Preoperative Peribulbar Block in Patients Undergoing Retinal Detachment Surgery Under General Anesthesia: A Randomized Double-Blind Study

Anesthetic Approach in Ambulatory Vitrectomy: Peribulbar Block vs. Balanced General Anesthesia

Background

Vitrectomy is one of the most common outpatient ophthalmic surgeries. The anesthetic technique used in outpatient surgery should contribute to a faster functional recovery, better pain control, and fewer complications. The aim of this study was to compare peribulbar block and balanced general anesthesia, in patients undergoing outpatient vitrectomy.

Methods

A prospective cohort study was carried out, including adult patients undergoing ambulatory vitrectomy, between January and February 2018. Peribulbar block or balanced general anesthesia was the independent variable analyzed. Clinical and perioperative variables were evaluated, namely, postoperative pain, nausea, and vomiting in the postoperative period, intraoperative hypotension, patient satisfaction with the anesthetic technique, time to oral diet introduction and to hospital discharge, operating room occupancy time, and pharmacological costs. SPSS^® 27 was used for statistical analyses.

Results

Twenty-one patients were evaluated, 11 of whom underwent peribulbar block and 10 underwent balanced general anesthesia. Patients undergoing peribulbar block did not experience postoperative pain when compared to patients undergoing balanced general anesthesia (p=0.001). Intraoperative hypotension occurred in 18.2% of patients undergoing peribulbar block and in 70% of those undergoing balanced general anesthesia (p=0.03). Time to oral diet introduction (<1 hour vs. > 2 hours; p < 0.05), operating room occupancy time (70 vs. 90 minutes; p=0.027), time to hospital discharge (17 vs. 22.5 hours; p=0.004), and pharmacological costs (4.65 vs. 12.09 euros; p < 0.05) were lower in patients undergoing peribulbar block versus balanced general.

Conclusions

Peribulbar block seems to meet the criteria of an ideal anesthetic technique in outpatient vitrectomy surgery.

The Oculocardiac Reflex: A Review

BACKGROUND

A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination.

METHODS

World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response.

RESULTS

With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR.

CONCLUSION

Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.

Formulation of a Peribulbar Block for Prolonged Postoperative Pain Management in Vitreoretinal Surgery: A Randomized Clinical Trial

PURPOSE

To evaluate postoperative pain level using a supplemental peribulbar injection at the conclusion of retinal surgery.

DESIGN

Prospective, parallel-assigned, single-masked, randomized clinical trial.

PARTICIPANTS

Fifty-eight patients undergoing scleral buckle, vitrectomy, or combined surgery.

METHODS

In a single academic institutional practice, 58 patients undergoing scleral buckle, vitrectomy, or combined surgery were enrolled. Exclusion criteria included those with a risk for glaucoma, a pre-existing chronic pain disorder, among others. Patients were assigned randomly to receive a postoperative peribulbar formulation of either bupivacaine, triamcinolone acetonide, and cefazolin (group A) or bupivacaine, balanced salt solution, and cefazolin (group B). The postoperative pain score and ocular motility were assessed by a masked observer on the first postoperative day.

MAIN OUTCOME MEASURES

The primary outcome measure was the postoperative pain score. Secondary outcome measures included oral analgesic use, ocular motility, and intraocular pressure (IOP).

RESULTS

The mean pain scores were 2.8±2.9 for group A and 3.8±2.6 for group B (P = 0.095). Pain was absent in 28% of group A patients versus 14% of group B patients (P = 0.11). Group A required less narcotic pain medication (hydroxycodone: group A, 0.7±3 mg vs. group B, 3±6 mg; P = 0.05; oxycodone: group A, 7±7 mg vs. 9±13 mg; P = 0.2) than group B. Motility was full in group B and limited in group A (P ≤ 0.001), with no differences in mean IOP measurements at any point after surgery.

CONCLUSIONS

We did not demonstrate a statistically significant reduction in mean postoperative pain scores. However, patients in group A required less hydroxycodone use and had greater akinesia, suggesting prolonged neural blockade.

[A 23-gauge pars plana vitrectomy after induction of general anesthesia: effect of additional retrobulbar anesthesia on postoperative pain]

PURPOSE

Some studies have shown a significant reduction of postoperative pain by additional regional anesthesia in 20-gauge pars plana vitrectomy (20-G-ppV) with the patient under general anesthesia (AN). This observational study examined whether the advantages of additional retrobulbar anesthesia can also be observed with 23-gauge vitrectomy in AN.

MATERIAL AND METHODS

Surgery was performed in 130 patients under AN of which 88 received an additional retrobulbar block (group AN+) and 42 patients were treated without additional injection of retrobulbar anesthesia (group AN) using bupivacaine 0.5 % and mepivacaine 1%. The AN was performed with fentanyl and propofol. Postoperatively, the subjective patient pain was recorded using a numeric scale and the use and amount of analgesic drugs in the postoperative course were monitored.

RESULTS

The mean age of the patients was 53.6 ± 16.8 years, 52.6% of the patients were male, 31.5% were staged as American Society of Anesthesiologists (ASA) level I, 52.3% as ASA II and 15.4% as ASA III. At no time did the study show a statistically significant difference in pain frequency, intensity and analgesic consumption. However, the results suggest that patients in the AN+ group tended to experienced delayed and more intense postoperative pain, which is also reflected in the postoperative use of pain relief medications.

CONCLUSIONS

This study did not show any advantage by additional retrobulbar anesthesia regarding postoperative analgesia compared to an adequate treatment with peripheral acting analgesics during surgery and the early postoperative period.

A qualitative study of regional anaesthesia for vitreo-retinal surgery

AIM

The aim of this research was to collect experiential knowledge about regional ocular anaesthesia - an integral component of most vitreo-retinal surgery.

BACKGROUND

Anaesthesia for vitreo-retinal surgery has predominantly used general anaesthesia, because of the length and complexity of the surgical procedure. However, recent advances in surgical instrumentation and techniques have reduced surgical times; this decision has led to the adoption of regional ocular anaesthesia for vitreo-retinal day surgery. Although regional ocular anaesthesia has been studied from several perspectives, knowledge about patients' experience of the procedure is limited.

DESIGN

An interpretive qualitative research methodology underpinned by Gadamer's philosophical hermeneutics.

METHODS

Eighteen participants were interviewed in-depth between July 2006-December 2007 following regional ocular anaesthesia. Interview data were thematically analysed by coding and grouping concepts.

FINDINGS

Four themes were identified: 'not knowing': the time prior to the experience of a regional eye block; 'experiencing': the experience of regional ocular anaesthesia; 'enduring': the capacity participants displayed to endure regional ocular anaesthesia with the hope that their vision would be restored; and 'knowing': when further surgery was required and past experiences were recalled.

CONCLUSIONS

The experience of regional ocular anaesthesia had the capacity to invoke anxiety in the participants in this study. Many found the experience overwhelming and painful. What became clear was the participant's capacity to stoically 'endure' regional ocular anaesthesia, indicating the value people placed on visual function.

Preemptive analgesia with ropivacaine for pars plana vitrectomy: randomized controlled trial on efficacy and required dose

BACKGROUND

The rationale of preemptive analgesia in ocular surgery is avoiding central sensitization because of nociceptive stimuli. The applicability in clinical practice has been argued because evidence for a relevant effect is missing. The present study attempts to demonstrate a clinically relevant pain reduction by preemptive peribulbar ropivacaine injection.

METHODS

Sixty patients scheduled for vitrectomy under general anesthesia between March and June 2007 were randomly assigned to receive 0.75% ropivacaine with 75 IU of hyaluronidase as peribulbar injection of 1, 3, or 5 mL before or 5 mL after surgery. Control subjects were 30 patients without any additional analgesic treatment. Groups were compared regarding procedure duration, consumed amount of analgesics during and after surgery, and pain 1, 3, and 24 hours postoperatively.

RESULTS

Postoperative pain was most marked in control subjects and in the group that received the injection after surgery. Before surgery, the dose of 5 mL of ropivacaine was most effective (postoperative pain median = 0), whereas patients who had received 1 mL or 3 mL reported some pain.

CONCLUSION

The study highlights the benefit of the concept of preemptive analgesia in general: the peribulbar injection of 5 mL of 0.75% ropivacaine before surgery provides a substantial benefit in terms of analgesic demand and postoperative discomfort.

Interventions for age-related visual problems in patients with stroke

BACKGROUND

The prevalence of eye problems increases with age and, consequently, so does the level of visual impairment. As the incidence of stroke also increases with age, a significant proportion of stroke patients will have age-related visual problems. It is possible that the effect of interventions for age-related visual problems may differ in the population of stroke patients compared to the wider population of older people. The interaction between the problems arising directly from stroke and those arising directly from age-related visual problems will be complex. Interventions for age-related visual problems may also be affected by the presence of other stroke-related co-morbidities. Consequently, the nature and outcome of interventions for age-related visual problems may be different in patients with stroke.

OBJECTIVES

The aim of this review is to determine if interventions for age-related visual problems improve functional ability following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (March 2011), the Cochrane Eyes and Vision Group Trials Register (December 2009) and nine electronic bibliographic databases including: the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), AMED (1985 to February 2011) and PsycINFO (1967 to February 2011). We also searched reference lists and trials registers, handsearched journals and conference proceedings, and contacted experts.

SELECTION CRITERIA

Randomised trials in adults after stroke, where the intervention is specifically targeted at assessing, treating or correcting age-related visual problems, or improving the ability of the patient to cope with visual impairment. Primary outcome was functional ability in activities of daily living and secondary outcomes included functional ability in extended activities of daily living, visual acuity, visual field, visual function, balance, falls, depression and anxiety, discharge destination/residence after stroke, quality of life and social isolation, adverse events and death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and planned to extract data and appraise trials. We planned that assessment of methodological quality would be undertaken for allocation concealment, blinding of outcome assessor, method of dealing with missing data and other potential sources of bias.

MAIN RESULTS

We considered 7357 titles, 460 abstracts and 85 full papers. We identified no studies for inclusion in this review.

AUTHORS' CONCLUSIONS

There are no implications for practice arising from this review. Evidence relating to the management of patients (from the general population) with age-related visual problems is available from other Cochrane reviews and is likely to be the best evidence available for making treatment decisions about individual patients. Subgroup analyses within these reviews to explore the effect of interventions for age-related visual problems in patients with stroke are recommended. We recommend that the objectives and selection criteria for this Cochrane review are amended and clarified prior to any future updates.