Second cluster of strabismus cases after periocular anesthesia without hyaluronidase

Use of hyaluronidase as an adjunct to local anaesthetic eye blocks to reduce intraoperative pain in adults

BACKGROUND

Hyaluronidase has been used over many decades as an adjunct to local anaesthetic solution to improve the speed of onset of eye blocks and to provide better akinesia and analgesia. With the evolution of modern eye surgery techniques, fast onset and akinesia are not essential requirements anymore. The assumption that the addition of hyaluronidase to local anaesthetic injections confers better analgesia for the patient needs to be examined. There has been no recent systematic review to provide evidence that hyaluronidase actually improves analgesia.

OBJECTIVES

To ascertain if adding hyaluronidase to local anaesthetic solutions for use in ophthalmic anaesthesia in adults results in a reduction of perceived pain during the operation and to assess harms, participant and surgical satisfaction, and economic impact.

SEARCH METHODS

We carried out systematic searches in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and four other databases in June 2017. We searched the trial registers at www.ISRCTN.com, ClinicalTrials.gov and www.clinicaltrialsregister.eu for relevant trials. We imposed no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated the effect of hyaluronidase on pain experienced by adults during intraocular surgery using a rating scale.

DATA COLLECTION AND ANALYSIS

Two review authors (HR and KA) independently extracted data and assessed methodological quality using standard procedures as expected by Cochrane.

MAIN RESULTS

We included seven trials involving 500 participants that studied the effect of hyaluronidase on intraoperative pain. Four of the seven trials with 289 participants reported the primary outcome in a dichotomous manner, and we proceeded to meta-analyse the findings which showed a moderate heterogeneity that could not be explained (I² = 41% ). The pooled risk ratio (RR) for these four trials was 0.83 with the 95% confidence interval ranging from 0.48 to 1.42. The reduction in intraoperative pain scores in the hyaluronidase group were not statistically significant. Among the three trials that reported the primary outcome in a continuous manner, the presence of missing data made it difficult to conduct a meta-analysis. To further explore the data, we imputed standard deviations for the other studies from another included RCT (Sedghipour 2012). However, this resulted in substantial heterogeneity between study estimates (I² = 76% ). The lack of reported relevant data in two of the three remaining trials made it difficult to assess the direction of effect in a clinical setting.Overall, there was no statistical difference regarding the intraoperative reduction of pain scores between the hyaluronidase and control group. All seven included trials had a low risk of bias.According to GRADE, we found the quality of evidence was low and downgraded the trials for serious risk of inconsistency and imprecision. Therefore, the results should be analysed with caution.Participant satisfaction scores were significantly higher in the hyaluronidase group in two high quality trials with 122 participants. Surgical satisfaction was also superior in two of three high quality trials involving 141 participants. According to GRADE, the quality of evidence was moderate for participant and surgical satisfaction as the trials were downgraded for imprecision due to the small sample sizes. The risk of bias in these trials was low.There was no reported harm due to the addition of hyaluronidase in any of the studies. No study reported on the cost of hyaluronidase in the context of eye surgery.

AUTHORS' CONCLUSIONS

The effects of adding hyaluronidase to local anaesthetic fluid on pain outcomes in people undergoing eye surgery are uncertain due to the low quality of evidence available. A well designed RCT is required to address inconsistency and imprecision among the studies and to determine the benefit of hyaluronidase to improve analgesia during eye surgery. Participant and surgical satisfaction is higher with hyaluronidase compared to the control groups, as demonstrated in moderate quality studies. There was no harm attributed to the use of hyaluronidase in any of the studies. Considering that harm was only rarely defined as an outcome measure, and the overall small number of participants, conclusions cannot be drawn about the incidence of harmful effects of hyaluronidase. None of the studies undertook cost calculations with regards to use of hyaluronidase in local anaesthetic eye blocks.

Strabismus After Ocular Surgery

Many types of ocular surgery can cause diplopia, including eyelid, conjunctival, cataract, refractive, glaucoma, retinal, and orbital surgery. Mechanisms include direct injury to the extraocular muscles from surgery or anesthesia, scarring of the muscle complex and/or conjunctiva, alteration of the muscle pulley system, mass effects from implants, and muscle displacement. Diplopia can also result from a loss of fusion secondary to long-standing poor vision in one eye or from a decompensation of preexisting strabismus that was not recognized preoperatively. Treatment, which typically begins with prisms and is followed by surgery when necessary, can be challenging. In this review, the incidence, mechanisms, and treatments involved in diplopia after various ocular surgeries are discussed. [J Pediatr Ophthalmol Strabismus. 2017;54(5):272-281.].

Pain Levels after Local Anaesthetic with or without Hyaluronidase in Carpal Tunnel Release: A Randomised Controlled Trial

Purpose. Hyaluronidase is an enzyme that temporarily liquefies the interstitial barrier, allowing easy dispersal of local anaesthetic through cleavage of tissue planes. This prospective, blinded, randomised controlled study investigates the utility of adding hyaluronidase to local anaesthetic in the setting of carpal tunnel release. Methods. 70 consecutive carpal tunnel release patients were recruited and randomised into a control group only receiving local anaesthetic and a hyaluronidase group receiving both hyaluronidase and local anaesthetic. Pain scores were rated using the visual analogue scale (VAS) by patients immediately after local anaesthetic injection and again immediately after the carpal tunnel release. Results. Preoperative VAS scores, taken after local anaesthetic injection, were greater than postoperative VAS scores. Postoperative VAS scores were significantly lower in the hyaluronidase group and tourniquet times were significantly shorter in the hyaluronidase group. Conclusion. Hyaluronidase addition to local anaesthetic in carpal tunnel release resulted in significant reductions in operative time and pain immediately after operation.

Iatrogenic diplopia [corrected]

Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.

[Hyaluronidase: Here we go again]

OBJECTIVE

To summarize the benefits and lateral effects of hyaluronidase (H) use in ophthalmologic anaesthesia and to address its unavailability in current practice in France.

DATA SOURCES

The Medline data bank and the Cochrane database were consulted. The keywords employed separately or in combination were: H, regional anaesthesia, ophthalmologic surgery, local aneasthetics myotoxicity, diplopia.

STUDY SELECTION

Original articles since 1949 were selected. We also selected isolated clinical cases according to their relevance compared with the existing literature.

DATA SYNTHESIS

H is a "spreading factor" of animal origin used as an adjuvant in ophthalmic anaesthesia for more than half a century. It allows a moderate better block quality with a slightly quicker onset. It also limits the acute intraocular pressure increase secondary to periocular injection and seems to have a protective effect against local anaesthetics myotoxicity resulting in postoperative strabismus. However, during these last 50 years, numerous studies often ended in divergent results.

CONCLUSION

H seems to be a useful adjuvant in ophthalmologic anaesthesia in spite of his current unavailability in France. Recombinant H could be the solution in the near future.

The effect of hyaluronidase on ultrasound-measured dispersal of local anaesthetic following sub-Tenon injection

PURPOSE

To determine by B-scan ultrasonography if the addition of hyaluronidase affects the dispersal of anaesthetic fluid after sub-Tenon's injection.

DESIGN

Single-centre prospective randomised double-blind study.

MATERIALS AND METHODS

We performed a trial in 19 patients who were randomised to receive 5 ml of lidocaine 2% alone, or with hyaluronidase 15 IU/ml. A pre-anaesthetic B-scan ultrasound was performed followed by a standard infero-nasal sub-Tenon's injection. Further B-scan ultrasound studies were performed at 1, 3, and 5 min recording depth of local anaesthetic fluid. Data was analysed with Fisher's exact test and Student's t-test where appropriate. Results were considered significant when P<0.05.

RESULTS

The maximum depth of local anaesthetic was significantly less in the hyaluronidase group than the control group at 3 and 5 min (0.79 vs1.65 mm, P-value 0.01 and 0.43 vs1.52 mm, P-value 0.002 respectively). There were no statistically significant differences in the akinesia, pain and surgical satisfaction scores between the two groups.

CONCLUSIONS

The addition of hyaluronidase significantly augments the dispersal of local anaesthetic fluid, as measured by B-scan ultrasonography.

Prognostic factors for strabismus surgery after cataract surgery

PURPOSE

To evaluate the clinical features of strabismus that present after cataract surgery and determine the motor and sensory results after surgical correction of the strabismus.

SETTING

Department of Ophthalmology, the Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

METHODS

Thirty-one patients who had strabismus surgery after cataract surgery between January 1996 and June 2004 were included in the study. The clinical features of strabismus and the factors contributing to successful strabismus surgery results were retrospectively analyzed. Sensory functional tests were performed postoperatively.

RESULTS

Fifteen patients (48.4%) had exotropia. The types of cataract included traumatic (35.5%), congenital (32.3%), and senile (25.8%). Prolonged deviation was the statistically significant factor contributing to final alignment (P = .023). Fourteen of 31 patients had stereoacuity measurement; all achieved a stereoacuity of 3000 seconds of arc. Five of the 14 patients (35.7%) had better than 200 seconds of arc.

CONCLUSIONS

The anatomical results and sensory function of the patients were generally good. When appropriate, surgical intervention to treat strabismus after cataract surgery should be offered, and this is important for restoration of fusion.

Persistent strabismus after cataract extraction

BACKGROUND

Transient ocular misalignment as a complication of parabulbar and peribulbar anesthesia has already been reported in the literature. The aim of our study was to present a case of irreversible iatrogenic vertical strabismus after cataract surgery, which had to be operated on.

METHODS

Clinical and orthoptic evaluation of a female patient with vertical diplopia after phacoemulsification cataract surgery.

RESULTS

One week after the uneventful surgery, a 68-year-old patient complained of a sudden vertical deviation in the operated eye. The patient had not had a history of previous motility disorders. On examination, the patient showed hypertropia in the left eye of 15-20 degrees in primary position. Three and 6 months postoperatively, there was no a spontaneous improvement, while the persistent vertical deviation was 40 prism dioptres. Strabismus surgery was required 1 year after the cataract surgery.

CONCLUSION

Diplopia is a complication of peribulbar anesthesia which could be persistent. The superior and inferior rectus muscle are especially vulnerable. Its occurrence may be technique--related and the incidence increases when hyaluronidase is not available.

Persistent diplopia after retrobulbar anesthesia

PURPOSE

To determine the causative factors of persistent diplopia after retrobulbar anesthesia.

SETTING

Strabismus Section, Department of Ophthalmology, Seoul National University, Seoul, South Korea.

METHODS

Prism and alternate cover tests in the diagnostic positions of gaze and ductions/versions were performed in 28 patients with persistent diplopia 6 months after retrobulbar anesthesia. The Lancaster test, Bielshowsky head tilt test, double Maddox rod test, fundoscopic examination for torsion, forced duction test, force generation test, tensilon test, thyroid function test, and/or orbit computed tomography were performed when necessary.

RESULTS

Most of the patients (26 patients, 93%) did not have diplopia before retrobulbar anesthesia. Of the 14 patients with extraocular muscles imbalance, 12 patients showed vertical rectus overaction (11 superior recti, 1 inferior rectus) and 2 patients, mild vertical rectus underaction. Nine patients were presumed to have a sensory strabismus related to the preoperative poor vision, but this went unnoticed preoperatively. Three patients showed a small vertical deviation without any specific causative factors.

CONCLUSIONS

Fifty percent of the cases of diplopia were associated with either direct trauma or anesthetic myotoxicity to the extraocular muscles, in which overactions were more common than underactions. Thirty-two percent of the patients were presumed to have sensory strabismus, which suggested the importance of preoperative examination for strabismus as well as providing an explanation about the risk of postoperative diplopia before surgery.

Effect of retrobulbar injection of lidocaine on saccadic velocities

PURPOSE

To determine whether exposing the extraocular muscles (EOMs) to lidocaine via retrobulbar injection for cataract surgery has a demonstrable negative effect on subsequent function of the muscle.

SETTING

York Finch Eye Associates, Humber River Regional Hospital, and Toronto Western Hospital Research Institute, Toronto, Ontario, Canada.

METHODS

This study comprised 37 eyes that had phacoemulsification and posterior chamber intraocular lens implantation; 13 eyes had retrobulbar lidocaine with hyaluronidase and 24 eyes, topical anesthesia. The postoperative saccadic velocities were compared with the preoperative velocities using a sensitive recording device. The results were compared within and between the retrobulbar lidocaine and topical anesthesia groups.

RESULTS

No detectable decrement in postoperative saccadic velocities was detected in any patient, and no difference was found between the groups.

CONCLUSIONS

Exposing EOMs to lidocaine for cataract surgery had no detectable negative effect on saccadic velocities 1 week after surgery.

Strabismus after regional anesthesia for cataract surgery

BACKGROUND

An adult strabismus clinic in a regional eye centre provided an opportunity to estimate the risk of postoperative diplopia from regional anesthesia after cataract surgery and to describe the management of these patients.

METHODS

Retrospective cohort analysis. All cases were referred over a 22-month period (November 1997 to September 1999) for investigation of postoperative diplopia after cataract surgery. The surgical and anesthetic records were reviewed to determine the number and location of injections, and the volume and type of regional anesthesia. The evolution and management of patients' diplopia was studied prospectively.

RESULTS

Twenty-one patients (12 women and 9 men aged 63 to 88 [median 76] years) were ascertained with postoperative diplopia. In 11 cases the right eye was affected, and in 10 cases, the left eye. Vertical diplopia occurred most commonly from inferior rectus restriction (16 cases). Three cases resolved without treatment, which indicated that the diplopia was transient. Four patients declined treatment, five required prism in eyeglasses only, and nine required strabismus surgery. One patient required surgery and prism in eyeglasses. Two patients required more than one strabismus operation to relieve the diplopia. For the period of data collection, we estimate the risk of nontransient postoperative diplopia from regional anesthesia as 2.6 cases per 1000 cataract procedures (95% confidence interval 1.9-4.7).

INTERPRETATION

Patients should be forewarned of the risk of diplopia after cataract surgery with regional anesthesia. The treatment of the diplopia may require prism in eyeglasses or strabismus surgery or both.

Diffusion and short-term efficacy of botulinum toxin A after the addition of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis

BACKGROUND

Botulinum toxin adequately treats hyperkinetic facial lines and hyperhidrosis. Higher doses of botulinum toxin appear to enhance efficacy and longevity possibly through greater evenness of diffusion; however, recurrent treatments with higher doses are expensive.

OBJECTIVE

To admix botulinum toxin with hyaluronidase and to test whether there is maintenance of efficacy, a spread of effect, and possibly a decrease in required dose compared with botulinum toxin.

METHODS

Six patients participated in a double-blinded side-to-side comparison pilot study with photographic analysis for frontalis overactivity and Minor's iodine and gravimetric testing for axillary hyperhidrosis.

RESULTS

Initial efficacy of botulinum with admixed hyaluronic acid appeared maintained with possibly increased diffusion when hyaluronic acid is added. No difference was evident on short-term review of patients treated with 50 U of botulinum in one axilla compared with the contralateral side injected with 25 U with admixed hyaluronidase.

CONCLUSION

There may be a role for hyaluronic acid in aiding diffusion and decreasing the required dose of botulinum toxin in hyperhidrosis axillaris.

Comparative characterization of bovine testicular hyaluronidase and a hyaluronate lyase from Streptococcus agalactiae in pharmaceutical preparations

Although bovine testicular hyaluronidase (BTH) has been used in several medical fields for many years, these drugs are poorly characterized. We compared pharmaceutical BTH preparations (Neopermease, Hylase "Dessau") and a hyaluronate lyase from Streptococcus agalactiae. The BTH preparations were complex mixtures of proteins (SDS-PAGE, gel filtration) with enzymatic activity in different fractions. In the case of Neopermease the highest specific activity was found in the 58 kDa fraction (optimum at pH 3.6), whereas the 77 and 33 kDa fractions showed markedly lower specific activities at an optimal pH of 6.2. Maximum specific activity of the bacterial enzyme (approx. 1000 micromol min(-1) mg(-1)) was found at pH 5.0, being 410- and 5100-times higher compared to Neopermease and Hylase "Dessau", respectively. The hyaluronate lyase preparation was separated into two main proteins [100 kDa (pI=8.9) and 85 kDa (pI=9.2)] which were enzymatically active in SDS substrate-PAGE. Zymography after limited proteolysis of the bacterial enzyme with trypsin revealed active fragments (75-50 kDa). Our results suggest that hyaluronate lyase is an alternative for BTH, of which there has been a shortage, since companies have stopped the production of BTH preparations due to the risk of BSE.