Topical anesthesia: possible risk factor for endophthalmitis after cataract extraction

PURPOSE: To assess the relationship between the risk for acute endophthalmitis after cataract extraction and whether certain factors, such as surgeon qualification, numerical order, duration of surgery, operating theater, and type of anesthesia (topical or retrobulbar), could be modified to decrease the risk. SETTING: Single-center academic practice. METHODS: Two epidemiological studies were performed: a case-control study and a retrospective cohort study. The surgical records of all patients with clinically diagnosed endophthalmitis within 30 days after cataract surgery performed between February 2002 and September 2003 were reviewed. The endophthalmitis cases were compared with 108 randomly selected controls (4 controls per case). The global incidence of endophthalmitis and the incidence according to type of anesthesia were calculated. RESULTS: Of 5011 cataract extractions performed, 27 cases of endophthalmitis occurred. The incidence was 5.39 per 1000 procedures. An independent statistically significant relationship was found between endophthalmitis and the use of topical anesthesia (odds ratio [OR], 11.8; 95% confidence interval [CI], 2.4-58.7) and surgery longer than 45 minutes (OR, 7.2; 95% CI, 1.7-29.7) but not between the other variables. The incidence of endophthalmitis was 1.8 per 1000 cataract extractions with retrobulbar anesthesia and 6.76 per 1000 with topical anesthesia (relative risk [RR], 3.76; 95% CI, 0.89-15.85). After the start of the study period was extended to May 2001, the incidence of endophthalmitis was 1.3 per 1000 cataract extractions with retrobulbar anesthesia and 8.7 per 1000 with topical anesthesia (RR, 6.72; 95% CI, 1.63-27.63). CONCLUSION: Results suggest that there may be an association between topical anesthesia and endophthalmitis after cataract extraction.     

Simultaneous bilateral cataract surgery--advantages and disadvantages

During the past decade, advances in techniques and technology led to major changes in cataract surgical practice patterns. In this progression towards ever faster eye rehabilitation after surgery, simultaneous bilateral cataract surgery (SBCS) may be the next and ultimate step. It is not routinely performed: however, there are certain situations in which SBCS might be beneficial to the patients. It has been considered a good option in patients who have significant cataract in both eyes and are not good candidates for having anesthesia and surgery twice. The question is, if the benefits by bilateral surgery justify the risk of simultaneous complications, in particular endophthalmitis. In this perspective we present the clinical, social and economic advantages and disadvantages of such surgical procedures.     

Aerosol containment box for laser treatment of retinopathy of prematurity in COVID-19 pandemic

Type 1 retinopathy of prematurity (ROP) requires emergency intervention and laser is an established modality of treatment. Laser treatment for ROP under topical anesthesia can be considered as an aerosol-generating procedure due to crying that puts health care workers at high risk of COVID-19 transmission. Aerosol containment box (ACB) is known to minimize aerosol transmission and there are reports of ROP laser done through incubator. Combining these two ideas, we describe a new application of ACB with suction for laser treatment of ROP thereby, reducing risk to health care team without compromising timely effective, and safe treatment for ROP.     

Prevalence of systemic and ocular diseases in age-related cataract patients

BACKGROUND: Cataract patients often display concomitant ocular and systemic diseases which may influence the decision between general and regional anesthesia. The aim of this study was to quantify co-morbidity of these patients and assess the influence of the two types of anesthesia an the anesthesiological risk on the frequency of intra- and post-operative complications and visual outcome. METHODS: In this prospective study, in patients scheduled for cataract extraction at the University Eye Hospital and Clinic of Ulm (tertiary eye care center) all systemic and ocular diseases as well as intra- and postoperative complications were analyzed. The prevalence of the co-morbidity in our patients was compared to other studies including age-matched controls. The anesthesiological risk was quantified using the classification scheme of the American Society of Anesthesiologists (ASA). RESULTS: Eighty-eight patients with a mean age of 70.4 +/- 11.7 years were analyzed. Sixty-one% of patients displayed systemic as well as ocular co-morbidity. Only systemic or ocular comorbidity was present in 32% and 5% of patients, respectively. Two% of patients exhibited neither ocular nor systemic comorbidity. In 61% of patients the surgery was performed in regional anesthesia and in 39% in general anesthesia. The prevalence of systemic and ocular co-morbidity as found in our study was significantly higher as compared to that in the general population of the same age. Visual improvement and the frequency of intra- and postoperative complications were independent on type of anesthesia and anesthesiological risk. CONCLUSIONS: Patients who were scheduled at our institution for cataract surgery exhibited a high frequency of ocular as well as systemic co-morbidity. This can be interpreted in such a way that patients with a high level of co-morbidity are referred to tertiary eye care centers for cataract surgery.     

双眼是否可同期行白内障手术

双眼同期白内障手术在发展中国家开展较少,许多医师不赞同进行双眼同期手术主要是担心术后并发眼内炎,以及不利于调整第二只眼包括人工晶状体度数误差在内的手术方案。近年来,随着现代白内障手术安全性和可靠性的提升,应重新考虑双眼同期白内障手术的可行性,其具有节约医疗资源与成本,降低麻醉包括全身麻醉的风险,提升视觉效果及儿童患者的手术效果等多种优势。（国际眼科纵览,2020, 44：87-91）     

Monitored anesthesia care for enucleations and eviscerations

OBJECTIVE: To report the technique and success of using monitored anesthesia care instead of general anesthesia for ocular enucleation and evisceration surgeries. DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Twelve enucleated patients (Soparkar and Patrinely) and 146 eviscerated patients (Kulwin and Kersten). METHODS: Surgical logs of two oculoplastic practices were reviewed searching for cases of ocular enucleations and eviscerations performed under monitored anesthesia care between 1990 and 2001. Identified hospital and clinic charts were then reviewed. MAIN OUTCOME MEASURES: Monitored anesthesia care was deemed successful if (1) there were hemodynamic stability and complete analgesia intraoperatively; (2) there was absence of any chart documentation regarding patient or family psychological distress over the anesthesia method used; and (3) patients were discharged from the hospital without the need for observation or treatment > or = 23 hours. RESULTS: Between 1990 and 2001, 146 eviscerations were performed under local anesthesia with monitored anesthesia care by two surgeons (RCK, DRK) as their routine practice pattern. In 1996, Drs. Soparkar and Patrinely began performing enucleations under monitored anesthesia care in selected cases, and from 1996 to 2001, these surgeons enucleated 12 patients under monitored anesthesia care. Four of the enucleated patients requested surgery without general anesthesia. The remaining eight patients had been refused surgery by at least one other specialist because of the patient's perceived high medical risk for complications under general anesthesia. In all 158 patients, the procedures were deemed successful by the preceding criteria. CONCLUSIONS: This four-surgeon case series reports the successful use of local anesthesia with monitored care for ocular enucleation and evisceration procedures, offering several potential advantages over the traditional use of general anesthesia.     

Orbital regional anesthesia: complications and their prevention

Serious complications following orbital regional anesthesia are rare, but occur following both needle and blunt cannula (sub-Tenon's) techniques. Each technique of orbital regional anesthesia has its own risk/benefit profile. This article reviews the etiology, risk factors, treatment and prevention of complications of commonly used akinetic orbital blocks. Ophthalmologists and ophthalmic anesthesiologists must be prepared to deal with rare, but serious complications, that can occur with any technique of orbital regional anesthesia.     

Peribulbar anesthesia for strabismus surgery

We prospectively studied 76 patients to analyze the effectiveness of peribulbar anesthesia during strabismus surgery. The patients, ranging in age from 14 to 77 years, were given anesthesia with standard preoperative medication and a peribulbar injection of a mixture of 2% mepivacaine hydrochloride and hyaluronidase. Only one of the 76 patients required an additional injection of anesthetic to achieve adequate anesthesia. No morbidity was associated with the peribulbar anesthesia. Local anesthesia, particularly retrobulbar anesthesia, has been used as an alternative technique in an attempt to reduce the morbidity and mortality associated with general anesthesia in ocular surgery, particularly in those patients with high-risk characteristics. Even with retrobulbar anesthesia, however, there is a risk of morbidity and, in rare cases, mortality. Our results suggest that the use of peribulbar anesthesia is a safe and effective means of anesthesia in strabismus surgery because of minimal associated morbidity.     

Staggered sub-Tenon's blocks: a novel anesthetic approach for bilateral strabismus surgery

Bilateral strabismus surgery is usually performed under general anesthesia. However, sometimes general anesthesia is not in the best interest of patients presenting with advanced multiple comorbidities. These patients are best treated with local anesthesia instead. However, the bilateral nature of the surgery becomes an issue because bilateral akinetic needle blocks for ophthalmic surgery have not been described before. This article describes a novel approach for bilateral eye surgery in three patients who were at high risk from general anesthesia but needed to have the surgery performed in the same sitting. Staggered blunt needle sub-Tenon's blocks were chosen over sharp needle akinetic extraconal peribulbar or intraconal retrobulbar blocks on account of their predictability, relative safety, and efficacy. The potential systemic complications of bilateral injections were minimized by staggering the blocks. This technique may be an option for high-risk patients who are not candidates for general anesthesia but require bilateral ophthalmic surgery performed in a single surgical episode.     

Topical anesthesia for penetrating keratoplasty

PURPOSE: To evaluate the use of topical anesthesia for penetrating keratoplasty (PKP) in situations where retrobulbar, peri/parabulbar, or general anesthesia are inadvisable or not readily available. METHODS: This was a retrospective analysis of a consecutive case series consisting of 8 eyes in 8 patients who had PKP with topical anesthesia between September 1995 and December 1997 in cases where retrobulbar, peri/parabulbar, or general anesthesia either could not be performed or presented too great a risk to the patient. Some cases were supplemented with small limbal injections, mild intravenous sedation (fentanyl), and/or intraocular anesthesia. In one case, intraocular 1% lidocaine was placed directly into the vitreous cavity to allow an open-sky vitrectomy. RESULTS: In all cases, PKP was completed without complications. All patients tolerated the procedure well and reported only mild discomfort. However, in 2 cases, an ACIOL was left in place because lens manipulation caused pain in the ciliary body and iris root areas. CONCLUSIONS: PKP can be performed successfully with topical anesthesia in cooperative patients who have perforated corneal ulcers, significant anticoagulation, or severe medical conditions, which make alternative forms of anesthesia more risky.     

Anesthesia for eye operations in mitochondrial encephalomyelopathy

Mitochondrial encephalomyopathy involves a disturbance of the mitochondrial respiratory chain, as a result of which the blood lactate level is elevated. In stress situations a lactate acidosis can occur. The disease may be subdivided into three main syndromes: Kearns-Sayre syndrome (KKS), "myoclonus epilepsy with ragged red fibers syndrome" (MERRF), and "mitochondrial myopathy, encephalopathy, lactic acidosis and strokelike episodes syndrome" (MELAS). There are also several intermediate forms. Ophthalmological symptoms are frequent and occasionally have to be treated surgically. A 20-year-old male patient with a mixed form of these syndromes including elements of KSS and MERRF had to undergo cataract extraction. The authors decided to perform the operation under local anesthesia and sedation, with the anesthetist on standby. No problems arose. In all cases where mitochondrial encephalomyopathy is suspected the diagnosis should be confirmed by a muscle biopsy and the risk of cardiac arrest, respiratory insufficiency, and epileptic seizures ruled out prior to surgery. Local anesthesia with sedation appears to be the most favorable form of anesthesia provided the maximum dose is observed and a substance with a high convulsion threshold is chosen. Perioperative monitoring by an anesthetist and temporary provision of a cardiac pacemaker are necessary.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraorbital surgery for trigeminal neuralgia

PURPOSE: First-division trigeminal neuralgia, or tic douloureux refractory to medications, presents problems to the surgeon because of the desirability of preserving corneal sensation. A new operation is described that may provide longer duration of pain relief than conventional supraorbital neurectomy, with preservation of the corneal reflex. METHODS: Four patients underwent resection of the supratrochlear and supraorbital nerves within the orbit accessed from an upper eyelid skin crease incision. RESULTS: Three patients with typical idiopathic trigeminal neuralgia involving branches of the frontal nerve are without pain 22 to 25 months after surgery. The final patient with atypical pain had no improvement after the procedure. Frontal nerve distribution anesthesia is present in all patients. Postoperative ptosis resolved in all patients within 4 months of surgery. CONCLUSIONS: This procedure should be added to the treatment options for patients with first-division trigeminal neuralgia. By avoiding injury to the trigeminal root and ganglion, this surgery carries no risk of facial motor dysfunction, dysthesia, and/or anesthesia in the other trigeminal branches including corneal anesthesia.     

Congenital corneal anesthesia in children: diagnostic and therapeutic problems

Congenital corneal anesthesia (CCA) is an uncommon condition difficult to diagnose. We report the case of a 9-month-old girl who presented bilateral congenital corneal anesthesia. The child had a corneal ulcer which had been unresponsive to adapted local treatment. Self-inflicted corneal injuries were present. Local treatment and arm splints led to quick healing. CCA occurs either alone or in association with neurological diseases (familial dysautonomia) or systemic congenital abnormalities (Goldenhar Gorlin syndrome). It is important to search for corneal anesthesia in children with chronic ulcerations of the cornea and self-inflicted injuries. Early diagnosis is important due to the risk for the visual prognosis. Short and longterm prevention of self-inflicted corneal injuries should be associated with a local treatment to assure rapid healing and a relapse free outcome.     

白内障超声乳化吸出术后视网膜中央动脉阻塞风险因素分析

目的　探讨白内障超声乳化吸出术后发生视网膜中央动脉阻塞（ｃｅｎｔｒａｌｒｅｔｉｎａｌａｒｔｅｒｙｏｃｃｌｕｓｉｏｎ,ＣＲＡＯ）的风险因素及相关预后情况。方法　本研究为病例对照研究。收集２００９年１月至２０１５年１２月在郑州大学第二附属医院眼科行白内障超声乳化吸出术的连续病例８３６５例,纳入７２８３例（９１００眼）,统计ＣＲＡＯ例数７例（即ＣＲＡＯ组）,利用随机数列法,以１８比例在纳入病例中随机选取５６例（５６眼）作为对照组,若入选者为ＣＲＡＯ患者则剔除,继续选择。统计白内障核硬度、术前最佳矫正视力、眼压、麻醉方式、术中后囊膜破裂情况、全身疾病等,采用Ｆｉｓｈｅｒ确切概率法、ｔ检验、Ｌｏｇｉｓｔｉｃ回归等统计学方法分析ＣＲＡＯ的风险因素。结果　球后麻醉（风险比３．３０７,Ｐ＝０．０１２）、后囊膜破裂（风险比４．２８７,Ｐ＝０．０３４）是术后ＣＲＡＯ发生的危险因素,高血压、颈动脉斑块患者ＣＲＡＯ发生率与对照组相比差异均有统计学意义（均为Ｐ＜０．０１）,是危险因素。而术前最佳矫正视力（≤０．０１）、高度近视、青光眼病史、糖尿病病史等差异对于ＣＲＡＯ发生并无统计学意义（均为Ｐ＞０．０５）。结论　高血压、颈动脉斑块、球后麻醉及后囊膜破裂均为白内障超声乳化吸出术后ＣＲＡＯ发生的危险因素。     

Repair of scleral rupture and total retinal detachment in a self-injuring psychotic patient under local anesthesia: a case report.

PURPOSE: Ocular self-injury by psychotic patients is an uncommon cause of ocular morbidity that poses peculiar problems. This report describes a schizophrenic self-injuring patient with scleral rupture and retinal detachment (RD), treated under loco-regional anesthesia. CASE REPORT: A 65-year-old man presented with scleral rupture, hyphema, traumatic lens luxation, vitreous prolapse, vitreous hemorrhage and total RD after deliberately hitting his head. The fellow eye had been successfully operated with scleral buckle surgery for the same reason two years earlier. The patient underwent a two-step surgical procedure under local anesthesia, with repositioning and resection of the uveal prolapse and scleral rupture repair and, separately, lens removal pars plana vitrectomy (PPV), membrane peeling, retinotomy, laser treatment and SiO tamponade. RESULTS: Twelve months after PPV, the cornea was clear, IOP was 16 mmHg, the retina was attached and VA was 20/200. The fellow eye maintained 20/30 VA. CONCLUSIONS: In psychotic patients the intrinsic difficulty of a traumatic RD is combined with systemic illness, no compliance and the risk of recurrence. Although ocular traumas usually require general anesthesia, this patient underwent both interventions under local anesthesia with sedation, because of his psychotic condition and chronic liver failure. Local anesthesia and sedation proved effective in controlling pain and intra-operative compliance even in such a difficult patient. Although it is reasonable to question operating on such patients, we nonetheless believe that every attempt should always be made at gaining useful vision in both eyes since these patients are at a high risk of recurrent ocular trauma.     

Anesthesia and preoperative and postoperative medications

Retrobulbar blocks, although widely used, still have potentially serious complications. Topical anesthesia presents less risk of injury to the globe and less pain but requires careful usage and an experienced surgeon. New techniques, however, allow for an increase in the percentage of patients able to have topical anesthesia. Preoperatively, 2.5% phenylephrine is found to be just as effective as 10% phenylephrine, and, when compared with wound closure and surgeon's experience, the effect of prophylactic medications was found to be negated. Postoperatively, diclofenac is found to be as effective an anti-inflammatory agent as prednisolone. Also, the addition of 10% phenylephrine to 4% pilocarpine drops enhances the effectiveness of pharmacologic treatment of postoperative iridocorneal adhesions. In addition, ophthalmologists should be aware of emerging antibiotic resistance.     

Pediatric intraocular pressure measurements: Tonometers,central corneal thickness,and anesthesia

Measuring intraocular pressure (IOP) is the cornerstone of a comprehensive glaucoma examination. In babies or small children, however, IOP measurements are problematic, cannot often be performed at the slit lamp, and sometimes require general anesthesia. Therefore, it is essential for an ophthalmologist who examines a pediatric patient to be aware of the different tonometers used in children, as well as the effects of central corneal thickness and anesthesia on IOP measurements. Goldmann applanation tonometry is the gold standard for IOP assessment. Most alternative tonometers tend to give higher IOP readings than the Goldmann applanation tonometer, and readings between different tonometers are often not interchangeable. Similar to Goldmann tonometry, many of these alternative tonometers are affected by central corneal thickness, with thicker corneas having artifactually high IOP readings and thinner corneas having artifactually lower IOP readings. Although various machines can be used to compensate for corneal factors (e.g., the dynamic contour tonometer and ocular response analyzer), it is important to be aware that certain ocular diseases can be associated with abnormal central corneal thickness values and that their IOP readings need to be interpreted accordingly. Because induction and anesthetics can affect IOP, office IOPs taken in awake patients are always the most accurate.     

Unusual presentation of Amsler's sign in Fuchs' heterochromic uveitis

Hyphema occurring after ocular paracentesis has been described as a classic feature of Fuchs' heterochromic uveitis (FHU) (Amsler's sign). We describe a case of hyphema occurring after peribulbar anesthesia in a patient with FHU. The bleeding occurred before the surgery began. Although the occurrence of this phenomenon does not preclude successful surgical outcomes, topical anesthesia may lower the risk preoperatively.     

Combined topical anesthesia and sedation for open-globe injuries in selected patients

PURPOSE: To evaluate the efficacy and safety of topical anesthesia (TA) and IV sedation in surgery for less severe open-globe injury (OGI). DESIGN: Noncomparative consecutive interventional case series. PARTICIPANTS: Of 67 OGI cases reviewed at the Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy, in the period from 1999 to 2000, 10 eyes (14.9%) of 10 consecutive patients (age range, 6-58 years) were repaired using TA and IV sedation. All patients belonged to the American Society of Anesthesiologists risk class I or II. Nine eyes had corneoscleral wounds, four had vitreous loss, two had traumatic cataract, and three had an intraocular foreign body (IOFB); one patient had interruption of a continuous penetrating keratoplasty suture. Preoperatively, best-corrected visual acuity (BCVA) ranged from hand movement to 20/20. INTERVENTION: Corneoscleral suture was performed in nine patients, vitreous excision in four, uveal excision or reposition in four, IOFB removal in three, and cataract extraction in two; corneal button resuture was carried out in one patient. All patients received topical oxybuprocaine hydrochloride 0.4%, and IV propofol, midazolam, and fentanyl for anesthesia. MAIN OUTCOME MEASURES: The change in BCVA was evaluated. Within 24 hours after surgery, each patient was asked to grade subjective pain and discomfort on a 4-point scale. The surgeon was asked to report difficulties attributable to the operating conditions. Complications related to anesthesia and to surgery were assessed. RESULTS: Best-corrected visual acuity stabilized or improved in all patients. All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during external bipolar cautery and conjunctival closure. No patient required additional anesthesia. The operating conditions as reported by the surgeons were graded slightly difficult in all cases but one, which was graded moderately difficult. No patient had surgical or anesthesia-related adverse events or life-threatening complications. CONCLUSIONS: Topical anesthesia and IV sedation are safe and effective and could be a reasonable alternative for less severe OGI. The degree of patient discomfort is only marginal during surgery and postoperatively. However, surgical training and patient preparation are the keys to the safe use of this anesthetic modality.     

Impairment of ocular blood flow during regional orbital anesthesia

BACKGROUND: Regional anesthesia for ophthalmic surgery has been associated with ischemic complications, such as central retinal vascular occlusion, optic atrophy and ischemic optic neuropathy. Impairment of pulsatile ocular blood flow (POBF) may occur with regional orbital anesthesia. In this study we quantified POBF in patients undergoing regional orbital anesthesia. METHODS: Eleven patients (12 eyes) with a mean age of 76.5 years having regional orbital anesthesia for cataract or retinal surgery at a private refractive surgical centre in Calgary had POBF monitoring before, during and 15 minutes after induction of anesthesia. RESULTS: There were no significant changes in intraocular pressure or heart rate during the induction phase or 15 minutes after induction of regional orbital anesthesia. However, ocular blood flow indices, including pulse amplitude, pulse volume and POBF, were significantly reduced following attainment of regional orbital blockade (p < 0.05). With time there was recovery in these variables, but they all remained significantly reduced from baseline 15 minutes later. INTERPRETATION: Ocular blood flow appears to be significantly impaired during regional orbital anesthesia, induced as described. There could be benefit in monitoring POBF to reveal otherwise undetectable deleterious effects on retinal circulation in patients having retrobulbar injections, orbital compression or digital manipulation of the globe.