Subconjunctival bupivacaine in strabismus surgery

Comparison of topical oxybuprocaine and intravenous fentanyl in pediatric strabismus surgery

PURPOSE

To compare the outcomes such as postoperative nausea/vomiting, analgesic requirements, and hospital stay following the use of topical oxybuprocaine hydrochloride 0.4% or intravenous (IV) fentanyl in children undergoing strabismus surgery.

METHODS

This was a prospective cohort study. Children operated under general anesthesia for strabismus were given topical oxybuprocaine hydrochloride 0.4% (Group T) and IV fentanyl (Group F) before surgery. The episodes of nausea/vomiting, pain score, requirement of additional analgesia during postoperative period, and duration of hospital stay were compared in two groups.

RESULTS

There were 47 children in Group T and 59 children in Group F. The median pain score in two groups were 2.38 (25% quartile; 2.0) and 3.00 (25% quartile; 3.00), respectively. The difference was significant (K W P < 0.03). The episodes of nausea/vomiting in two groups were in 2 and 6 children in Group T and Group F, respectively. The median hospital stay of children of Group T and Group F were 242 and 285 min, respectively. The difference was not statistically significant (P = 0.22).

CONCLUSIONS

Using intraoperative topical oxybuprocaine drops, one can achieve better analgesic outcomes and reduce risk of nausea and vomiting compared to intravenous opioid analgesics and therefore, the hospital stay could also be marginally reduced.

Sub-Tenon's ropivacaine block for pain relief after primary strabismus surgery

PURPOSE

Pain is the main cause of patient distress/dissatisfaction after strabismus surgery. The aim of the study was to evaluate the effect of sub-Tenon's block with ropivacaine at the end of strabismus surgery on post-operative pain.

METHODS

A prospective trial was conducted in 79 patients (age 1.0-65 years) scheduled for outpatient primary strabismus surgery with fixed sutures under general anesthesia (GA) at a major tertiary hospital. Half the patients were randomly allocated to receive sub-Tenon's block with ropivacaine 0.2% at conclusion of the operation. Primary outcome measures were visual analog scale (VAS) scores at arrival to the post-anesthesia care unit (PACU), at discharge 3 hr later, 12-16 hr post-operatively, and 24 hr post-operatively. Supplemental analgesia requirements and patient satisfaction were recorded as well. Data were presented as median (range). Mann-Whitney test, Pearson chi(2)-test or Fisher's exact test was used for statistical analysis; p <or= 0.05 was considered significant.

RESULTS

There were no between-group differences in median VAS scores at arrival to the PACU and at discharge, with a borderline difference at 24 hr post-operatively (p = 0.06). At 12-16 hr post-operatively, the median score was 0.0 (range 0-5) in the study group and 4.0 (range 0-6) in the controls (p < 0.001). The lower VAS score in the study group was associated with a lower rate of supplemental analgesia use (21.9% versus 57.9%, p = 0.001), fewer doses of supplemental analgesia (10 doses versus 35, p = 0.03), and higher patient satisfaction (p < 0.001).

CONCLUSIONS

Sub-Tenon's block with ropivacaine 0.2% at the completion of outpatient primary strabismus surgery with fixed sutures under GA reduces pain 12-16 hr post-operatively and analgesia requirements 4-23 hr post-operatively.

Subtenons lidocaine injection for postoperative pain relief after strabismus surgery in children: A prospective randomized controlled trial

BACKGROUND

We previously reported a pilot study of the use of subtenons lidocaine after primary, unilateral strabismus surgery in children. This study suggested an association between subtenons lidocaine administration at the conclusion of surgery and a reduction of pain in the immediate postoperative period. As a result of this pilot study we performed a full-scale prospective, randomized controlled trial to fully evaluate the efficacy of this intervention.

METHODS

Children undergoing primary surgery or reoperations for strabismus were recruited. If randomized to the treatment group, 1 ml of 2% lidocaine was injected into the subtenons space of each operated eye, just prior to conjunctival closure. The child's parents, who were masked to the intervention, assessed pain over 4 h postoperatively using an objective pain-scoring tool. Pain scores were recorded on return to the ward (0 h, approximately 20 to 30 min after the completion of surgery) and at 1, 2, and 4 h later.

RESULTS

One hundred eleven children were recruited, of whom 91 (82.0%) underwent unilateral and 20 (18.0%) underwent bilateral surgery. Ninety operations (81.1%) were primary procedures and 21 (18.9%) were reoperations. Fifty-four children (48.6%) were randomized to the treatment group and 57 (51.4%) were randomized to the control group. A subtenons lidocaine injection was associated with a significant reduction in pain at the 0 h observation (P = 0.0056), and the total pain score over the 4-h postoperative period was significantly lower in the treatment group compared to controls (P = 0.0381). There was no difference between the groups with respect to the need for additional systemic analgesia (P = 0.307).

CONCLUSION

This study showed that an intraoperative injection of subtenons lidocaine is associated with a significant reduction in postoperative pain during the first postoperative hour for all types of childhood strabismus surgery. There was no difference between the groups in the need for systemic analgesia.

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery

METHODS

Fifty children (age 5-14 years, ASA I-II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique.

RESULTS

Intraoperative values of haemodynamic variables were significantly higher in the control group (P < 0.01). Requirement for intraoperative rescue analgesic and postoperative analgesia was higher in the control group (P < 0.05 and P < 0.001, respectively). Children in the block group had lower postoperative pain scores at all times. Incidence of oculocardiac reflex was significantly higher (P < 0.001) in the control group. Seventy-six percent of children in the control group had postoperative nausea and vomiting compared to 20% children in the block group (P < 0.001).

CONCLUSION

There were no complications related to the block. Peribulbar block appears to be a safe and useful analgesic technique for paediatric ophthalmic surgery.

Adjunctive intra-operative local anaesthesia in paediatric strabismus surgery: a randomized controlled trial

PURPOSE

The aim of the present study was to test the hypothesis that adjunctive local anaesthesia decreases postoperative pain, vomiting or length of stay in children having strabismus repair

METHOD

A prospective, randomized, triple-armed clinical trial involving a treatment comparison between topical amethocaine, sub-conjunctival bupivacaine and, as a placebo, topical normal saline was performed. All treatments were given at the end of surgery before emergence from the anaesthetic.

RESULTS

Overall, there was no statistically significant difference between outcome measures in the three trial groups. Using post hoc analysis there was a statistically significant difference between the groups receiving amethocaine and bupivacaine compared with the saline group in terms of the pain score at 120 min postoperatively. This difference has little clinical significance.

CONCLUSIONS

Neither topical amethocaine nor subconjunctival bupivacaine makes a clinically significant difference to postoperative pain, emesis or length of stay. Moderate dose paracetamol per rectum alone appears to be effective analgesia for strabismus surgery, although it probably masked any small adjunctive effect of the topical anaesthesia used in the present trial.

Ocular pain: a casualty study. The spectrum and prevalence of pain in acute eye disease

This study examined the prevalence and severity of ocular pain in eye casualty patients. All new patients presenting over a 1 month period were invited to indicate their pain level using a visual analogue scale. The results for 352 patients were analysed, and median pain levels calculated for 29 common diagnoses. Of those responding, 94% (= 47% of all new patients) had ocular pain at presentation. While many results were predictable, some diagnoses were associated with higher pain scores than expected. Junior ophthalmologists also were asked to indicate their perceptions of pain severity for the 29 diagnoses using the same visual analogue scale.

Subconjunctival bupivacaine versus topical amethocaine in strabismus surgery

A prospective study was performed to evaluate and compare the effect of subconjunctival bupivacaine and topical amethocaine on pain relief after strabismus surgery. A total of 40 children scheduled for elective operation were randomly allocated to receive either subconjunctival bupivacaine or topical amethocaine at the end of surgery. Post-operative pain was evaluated using a four-point assessment score. We show that both techniques provide good post-operative pain relief. We advocate that either could be used routinely in strabismus surgery although topical amethocaine is easier to administer.