Efficacy of lidocaine 2% gel in pterygium surgery

Evaluation of Topical Lignocaine Jelly 2% for Recurrent Pterygium Surgery with Glue-free Autologous Conjunctival Graft

AIM

This study aims to evaluate the efficacy of lignocaine 2% jelly as a topical anesthesia in recurrent pterygium surgery with glue-free conjunctival limbal autograft.

MATERIALS AND METHODS

A prospective, nonrandomized, observational study, comprising of 51 patients (51 eyes) having recurrent pterygium, was conducted at a tertiary eye care center in central India. Pterygium excision with glue-free autologous conjunctival grafting was done under 2% lignocaine jelly. The visual analog scale was utilized to record the intra- and post-operative pain score. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. Anesthetist also noted vital parameters and any intravenous drugs required.

RESULTS

No difference in intra- and post-operative pain score (P = 0.24) was observed in the patients. Zero score, i.e. no pain was noticed in 30 patients (58.8%) patients. The average surgical time was 29.20 min (+1.11). The average surgeon discomfort score was 0.18 + 0.51. Inadvertent eye movement was seen in 3 patients (5.9%). Lid squeeze was noted in 45 patients (88.2%) during placement of lid speculum. Forty-eight patients (94.1%) gave preference to the topical anesthesia of 2% lignocaine jelly compared to the previous mode of anesthesia.

CONCLUSION

Pterygium surgery with glue-free autogenous conjunctival grafting can be performed successfully by preoperative local application of 2% lignocaine jelly. The ease of application, lack of toxicity and sufficient effect to complete the surgery make it an efficient alternative to injectable anesthetics.

Pilot Study Comparing Topical Anesthetic Agents in Pterygium Surgery: Subconjunctival Injection Versus 2% Lidocaine Gel Versus 5% Lidocaine Gel

PURPOSE

To compare the efficacy of different concentrations of topical lidocaine gel with standard subconjunctival anesthesia.

METHODS

This was a prospective randomized controlled pilot study with 3 different groups. Group SC received subconjunctival lidocaine and proparacaine drops as needed during surgery. Group L2 received 2% lidocaine gel and group L5 received 5% lidocaine gel. Both lidocaine gel groups could receive another gel dose as needed during the procedure. The primary outcome was pain, which was experienced during and after surgery. The assessment was done using a 10-point linear analog scale at predetermined stages of surgery (1-first incision, 2-pterygium body excision, 3-conjunctival suturing, 4-immediate postoperative period after patching, and 5-assessment by a trained nurse in the absence of a surgeon after operation).

RESULTS

We enrolled 45 consecutive patients who underwent primary pterygium surgery. Statistical significance between groups was found in mean pain at administration (2.2 vs. 0.4 vs. 0.0 in SC, L2, and L5 groups, respectively, with P < 0.05). The number of reapplications of anesthetic drops did not differ between the groups. We found a correlation between reapplication of the anesthetic and pain at administration and duration of the procedure.

CONCLUSIONS

We demonstrated that the use of lidocaine gel at concentrations of 2% and 5% in pterygium surgery was as effective as subconjunctival injection of lidocaine in reducing intraoperative and postoperative pain, producing significantly less pain during initial administration of the anesthetic.

Overview of ocular anesthesia: past and present

PURPOSE OF REVIEW

Many choices of ocular anesthetic techniques are available to the ophthalmologist. This study reviews currently used techniques of topical, subconjunctival and regional block anesthesia used in ophthalmic procedures.

RECENT FINDINGS

The choices of anesthetics that are available are considered and a new ocular anesthetic gel is described that provides sustained ocular surface anesthesia, minimal side-effects and may also have antimicrobial properties.

SUMMARY

Consideration of ocular anesthetic techniques and anesthetic choice plays a critical role for the success and safety of ophthalmic surgery.

Ropivacaine for topical anesthesia in pterygium surgery with fibrin glue for conjunctival autograft

PURPOSE

To evaluate efficacy of ropivacaine 1% for topical anesthesia in pterygium surgery with conjunctival autograft using fibrin glue for attaching the graft to the bare sclera.

METHODS

Thirty-seven patients affected by primary pterygium underwent surgical excision under topical anesthesia with ropivacaine 1%. We performed a surgical approach with dissection of the pterygium, scraping of corneal bed with a motorized burr, meticulous excision of underlying Tenon's capsule, preparation of a free autologous conjunctival graft in the superior sector, excision of the graft, and position of the same to cover the scleral bed exposed in the nasal area with respect to limbus and stromal orientation fixing the graft with fibrin glue.

RESULTS

It was possible to perform all the procedures without any supplemental anesthesia and sedation. The pain reported by patients, recorded by a 0 to 10 scale, was low during the entire surgery. The technique with conjunctival autograft using a fibrin sealant allowed for short operative times and good aesthetic and functional results.

CONCLUSIONS

Topical anesthesia with ropivacaine is safe and effective in pterygium surgery. The Long-lasting anesthesia with this agent permitted performing our surgical procedures with autograft conjunctival graft and fibrin glue to attach the flap with low pain perceived by our patients, low surgical invasivity, and short duration of surgery.

A novel lidocaine hydrochloride ophthalmic gel for topical ocular anesthesia

Topical anesthetics play an important role in the practice of ophthalmology, both for procedures in the office and in the operating room. The need for safe, long-acting topical ocular anesthetic agents is ongoing, and has been highlighted by the increase of intravitreal administration of pharmacologic agents. Current practices for ocular anesthesia include subconjunctival injection of 2% aqueous lidocaine, topical 2% lidocaine drops and topical 0.5% tetracaine. Tetracaine is not yet FDA approved, and is associated with corneal epithelial toxicity and delayed epithelial healing after multiple administrations. Lidocaine jelly (2%) preparations have been reported to be beneficial in several systemic procedures, including those of the upper airway, dental, urogenital, and gastrointestinal. It has been theorized, and recent studies support the idea, that gel formulations of lidocaine may enhance anesthetic effect, and therefore be superior to anesthetic solutions for topical cataract surgery. The viscous nature of gel formulations is thought to lengthen contact time, resulting in better anesthesia at lower drug concentrations. Furthermore, several studies suggest that lidocaine is bactericidal and bacteriostatic, and may have a supplementary role in preventing and treating surgical site infections. Akten™, lidocaine 3.5% gel (Akorn, Buffalo Grove, IIlinois) was FDA approved for all ophthalmic procedures in October 2008. This gel is a preservative-free, lidocaine-based anesthetic gel consisting of 35 mg/mL of lidocaine hydrochloride. We describe the properties, including chemical structure, indications, evidence of support, use, adverse effects, and precautions, which we believe enable Akten to provide superior anesthesia, while minimizing side effects.

Safety, efficacy, and patient acceptability of lidocaine hydrochloride ophthalmic gel as a topical ocular anesthetic for use in ophthalmic procedures

Purpose:

To review the current literature on safety, efficacy, and measures of surgeon and patient satisfaction with lidocaine hydrochloride gel as a tool for ocular anesthesia.

Methods:

Pubmed search using keywords “lidocaine gel,” “ophthalmic,” and “surgery” and compiling cross-references. Twenty-six total references were reviewed, including 15 prospective randomized controlled trials (RCTs, total N = 933, average N = 62), 6 nonrandomized prospective studies (total N = 234, average N = 39), 2 animal studies, 1 microbiologic study, and 2 letters to the editor.

Results:

The RCTs and nonrandomized prospective studies evaluated a number of measures including timing of onset of anesthesia, duration of anesthesia, intraoperative and postoperative pain, need for additional anesthetic applications, intracameral lidocaine levels, and adverse effects. Control groups received topical drops, subconjunctival anesthetic, retrobulbar anesthetic, or sham gel. Lidocaine gel was shown to be at least as effective for pain control as alternative therapies in all studies, with longer duration of action than topical drops. Patient and surgeon satisfaction were high, and adverse effects were rare and comparable to those for anesthetic drop formulations. Surgical settings included cataract, pterygium, trabeculectomy, strabismus, intravitreal injection, vitrectomy, and penetrating keratoplasty.

Conclusions:

Lidocaine gel is a safe, effective, and potentially underutilized tool for ophthalmic surgery.

Comparative efficacy of topical tetraVisc versus lidocaine gel in cataract surgery

Background

To compare the clinical efficacy of lidocaine 2% with tetracaine 0.5% for cataract surgery.

Methods

In a randomized, multi-surgeon, controlled clinical trial,122 consecutive cataract cases eligible for topical anesthesia, were randomly assigned to receive lidocaine 2% gel (1 ml) or tetracaine solution 0.5% (TetraVisc, 0.5 ml) before clear corneal phacoemulsification. Main outcome measure was visual analog scale (0 to 10), which was used to measure intra-operative pain. Secondary outcome measures included patients' discomfort due to tissue manipulation and surgeon graded patients' cooperation. Duration of surgery and intra-operative complications were also recorded.

Results

The mean age in TetraVisc (TV) group was 70.4 years and in the lidocaine gel group (LG) it was 70.6 years (p = 0.89). Patient reported mean intra-operative pain scores by visual analog scale were 0.70 ± 0.31 in TV group and 1.8 ± 0.4 in LG group (P < 0.001). Mean patient cooperation was also marginally better in the TV group (8.3 ± 0.3) compared to LG group (8.4 ± 0.6) (P = 0.25). 96% of patients in TV group showed intra-operative corneal clarity compared to 91% in LG group. TV group had less (1 out of 61 patients, 1.6%) intra-operative complications than LG group (3 out of 61 patients, 4.8%). No anesthesia related complications were noted in either group

Conclusion

Topical TetraVisc solution was superior to lidocaine 2% gel for pain control in patients undergoing clear corneal phacoemulsification. Lidocaine 2% gel is similar to TetraVisc in patient comfort and surgeon satisfaction.

Trial Registration

Clinical trials number: ISRCTN78374774

Corneal and conjunctival findings after mitomycin C application in pterygium surgery: an in-vivo confocal microscopy study

PURPOSE

To perform a qualitative assessment of the topical side-effects of mitomycin C on cornea after pterygium surgery.

METHODS

In-vivo confocal microscopy (Heidelberg Retina Tomograph II in combination with the Rostock Cornea Module) was performed in 10 patients with unilateral primary pterygium. Mitomycin C 0.02% was applied topically to seven eyes for 5 min intraoperatively and twice daily for 5 days postoperatively. Three eyes underwent surgery without application of cytostatic agent. Patient follow-up was 1 month.

RESULTS

After application of mitomycin C, complete epithelialization of the operated zone was found 2 weeks after surgery. In-vivo confocal microscopy revealed signs of superficial punctate keratitis for 2 weeks in the central cornea only after application of mitomycin C. The presence of epithelial and stromal oedema in this group was noted for up to 2 weeks in the central cornea and for up to 4 weeks in the operated zone. In the control group, complete epithelialization was found after 1 week; there were no signs of oedema after 1 week in the central cornea or after 2 weeks in the operated zone. Leucocyte infiltration and increased Langerhans cell density were noted in both groups in the operated and central zones. Analysis of the conjunctiva revealed a decrease in goblet cell density following cytostatic application.

CONCLUSION

Local application of mitomycin C delays corneal epithelialization, and prolongs postoperative epithelial and stromal oedema in both the centre and periphery. Moreover, signs of punctate keratitis were noted 2 weeks after surgery in central intact cornea. Nevertheless, in-vivo confocal microscopy shows that these changes are reversible 4 weeks after application of mitomycin C 0.02%.

Manual small incision cataract surgery under topical anesthesia with intracameral lignocaine: study on pain evaluation and surgical outcome

The authors here describe manual small incision cataract surgery (MSICS) by using topical anesthesia with intracameral 0.5% lignocaine, which eliminates the hazards of local anesthesia, cuts down cost and time taken for the administration of local anesthesia.

Polyglactin sutures versus nylon sutures for suturing of conjunctival autograft in pterygium surgery: a randomized, controlled trial

PURPOSE

To compare the use of polyglactin sutures versus nylon sutures for conjunctival autograft suturing in pterygium surgery.

METHODS

A prospective, randomized, controlled, clinical trial was conducted, in which 32 eyes of 32 patients with primary nasal pterygium were randomized to undergo pterygium surgery with the use of nylon sutures or polyglactin sutures for conjunctival autograft suturing. Patients were followed up for 3 months. Outcome measures included postoperative discomfort according to a visual analogue scale (VAS), graft hyperaemia, graft oedema and tarsal conjunctival papillary reaction.

RESULTS

There was no significant difference in the postoperative discomfort as assessed by VAS in both groups at all follow-up visits. Patients who had polyglactin sutures for suturing conjunctival autograft were noted to have more tarsal conjunctival papillary reaction at day 1 (p = 0.01) and more graft hyperaemia at week 1 (p = 0.019) after the operation. At 4 weeks postoperatively, significantly more nylon sutures remained on the autograft (p = 0.021), some of which were buried and could not be removed.

CONCLUSIONS

Both polyglactin and nylon are effective suture materials for autograft suturing in pterygium surgery and cause comparable postoperative discomfort. Polyglactin sutures resulted in slightly more conjunctival reaction in the early postoperative period compared with nylon sutures.

Pain Relief after Pterygium Surgery with Viscous Lidocaine

PURPOSE

The aim of the current study is to investigate the efficacy of lidocaine 2% gel for the control of pain experienced after pterygium surgery.

METHODS

We conducted a prospective, randomized clinical trial on 45 eyes of 45 patients who underwent pterygium surgery. The patients were randomized into 2 groups. Group 1 was provided with topical 2% lidocaine gel and group 2 with artificial tear gel. The primary outcome of interest was the pain experienced at the 4th, 7th and 10th postoperative hours. Corneal reepithelization was evaluated by slitlamp biomicroscopy. Pain was determined using a 10-point linear visual analogue scale. No systemic analgesic or topical nonsteroidal anti-inflammatory drop was administered.

RESULTS

The groups had similar demographic data. The mean pain scores of the study and the control groups according to the visual analogue scale were: 4.13 +/- 1.86 and 6.50 +/- 1.47 (p = 0.001) at the 4th postoperative hour, 4.00 +/- 1.16 and 4.00 +/- 1.16 (p = 0.001) at the 7th , and 2.39 +/- 0.89 and 3.63 +/- 1.00 (p = 0.001) at the 10th postoperative hour, respectively. The mean area of the corneal epithelial defect in the lidocaine gel group was 4.78 +/- 1.04 mm2 and 4.68 +/- 0.89 in the artificial tear gel group (p = 0.42). The mean corneal reepithelization time was 37.56 +/- 10.42 h in the lidocaine gel group and 34.36 +/- 10.00 h in the artificial tear gel group (p = 0.26). There were no side effects related to the drugs observed in either of the 2 treatment groups.

CONCLUSION

We conclude that topical lidocaine gel is an effective and safe anesthetic agent for the control of pain experienced shortly after pterygium surgery.