Sub-Tenon's injection for local anesthesia in posterior segment surgery

Efficacy and safety of trans-sub-Tenon's retrobulbar anesthesia for pars plana vitrectomy: a randomized trial

AIM

To compare the efficacy and safety of trans-sub-Tenon's ciliary nerve block anesthesia and transcutaneous retrobulbar anesthesia in patients undergoing pars plana vitrectomy (PPV).

METHODS

A prospective, randomized, double-blinded clinical trial was conducted at Zhongda Hospital, Affiliated with Southeast University, from February 2021 to October 2021. Patients undergoing PPV were randomly allocated into two groups: the trans-sub-Tenon's anesthesia group (ST group) and the retrobulbar anesthesia group (RB group) in the ratio of 1:1. The ST group received 2 ml ropivacaine through the Tenon capsule to the retrobulbar space, while the RB group received 2 ml ropivacaine via transcutaneous retrobulbar injection. Visual analog score (VAS) was used to evaluate pain during the whole process, including during anesthesia implementation, intraoperatively and on the first day after the operation. Movement evaluation (Brahma scores) and anesthesia-related complications were also noted.

RESULTS

Finally, a total of 120 patients were included in the study (60 in the ST group and 60 in the RB group). There were no significant differences in baseline patient characteristics or surgical features between the two groups. The VAS pain scores for anesthesia implementation were 0.52 ± 0.47 in the ST group and 1.83 ± 0.87 in the RB group (P < 0.001). The VAS scores during the operation were 0.53 ± 0.49 in the ST group and 1.48 ± 1.02 in the RB group (P < 0.001) and those on the first day after the operation were 0.37 ± 0.38 in the ST group and 0.81 ± 0.80 in the RB group (P = 0.002). No patients required supplemental intravenous anesthesia intraoperatively. The Brahma movement scores were 0.70 ± 1.64 in the ST group (scores ranging from 0 to 8) and 2.38 ± 3.15 in the RB group (ranging from 0 to 12) (P = 0.001). Forty-two patients in each group received laser photocoagulation during surgery. Fifteen patients (36%) in the ST group could not see the flashes of the laser, compared to 8 patients (19%) in the RB group (P = 0.087). No serious sight-threatening or life-threatening complications related to anesthesia were observed in either group.

CONCLUSIONS

For PPV, trans-sub-Tenon's ciliary nerve block anesthesia was more effective in controlling pain than transcutaneous retrobulbar anesthesia during the whole surgery process, including during anesthesia implementation, intraoperatively and on the first day after the operation. Additionally, it could achieve better effect of akinesia and was relatively safe. Trans-sub-Tenon's anesthesia could be considered an alternative form of local anesthesia during vitreoretinal procedures.

TRIAL REGISTRATION

The study protocol has been registered at ChiCTR.org.cn on February 2021 under the number ChiCTR2100043109 .

Patient and surgeon comfort in vitreoretinal surgery performed with Sub-Tenon's Anaesthesia

Background. Since Stevens first introduced Sub-Tenon's anaesthesia into cataract surgery it has shown itself to be a safe, simple, and efficient technique. The advantages of this type of block are comparable to those of sharp needle anaesthesia and complications are minimal. Several studies have found that the anaesthesia provided by Sub-Tenon's capsule injection is as good as or better for cataract surgery than that achieved by retrobulbar injection, but the efficacy of Sub-Tenon's block in vitreoretinal surgery is less well established. Methods. We performed 50 vitreoretinal procedures; 50 eyes received a Sub-Tenon's injection of a 5 ml mixture (50:50) of lidocaine and ropivacaine, plus 15 IU mL-1 of Hyaluronidase. Results. In 45 cases, only one injection was needed to achieve sufficient anaesthesia and akinesia; in 5 cases a second injection was performed five minutes after the first. Mean surgical time was 45.7 minutes. After surgery, each patient was asked to indicate his value on the VAS pain scale. Mean VAS degree was 2.4. In 7 cases, VAS was > 3 and the pain was successfully managed with the administration of paracetamol in the postoperative period. No light perception was detected at the end of surgery in 33 patients. All cases with 2 injections had no light perception at the end of surgery. Anaesthesia lasted throughout the surgery in all cases. The surgeon performed all surgery comfortably and with no difficulty. Conclusions. According to our experience and to a growing body of evidence, Sub-Tenon's anaesthesia appears to be a safe, simple, versatile, and effective technique and should be considered as a real alternative method of anaesthesia in vitreoretinal surgery.

Pain during pars plana vitrectomy following sub-Tenon versus peribulbar anesthesia: A randomized trial

Purpose

To compare pain during pars plana vitrectomy (PPV) following topical lidocaine jelly and sub-Tenon anesthesia versus peribulbar anesthesia.

Methods

Prospective, single-center, randomized study. Patients scheduled for PPV for macular hole (MH) or epiretinal membrane (ERM) at the Retina and Vitreous Section of the Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo were randomly assigned to one of two groups in a 1:1 allocation ratio. Patients assigned to Group ST received topical anesthesia with 2% lidocaine jelly followed by sub-Tenon anesthesia with 2–4 ml of 1% ropivacaine. Patients assigned to PB received peribulbar anesthesia with 4–6 ml of 1% ropivacaine. After PPV, patients in both groups were asked to rate the level of pain they felt during the entire procedure (including anesthesia administration and PPV) by pointing at a 0–100 Visual Analogue Pain Scale (VAS). Data regarding demographics, patient characteristics and surgical features were also collected.

Results

Fifty-four patients were enrolled in the study (26 in Group ST and 28 in Group PB). Baseline characteristics, including age, gender, and presence of comorbidities, were similar in both groups. The surgery performed was PPV alone in 10 and 14 patients in the ST and PB groups, respectively, and combined phacoemulsification and PPV in 16 and 14 patients in the ST and PB groups, respectively (p = 0.39, Pearson). Surgery duration (mean ± SD minutes) was similar in the two groups (62 ± 12 for ST and 70 ± 20 for PB, p = 0.09, t-Test). No patients needed supplemental topical or intravenous anesthesia during surgery. No sight- or life-threatening complication was observed in either group. VAS score was significantly lower in the ST compared to the PB group (median (interquartile range) was 1 (2.25–0) in the ST group compared to 11.5 (29.75–5) in the PB group, p< 0.0001, Wilcoxon).

Conclusion

In this study of patients who underwent PPV for MH or ERM, topical followed by sub-Tenon anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia. Compared to peribulbar anesthesia which is administered with a sharp needle, sub-Tenon anesthesia administered with a blunt cannula may be associated with a reduced risk of such adverse events as globe perforation, retrobulbar hemorrhage, and inadvertent injection of anesthesia into the optic nerve sheath.

Local Anesthesia With Blunt Sub-Tenon's Cannula Versus Sharp Retrobulbar Needle for Vitreoretinal Surgery: A Retrospective, Comparative Study

BACKGROUND AND OBJECTIVE

To evaluate the safety and efficacy of a blunt sub-Tenon's cannula for local anesthesia before vitreoretinal surgery compared to a sharp retrobulbar needle.

PATIENTS AND METHODS

Retrospective, comparative study of all patients undergoing vitreoretinal surgery at the Medical College of Wisconsin between August 2009 and November 2013. Institutional review board approval was obtained.

RESULTS

Of 940 surgeries performed with a sub-Tenon's cannula, 99% (938 of 940) were completed. Of the 771 surgeries performed with a sharp retrobulbar needle, 99% (770 of 771) were completed. Factors associated with use of a sharp retrobulbar needle over sub-Tenon's cannula were presence of prior scleral buckle (P < .01) and inclusion of scleral buckle placement in the procedure (P < .01). No case of globe perforation, severe retrobulbar hemorrhage, or severe conjunctival chemosis was observed in either group.

CONCLUSION

Blunt sub-Tenon's cannula appears as effective and safe as a sharp retrobulbar needle for local anesthesia during vitreoretinal surgery. Vitreoretinal surgeons may wish to consider a blunt sub-Tenon's cannula for local surgical anesthesia.

Effect of clonidine added to lidocaine for sub-Tenon's (episcleral) anesthesia in cataract surgery

PURPOSE

We aimed to evaluate the duration of anesthesia, analgesia and ocular akinesia of clonidine added to lidocaine in sub-Tenon's anesthesia in patients undergoing cataract surgery.

METHODS

Forty patients were prospectively enrolled. They were randomized to two sub-Tenon's anesthesia groups: group L (6 ml of lidocaine 2 %, 1 ml of 0.9 % saline and 25 UI/ml of hyaluronidase), and group C (6 ml lidocaine 2 %, clonidine 1 μg/kg, 1 ml of 0.9 % saline and 25 UI/ml of hyaluronidase). Duration of sensory anesthesia, ocular akinesia in all directions, akinesia of the levator palpebrae superioris and orbicularis oculi muscles, the duration of analgesia (time to the first postoperative use of analgesics), the overall use of analgesics and the presence of adverse effects were recorded .

RESULTS

The duration of sensory anesthesia and akinesia of the four rectus, levator palpebrae superioris, and orbicularis oculi muscles was significantly longer in group C (p < 0.05). The number of patients who required analgesics was similar between the groups but the duration of analgesia was longer in group C (p < 0.05). No significant adverse effects were observed.

CONCLUSION

The addition of clonidine 1 μg/kg to 2 % lidocaine in sub-Tenon's anesthesia for cataract surgery increased the duration of sensory anesthesia, ocular akinesia, and the duration of analgesia.

Novel retrobulbar anesthesia technique through the sub-Tenon's space using a sharp needle in a blunt cannula

BACKGROUND AND OBJECTIVE

The authors developed a new technique for retrobulbar anesthesia and compared it with the conventional transcutaneous method in 223 eyes undergoing vitrectomy.

PATIENTS AND METHODS

In the new technique, a 24-mm-long 19-gauge curved cannula with a 27-gauge straight needle with an oval tip was inserted into the sub-Tenon's space, and then the oval-tipped needle was replaced with a 50-mm-long 25-gauge curved needle. Anesthetic was then injected into the muscle cone from the syringe. The authors compared 118 eyes undergoing vitrectomy with the new technique and 105 eyes undergoing the procedure with conventional anesthesia.

RESULTS

The pain scores were 0.1 ± 0.32 for the new technique and 1.57 ± 0.73 for the conventional technique (P < .001). Additional anesthetic required was 0.1 ± 0.33 mL using the new technique and 0.3 ± 0.68 mL using the conventional method (P = .03).

CONCLUSION

This novel approach to retrobulbar anesthesia using a guarded cannula is safe and effective, causing less pain than the conventional technique.

Are ocular injection anesthetic blocks obsolete? Indications and guidelines

PURPOSE OF REVIEW

In this era of topical anesthesia for ocular surgery, anesthetic ocular blocks are still important when profound anesthesia and akinesia are required. Although injection ocular blocks, retrobulbar and peribulbar anesthesia, have been supplanted for most ocular surgery in many centers by sub-Tenon's irrigation block because of its superior safety profile, still worldwide, injection blocks remain popular.

RECENT FINDINGS

We present here the results of a survey of the literature published over the last 5 years to assess current international preferences for ocular anesthesia injection blocks. We discuss the reasons why sub-Tenon's anesthesia is not more universally popular and advocate for its greater acceptance because of safety. Specific narrow indications for performing injection ocular blocks are presented. Also, guidelines for performing retrobulbar anesthesia which reduce the risk of serious ocular complications are provided as well as our rationale for preferring retrobulbar to peribulbar anesthesia.

SUMMARY

Sub-Tenon's block should be performed in the operating theatre in preference to retrobulbar or peribulbar anesthesia except for limited indications. When injection ocular block is deemed necessary, we feel that retrobulbar anesthesia with the technique described may be safer than peribulbar anesthesia.

National survey of day-case vitreoretinal surgery in the United Kingdom

INTRODUCTION

Day-case surgery has become uniformly accepted in ophthalmology for most procedures but not for complex, lengthy ones, including vitreoretinal surgery. There is a need for uniform practice that is not only financially and resource efficient, but also convenient for patients.

PURPOSE

To describe current practice patterns of day-case vitreoretinal (DCVR) surgery in the United Kingdom.

METHODS

A 16-part e-mail questionnaire was sent to UK vitreoretinal consultants, with day-case surgery defined as patients admitted and discharged following surgery on the same day. The questionnaire was sent to all consultant members of the Britain and Eire Association of Vitreoretinal Surgeons using the e-mail address beavrs@yahoogroups.com to increase the response rate.

RESULTS

The overall response rate was 41%. Of 55 responders, 9% do not undertake DCVR surgery, but 61% perform DCVR surgery in >75% of patients. Of all undertaking DCVR surgery, 85% of responders discharge patients home and 13% to a hostel. A total of 76% of responders use local/sub-Tenon anesthesia in >50% of patients undergoing DCVR surgery. A total of 15% of responders were not in favor of DCVR surgery. Common reasons for not undertaking DCVR surgery were significant traveling distances for patients, patient choice, and the need for support during posturing.

CONCLUSIONS

The practice of DCVR surgery across the United Kingdom is variable and is influenced by local factors, patient factors, and surgeon views. There is a lack of guidelines to help decision-making. Common standards are required to maximize clinical outcomes and patient satisfaction, as well as reduce the cost burden of hospital admissions.

Superficial extraconal blockade for vitreoretinal surgery

Context:

Needle length plays an important role for the success of ophthalmic block. The standard practice is to use 25 mm needles length; however, unnecessarily long needles may increase the risk of complications especially in the presence of staphyloma or previous scleral buckle.

Aims:

This work was designed to compare the efficacy of using 15 and 25 mm needle in performing extraconal block for patients undergoing vitreoretinal surgery.

Settings and Design:

Prospective randomized double blinded study.

Materials and Methods:

A total of 120 patients were enrolled in this study and were divided in two groups. In group (1) extraconal block was performed using 25 mm needle, while in group (2) 15 mm needle was used. After primary injection, assessment of the block was done by an anesthesiologist who was unaware of the needle used. If satisfactory akinesia was not achieved a supplementation was provided. At the end of the procedures, patients and surgeons were asked to assess their pain and satisfaction with the anesthetic technique.

Statistical Analysis used:

The sample size calculation using N-Quary version 4. Numerical and categorical data were analyzed using an independent sample, a two-tailed t-test, and chi-square test, respectively.

Results:

The volume of primary injectable was significantly higher in group 2. The two groups were comparable as regards total volume of local anesthetic, supplementation rate, akinesia, pain score, and surgeon satisfaction.

Conclusions:

Using 15 mm needle length to perform extraconal blockade for posterior segment procedures is equally effective to 25 mm needle.

Preoperative Sub–Tenon’s Capsule Injection of Ropivacaine in Conjunction with General Anesthesia in Retinal Detachment Surgery

OBJECTIVE

To evaluate the effects of preoperative sub-Tenon's capsule injection of ropivacaine on intraoperative hemodynamics, postoperative pain, nausea, and recovery in patients undergoing scleral buckling surgery under general anesthesia (GA).

DESIGN

Randomized double-masked controlled clinical trial.

PARTICIPANTS

Ninety-eight patients with primary rhegmatogenous retinal detachment undergoing scleral buckling surgery under GA.

METHODS

Random allocation to either preoperative sub-Tenon's capsule injection of 3 ml of 0.75% ropivacaine or sub-Tenon's capsule injection of 3 ml of saline (controls) immediately before a scleral buckling procedure under GA. Intraoperative monitoring of hemodynamic parameters, need of analgesia with sevoflurane and alfentanil, time in the recovery unit, measurements of pain and nausea on the visual analog scale (VAS) up to 12 hours postoperatively, and consumption of analgesics and antiemetics was recorded.

MAIN OUTCOME MEASURES

Intraoperative systolic blood pressure (BP); bradycardia; minimum alveolar concentration (MAC) of sevoflurane; maximum postoperative VAS scores of pain and nausea; time in recovery unit; and total need of alfentanil, ketobemidone, dextropropoxyphene, and dixyrazine.

RESULTS

Ninety-seven patients were analyzed (48 in the ropivacaine group and 49 controls). A significantly lower intraoperative systolic BP (104+/-6 vs. 112+/-7 mmHg; P = 0.004), less need of sevoflurane (1.33+/-0.19 vs. 1.56+/-0.23; P = 0.03), and shorter time in the recovery unit (67+/-9 vs. 76+/-16 minutes; P = 0.01) were observed in the ropivacaine group. Maximum VAS pain scores were 50+/-21 in the control group and 36+/-25 in the ropivacaine group (P = 0.05), with a significantly lower consumption of opioids (ketobemidone) in the ropivacaine group (3.6+/-3.5 vs. 1.3+/-2.0 mg). No significant difference was observed regarding nausea or need of dixyrazine or dextropropoxyphene postoperatively.

CONCLUSIONS

Preoperative sub-Tenon's capsule injection of ropivacaine in scleral buckling surgery under GA lowers the intraoperative systolic BP, reduces the amount of inhalable sevoflurane needed, and enhances postoperative vigilance through reduction of pain and need of opioids.

Intraoperative eye position after sub-Tenon's anesthesia for cataract surgery

BACKGROUND

To evaluate the incidence and extent of ocular deviation associated with sub-Tenon's anesthesia.

METHODS

Seventy-five consecutive patients undergoing routine phacoemulsification with sub-Tenon's anesthesia at the Eye Unit, Royal Gwent Hospital, were prospectively enrolled in this observational case series. The exclusion criteria were patients taking warfarin, or patients with preexisting ocular motility disorders, allergy to local anesthetics, or previous surgery for squint or retinal detachment. Eleven patients were subsequently excluded from the study group as they required additional anesthesia blocks before measurements were taken for ocular deviation. We injected 5 mL of a local anesthetic mixture of 2% lignocaine and 7.5 mg/mL levobupivacaine in the sub-Tenon's space in the inferonasal quadrant. Ocular deviation was assessed objectively by means of the Krimsky test. Forced duction tests were performed before and after anesthesia.

RESULTS

Hyperdeviation was documented in 49 (77%) eyes, exodeviation in 62 (97%), and hypodeviation in 6 (9.4%). No esodeviations were documented. Only 2 patients were orthophoric after anesthesia. Mean vertical deviation was 4.4 prism dioptres (PD) (SD 4.7 PD, 95% CI 3.2-5.5 PD, range 0-14 PD). Mean horizontal deviation was 19.5 (SD 9.6, 95% CI 17-22, range 0-50) PD. Forced duction test revealed no mechanical restriction before or after anesthesia.

INTERPRETATION

This study suggests that there is an appreciable ocular deviation with sub-Tenon's anesthesia. Intraoperative ocular deviation may make certain procedures more difficult; therefore, we recommend a low threshold for an additional corrective block administered before surgery to rectify the deviation.

A review of sub-Tenon's block

The place of sub-Tenon's block in ophthalmic surgery is now established. This block was introduced into clinical practice in the early 1990s as a simple, safe and effective technique. Since then, techniques have evolved, newer cannulae have been introduced and many complications, both minor as well as major, have been reported. This review deals with the recent developments in sub-Tenon's block.

A comparison of lidocaine 2% with levobupivacaine 0.75% for sub-Tenon's block

BACKGROUND AND OBJECTIVE

To compare the onset of action, and quality of block, of lidocaine 2% with levobupivacaine 0.75% for sub-Tenon's block in patients undergoing cataract surgery.

METHODS

We performed a two-centre trial in 91 patients who were randomized to receive 4 mL of lidocaine 2% (n = 44) or levobupivacaine 0.75% (n = 47) for sub-Tenon's block, both with hyaluronidase 15 IUmL(-1). Onset of akinesia was assessed every 2 min for 10 min. Numbers of patients requiring supplementary injections to achieve clinically satisfactory akinesia or rescue analgesia were recorded. Data were analyzed with Fisher's exact test, U-test and t-test where appropriate. Results were considered significant when P < 0.05.

RESULTS

The speed of onset was statistically significantly faster for lidocaine compared to levobupivacaine (3.02 vs. 5.06 min, P < 0.001). There was no statistical difference in number of patients requiring a supplementary injection of local anaesthetic (levobupivacaine 3 vs. lidocaine 0, P = 0.24), rescue analgesia with topical tetracaine (levobupivacaine 0 vs. lidocaine 2, P = 0.5), or ocular akinesia scores at the completion of surgery (lidocaine 1.4 vs. levobupivacaine 1.6, P = 0.12). Pain scores measured by a verbal analogue scale were not significantly different for injection, perioperatively or postoperatively.

CONCLUSIONS

Both agents produce a rapid onset of anaesthesia when used for sub-Tenon's block. The difference between the two agents, although statistically significant, is not clinically important.

L’anesthésie topique en chirurgie de la cataracte ambulatoire de l’adulte sans anesthésiste présent

To review the local anesthesia environment in France in adult out-patient cataract surgery. The author considers the presence or absence of an anesthesiologist in the operating room. The report shows that in many circumstances there is no need for an anesthesiologist if the following criteria are respected: the adult is fully informed, in rather good health, with no acute risk factors, and surgery is performed by a senior surgeon in a certified operating room. In France, a move toward more flexible regulations is expected, with a new cooperation between ophthalmologists and anesthesiologists that will lead to a new true risk/benefit/obligation ratio. Respect of the individual and safety remain crucial requirements making systematic generalizations impossible.

Sub-Tenon infiltration or classical analgesic drugs to relieve postoperative pain

BACKGROUND

In a prospective randomized double-blind study, the analgesic effect produced by sub-Tenon infiltration was compared with classic analgesic drugs in patients scheduled for posterior segment surgery under general anaesthesia.

METHODS

One hundred patients were randomized into two groups of 50. One group received sub-Tenon infiltration (group 1) with 3 mL of bupivacaine 0.50% by the surgeon before the end of the surgery and the other (group 2) received only classical analgesic drugs postoperatively. A visual analogue scale (VAS) (graded from 1 to 10) was used to assess pain. For both groups, when VAS was between 1 and 3 paracetamol (3 g/24 h) associated with ketoprofen (200 mg/24 h) was given; between 3 and 6 nalbuphine (0.2 mg/kg slowly intravenously repeated every 4 h if necessary) was given; and over 6 morphine was given. Morphine 1 mg was injected every 2 min until VAS below 3 was obtained.

RESULTS

All patients in group 2 (control) experienced pain in the recovery room period; however, no patient in group 1 required analgesic drugs in the first 6 h after the sub-Tenon infiltration. In the recovery room period, the VAS pain score in patients who received sub-Tenon infiltration (group 1) was 0.6 +/- 1.3 (mean +/- SD) compared to 3.4 +/- 2.2 in group 2. The difference was statistically significant (P = 0.000001). All patients in group 2 asked for analgesic drugs in the recovery room, some of whom required morphine. Despite the administration of drugs the pain score was statistically higher in group 2. Between the end of the recovery room period and the 6th hour, the VAS pain score in group 1 was statistically lower. From the 6th until the 24th hour, the pain score was not statistically significantly different between the groups. Regarding consumption of analgesic drugs from the recovery room until the 24th hour, the consumption of level 1 analgesic drugs (paracetamol, ketoprofen) and level 3 (morphine) was statistically lower in group 1 (P = 0.0009). The difference was not significant for level 2, probably because the number of patients was not sufficient.

CONCLUSION

Sub-Tenon infiltration with 3 mL of bupivacaine 0.50% offers excellent postoperative analgesia for about 6 h and is an excellent alternative to classical drugs. Furthermore, it is highly reliable and safe.

Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries

PURPOSE

To report factors associated with the use of local anesthesia with intravenous sedation (local anesthesia/sedation) rather than general anesthesia for surgery for open globe injuries in adult reparable eyes.

DESIGN

Retrospective, nonrandomized, comparative case series.

METHODS

Medical records were reviewed of all patients with open globe injuries repaired at Bascom Palmer Eye Institute between 1995 and 1999. "Adult reparable eyes" (eyes in patients >/=18 years of age, not treated with primary enucleation or evisceration, followed up >/=2 months) were included.

RESULTS

In all, 220 eyes of 218 patients met inclusion criteria. General anesthesia was employed in 80 of 200 (36%) and local anesthesia/sedation in 140 of 220 (64%). Patients who had local anesthesia/sedation were significantly more likely to have an intraocular foreign body (31% vs 14%; P =.010, chi-square test), better presenting visual acuity (1.8 logMAR [logarithm of the minimum angle of resolution] units vs 2.5 logMAR units; P <.001, t test), more anterior wound location (75% corneal/limbal vs 65%; P =.003, chi-square), shorter wound length (6.3mm vs 10.8mm; P <.001, t test), and dehiscence of previous surgical wound (26% vs 12%; P =.021, chi-square) and were significantly less likely to have an afferent pupillary defect (22% vs 51%; P <.001, chi-square). There was no anesthesia-related complication in either group. The local anesthesia/sedation group had a shorter mean operating time than did the general anesthesia group (78 minutes vs 117 minutes; P <.001, t test). The general anesthesia group had a longer mean follow-up than the local anesthesia/sedation group (20.2 months vs 13.9 months, respectively; P =.002, t test). Change in visual acuity between the presenting and final examinations was similar for open globe injuries repaired with general anesthesia compared with local anesthesia/sedation (0.94 vs 0.72 logMAR units of visual acuity, respectively; P =.16, t test).

CONCLUSIONS

Local anesthesia/sedation is a reasonable alternative to general anesthesia for selected patients with open globe injuries.

Anesthesia through a novel retrobulbar catheter provides perioperative pain control for 24 h after pars plana vitrectomy

PURPOSE

The purpose of this study was to assess the retrobulbar catheter technique for perioperative pain control in pars plana vitrectomy.

METHODS

One hundred consecutive pars plana vitrectomies (duration 20-220 minutes) in 88 patients (age range 37-88 years) were performed by the same surgeon under retrobulbar anesthesia using a commercially available retrobulbar needle. Initially, 7 ml of mepivacaine 2% were injected, a 28-gauge flexible catheter was introduced into the retrobulbar space and the needle was withdrawn. The catheter was removed 24 h after surgery. Intraoperatively and postoperatively, the patients were asked to rate pain using a numerical scale from 0 to 10. When pain was more than grade 3, 2 ml of a local anesthetic were re-injected through the catheter.

RESULTS

A first re-injection was given intraoperative/y 53.0 +/- 34.6 minutes after the start of surgery during 35/100 procedures, and second and third injections were needed during 12 /100 and 4/100 procedures, respectively. The first postoperative re-injection was given 3.9 +/- 1.5 hours after the start of surgery in 54 procedures, and second and third injections were carried out in 35/100 and 10/100 procedures respectively.

CONCLUSIONS

The results suggest that a temporary indwelling retrobulbar catheter allows long-lasting titratable local anesthesia during pars plana vitrectomy and titratable postoperative analgesia.

Pars plana vitrectomy for cystoid macular edema secondary to sarcoid uveitis

OBJECTIVE

To examine the results of pars plana vitrectomy for cystoid macular edema secondary to sarcoid uveitis resistant to medical treatment.

DESIGN

Retrospective, interventional, noncomparative case series.

SUBJECTS

Fourteen consecutive subjects (18 eyes) with cystoid macular edema associated with sarcoid uveitis resistant to medical treatment.

INTERVENTION

All eyes underwent pars plana vitrectomy. Nine eyes also underwent peeling of the epiretinal membrane or removal of the posterior vitreous cortex.

MAIN OUTCOME MEASURES

Status of macular edema, visual acuity, and complications.

RESULTS

Ten eyes (56%) improved 2 or more lines of Snellen visual acuity within 12 months. Six eyes (33%) remained unchanged, within a line of preoperative Snellen visual acuity, and two eyes (11%) worsened by 2 or more lines of Snellen visual acuity. Slit-lamp biomicroscopy showed that cystoid macular edema had resolved in 14 eyes (78%) within 9 months postoperatively. One eye (6%) had minimal edema, whereas three eyes (17%) remained unchanged biomicroscopically at the final visit. Postoperative complications included cataract formation, glaucoma, optic nerve atrophy, epiretinal membrane formation, and tractional retinal detachment. No severe postoperative inflammation was noted.

CONCLUSIONS

Pars plana vitrectomy seems to have a beneficial effect on cystoid macular edema caused by sarcoidosis resistant to medical treatment.