hydroxyapatite and high-density porous polyethylene [25 27]. The hydroxyapatite implant is usually wrapped in a material such as donor sclera, pericardium, or synthetic mesh to decrease the rate of extrusion of the implant and to facilitate the attachment of the extraocular muscles to the implant [28 30]]. The porous polyethylene implant, in contrast to hydroxyapatite, is less expensive and does not require wrapping because of its smoother surface. Greater malleability of the porous polyethylene implant makes it possible to suture the extraocular muscles directly to the implant [26]. Because of the fibrovascular ingrowth into an integrated implant, a titanium peg can be placed into the implant, which couples to the posterior surface of the prosthesis for increased motility of the prosthesis. Placement of the peg is usually performed at least

6 months after enucleation to allow for sufficient vascularization of the implant. Although motility peg placement can improve patient satisfaction after enucleation [31], a significant proportion of patients suffer from minor, peg-associated complications [32]. Therefore, most surgeons in the United States choose not to place a motility peg [27]. After the orbital implant material has been selected and the implant has been placed into the muscle cone [33], the rectus muscles are sutured to the implant, to the wrapping material, or to one another anterior to the implant. Tenons capsule is closed, with care not to incarcerate conjunctiva in the closure. The conjunctiva is closed in a separate layer to avoid conjunctival cyst formation. A conformer is placed to occupy the fornices while the wound is healing, and this is replaced by an ocular prosthesis in about 6 weeks. Enucleation can result in significant immediate postoperative pain that requires outpatient oral narcotics or inpatient analgesia [34,35]. Inadequate postoperative pain relief can result in crying and restlessness, which leads to hematoma formation, increased pain, delayed wound healing, and prolonged recovery. To reduce acute postoperative pain and bleeding, 3 5 mL of a long-acting anesthetic with epinephrine can be injected into the retrobulbar space at the end of the surgical procedure. However, the relief is only temporary. As an alternative, or in combination with oral narcotics, an orbital catheter can be placed for repeated delivery of a local anesthetic on an outpatient basis [36,37]. Although the death of a patient who had a connective tissue abnormality has been attributed to the use of a particularly long indwelling orbital catheter [38], in general, these catheters safely provide superior postoperative pain control and allow a patient to recover in a comfortable environment surrounded by a familiar support structure [37]. Perioperative complications of enucleation include orbital hemorrhage and edema, orbital infection, and conformer extrusion. These risks can be minimized by preoperatively discontinuing anticoagulants, leaving the clamp around the optic nerve for several minutes after transaction of the optic nerve, and administering systemic and topical antibiotics for 7 days postoperatively. A temporary suture tarsorrhaphy can aid in the retention of the conformer in cases of more severe postoperative edema. Other complications, including implant migration, exposure, and extrusion, can be minimized by the use of an integrated implant. Long-term complications after enucleation affecting cosmesis and fitting of the ocular prosthesis include ptosis, lower

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eyelid retraction, superior sulcus deformity, and relative enophthalmos of the prosthesis because of reduced orbital volume [39].

Evisceration can unsuspectingly disseminate an intraocular tumor, and therefore, when evisceration is being considered, ophthalmic ultrasound should be performed to eliminate the possibility of intraocular malignancy [50]. Technique

Evisceration Evisceration is the complete removal of the contents of the eye while the scleral shell attached to the extraocular muscles remains intact. Evisceration is another surgical procedure that can effectively eliminate intractable ocular pain [15]. When compared with enucleation, evisceration is a simpler procedure, recovery is faster, and there is less trauma to the orbital tissues [40]. This leads to superior cosmesis and prosthesis movement because of the preservation of the muscular attachments to the sclera and their relationship to the orbital implant [41 43]. Evisceration, because it removes only a portion of the eye, may be more acceptable to patients who are having difficulty psychologically with enucleation. In the pre-antibiotic era, evisceration was the treatment of choice for a blind painful eye in the setting of endophthalmitis, because it minimized the chance of orbit and central nervous system contamination with infectious organisms [44]. Many surgeons still prefer evisceration in the setting of endophthalmitis. Although evisceration has many advantages over enucleation, significant controversy surrounds the evisceration procedure because of the very small risk of sympathetic ophthalmia. Sympathetic ophthalmia is a bilateral granulomatous panuveitis that occurs after penetrating ocular surgery or injury that involves the uvea of one eye. The exact pathogenesis of sympathetic ophthalmia is unknown, but it is thought that the ocular penetration may release a uveal antigen that stimulates an immunologic response [45]. Although an increased risk of sympathetic ophthalmia theoretically exists after evisceration because of the inability to completely remove the uveal tissue from the sclera [41,43,44,46], the true incidence of sympathetic ophthalmia after evisceration is unknown [44,47]. Even though anecdotal reports of sympathetic ophthalmia exist in the older literature, many surgeons believe that evisceration is a safe and effective procedure with little risk of sympathetic ophthalmia and better cosmesis and motility [27,47,48]. A disadvantage of evisceration when compared with enucleation is increased pain in the immediate postoperative period [41,44,49]. However, evisceration ultimately results in pain relief equivalent to that of enucleation; most patients achieve pain relief within 6 weeks and the rest within 15 months [15].

Like enucleation, the surgical technique of evisceration is well described in textbooks [21,51]. The technique usually involves removing the cornea if it is thin or severely traumatized. Also, some patients may complain of postoperative corneal sensitivity if the cornea is left intact [43]. After a 360 conjunctival peritomy, the conjunctiva and Tenons capsule are undermined for several millimeters, the anterior chamber is entered at the limbus, and the cornea is removed with scissors. Anterior relaxing incisions are made in the sclera to facilitate entry of a larger implant into the scleral cavity. An evisceration spoon is used to remove the intraocular contents from the sclera. The interior surface of the scleral shell is wiped with absolute alcohol to remove any residual uveal pigment and then rinsed with saline. The sites of the four vortex veins and the optic nerve head should be cauterized to minimize bleeding. Posterior meridional and equatorial sclerotomies make it possible to place an 18- or 20-mm implant and still maintain effective closure without tension [52]. It is important to avoid incising the sclera through a rectus muscle insertion when performing the sclerotomies to minimize the chance for intraoperative hemorrhage. After placement of a non-porous or porous implant, the scleral edges are overlapped and secured with mattress sutures. It is usually necessary to trim the scleral corners to avoid redundancy and allow for a smooth closure. Interrupted absorbable sutures are used to close Tenons capsule and the conjunctiva is closed by using a running absorbable suture. In cases of endophthalmitis, placement of an orbital implant is usually performed as a secondary procedure after evisceration, to minimize the risk of implant infection [19,21], although some believe it is safe to place the implant during the primary procedure [53]. Complications after evisceration with an implant are similar to enucleation: possible implant exposure, infection, or extrusion as well as periorbital changes such as superior sulcus defect [54].

Summary Debilitating ocular pain poses a significant challenge to the ophthalmologist. Enucleation or eviscera-

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tion of a blind painful eye is usually recommended because of its ability to permanently eliminate the eye pain. However, many people are uncomfortable psychologically with removal of their eye, however painful, and other patients are not good surgical candidates. For both of these situations, retrobulbar injection provides an excellent alternative for temporary pain relief.

[17]

[18]

[19]

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drome: its prevalence, phenomenology, and putative mechanisms. Neurology 2003;60(9):1542 3. Nicolodi M, Frezzotti R, Diadori A, et al. Phantom eye: features and prevalence. The predisposing role of headache. Cephalalgia 1997;17(4):501 4. Schaefer DP, Rocca RCD. Enucleation. In: Nesi FA, Lisman RD, Levine MR, editors. Smiths ophthalmic plastic and reconstructive surgery. St. Louis7 Mosby; 1998. p. 1015 52. Nunery WR, Hetzler KJ. Enucleation. In: Hornblass A, editor. Oculoplastic, orbital, and reconstructive surgery. Baltimore7 Williams & Wilkins; 1988. p. 1200 20. Iliff NT, Merbs SL. Enucleation. In: Gottsch JD, Stark WJ, Goldberg MF, editors. Rob & Smiths operative surgery: ophthalmic surgery. Great Britain7 Arnold; 1999. p. 58 63. Nunery WR, Chen WP. Enucleation and evisceration. In: Bosniak SL, editor. Principles and practices of ophthalmic plastic and reconstructive surgery. Philadelphia7 W.B. Saunders; 1996. p. 1035 45. Griffis CA. The effect of intraoperative retrobulbar block on anesthetic management of enucleation under general anesthesia. Nurse Anesth 1991;2(1):28 32. Calenda E, Assadi C, Retout A, et al. Is eye enucleation or evisceration possible under peribulbar anaesthesia? Eur J Anaesthesiol 1997;14(5):551 2. Calenda E, Muraine M, et al. Local anesthesia for preoperative and postoperative pain control in eye enucleation or evisceration: 20 cases. Reg Anesth Pain Med 1998;23(5):525 6. Perry AC. Integrated orbital implants. Adv Ophthalmic Plast Reconstr Surg 1990;8:75 81. Karesh JW, Dresner SC. High-density porous polyethylene (Medpor) as a successful anophthalmic socket implant. Ophthalmology 1994;101(10):1688 95 [discussion 95 6]. Su GW, Yen MT. Current trends in managing the anophthalmic socket after primary enucleation and evisceration. Ophthal Plast Reconstr Surg 2004;20(4): 274 80. Jordan DR, Klapper SR, Gilberg SM. The use of vicryl mesh in 200 porous orbital implants: a technique with few exposures. Ophthal Plast Reconstr Surg 2003; 19(1):53 61. Kassaee A, Kashkouli MB, Panjtanpanah M, et al. Mersilene mesh versus sclera in wrapping hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 2006;22(1):41 4. Arat YO, Shetlar DJ, Boniuk M. Bovine pericardium versus homologous sclera as a wrapping for hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 2003;19(3):189 93. Song JS, Oh J, Baek SH. A survey of satisfaction in anophthalmic patients wearing ocular prosthesis. Graefes Arch Clin Exp Ophthalmol 2005;Aug 17(DOI: 10.1007/ s00417-005-0037-0):1 6. Jordan DR, Chan S, Mawn L, et al. Complications associated with pegging hydroxyapatite orbital implants. Ophthalmology 1999;106(3):505 12.

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merbs [44] Migliori ME. Enucleation versus evisceration. Curr Opin Ophthalmol 2002;13(5):298 302. [45] Chan CC, Mochizuki M. Sympathetic ophthalmia: an autoimmune ocular inflammatory disease. Springer Semin Immunopathol 1999;21(2):125 34. [46] Green WR, Maumenee AE, Sanders TE, et al. Sympathetic uveitis following evisceration. Trans Am Acad Ophthalmol Otolaryngol 1972;76(3):625 44. [47] Bilyk JR. Enucleation, evisceration, and sympathetic ophthalmia. Curr Opin Ophthalmol 2000;11(5): 372 86. [48] Levine MR, Pou CR, Lash RH. The 1998 Wendell Hughes Lecture. Evisceration: is sympathetic ophthalmia a concern in the new millennium? Ophthal Plast Reconstr Surg 1999;15(1):4 8. [49] Calenda E, Retourt A, Muraine M. Is evisceration of the eye more painful than enucleation? Eur J Anaesthesiol 1999;16(2):117. [50] Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv Ophthalmol 2000;44(4):277 301. [51] Schaefer DP. Evisceration. In: Nesi FA, Lisman RD, Levine MR, editors. Smiths ophthalmic plastic and reconstructive surgery. St. Louis7 Mosby; 1998. p. 105363. [52] Stephenson CM. Evisceration of the eye with expansion sclerotomies. Ophthal Plast Reconstr Surg 1987; 3(4):249 51. [53] Dresner SC, Karesh JW. Primary implant placement with evisceration in patients with endophthalmitis. Ophthalmology 2000;107(9):1661 4 [discussion 4 5]. [54] Marshak H, Dresner SC. Multipurpose conical orbital implant in evisceration. Ophthal Plast Reconstr Surg 2005;21(5):376 8.

[33] Soll DB. Enucleation surgery. A new technique. Arch Ophthalmol 1972;87(2):196 7. [34] Waterman H, Slater R, Leatherbarrow B, et al. Postoperative nausea and vomiting following orbital hydroxyapatite implant surgery. Eur J Anaesthesiol 1998; 15(5):590 4. [35] Waterman H, Leatherbarrow B, Slater R, et al. The hydroxyapatite orbital implant: post-operative pain. Eye 1998;12(Pt 6):996 1000. [36] Fezza JP, Klippenstein KA, Wesley RE. Use of an orbital epidural catheter to control pain after orbital implant surgery. Arch Ophthalmol 1999;117(6):784 8. [37] Merbs SL, Grant MP, Iliff NT. Simple outpatient postoperative analgesia using an orbital catheter after enucleation. Arch Ophthalmol 2004;122(3):349 52. [38] Garg S, Piva A, Sanchez RN, et al. Death associated with an indwelling orbital catheter. Ophthal Plast Reconstr Surg 2003;19(5):398 400. [39] Hornblass A, Biesman BS, Eviatar JA. Current techniques of enucleation: a survey of 5,439 intraorbital implants and a review of the literature. Ophthal Plast Reconstr Surg 1995;11(2):77 86 [discussion 7 8]. [40] ODonnell BA, Kersten R, McNab A, et al. Enucleation versus evisceration. Clin Experiment Ophthalmol 2005;33(1):5 9. [41] Dortzbach RK, Woog JJ. Choice of procedure. Enucleation, evisceration, or prosthetic fitting over globes. Ophthalmology 1985;92(9):1249 55. [42] Kostick DA, Linberg JV. Evisceration with hydroxyapatite implant. Surgical technique and review of 31 case reports. Ophthalmology 1995;102(10):1542 8 [discussion 8 9]. [43] Walter WL. Update on enucleation and evisceration surgery. Ophthal Plast Reconstr Surg 1985;1(4):243 52.

Ophthalmol Clin N Am 19 (2006) 293 307

Complications of Anesthesia for Ocular Surgery

Marc Goldberg, MDT
Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA

Ophthalmic anesthesia is unique because ophthalmic surgery itself rarely causes unanticipated hemodynamic instability. Unlike more invasive surgery, intravascular fluid shifts, blood loss, and changes in cardiac, respiratory, hepatic, and renal function are almost never caused by the surgical procedure. Complications of anesthetic management stand alone; patients are subject to every known complication of anesthesia, magnified at times by ophthalmologic or patient demographic factors, but not caused by those factors. Ocular anesthesia complications can be divided into three categories: complications of monitored anesthesia care (MAC), complications of general anesthesia, and a small set of complications unique to ophthalmic surgery. Systematic study of anesthesia complications began in 1984 when the American Society of Anesthesiologists (ASA) initiated a review of closed medical malpractice claims, the ASA Closed Claims Project. Malpractice insurers voluntarily reported details of 5,475 claims against anesthesiologists that were finally adjudicated between 1970 and 1999 [1]. It was quickly evident that respiratory misadventures, particularly inability to ventilate patients by mask or intubate patients tracheas, were the cause of the worst outcomes and highest dollar payouts for malpractice claims. Analysis of the types of claims allowed classification by root causes and prompted specific anesthesia practice guidelines that have significantly improved patient safety and reduced the number of claims and their severity (Fig. 1) [2]. Malpractice costs for anesthesiologists have reflected

this emphasis on safety. Average cost for malpractice insurance for anesthesiologists is $21,000 per year, less than 20 years ago in constant dollars [3]. The Closed Claims Project allowed analysis of clusters of complications, showing systemic issues or common root causes and suggesting methods of prevention not evident via analysis of any one particular claim. Closed claims results show that the frequency of hypoxic episodes resulting in brain death or damage has decreased, although these claim payouts are still in the hundreds of thousands of dollars [4]. As Cheney [4] noted, in the 1970 to 1979 period, 41% of closed claims were for death and 15% were for brain damage. By 1990 to 1994, only 22% of closed claims were for death and only 9% were for brain damage. This correlates with the universal introduction of pulse oximetry and capnometry in firstworld countries. At the other end of the frequency/ payout spectrum, dental damage during airway manipulation is now the most frequent minor claim. Warner found an incidence of dental injury in 1 in 2,805 patients who had endotracheal intubation [5]. The mean repair cost was $782, with a range of $88 to $8,200. Closed claims analysis is used in this article to elaborate the complications of MAC and general anesthesia.

Complications of monitored anesthesia care Postoperative nausea and vomiting The most frequent complication of MAC is postoperative nausea or vomiting (PONV). A wide variety of afferent pathways, including vagal, sympathetic, and vestibular nerves, activated by visceral distention or traction, activate the chemoreceptor trigger zone

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Fig. 1. American Society of Anesthesiologists Difficult Airway Algorithm. As a practice parameter and standard of care, the difficult airway algorithm provides guidance for management of suspected and unsuspected airways. The conceptualization behind its adoption has significantly decreased anesthesia morbidity and mortality from hypoxia. (Adapted from American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993;78(3):597 602.)

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Fig. 2. Cumulative risk of PONV. Risk factors include female gender, nonsmoking, history of motion sickness or PONV, and the use of postoperative narcotics. (Data from Apfel CC, Laara E, Koivuranta M. A simplified risk score for predicting post operative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693 700.)

(CTZ), located on the floor of the fourth ventricle. Higher cortical pathways triggered by pain, hypoxia, increased intracranial pressure, and odors also activate the CTZ. All narcotics act directly on the CTZ to cause PONV, but reversal of narcotic action by naloxone may paradoxically increase PONV because of the resulting increased perception of pain. Different studies estimate the incidence of PONV to be between 10% and 80%. Risk factors include female gender, particularly in premenopausal women, nonsmoking, use of narcotics and nitrous oxide, a past history of PONV or motion sickness, younger age, and gynecologic and certain ophthalmic surgeries. Apfel and colleagues [6] developed a risk score for prediction of PONV, demonstrating that the risks were cumulative (Fig. 2). PONV is the complication most feared by patients. In addition to patient discomfort, PONV contributes to increased nursing costs, delays in postoperative discharge from the operative facility, and readmissions to hospital. Prevention of PONV is more effective than treatment, but antiemetics have independent adverse side effects and increase the cost of surgery. Identification of at-risk patients allows targeting of prophylactic treatment. Prophylaxis is more cost-effective for the high-risk pediatric patient having strabismus surgery than for the elderly patient having cataract removal. Narcotic treatment, a major trigger of PONV, should be avoided whenever possible for ocular patients. Thousands of papers in the anesthesiology literature have assessed different antiemetic regimens, with no clear consensus as to which regimen is most effective. Avoidance of triggering agents, particularly

narcotics and nitrous oxide, has been shown in multiple studies to decrease the incidence of PONV. Some studies find a benefit to high inspired oxygen concentrations; other studies do not [7,8]. Acetaminophen and ketorolac may substitute for narcotics for relief of postoperative pain. Nonnarcotic analgesics are more effective if administered before the onset of surgical stimulation. The modern use of propofol, which itself has an antiemetic effect, and midazolam for sedation has decreased the incidence of PONV compared with barbiturates and diazepam [9]. The most common agents used prophylactically or for treatment of PONV are the antiserotonin drugs ondansetron, dolasetron, and granisetron. These drugs have no effect on dopaminergic, cholinergic, adrenergic, or histaminic receptors and have a remarkably low incidence of adverse side effects. Ondansetron may be associated with headaches (9%), and dolasetron may cause symptomatic electrocardiographic changes, including increases in PR and QRS intervals [10,11]. Depending on type of surgery and patient population considered, 5-HT3 receptor blockers have been found to significantly decrease the incidence of PONV or to decrease it no more than supplemental oxygen [12,13]. The corticosteroid dexamethasone has prophylactic PONV and antiemetic effects, demonstrated in many studies. Bhatia and colleagues [14] found a much lower incidence of PONV in pediatric strabismus patients prophylactically treated with dexamethasone 0.25mg/kg (P = .001) between 0 and 24 hours after surgery than in the control group. Fifty-one percent of children who received dexamethasone had no PONV compared with only 15% of children in the

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control group. Hyperglycemia and impaired wound healing were not seen. Droperidol, a centrally acting butyrophenone, is extremely effective in low doses for PONV prophylaxis and treatment by itself and in combination with other drugs [15]. After several incidents of prolonged QT intervals leading to the ventricular dysrhythmia torsades de pointes, the American Food and Drug Administration issued a black box warning against the use of droperidol for PONV. A review of the cases, particularly considering the many millions of previous uses of droperidol for PONV, suggests that the warning was unnecessary [16]. Metaclopramide acts on central domaminergic receptors and has long been used as an adjunct, rather than as a primary anti-PONV drug. By itself, it has little efficacy and probably has no role in nonrescue PONV treatment [17,18]. Extrapyramidal side effects, although rare, are extremely disturbing. PONV is the most common complaint after MAC anesthesia. Adequate (pre-) treatment of pain with nonnarcotic analgesics and avoidance of narcotics whenever possible, and prophylactic pretreatment of high-risk patients with use of serotonin antagonists and dexamethasone, are the most reliable means to avoid PONV. Oversedation and undersedation Another frequent complication of MAC for ophthalmic surgery is over- or undersedation of patients. Adequate topical or nerve block anesthesia is critical to use of MAC because using intravenous sedatives (propofol, midazolam, narcotics) to compensate for inadequate local anesthetic will result in oversedation and airway obstruction. Careful attention to the patients level of consciousness and comfort is critical to avoid the extremes of either patient discomfort or hypoxia and respiratory compromise during surgery. During ocular surgery, the anesthesia provider has impaired access to the patients airway and less ability to assess patient response because the patients head position is oriented away from the anesthetist. There is an unfortunate tendency to be less in contact with the patient and to lower the level of vigilance; MAC is sometimes considered less of an anesthetic than general anesthesia. The same level of vigilance is required for MAC as for general anesthesia. For certain patients, MAC is more difficult to provide than general anesthesia. Though the use of the pulse oximeter has decreased the incidence of unrecognized hypoxia, electronic monitoring should not substitute for visual and tactile contact with the patient.

Inadvertent local anesthetic injection Intravascular and subarachnoid injection of local anesthetic agents is an infrequent but serious complication of MAC [19]. Undoubtedly an underreported complication, unexpected subarachnoid local anesthetic injection has decreased with replacement of retrobulbar blocks by topical, peribulbar, or subtenons injection of local anesthetic. Newer topicalization techniques have also decreased the incidence of accidental intraorbital injection of local anesthetics. Intravenous injection of ophthalmic volumes of local anesthetics (eg, 5 to 10 mL of bupivicaine or carbocaine 0.5%) may cause transient CNS effects but rarely cause cardiovascular collapse, as would larger volumes of local anesthetics. Intraarterial injection of these volumes of local anesthetics may cause a grand-mal seizure or respiratory arrest. Although the incidence of intravascular and subarachnoid local anesthetic injection has decreased, anesthesia providers must be ready immediately to secure the patients airway and to administer advanced cardiac life support if needed. Complications of general anesthesia Ophthalmic anesthesia is subject to all of the potential complications of general anesthesia even though the level of surgical stimulation and fluid shifts are smaller than for other operations. A list of general anesthesia complications appears in Box 1. As noted, skillful airway management is critical to avoid hypoxia upon induction of anesthesia. Evaluation begins with the history of previous anesthetics, particularly whether patients have been told that their

Box 1. General anesthesia complications Airway difficulties Cardiac compromise and arrest Respiratory depression and aspiration Unexpected awareness during anesthesia Failure to regain consciousness Complications of monitoring Peripheral nerve damage Allergic reactions Hepatic and renal compromise Equipment malfunctions, mechanical misadventures, and syringe swap Mortality Dental damage Airway management

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tracheas are difficult to intubate. After difficulty in either ventilating by mask or intubating, the anesthesiologist must inform the patient or family of the difficulty. This is best done via a letter that explains the problems encountered and how the airway was ultimately established (or not). Patients with known difficult airways should be advised to share such a letter with future anesthesiologists and to consider obtaining a MedicAlert bracelet for difficult intubation. The anesthesiologist observes the airway, looking for the visibility of the epiglottis, tonsil pillars, uvula, and soft palate as the airway class advances from 0 to 4, as described by Mallampati [20]. A class 0 airway, wherein the epiglottis itself is visible, should present little intubation difficulty. A class 4 airway, with a large tongue, small oral opening, protruding teeth, and only hard palate visible, correlates with 84% sensitivity and 71% specificity for inadequate view on laryngoscopy [21]. The anesthesiologists goal is to detect potentially difficult airways before induction of general anesthesia, however, Mallampati classification and other screening systems imperfectly predict intubating difficulty [22]. Morbid obesity, pregnancy, cervical spine disease, thyroid nodules, Downs syndrome, and congenital or acquired tracheal stenosis may also increase the potential for airway management problems. Patients with anticipated difficult intubations, or a history of difficult intubation, may require awake (sedated) fiberoptic intubation to prevent loss of the airway and inability to ventilate the lungs. Laryngeal mask airways (LMA) are commonly used either to avoid endotracheal intubation or as rescue airways after difficult intubation or ventilation. LMAs can provide an airway seal up to 20 cmH20 pressure, giving some assurance against aspiration. However, many anesthesiologists are reluctant to rely on LMAs for positive pressure ventilation in paralyzed patients because of the risk of regurgitation of stomach contents and pulmonary aspiration. If an ophthalmology patient needs paralysis or the guarantee of minimal eye movement, and has a difficult airway, the anesthesiologist may prefer to secure the airway via awake fiberoptic intubation an intervention considerably more invasive than many ocular surgeries. The ASA Difficult Airway Algorithm (see Fig. 1) gives best practice parameters for the anticipated and unanticipated difficult airway. Peterson recently reviewed ASA closed claims data for difficult airway management between 1985 and 1999 [23]. Since promulgation of the ASA difficult airway algorithm, the likelihood of death or brain damage for an airway claim during induction decreased almost 50%, whereas the odds of death or brain damage during the other phases of the

anesthetic remained the same. The fear that practice guidelines may be used legally against physicians did not materialize. The airway algorithm was used in only 8% of claims to defend the care given; it was cited in only 3% of claims to criticize the care given. A related airway compromise at the end of the general anesthetic may result in life-threatening pulmonary edema. Obstruction of the airway, most commonly by laryngospasm, may result in markedly negative intrapleural pressures (up to 100 cmH20) and draws transcapillary fluid into the alveoli. Risk factors include young age, male gender, sleep apnea, hypertrophied adenoids or tonsils, hypoxia, and hyperadrenergic states. If early airway obstruction during emergence is suspected, mechanical airway opening (oral airways) or administration of small amounts of succinylcholine (5 to 10 mg) may relieve obstruction or laryngospasm and prevent development of negative-pressure pulmonary edema. If these measures fail, most patients require reintubation, positive-pressure ventilation, and postincident monitoring. Episodes resolve quickly without diuresis and without permanent sequellae, unlike other causes of postoperative pulmonary edema, such as aspiration pneumonia, acute respiratory distress syndrome, coexisting cardiac anomalies or myocardial infarction, and anaphylaxis.

Aspiration of gastric contents Passive or active aspiration of gastric contents can cause aspiration pneumonia, which has a high rate of morbidity and mortality. Traditional practice has called for an 8-hour fast before elective surgical procedures for adults. Recent studies have indicated that a total fast can decrease gastric pH and make aspiration-induced pulmonary damage worse. Fasting guidelines for children reflect this change [24]. Children under 6 months of age should have a 2-hour clear-liquid fast before elective surgery. Children between 6 and 36 months should fast for 3 hours; older children should fast for 8 hours. Formula and breast milk are considered solids and should occasion a 4-hour fast. Particulate aspiration is probably more harmful than acid aspiration. Patients at risk for aspiration include those who require emergency surgeries, morbidly obese or pregnant patients, and diabetics with gastric motility disorders. These patients are always considered to have full stomachs. Patients with difficult airways are also at risk due to gastric gas insufflation during airway manipulation.

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goldberg Table 1 American Society of Anesthesiologists Physical Status Classification ASA class I II III IV V VI Description Healthy patient Mild systemic diseases no functional limitation Severe systemic disease definite functional limitation Severe systemic disease that is a constant threat to life Moribund patient unlikely to survive 24 hours with or without surgery Organ donor

Warner and colleagues [25] found the incidence of aspiration in general anesthetics was 1 in 3,216; aspiration was 4.3 times more likely during emergency surgery. Most (64%) of patients who aspirated did not develop coughing, wheezing, or decreased arterial oxygen saturation within 2 hours of aspiration. This patient group did not develop respiratory sequellae. One half of the remaining patients needed respiratory support for longer than 6 hours after aspiration, and 5% of these patients died of respiratory insufficiency. Prophylaxis against aspiration includes delaying emergency surgery if possible, administration of nonparticulate antacids, use of cricoid pressure to prevent regurgitation during endotracheal intubation, and postintubation emptying of gastric contents by way of a nasogastric tube.

Cardiac complications All of the currently used potent inhalation anesthetics (isoflurane, sevoflurane, and desflurane) have negative inotropic effects and may affect heart rhythm and atrial-ventricular conduction.Cardiac concerns for young patients are primarily avoidance of severe bradycardia or asystole from the occulocardiac reflex and recognition of rare congenital or acquired valvular or cardiac structural anomalies, such as atrial or ventricular septal defects. Elderly patients present issues of myocardial ischemia, cardiomyopathy, and valvular stenosis or insufficiency. The preanesthetic history includes a functional assessment of the patients cardiac status using a standardized guideline, such as the American College of Cardiology/American Heart Association scale of cardiac risk factors, including exercise capability, recent history of myocardial infarction, dysrhythmias, congestive heart failure, and presence of a pacemaker or automatic implanted defibrillator [26]. These assessment systems are used to determine the extent of preoperative cardiac function investigation needed to reduce risk of intraoperative or postoperative myocardial ischemia. Patients with multiple risk factors who have not had a reasonable cardiologic evaluation may require consultation, a stress test or echocardiogram, or, rarely, cardiac catheterization before elective ophthalmic surgery. The incidence of myocardial infarction or ischemia after ocular surgery is small. McCannel and colleagues [27] followed 418 patients for 4 weeks who had received general anesthesia for vitreoretinal or ocular oncologic surgery. The incidence of myocardial infarction was 0.24% (one case). However, the

average American Society of Anesthesiology physical status of his patients was 2.1; elderly patients frequently have multiple medical conditions and a physical status of III or IV, indicating greater likelihood of postoperative complications (Table 1). Mortality and morbidity estimation based on ASA physical status must be qualified by the limited invasiveness of ocular surgery. General anesthesia permits alleviation of anxiety and pain with provision of high levels of arterial oxygenation and decreased myocardial demand for oxygen (from the negative inotropic effect of inhaled anesthetics). For patients and procedures not amenable to local anesthesia, general anesthesia is safe as long as the patients cardiac risk factors are assessed and optimized, symptoms and signs of ischemia are monitored and recognized, and airway obstruction and hypoxia throughout the perianesthetic period are avoided. Anesthesia personnel should be prepared to provide initial treatment of myocardial ischemia and should be advance cardiac life-support certified (or its equivalent) to treat dysrhythmias during or after surgery.

Awareness during anesthesia Unintended patient consciousness during general anesthesia has received increased recognition in the past 10 years [28]. The ASA Closed Claims Project disclosed 79 (1.9%) of 4,183 claims were for intraoperative awareness [29]. Estimates of awareness during anesthesia with use of neuromuscular blocking drugs (NMBs) are as high as 1 in 556 general anesthetics [30]. Potent inhalation anesthetics generally provide amnesia at 20% of the dose required to prevent movement upon surgical stimulation. Anesthetic adjuncts, such as midazolam, have excellent amnesic

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properties in small doses. However, patient variation, use of NMBs, and lack of definitive clinical signs of awareness make it difficult to detect. During general anesthesia with an LMA, spontaneous ventilation and avoidance of NMBs require deep enough levels of anesthesia to prevent movement so that consciousness rarely occurs. Patient paralysis may mask inadequate anesthesia. Emergency (eg, trauma, Caesarian section) and cardiac surgery patients, who receive more NMB than inhalation agent, are more at risk of awareness than ocular patients. Patients may remember a combination of consciousness, conversations, or pain during general anesthesia. Self-doubt, anger, nightmares, and fear of future operations may result, as a form of posttraumatic stress syndrome [31]. Treatment involves frank discussion with the patient acknowledging that awareness has occurred. Fear of legally admitting liability should not dissuade the anesthesiologist from discussing the problem with the patient. The best legal defense against a claim for awareness during anesthesia is that the anesthesiologist has informed a patient of the risk before the operation; (2) talked to her after the surgery about her experience; and (3) provided her with an explanation or an apology [32]. Some of the increased concern about awareness during general anesthesia may coincide with the introduction of a monitor that purports to detect it [33]. The BIS monitor uses a proprietary algorithm to process an electroencephalographic signal. It produces an absolute number from 0 (isoelectric EEG) to 100 (fully awake); awareness and recall supposedly do not occur when the BIS score is between 50 and 60. OConnor and colleagues [34] performed a power analysis to determine the cost of preventing awareness using BIS monitoring. If the incidence of awareness is 1 in 20,000, the cost to detect one case is $400,000; if the incidence is 1 in 100, the cost to detect one case is $2,000. Because there are reported cases of awareness using BIS monitoring, OConnor [35] concludes that BIS monitoring is not costeffective for prevention of awareness. The ASA is currently in heated discussion about adopting some type of EEG monitoring to detect and prevent intraoperative awareness. Until BIS or some equivalent monitor becomes a standard of care by way of a practice guideline, its use is at the discretion of the individual anesthesiologist. Ophthalmologic patients are rarely at high risk for awareness. Judicious use of NMBs and administration of low doses of potent inhalation agents along with pre- and postoperative patient consultation is the most costeffective way to prevent the consequences of awareness during general anesthesia.

Failure to regain consciousness after general anesthesia Unanticipated failure to regain consciousness after general anesthesia is fortunately a rare complication. The most common reason is probably anesthetic overdose. This is usually as a result of inadvertently continuing to administer inhalation anesthetics by failing to turn off the vaporizer, overuse of narcotics or NMBs, or syringe swap (eg, giving an NMB instead of a NMB reversal agent). Use of capnometry with analysis of inhalation agents is useful to detect their accidental continued administration. Peripheral nerve monitoring (twitch monitoring) allows assessment of the degree of neuromuscular blockade and the effectiveness of NMB reversal drugs. Recognizing the potential for reactive hypertension and tachycardia, naloxone, physostigmine, and flumazenil may be used to reverse sedation from, respectively, narcotics, centrally acting anticholinergic agents (scopolamine and rarely ophthalmic atropine), and benzodiazepines. Hyperventilation, used to quickly eliminate inhalation anesthetics, frequently decreases arterial carbon dioxide levels below the level required (PaCO2 of 45 mmHg). This eliminates the spontaneous hypercarbic ventilatory drive needed to activate the respiratory centers. Respiratory drive is also blunted by small residual doses of inhalation anesthetics. Because the patient (hopefully) lacks a hypoxic ventilatory drive, relative hypocarbia leaves the patient apneic until carbon dioxide levels rise with metabolism. Hypocarbic apnea combined with minimal stimulation and use of ocular local anesthetics can make the patient appear unresponsive for 10 to 20 minutes after cessation of a general anesthetic. After unexpected unresponsiveness persists and anesthetic overdose has been eliminated as a cause, less frequent and more serious causes must be considered. Metabolic causes of persistent unconsciousness include hypoglycemia, particularly in diabetic patients, hyperglycemia and hyperosmolar syndromes, hepatic and renal dysfunction, electrolyte imbalance (particularly hyponatremia), hypothermia and hyperthermia, and acidosis. Intraoperative neurologic injury may occur from hypoxemia or cerebral hypoxia and hypoperfusion, intracranial hemorrhage, and cerebral embolism. Though some operations are associated with cerebral impairment (heart surgery with cardiopulmonary bypass, major joint replacement), ocular surgery normally lacks this association. Failure to regain consciousness after general anesthesia requires maintenance of oxygenation and ventilation with mechanical ventilatory support; verification of arterial oxygen, carbon dioxide, pH, elec-

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trolyte, glucose, and serum osmolarity levels; and, if not tested preoperatively, determination of hepatic and renal function. CT or MRI scans may detect intracranial hemorrhage, mass lesions, or anoxic encephalopathy. If due to anesthetic overdose of some kind, patients will regain consciousness to some degree within hours of anesthetic cessation. If unconsciousness persists longer, neurologic or neurosurgical consultation should be obtained.

Monitoring complications Ophthalmic patients frequently have significant comorbidity, including coronary artery disease, chronic obstructive pulmonary disease, diabetes, and cerebral, renal, or hepatic insufficiency. Use of electrocardiogram, noninvasive blood pressure, capnometry, pulse oximetry, and temperature during general anesthesia is the standard of care [36]. Complications from these monitors are extremely rare. Invasive monitors, such as peripheral arterial, central venous, and pulmonary artery catheters, have a significantly higher risk of complications, including vessel thrombosis, arterial dissection, ventricular dysrhythmias, and infection [37]. A more subtle complication of invasive monitoring is lack of usefulness or misinterpretation of the information provided [38]. Considering the risks of invasive hemodynamic monitoring and its marginal benefits to the ocular patient who does not undergo massively stimulating surgery or suffer large fluid shifts, few of these patients need invasive monitoring for purely ocular surgery. The patient whose preoperative evaluation suggests a need for invasive monitoring is probably not in optimal medical condition for elective surgery.

may still occur despite these precautions. Neuropathies may not become manifest until days after surgery; the anesthesiologist will only discover them if the patient complains to the surgeon [41]. The ultimate outcome is not good; only 53% of Warners patients regained complete motor function and sensation a year after anesthesia and surgery [40]. Because good anesthesia practice (proper positioning and padding) does not reliably prevent postanesthetic neuropathy development, it may be useful to include this complication when obtaining informed consent for general anesthesia.

Allergic reactions during general anesthesia Most intravenous anesthetic agents have been reported to cause allergic reactions. However, reactions range from the expected (nausea from narcotics, reddish facial flushing from atropine) to the catastrophic (anaphylactic/anaphylactoid), requiring cardiopulmonary resuscitation. Preoperative evaluation involves careful questioning of the circumstances of a reaction to medication. For example, patients commonly claim to be allergic to local anesthetics, but true anaphylaxis is exceedingly rare, even reportable [42]. Much more likely, the circumstances will reveal an expected cerebral reaction to rapid injection of local anesthetic or cardiovascular reaction to rapid injection of adjuvant epinephrine (eg, during dental injections). Anaphylactic reactions are immune mediated; some previous exposure to a related antigen is necessary for antibody formation and reaction to occur. Anaphylactoid reactions are not immune related and may occur on first exposure to a triggering agent. Like most emergencies in anesthesia, recognition and immediate treatment is more important than definitive diagnosis of which agent has caused the reaction and why [43,44]. Anaphylactic reactions under general anesthesia produce any of the following symptoms and signs: wheezing, hypoxia, increased peak airway pressures, acute pulmonary edema, bronchospasm, tachycardia, dysrhythmia, severe hypotension or cardiovascular collapse, urticaria, or periorbital and perioral edema [45]. Treatment requires removal of the triggering agent if identified and discontinuation of anesthetic agents, early use of epinephrine and corticosteroids, fluid resuscitation, protection of the airway by way of endotracheal intubation, administration of 100% oxygen, and rapid termination of the surgical procedure. Even in the operating room context with instant observation, full monitoring and resuscitative mea-

Peripheral nerve damage Peripheral nerve damage is a surprisingly frequent complication after general anesthesia. The ASA Closed Claims study reviewed 670 claims for peripheral nerve damage (16% of 4,183 claims); most claims associated with general anesthesia were for injury to the ulnar nerve [39]. Warner and colleagues [40] found a rate of development of unilateral (91%) or bilateral (9%) ulnar neuropathy in 1 in 2,729 patients undergoing general anesthesia at the Mayo Clinic. Predisposing factors include male gender, thin or obese body habitus, and preexisting neuropathy and diabetes. Although proper padding and patient positioning during general anesthesia are critical to preventing ulnar nerve injury, postoperative deficits

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sures available, severe outcomes, such as cardiac arrest, renal failure, coma, persistent vegetative state, hemiplegia, or other neurologic sequellae, may result [46]. A recent French study reviewed 789 episodes of anaphylactic reactions during anesthesia. Most (58%) were caused by NMBs, particularly the newer nondepolarizing NMB rocuronium, with the rest caused by latex (17%), antibiotics (15%), and other various medications (10%) [47]. Rocuronium and succinylcholine were the NMBs most likely to cause these reactions; after allergy testing, cross-reactivity between NMBs was observed in 75% of cases [47]. Although the French study may have overestimated the incidence of anaphylaxis as a result of their method of skin testing, American and Norwegian studies also found NMBs to be the most common cause of perioperative anaphylactic reactions [48,49]. Inhalation agents do not cause anaphylactic reactions. The only instance of allergic reaction to inhalation anesthetics is rare, reportable cases of hepatitis after repeated exposure. Sufficient doubt has been cast on the existence of halothane hepatitis to consider it an exceedingly rare reaction [50]. However, prolonged exposure to inhalation anesthetics that produce trifluroacetyl (halothane, isoflurane, and desflurane) results in antibodies to the molecule in anesthesia personnel [51]. Inhalation agent related hepatitis remains a diagnosis of exclusion.

Renal and hepatic complications of general anesthesia Various metabolites of inhalation anesthetics have been theorized to cause renal function impairment. Fluoride ion from halothane, isoflurane, and sevoflurane can be measured, after long exposure, in micron concentrations associated with nephrotoxicity in animals [52]. However, Kharasch and colleagues [53] measured serum creatinine, blood urea nitrogen, creatinine clearance, urinary protein, and glucose excretion for 24 and 72 hours after 9 hour mean exposure to sevoflurane and isoflurane and found no evidence of renal function impairment. Sevoflurane metabolism under particular conditions (low fresh gas flows, particularly desiccated carbon dioxide absorbent) produces a haloalkane called compound A, which causes nephrotoxicity in rats [54]. Kharasch [53] and others who have reviewed this issue have concluded that the incidence of renal function abnormalities produced by sevoflurane must be exceedingly small given the large number of sevoflurane anesthetics given since its introduction [55]. For

ophthalmic patients with compromised renal function (eg, diabetics), sevoflurane may be used safely as long as systemic hypotension and low fresh gas flows (allowing washout of any compound A generated) are avoided. All potent inhalation anesthetics undergo hepatic metabolism. Up to 15% to 20% of halothane is metabolized, but the newer inhalation agents, sevoflurane and desflurane, undergo only 0.5% to 1% metabolism [56]. There are case reports of fulminant postoperative liver damage associated with all currently used inhalation anesthetics [57 59]. Proving a causal association between hepatic dysfunction and either a single or repeated exposure to an inhalation anesthetic is exceptionally difficult. Patients who present with hepatic dysfunction after anesthesia most often have other comorbidities or surgeries that predispose them to hepatic damage. Many studies have closely measured hepatic function and found minimal alterations after anesthesia. For example, Suttner and colleagues [60] found that though hepatocyte oxygenation levels slightly decreased during general anesthesia with desflurane and sevoflurane, overall hepatic function was unchanged. Various mechanisms have been proposed for hepatic injury after general anesthesia. Concurrent viral hepatitis may be unmasked by the stress of surgery and anesthesia, and most likely accounts for most anesthesia-related hepatic dysfunction. Oxidative and reductive metabolism of inhalation anesthetics results in compounds hepatotoxic in some species (rats, cats) but not others (dogs, mice) [61]. Metabolites of halothane have been found to bind to liver proteins and act as haptenes to produce hepatocyte-specific antibodies, which in certain families and patient populations reliably cause postexposure hepatitis [62]. Risk factors for inhalation agent-related hepatitis include obesity, middle age, female gender, and Mexican-American ethnicity. Obesity allows extended duration of storage and slow release and further metabolism of lipid-soluble agents. Repeated exposure, except in patients previously suspected of inhalation-related hepatitis, does not predispose to hepatic dysfunction. The entire subject of inhalation-related hepatic dysfunction has been compared with a sea of mystery, with some islands of knowledge, but generally pervaded by clouds of speculation, misinformation, and ignorance [63]. The diagnosis of postinhalation agent hepatitis is a diagnosis of exclusion, and cases are rare enough to be reportable. Proper attention to preexisting liver function via history and laboratory examination, avoidance of (repeated) exposure in the face of a family history of anesthesia-related hepatitis,

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and avoidance of liver hypoxia and hypoperfusion should make postocular surgery hepatitis an extremely rare complication of general anesthesia.

Equipment malfunctions and mechanical misadventures Anesthesia gas delivery systems and monitors are highly reliable but are subject to human error (common) and mechanical or electronic failure (rare) [64]. The standard of care is that anesthesia machine and monitor readiness are checked extensively at the beginning of the day and briefly before each subsequent case against a US Food and Drug Administration functionality checklist, much as a commercial airline pilot goes through a checklist before takeoff [65]. Unfortunately, compliance with the checklist requirement has been less than optimal. ArmstrongBrown and colleagues [66] reported that academic attending anesthesiologists checked, on average, only 10 of 20 items on a standardized checklist. Intensive training may improve machine checkout performance [67]. Simulations with intentionally created machine faults have also been disappointing. In a machine with five intentional faults, 7% of anesthesiologists found no faults and only 3% found all five faults. The average number found was 2.2 faults [68]. Anesthesiologists have reported some incredible human errors (eg, complete anesthesia circuit obstruction due to failure to remove shrink-wrap from carbon dioxide absorber canisters) [69]. However, candor in reporting mechanical problems has led to improvements in safety. For example, now carbon dioxide canisters are packaged in corrugated plastic, which cannot be ignored. Modern anesthesia machines do not allow administration of hypoxic gas mixtures; ophthalmic office practices should ensure that they do not use older machines without this failsafe. Devices to independently measure inspired oxygen concentration are particularly important in isolated or office facilities. Anesthesia machines also have alarms that detect low oxygen supply pressure, to alert to the need to switch to new oxygen supply tanks or emergency oxygen tanks mounted on the machine. Initial and continuous measurement of end-tidal carbon dioxide during general anesthesia is a firm standard of care [70]. If a functioning capnometer is not available, general anesthesia should not be provided. Introduction of capnometry has eliminated otherwise undetected esophageal intubation, which was previously a major source of anesthetic morbidity and mortality, particularly in obese patients with

difficult airways and distant breath sounds. Analysis of inspired and exhaled inhalation anesthetics, now commonly and economically available on capnometers, assists in not only decreasing unexpected awareness during anesthesia but also in facilitating anesthesia emergence. An exhaustive list of equipment-related problems with general anesthesia cannot be repeated here. Entire monographs have been dedicated to mechanical misadventures in anesthesiology (including an amusing photograph of a large H oxygen cylinders missile trajectory when its yoke was broken and it flew out of an operating room onto the sidewalk below) and understanding anesthesia equipment [71,72]. New equipment malfunctions are reported continuously and corrective actions are taken accordingly. Compliance with machine checkout procedures, scrupulous adherence to monitoring standards, and avoidance of personnel fatigue will increase detection and prevention of mechanical problems with general anesthesia [73]. Another common source of human error frequent enough to mention is syringe swap [74]. Anesthesia drugs are drawn from vials into labeled syringes in advance of usage. Care must be taken to avoid mistaking look-alike vials or labels. Meticulous identification of syringes immediately before injection can prevent mistakes such as giving more NMB or narcotic when an NMB reversal agent is intended. Modern inhalation vaporizers are agent specific and have a key-lock system to prevent accidental introduction of incorrect agents. Unfortunately, anesthesia personnel can be resourceful at bypassing safety systems.

Malignant hyperthermia Malignant hyperthermia (MH) deserves mention in a compendium of general anesthesia complications because it has received attention disproportionate to its incidence and is not likely to be encountered by an ophthalmologist not specializing in pediatrics. MH is an autosomal-dominant variable-penetrance genetic defect of calcium reuptake. The incidence is reported to be 1 in 15,000 children and may be more common in pediatric strabismus patients [75]. The adult incidence is less than 1 in 50,000 anesthetics. Succinylcholine and inhalation anesthetic agents trigger MH and result in skeletal muscle hypermetabolism. Before capnometry, the first indication of MH susceptibility was often high body temperature, paradoxical masseter muscle rigidity, or oliguria and myoglobinuria. By the time these signs appeared, survival from an untreated episode was less than

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30%. Routine use of capnometry allows early detection of MH episodes, as the first sign of an episode is hypercapnia despite seemingly adequate minute ventilation. A Web site (www.mhaus.org) and an expert-assisted hotline (United States and Canada, 1-800-644-9737, outside North America, 0011 315 464 7079), as well as a registry of known patients in North America, is maintained by the Malignant Hyperthermia Association of the United States (MHAUS). Family history of high temperature or fatality after anesthesia is suggestive of susceptibility, but nondiagnostic. Although several animal models, human blood tests, and DNA mapping have been studied, definitive diagnosis of MH is still made either after a well-documented episode or by way of muscle biopsy with in-vitro characteristic reactivity to triggering agents. Patients with a suggestive family history need not undergo muscle biopsy; a nontriggering anesthetic with propofol, midazolam, fentanyl, and a nondepolarizing NMB can be safely given [76]. The skeletal muscle relaxant dantrolene is a specific inhibitor of MH-induced hypermetabolism. Although expensive, it is a standard of care that dantrolene be readily available wherever inhalation anesthesia is provided. If geographically feasible, several facilities may share parts of the supply of dantrolene to decrease the per-facility cost.

Whether a particular type of anesthetic (MAC versus general, or one agent versus another) can prospectively affect mortality has been an extremely controversial subject. Thousands of studies and metaanalyses have not provided a clear answer. In the ocular surgery setting, the common-sense thought that general anesthesia is a more invasive intervention than MAC is often, but not always, correct. MAC anesthesia affects cardiovascular and respiratory function less than general anesthesia and usually provides faster return to preoperative functionality. However, patients with extreme anxiety, claustrophobia, chronic obstructive pulmonary disease, motion disorders, compromised airways, and those who need long (greater than 1.5 hours) surgery may have less physiological stress with general anesthesia than with MAC. General anesthesia with a secure airway, lack of tachycardia and hypertension, and an immobile surgical field is less stressful (for everyone) than big MAC anesthesia with sedation, resulting in airway obstruction and patient head or body movement. Choice of MAC versus general anesthesia depends in part on the patients ASA physical classification but also on type and duration of surgical procedure and patient, anesthesiologist, and surgeon emotional characteristics. Perioperative mortality is influenced more by skill in selection and administration of the anesthetic than by choice of MAC versus general anesthesia or the particular agent chosen.

Anesthetic mortality Older patients often fear general anesthesia. Before modern monitoring techniques and anesthetic agents, mortality from general anesthesia was as high as 1 in 1,216 anesthetics [77]. By 1989, Eichhorn [78] was able to report a mortality rate solely attributable to general anesthesia of 1 in 200,000. The reduction in mortality closely followed introduction of standardized monitoring protocols despite some caviling about the introduction of mandatory monitoring standards without double blind study verification of efficacy [36,79]. The American Society of Anesthesiologists developed a clinical classification of patient preoperative physical status in 1941, and although attempts have been made to supplant it, it remains in use today (see Table 1). Anesthetic mortality is roughly correlated with physical status. Wolters found a mortality rate of 0.1% for ASA physical status I patients and 18% for ASA physical status IV patients [80]. Type of surgery (major vascular) and emergency surgery also increase anesthetic mortality. Patient tolerance of critical incidents (near misses) decreases as ASA physical status increases. Dental damage Damage to teeth during either anesthetic induction or emergence is one of the most frequent but minor complications of general anesthesia [81]. As major morbidities and mortalities decrease, the incidence of dental claims in the ASA Closed Claims database has increased; dental injuries may account for as many as 33% of anesthesia-related malpractice claims [82]. Warner and colleagues [5] found an incidence of dental injuries requiring repair or extraction in 1 in 4,537 general anesthetics. Risk factors include poor dentition, preexisting crowns or caps, and various indices of difficult intubation. The level of resident training did not affect the likelihood of dental injury [83].

Anesthesia complications specific to the eye and ocular surgery Several ophthalmic complications of general anesthesia should not be of concern during ocular surgery.

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Corneal abrasions account for 3% of ASA closed claims; these cause pain, but permanent corneal damage is rare. Malpractice payouts are low, and the median payout is $3,000 [84]. Despite ophthalmologic control of the surgical area, anesthesiologists should be careful to prevent corneal abrasions of the nonoperative eye. Catastrophic visual loss after nonophthalmologic surgery is rare. Ischemic optic neuropathy and retinal arterial or venous occlusion are the most likely mechanisms of injury [85]. Predisposing factors include preexisting hypertension, diabetes, sickle cell anemia, renal failure, gastrointestinal ulcer, narrowangle glaucoma, vascular occlusive disease, cardiac disease, arteriosclerosis, polycythemia vera, and collagen vascular disorders. Precipitating factors for ischemic optic neuropathy include prolonged hypotension, anemia, surgery trauma, gastrointestinal bleeding, hemorrhage, shock, prone position, direct pressure on the globe, and long operative times. Prone and Trendelenburg positions and increased intracranial pressure are additional risk factors. Unexpected vision loss in the nonoperative eye after ocular surgery is extremely rare. Certain specific complications of general anesthesia occur during ocular surgery. Thirty percent of ASA closed claims for ocular injury were due to unexpected patient movement during ocular surgery; blindness resulted in every case [84]. Inadequate muscle relaxation by NMBs during inadequately deep general anesthesia, or coughing from endotracheal intubation, may cause retinal detachment, corneal laceration, lens subluxation, or expulsion of intraocular contents during corneal grafting. Prevention requires use of neuromuscular blockade monitoring, assurance of adequate levels of anesthesia, and acceptance of delayed NMB reversal upon completion of surgery as the price of assuring unexpected movement during surgery. The hoary debate about the effect of succinylcholine on intraocular pressure during ruptured globe surgery has been obviated by use of nondepolarizing NMBs [86]. Increased intraocular pressure from succinylcholine may be associated with small corneal lacerations or globe puncture wounds that have maintained overall globe integrity. If the globe is ruptured or the laceration is large enough that the intraocular pressure is near 0 mmHg, succinylcholine will not increase the intraocular pressure. Use of a large dose of nondepolarizing NMB provides emergency muscle relaxation for intubation quickly compared with succinylcholine [87]. A rare but avoidable complication of general anesthesia after retinal surgery is blindness caused by

nitrous oxide-induced expansion of perflurocarbon or sulfur hexafluoride bubbles. Nitrous oxide will diffuse into gas-filled spaces faster than nitrogen; oxygen or ophthalmic gases diffuse out and cause retinal ischemia. Yang and colleagues [88] first reported a case of blindness after nonocular general anesthesia in 2002, and seven cases have been reported since then. Patients who have retinal surgery with use of intraocular gas bubbles should wear warning bracelets until the bubble has likely dissipated. The anesthesia history should disclose recent ocular surgery for past retinal surgery or current retinal surgery, and nitrous oxide is easily avoided.

Summary Complications of MAC and general anesthesia are increasingly rare, and severe morbidity and mortality have decreased as techniques for prevention and treatment have become widespread. Ocular anesthesia involves population subsets (geriatric, pediatric, vascular, and diabetic) that have known propensities to have certain complications, and ophthalmic surgery requires certain routine precautions to avoid the most common complications. Vigilance in patient evaluation, equipment and drug preparation, and monitoring during surgery, despite production pressure of modern anesthetic practice, is the best way to prevent avoidable anesthesia complications [89].

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and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996;77(2):217 22. Owen H, Waddell-Smith I. Dental trauma associated with anaesthesia. Anaesth Intensive Care 2000;28(2): 133 45. Holzer JF. Current concepts in risk management. Anesthesiol Clin North Am 1984;22:91 102. Gaiser RR, Castro AD. The level of anesthesia resident training does not affect the risk of dental injury. Anesth Analg 1998;87(2):255 7. Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries associated with anesthesia. A closed claims analysis. Anesthesiology 1992;76(2):204 8. Rupp-Montpetit K, Moody ML. Visual loss as a complication of non-ophthalmic surgery: a review of the literature. Insight 2005;30(1):10 7. Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe. Tracing the teaching. Anesthesiology 2003;99(1):220 3. Chiu CL, Jaais F, Wang CY. Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anesthesia. Br J Anaesth 1999;82(5):757 60. Yang YF, Herbert L, Ruschen H, et al. Nitrous oxide anaesthesia in the presence of intraocular gas can cause irreversible blindness. BMJ 2002;325(7363):532 3. Leedal JM, Smith AF. Methodological approaches to anaesthetists workload in the operating theatre. Br J Anaesth 2005;94(6):702 9.

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Economic Evaluation of Different Systems for Cataract Surgery and Anesthesia

Kevin D. Frick, PhD
Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Health Services Research and Development Center, 624 North Broadway, Room 606, Baltimore, MD 21205, USA

Economic evaluation is an increasingly important component of health and medical care policy making although it continues to be met with some resistance in part because of misgivings about the methods that are used [1,2]. Many fields of medical care services and public health have extensive economic evaluation literature. In ophthalmology, the literature is less well developed and there is an ongoing discussion of the most appropriate methods [3 5]. This article (1) outlines different types of economic evaluations providing examples on their potential use in ophthalmic care decision making, (2) reviews three articles in the brief recent literature on the cost-effectiveness of ophthalmic anesthesia and cataract surgery in the United States with a focus on explaining methods that were used, and (3) discusses ways in which research in this area might be moved forward.

Types of economic evaluations High-quality economic evaluations provide a logically consistent and methodologically rigorous way of describing the costs associated with a condition or comparing costs of a treatment to effects of the treatment. Evaluations include information on costs, clinical effectiveness measures, quality of life, or other aspects of the value that individuals place on care and the effects of care.
This work was supported by the National Eye Institutes grant no. 5R01EY012045. E-mail address: kfrick@jhsph.edu

In most evaluations, all spending is given equal weight in the cost analysis and the clinical and quality of life changes for all patients are given equal weight in the assessment of effectiveness [6]. Treating everyone equally is fair, but it does not capture other values that may be of interest. For example, there is no explicit consideration of whether the treatment is more likely to be administered to those of higher or lower socioeconomic status. An intervention may be aimed at one socioeconomic group so that the results will obviously be interpreted with a focus on a specific socioeconomic group, or subgroup analyses may be conducted to help policy makers understand the effects on different groups. However, general cost-effectiveness analysis of a treatment affecting multiple socioeconomic groups does not dictate or even use relative values for different individuals. All analyses must be interpreted with an understanding of how the analysis treats different individuals and whether this is consistent with the values of the policy maker or the affected population. The following six types of economic evaluations are discussed in this section [6 8].
     

Cost Cost Cost Cost Cost Cost

of illness/burden of disease minimization consequence effectiveness utility benefit

The types of studies are listed in order of increasing ability to provide policy makers with information that can be directly used to set policy. The

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.013

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reasons that the studies at the bottom of the list provide information that can be used more directly will become clear as each is described. Along with each definition, the use of the type of study for health decisions about cataract surgery or ophthalmic anesthesia will be illustrated. Cost of illness and burden of disease studies provide the least information for policy makers as both types of studies only describe the costs experienced and do not compare costs with effects. Cost of illness studies can take either an incidence cost approach or a prevalence cost approach [9]. Incidence costs are lifetime costs associated with a new case of the condition being studied. Prevalence costs are all costs of treating everyone with the condition in a given year. We will refer to cost of illness studies taking an incidence cost approach as cost of illness studies and those that take a prevalence approach as burden of disease studies. To illustrate the implications of these definitions, consider studies related to cataract surgery. A cost of illness study focusing on cataracts will enumerate the expected lifetime costs of an incident case of cataract. In contrast, a cataract burden of disease study will enumerate the amount of money that is spent to treat all cataract patients in a year. This includes treatment for both cases prevalent at the start of the year and cases incident during a year. If cataract prevention were the objective, a cost of illness study would provide information on the lifetime costs that could be avoided by preventing a cataract. If cataract surgery for an individual who is otherwise legally blind were the objective, a cost of illness study focusing on blindness would provide information on the lifetime costs that could be avoided by a successful surgery. In neither case does the cost of illness alone provide an economic reason for prioritizing cataract surgery. In both cases the cost of illness that could be avoided must be compared with the cost of treatment to make an economic recommendation. Burden of disease provides information on the impact of a condition on the economy in a year but can only be used to describe the total costs that can be avoided if all cases of the condition are eliminated. This type of study is useful for directing the publics attention to the importance of a condition but is not particularly useful in making policy recommendations. Cost minimization studies can be used to facilitate policy recommendations when two interventions or treatments have similar effects. Similar effects could mean literally the same effect. However, similar effects could also mean two treatments for which the effects are not statistically different. Finally, two

treatments might both meet a threshold criterion, and the policy maker may not be concerned with the degree to which the effects exceed the threshold. Healthy People 2010 provides an example of thresholds of interest [10], although many of the vision care objectives are developmental and the only objective for cataract is to reduce visual impairment as a result of a cataract. If each of two interventions reduced visual impairment and a policy maker was not interested in the magnitude of reduction, then the two alternatives could be compared to determine which has the lower costs. Cost minimization based on two alternatives meeting a threshold would be more useful if the objective were stated in the form of reduce the proportion of the population with visual impairment due to cataract to less than 1% of the population aged 65 or older. Another important aspect of cost minimization analyses is an understanding of the perspective from which costs are being considered. The perspective refers to whose costs are considered. The objective may be to minimize costs to the government, costs to a private insurer, costs to the patient, or costs to all of society. A single intervention may not minimize costs from all perspectives. Cost consequence studies are useful when there are multiple impacts of a treatment or intervention but it is difficult or impossible to find a suitable summary measure for the outcomes. This type of analysis may be more palatable to a policy maker; in spite of the lack of a summary measure, the outcomes are more transparent as the policy maker does not need to understand how dollar values are placed on clinical outcomes or how quality adjusted life years are calculated [7]. This type of analysis is not likely to be necessary for ophthalmology interventions or treatments. Ophthalmology care is usually aimed at avoiding or overcoming visual impairment or blindnessand cases of these conditions are often the primary outcomes of interest. These can affect quality of life and mortality, which can also be considered in cost outcome studies. When cost consequence studies are performed, they are less directly informative than cost minimization studies. Cost minimization studies can be used to make a clear case for one intervention based on having a lower cost when multiple interventions have similar effects. In contrast, cost consequence studies essentially provide a list of pros and cons. The policy maker must then make a comparison of the pros and cons in a relatively unstructured way. The result of a cost-effectiveness analysis is the amount of money spent per clinical outcome. In the context of cataract, the simplest clinical outcome

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is cases of visual impairment prevented. Obviously, there could be more specific measures of visual acuity or visual function as well. The key is that there is a clear primary outcome. These studies are useful when making a decision about a new treatment or intervention used for a specific condition or to avoid a specific clinical outcome. If there were an improvement in cataract surgical technique, a cost-effectiveness study could address the following question: using the new surgery rather than the old, how much extra money is spent and how many more cases of visual impairment are avoided? Taking the ratio of these two figures, the result can be expressed as the extra cost per extra case of visual impairment avoided. A limitation with this type of study is that there is no explicit way to compare costeffectiveness analyses done for different conditions or treatments. For example, there is no explicit way to determine whether spending $2000 to avoid a case of visual impairment is worth more or less than spending $10,000 to avoid a stroke. This limitation may not be severe, as health policy makers rarely make decisions on whether to treat visual impairment or stroke but most often seem to make decisions on the best way to treat a particular condition. Cost-utility analyses use a standard outcome that summarizes multiple types of morbidity and mortality. This summary measure is referred to as a quality adjusted life year. Ophthalmology patients can gain quality adjusted life years by increasing their quality of life (by maintaining visual functional) during the years they would have been alive anyway or by extending the length of their lives. The final result in cost utility analyses is not the extra dollars spent per extra case of visual impairment avoided, but the extra dollars spent per extra quality adjusted life year gained. The use of cost-utility results requires policy makers to decide whether it is worth spending a certain amount of money to gain a quality adjusted life year (QALY). The advantage over cost-effectiveness is that only a single figure is needed, because the theory underlying cost-utility analysis suggests that the reason for improvements in QALYs should not affect the value of the QALYs. Cost-benefit analyses require the analyst to express the benefits in dollars. Some effects of changes in health at the individual or population level are difficult to express in monetary terms and can only appear alongside the main result in a cost-benefit analysis. The primary result is the calculation of the difference between the dollar value of benefits and the costs, and the primary criterion for implementation is that the net benefit is positive, that is, benefits are larger than costs. Thus, the policy interpretation is

much more direct with cost-benefit analyses than with other cost outcome analyses. A simple cost-benefit analysis from the limited perspective of an insurer would ask whether there is a business case for a new treatment, or Does care under a new treatment regimen cost less than an older treatment regimen? From a broader societal perspective, there could be an interest in the amount of productivity gained by patients, the amount of decreased informal care provided by family and friends, and other results of morbidity and mortality that can be expressed in monetary terms. From a payers perspective, a new development in ophthalmic anesthesia could lead to higher costs in the operating room but lower total costs including recovery time. From societys perspective, a costbenefit analysis focusing on cataract surgery could define all economic changes related to cataract surgery and ask whether the dollar value of the beneficial changes is higher than the dollar value of the changes that increase costs.

Cataract surgery and anesthesia One recent study used a decision analytic model to evaluate different anesthesia management strategies [11]. This article demonstrates many methods common to economic evaluations. These methods include modeling, the need for transparent parameters, preference elicitation, sensitivity analysis, and appropriate incremental analysis. Decision trees and modeling Reeves and colleagues [11] used a decision tree to model the costs and effects of six anesthesia management strategies. A decision tree represents a sequence of decisions, random events, and outcomes. The outcomes usually include costs and either clinical or quality of life outcomes. The tree allows for the calculation of the probability of each outcome that is used to define expected costs and expected outcomes. The costs and clinical or quality of life outcomes are compared to determine which alternative yields the most preferred combination of costs and outcomes or which alternative yields the best outcome but is not excessively costly per unit of outcome. The authors provide a useful and understandable description of decision trees. Many economic evaluations rely on models because randomized trials would be unethical, or cost prohibitive, or require too much time relative to the time frame for policy making. In some cases, a model

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can be used as a precursor to a randomized trial. Models can be simple, for example, a screening model in which individuals are true positive, true negative, false positive, or false negative and the results do not vary once a patient is in one of these groups. Alternatively, models can be complex with multiple levels of random events necessary to represent events like annual diabetic retinopathy screenings over time. Transparent model parameters A key feature of the article by Reeves and colleagues [11] is a table that lists all the parameters in the model including probabilities of events, the costs associated with the choice of anesthesia management methods and the consequences of the methods, and the preferences for each method. The combination of a figure showing the decision tree and a table showing the parameters in the tree helps to make the model that is being used transparent so that readers can evaluate validity of the model. At one level of validation, a model must include appropriate outcomes that are linked to choices and random events in ways that make clinical sense. A model can also be externally validated if there is an outside data source that includes longitudinal data on individuals who begin at a point at which they would enter the model. The observed probability of various outcomes can then be compared with the results obtained when individuals are modeled to assess how well the model predicts the distribution of outcomes. The table in the Reeves and coworkers article [11] not only lists the parameters but also the sources of data for the parameters. In general, there are multiple sources of data for nearly every model-based cost-effectiveness or decision analysispast reports of randomized trials, administrative claims data, Medicare reimbursement rates for prices, average wholesale prices, survey data, and expert panel data. Expert panel data are generally the least preferred and should be used sparingly, but these data are sometimes the only data available. In this study, only the three probabilities of converting between types of anesthesia and preferences for management strategies were provided by the expert panel. Obtaining probabilities from an expert panel is less problematic than obtaining preferences. Stein [12] suggests that providers have a different perception of the utility of various treatments and health conditions than their patients have. The standard recommendation for preference measurement is that a cost-effectiveness or decision analysis should use preferences of a cross-section of individuals from society at large [6]. Societal preferences are thought

to be best to use when allocating societal resources. However, at least some authors focus on patient preferences [3]. Societal preferences can be difficult to obtain if the condition or treatment has not been studied before and if the condition or treatment is difficult to describe to a group of respondents who have not experienced the condition. Preference elicitation The research [11] used a visual analog scale approach for preference elicitation. This is the least cognitively demanding and least preferred method from a theoretical perspective, although for an assessment of the preferences for a temporary condition like anesthesia management rather than a chronic condition like blindness, it was completely appropriate. The visual analog scale approach to preference elicitation has two important limitations. First, given the historical definition of health utility measures, they are supposed to reflect tradeoffs and forced choices between alternatives [6]. The visual analog scale does not do this. Second, the visual analog scale described in the article used anchor points representing the ideal experience and the worst experience imaginable. Not everyone imagines the same worst experience. The scale used in most preference elicitation methods that involve a specific tradeoff is anchored by perfect health and death. Given the limitations of visual analog scale methods generally and the relatively narrow topic for which preferences were measured in this study, the preference scale can only be used to compare anesthesia management methods for cataract surgery. Preferences measured in this study lack comparability with preferences assessed in other studies. Comparability across studies is a goal of cost-utility analyses. Other preference elicitation measures include the time tradeoff and standard gamble [6]. These methods force respondents to make a choice between an alternative involving living the remainder of ones life in a less than optimal health state and a second alternative involving either living in perfect health a shorter amount of time for certain or a probability of perfect health or immediate death. These are more cognitively demanding and many respondents refuse to make this type of tradeoff, but they are based more clearly in economic theory. There is not a single preference value for blindness. One study found a value of 0.70 for monocular blindness and 0.35 for binocular blindness [13]. A second study demonstrated that among a legally blind sample there is a wide range of utilities that patients report for their own condition: those with no light perception have the

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lowest utility; those with light perception have higher utility; and those with visual acuity of 20/200-20/400 in the better seeing eye have the highest utility [14]. The utility weight for blindness in a community sample was 0.75 [15]. Sensitivity analysis Sensitivity analysis is a term for assessing changes in the cost-effectiveness results with changes in the values of parametersparticularly those that are assumed. Reeves and colleagues [11] conduct sensitivity analysis by varying one parameter or two parameters at a time. While this type of analysis indicates whether the results change when a parameter changes, this type of analysis does not give a clear indication of the likelihood of a change in the qualitative nature of the cost-effectiveness results. State of the art analyses at present use probabilistic sensitivity analyses in which parameters are drawn repeatedly from distributions and the results are reevaluated with each draw to describe the probability of the qualitative cost-effectiveness results holding. Incremental analysis Finally, the authors performed a proper incremental analysis. Sometimes authors simply ask how much it would cost per QALY or improved clinical outcome under each alternative. A true incremental analysis considers all the alternatives (six in this case) simultaneously. The alternatives are arranged in order by cost. Alternatives that are equally expensive but produce less positive outcome and alternatives that produce a similar positive outcome but cost more are eliminated from consideration. Among those that remain, the extra cost per extra unit of outcome is assessed as the policy choice changes from the least expensive to the most expensive alterative that has not been eliminated. This allows the policy maker to ask repeatedly, How much would more of the outcome cost? Based on economic criteria alone, resources should be allocated to the alternative with the maximum positive outcome for which the policy maker is willing to pay the cost per improved outcome. Conclusion The authors concluded that alternatives including topical anesthesia yielded a lower utility at approximately the same costs as alternatives without topical anesthesia. Among the three alternatives without topical anesthesia, having an anesthesiologist on call

cost only a small amount more than not having an anesthesiologist available but that the preference for the on-call scenario was much higher. In contrast, while having an anesthesiologist present increased the preference weight relative to having an anesthesiologist on call, the cost was over six times higher per patient.

Cataract surgery Two relatively recent US studies characterize the cost-effectiveness of cataract surgery separately in the first eye and the second eye [16,17]. Both used similar methods that will be described together. Modeling and parameters Similar to the work by Reeves and colleagues [11], both articles used modeling. An article on care for age-related macular degeneration patients still used a model but built more directly on a randomized trial [18]. The decisions modeled in the two articles on cataract surgery were surgery in the first eye or not and surgery in the second eye or in one eye only. In each model, the decision on surgery is followed by the possibility of one of four complications within the first 4 months. One of the complications (retinal detachment) is given a single preference value and each of the other three complications will result in one of two outcomes. A key implication of the model is that the preference weight improvement is the same no matter how old the patient is. When there are no complications, a gain of 0.15 units on a scale that ranges from 0 to 1 for surgery in the first eye is assumed to apply for the remainder of the persons life. A gain of 0.11 units on the same scale is assumed to apply for the remainder of the persons life after surgery in the second eye. The gains in utility from improved vision may diminish over time as a patient experiences other comorbidities that limit utility. Present value In the article analyzing the management of anesthesia, the analysis included preferences for the management strategy during the short surgery rather than for the chronic health state being addressed. In the cost-effectiveness analyses related to cataract surgery, the time period to which the preference applies is the remainder of the patients life. For most patients, the life expectancy is more than 1 year. The analysis applies relative weights to benefits and costs

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that occur in the future in comparison with those that occur immediately. This is the process of calculating a present value or discounting. Under the standard approach the relative weight for future events is smaller than for immediate events. For costs, the reasoning is straightforward. If a patient will need to spend $100 for eye care next year, the patient could put less than $100 in the bank now, earn interest, and have the $100 next year. This generalizes so that the present value of any dollars used a year from now is lower than number of dollars considered. Health benefits are treated the sameso a year with better vision that happens in the future is worth less than the current year with better vision. A commonly recommended discount rate is 3% [6,19]. This implies that the value of events that occur 1 year later is 97% of the value this year. One year later, the value is 97% of the 97%. This continues indefinitely and the value of a future benefit 24 years in the future is approximately one half of the value of the same benefit that occurs today. This can make the lifetime value of a health improvement considerably smaller than the 1-year gain multiplied by the remaining life expectancy. The authors of the two articles [16,17] use a 3% discount rate and it diminishes the QALYs gained from 1.78 without discounting to 1.25 in present value termsin effect decreasing the gains by one third. Sensitivity analyses Both articles [16,17] used one-way sensitivity analyses and analyses that changed all utility values simultaneously. The reason for changing all utility values simultaneously is not entirely clear. The effect of changing all values simultaneously is essentially that the differences in utilities will increase or decrease by the percentage of increase or decrease. The differences are critical to incremental costeffectiveness analysis. By way of example, increasing the utility of both no surgery and no complications by 10% would change the utilities from 0.71 and 0.86 (a difference of 0.15) [16] to 0.78 and 0.95 (a difference of 0.17). The increase in the difference is approximately 10%. One difficulty with a scale that is bounded at 1 is that increasing the utility of some of the states by a substantial amount makes the health state appear to be much less negative or much less worse than a perfectly healthy status. Conclusions Both studies demonstrate that cataract surgery costs a small amount for each QALY gained in the analysis using all the base assumptions and in all

sensitivity analyses. A key consideration is the interpretation of a small amount per quality adjusted life year gained. In the United States, a threshold of $50,000 per QALY gained is often used to separate treatments and interventions that are deemed to be relatively cost-effective from those that are not. However, there is not complete agreement on the appropriate threshold value [20].

Future of economic evaluation in ophthalmic anesthesia and cataract studies If economic studies continue to gain traction in health care priority setting, the number of economic evaluations of anesthesia management practices associated with ophthalmology procedures and economic evaluations of the procedures themselves is likely to grow. Economic evaluation can be an important input to policy making and treatment recommendations but should never be the only input. The studies reviewed are instructive; they provide a template and set a high standard for future studies. Additional assessment of patients and the general publics preferences for health states associated with vision problems and the incidence costs of visual impairment will make future studies more informative. Following methods recommendations, particularly making models and their parameters transparent will increase future studies impact.

Summary This article (1) outlines different types of economic evaluations, (2) reviews three recent articles on the cost-effectiveness of ophthalmic anesthesia and cataract surgery, and (3) discusses ways in which research in this area might be moved forward. Costutility analyses using decision trees, societal preferences, and probabilistic sensitivity analyses would represent the state-of-the-art in all respects. The three articles reviewed do not meet all three criteria. Reading, interpreting, and conducting such analyses in the future will be facilitated by understanding methods recommendations.

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