Drop, then decide approach to topical anesthesia

Comparison between ropivacaine and bupivacaine in deep topical fornix nerve block anesthesia in patients undergoing cataract surgery by phacoemulsification

Purpose

In this study, we intend to analyze ropivacaine and bupivacaine in various parameters during phacoemulsification under deep topical fornix nerve block (DTFNB), a known form of nerve block for phacoemulsification.

Methods

This prospective randomized study was conducted on 100 patients undergoing elective cataract surgery by phacoemulsification under DTFNB. Patients were divided into two equal groups of fifty patients each, Groups B (bupivacaine) and Group R (ropivacaine). Two sponges, approximately 2 mm × 3 mm dimensions, saturated with either 0.5% bupivacaine or 0.75% ropivacaine were placed deep in the conjunctival fornices to perform the deep topical block. Both groups were evaluated for magnitude of pain and discomfort at various stages of phacoemulsification using a simple pain scoring system. The level of surgeon satisfaction, requirement for supplementary anesthesia, and surgical complications were also evaluated. Quantitative variables between the two groups were compared using unpaired t-test. Qualitative variables were correlated using Chi-square test.

Results

Overall demographic parameters of patients were similar in both groups. Similar mean pain scores were found in the ropivacaine and bupivacaine groups, with no statistical significance. Surgical satisfaction and the need for supplemental anesthesia were also statistically insignificant.

Conclusion

Ropivacaine is a good alternative for deep topical anesthesia as it has a better safety margin and lesser toxic effect than other comparable local anesthetic agents.

Proparacaine hydrochloride topical drop and intracameral 0.5% lignocaine for phacotrabeculectomy in patients with primary open angle glaucoma

Aim:

To compare the efficacy and safety of 0.5% intracameral lignocaine to 1% intracameral lignocaine prior to phacotrabeculectomy.

Study Design:

Prospective, comparative, observational, and interventional study.

Setting:

Tertiary eye care center in central India.

Materials and Methods:

This study was comprised of 79 patients (79 eyes) with primary open angle glaucoma scheduled for phacotrabeculectomy. Patients were assigned to 1 of 2 Groups receiving proparacaine 0.5% eye drops and 1% intracameral lignocaine just prior to phacotrabeculectomy (Group 1, n = 39) and 0.5% intracameral lignocaine after completion of phacoemulsification just prior to trabeculectomy (Group 2, n = 40). The visual analogue scale was used to record intraoperative and postoperative pain. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. An anesthetist also noted the vital parameters and the requirement for intravenous medications.

Results:

There was no significant difference in the intraoperative pain score (P = 0.0733) or supplemental anesthesia (P = 0.372) between Groups. Postoperative pain score was statistically significant in Group 2 (P < 0.0001). The overall operating conditions in both Groups were comparable (P = 0.7389). A greater number of patients in Group 2 (88.57%) preferred the same anesthetic technique for combined surgery in the fellow eye. There was no difference in inadvertent eye movements and lid squeezing between Groups and they did not interfere with surgery.

Conclusion:

Topical anesthetic drops supplemented with 0.5% intracameral lignocaine before performing trabeculectomy is as effective as 1% intracameral lignocaine given at the beginning of phacotrabeculectomy for primary open angle glaucoma.

Comparative clinical trial of topical anaesthetic agents for cataract surgery with phacoemulsification: lidocaine 2% drops, levobupivacaine 0.75% drops, and ropivacaine 1% drops

PURPOSE

To assess the safety and efficacy of topical lidocaine, levobupivacaine, and ropivacaine in cataract surgery with phacoemulsification.

METHODS

One hundred and five patients scheduled for cataract surgery with topical anaesthesia were randomly allocated into 3 groups of 35 patients each to receive eye drops of lidocaine 2%, levobupivacaine 0.75%, or ropivacaine 1% every 5 min starting 30 min before surgery. Patients graded their pain using a 0-10-point verbal pain score (VPS) at different stages of the procedure. The levels of patient and surgeon satisfaction, the duration of surgery, complications, and the need for supplemental anaesthesia were recorded.

RESULTS

There was no significant difference in duration of surgery and demographic variables among the groups. At the intraoperative period, end of surgery, and postoperative first hour the mean VPS in the lidocaine group was significantly higher than the others (P<0.01), but no significant difference was found between the levobupivacaine and ropivacaine groups. At incision and 24 h after surgery, it was not significantly different among the groups. Surgeon and patient satisfaction scores were significantly better in the levobupivacaine and ropivacaine groups than in the lidocaine group (P<0.01).

CONCLUSIONS

Topical anaesthesia with levobupivacaine and ropivacaine were safe, feasible and more effective than lidocaine in cataract surgery. Levobupivacaine and ropivacaine provided sufficient and long-lasting analgesia without the need of supplemental anaesthesia for each patient.

Topical plus subconjunctival anaesthesia: foldable intraocular lens implantation in eyes without capsule support through a self-sealing incision

PURPOSE

To evaluate the clinical outcomes of topical plus subconjunctival anaesthesia for secondary implantation of foldable intraocular lens (IOL) (Ophtec PC 425Y) in eyes without capsule support through a self-sealing incision.

METHODS

We reviewed the medical records of 22 patients (22 eyes) who received topical plus subconjunctival anaesthesia for scleral fixation of a foldable IOL through small incision. The scleral incision technique was used for IOL scleral fixation. Twelve eyes had traumatic cataract, seven had postphacoemulsification complications and three were aphakic. We studied visual outcome, intraoperative complications and perioperative pain. Autorefractometry and keratometry measurements and central endothelial cell counts were evaluated 1 day preoperatively and 4 months postoperatively. The level of intraoperative pain was scored on a scale of 1-10, where 1 = no pain and 10 = severe pain.

RESULTS

Nineteen patients (86%) tolerated the procedure well, giving pain scores of 1-3, and none required supplemental anaesthesia. The mean age of the patients was 60 years. The postoperative best-corrected visual acuity (BCVA) ranged between 20/100 and 20/25. Four months postoperatively, the mean myopic shift by autorefractometry was -1.25 dioptre (D) and the mean postoperative astigmatism was 1.75 D. The mean central corneal endothelial loss at 4 months was 12.24% (range 4.5-17.2%). Five microscopic hyphaema occurred intraoperatively. Four cystoid macular oedema and four peripheral anterior synechia were the only complications, each occurring at the final follow-up.

CONCLUSION

Topical plus subconjunctival anaesthesia and scleral fixation of foldable IOL (Ophtec PC 425Y) was safe, quick, required a small incision, led to favourable visual outcomes and minimized the risk of intraoperative and postoperative complications in eyes without capsule support. However, a long-term study of a large population is required to confirm these findings.

Contact-topical plus intracameral lidocaine versus peribulbar anesthesia in combined surgery: a randomized clinical trial

PURPOSE

To compare the efficiency and safety of contact-topical anesthesia versus peribulbar injection anesthesia for phacotrabeculectomy.

MATERIALS AND METHODS

A total of 80 patients undergoing combined cataract and glaucoma surgery were randomly allocated to receive either contact or peribulbar anesthesia. No systemic sedatives were used in either group. Patients were asked to rate their pain level on a 5-point scale for 4 periods: during administration of the anesthetic agent; during surgery; immediately after surgery; and 24 hours postoperatively, while the surgeon recorded his subjective assessment of ease of surgery using a standardized template. The patients' general condition during surgery, as well as the results and short-term complications, were assessed.

RESULTS

The injected anesthesia group showed higher rates of discomfort and pain, and 37 patients reported pain ranging from mild to severe during anesthetic administration. The difference between groups was statistically significant (P < 0.001). During surgery, there were no differences in vital signs, patients' subjective pain evaluation, or surgeon stress. We found no differences between pain rates after surgery. Complications included prolonged chemosis, and we also noted that conjunctival hemorrhage occurred more frequently in the peribulbar group than in the contact anesthesia group.

CONCLUSION

Both anesthetic methods provide high levels of pain control without additional sedation during surgery. The use of contact-topical anesthesia avoids pain and reduces the possibility of complications during administration of anesthetics.

Factors associated with success in first-time trabeculectomy for patients at low risk of failure with chronic open-angle glaucoma

PURPOSE

To examine the relationships between study factors and trabeculectomy outcome in a representative sample of United Kingdom ophthalmology surgeons and patients.

DESIGN

Cross-sectional observational study by questionnaire.

PARTICIPANTS

All ophthalmic surgeons performing trabeculectomy in the National Health Service were invited to select their 4 most recent consecutive trabeculectomy cases satisfying study eligibility criteria before June 1996. Three hundred eighty-two surgeons supplied baseline data for 1450 patients and 1-year follow-up data for 1240 (85.3%) patients. All patients had undergone first-time trabeculectomy for chronic open-angle glaucoma.

METHODS

Data were collected by self-administered questionnaires at baseline and 6 and 12 months postoperatively. Univariate analysis of the relationships between study factors and success was performed by chi-square test (categorical variables) and Student's t or Mann-Whitney U tests (continuous variables). Multiple logistic regression modeling of explanatory variables significant at a P value of </=0.1 was then performed.

MAIN OUTCOME MEASURE

Trabeculectomy success, defined as a final intraocular pressure (IOP) less than two thirds of the preoperative IOP, excluding patients on antiglaucoma medications.

RESULTS

After multiple logistic regression modeling, diabetes (odds ratio [OR] = 0.485, 95% confidence interval [CI] = 0.271-0.868, P = 0.015), superior rectus traction suture (OR = 0.580, 95% CI = 0.348-0.959, P = 0.034), subconjunctival anesthetic (OR = 0.172, 95% CI = 0.065-0.459, P<0.0001), and nonspecialist surgeons (OR = 0.539, 95% CI = 0.335-0.865, P = 0.010) remained significantly associated with poorer outcome.

CONCLUSIONS

In this nationally representative sample of glaucoma patients undergoing first-time trabeculectomy, we have identified important associations between diabetes, superior rectus traction suture, subconjunctival anesthetic, nonspecialist surgeons, and diminished trabeculectomy success. These associations merit further examination.

Aqueous humor levels of topically applied bupivacaine 0.75% in cataract surgery

PURPOSE

To measure the intraocular levels of bupivacaine 0.75% topically applied before phacoemulsification and to develop standards for topical anesthesia in cataract surgery.

SETTING

Department of Ophthalmology, University Hospitals of Leicester, Leicester, United Kingdom.

METHODS

Forty eyes having phacoemulsification for senile cataract under topical anesthesia without sedation were randomly assigned to 1 of 2 preoperative topical anesthesia regimens. Bupivacaine 0.75% was applied in 0.1 mL drops 3 times in the 30 minutes before surgery in 18 eyes and 6 times in the 60 minutes before surgery in 22 eyes. Aqueous humor and serum samples were taken at the start of surgery and the bupivacaine levels measured. A visual analog pain score scale was used to indicate intraoperative pain.

RESULTS

The mean aqueous humor level of bupivacaine was 5.9 microg/mL +/- 4.3 (SD) after 3 drops and 5.7 +/- 4.0 microg /mL after 6 drops. The blood levels were less than 1.0 microg/mL. There was no statistically significant difference in the intraocular level of bupivacaine between the 2 groups. There was no difference in the age or sex distribution between the 2 groups, although there was an increase in the intraocular level of bupivacaine with age (approximately 1.4 microg/mL per decade; P =.048). There was no clear pattern associating the pain score with age, sex, or intraocular level of bupivacaine.

CONCLUSIONS

A 3-drop regimen of bupivacaine 0.75% in the half hour before cataract surgery penetrated the eye as effectively as 6 drops in the 1 hour before surgery and provided good analgesia for phacoemulsification. Bupivacaine 0.75% penetrated the eye increasingly effectively with increasing age.

Contact versus peribulbar anaesthesia in trabeculectomy: a prospective randomized clinical study

PURPOSE

To compare the pre-, intra- and postoperative pain scores and complication rates in trabeculectomy under contact-topical anaesthesia versus peribulbar injection anaesthesia.

METHODS

A total of 100 patients selected to undergo primary trabeculectomy were randomly allocated to receive either contact or peribulbar anaesthesia. Patients were asked to rate their pain levels on a 5-point scale for four periods: during the administration of the anaesthetic agent, during surgery, immediately after surgery and 24 hours postoperatively. At the same time, the surgeon was asked to record his subjective assessment of the stress he himself had suffered during the course of the intervention. Surgical parameters, intra- and early postoperative complications were also evaluated.

RESULTS

The difference between groups was statistically significant during anaesthetic administration. Six patients who received contact-topical anaesthesia reported mild discomfort during delivery of the anaesthetic agent, while 43 patients complained of mild to severe pain during the injection of bupivacaine (p < 0.001). Thirty-two patients in the contact anaesthesia group and 26 in the injected anaesthesia group reported no pain during surgery (p = 0.127). Only one patient in each group reported mild pain 30 min postoperatively. We found no differences between pain rates after surgery. Complications included prolonged chemosis and we also noted that conjunctival haemorrhage occurred more frequently in the peribulbar group than in the contact anaesthesia group (p = 0.012).

CONCLUSION

Both anaesthetic methods provided high levels of pain control without additional sedation during surgery. The use of contact-topical anaesthesia reduces both pain and the possibility of complications during the administration of anaesthetics.

Surgeon experience and patient comfort during clear corneal phacoemulsification under topical local anesthesia

PURPOSE

To evaluate patient comfort during topical anesthesia clear corneal phacoemulsification surgery performed by a surgeon in the learning curve or by an experienced surgeon.

SETTING

Royal Alexandra Hospital, Paisley, Scotland, United Kingdom.

METHODS

This study comprised 46 consecutive patients having phacoemulsification under topical anesthesia of proparacaine 0.5% (Proxymetacaine. Surgery was performed by a surgeon during his learning curve (n = 20) or by an experienced surgeon (n = 26). No sedation or intracameral anesthesia was used in either group. All patients had clear corneal phacoemulsification with foldable acrylic posterior chamber intraocular lens implantation. Each patient's subjective experience of overall pain perioperatively (period immediately surrounding and during surgery) and worst pain perceived during surgery was measured immediately after surgery using a 10-point visual analog scale.

RESULTS

There was no significant difference in patient-reported pain scores for overall pain perioperatively (P =.47, Wilcoxon rank sum test) and the worst pain perceived during surgery (P =.32, Wilcoxon rank sum test).

CONCLUSIONS

Topical anesthesia with proparacaine provided similar and reasonable analgesic effects in patients having surgery by a surgeon in the learning curve and those having surgery by an experienced surgeon. The discomfort perceived during surgery performed by an experienced surgeon was less, although not statistically significantly different.

A comparison of topical and retrobulbar anesthesia for trabeculectomy

PURPOSE

To compare the safety and efficacy of topical versus retrobulbar anesthesia for primary trabeculectomy

METHODS

A prospective study of 36 consecutive patients undergoing trabeculectomy who were randomized to receive topical (n = 18) or retrobulbar (n = 18) anesthesia. Operating conditions, patient comfort, and surgical outcome were evaluated.

SETTINGS

Tertiary-care university hospital ambulatory surgical center.

RESULTS

There were no differences in operating conditions (P = 0.14), pain during (P = 0.54) or after (P = 0.76) surgery, or supplemental anesthesia required (P = 0.34) between the two groups. Very few patients in either group were bothered by touch sensation, tissue manipulation, or the microscope light. Chemosis, subconjunctival hemorrhage and eyelid hemorrhage were seen exclusively in the retrobulbar group (P <0.03), and were all attributable to the injection. Inadvertent eye movement was present more frequently in the topical group (P = 0.01), although this did not pose a problem to the surgeon. No surgical complications were encountered in either group.

CONCLUSION

Topical anesthesia is a safe and effective alternative to retrobulbar anesthesia for primary trabeculectomy.

Topical versus retrobulbar anesthesia for combined phacotrabeculectomy: prospective randomized study

PURPOSE

To compare the safety and efficacy of topical and retrobulbar anesthesia for combined phacotrabeculectomy.

SETTING

Tertiary-care university hospital ambulatory surgical center.

METHODS

In this prospective study, 40 consecutive patients having combined phacotrabeculectomy were randomized to receive topical (n = 20) or retrobulbar (n = 20) anesthesia. Operating conditions, patient comfort, and surgical outcome were evaluated.

RESULTS

There was no significant between-group difference in operating conditions (P =.56), pain during (P =.41) or after (P =.23) surgery, or supplemental anesthesia required (P =.49). Few patients in either group were bothered by tissue manipulation or the microscope light, although more patients in the topical group were slightly bothered by touch sensation (P =.05). Chemosis, subconjunctival hemorrhage, and eyelid hematoma were seen almost exclusively in the retrobulbar group (P <.05). Inadvertent eye movement was present more frequently in the topical group (P =.04), although this did not pose a problem to the surgeon.

CONCLUSION

Topical anesthesia is a safe and effective alternative to retrobulbar anesthesia for combined phacotrabeculectomy.

Rand-Stein analgesia protocol for cataract surgery

OBJECTIVE

To describe the safety and efficacy of an analgesia protocol that enables the surgeon to maintain control over an alert patient experiencing seemingly painless ambulatory cataract surgery, while eliminating the risks and side effects associated with general, local, topical, and intracameral anesthesia.

DESIGN

Noncomparative, interventional case series.

PARTICIPANTS

Five thousand one hundred sixty-eight consecutive cataract surgery cases operated on by the same surgeon from April 1, 1993 through June 1, 1998.

METHODS

This technique produces profound ocular analgesia, avoiding any undesired sedative effects, using very low-dose, titrated, intravenous alfentanil. Complete control of the uncooperative patient, including lid squeezing and ocular and general body movements, is obtainable whenever necessary using very low-dose, titrated, intravenous methohexital.

MAIN OUTCOME MEASURES

Success was defined as surgery completed in a controlled manner without the need to convert to general, local, topical, or intracameral anesthesia and the patient's experience being perceived as pain free.

RESULTS

One hundred percent of the cases were successful without ever deviating from the protocol.

CONCLUSIONS

This analgesia protocol offers advantages for cataract surgery. It virtually eliminates the morbidity of cataract surgery associated with other anesthesia techniques while providing excellent and reliable control. It allows for an immediate postoperative recovery with instantaneous vision restoration. These patients are generally awake, alert, and retain their protective reflexes.

Provision of anesthesia with single application of lidocaine 2% gel

PURPOSE

To compare the efficacy of a single application of lidocaine 2% gel with tetracaine 0.5% drops for topical anesthesia in clear corneal cataract surgery.

SETTING

The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

METHODS

A preliminary toxicity study applied lidocaine 2% gel in the conjunctival fornices of rabbit eyes (n = 9). Biomicroscopic examination was performed and then enucleation at sequential intervals after the application. Intentional intracameral injection of lidocaine gel was performed (n = 3), followed by enucleation. Histopathological analysis was performed on all eyes. A randomized clinical trial comparing topical anesthesia in clear corneal cataract surgery was performed in 25 eyes of 25 patients (12 eyes randomly assigned to lidocaine gel, 13 eyes to tetracaine drops). Corneal sensation was measured with the Cochet-Bonnet aesthesiometer before application of the topical anesthesia, 5 minutes after application, and at the conclusion of surgery. Additional intraoperative local anesthesia and systemic sedation were recorded. Patients' subjective level of comfort was reported 20 minutes after surgery, and the surgeon's perception of patients' comfort was also noted.

RESULTS

In rabbits, lidocaine gel did not cause clinical or histopathological alteration of the ocular tissues. In the clinical study, median corneal sensitivity before application, after 5 minutes, and postoperatively was 6, 0, 0 (maximum sensitivity = 6), respectively, in the lidocaine gel group and 5, 0, 0, respectively, in the tetracaine drops group. Additional local anesthesia was administered in 17% and 31% of patients, respectively. Satisfactory comfort was reported by 58% in the lidocaine gel group and 62% in the tetracaine drops group.

CONCLUSIONS

A single application of lidocaine 2% gel was a safe and effective alternative to multiple topical anesthetic drops for clear corneal cataract surgery. Lidocaine 2% gel was similar to tetracaine drops in provision of corneal anesthesia and patient comfort, while causing no significant toxicity to the ocular surface.

A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine

OBJECTIVE

To determine whether intraocular lidocaine increases patient comfort during cataract surgery while under topical anesthesia.

DESIGN

Prospective, randomized, double-masked, placebo-controlled clinical trial.

PARTICIPANTS

Both men and women between 45 and 85 years of age who were scheduled for elective cataract surgery while under topical anesthesia participated. Sixty-eight patients were randomized to each group.

INTERVENTION

Patients were randomized to receive either topical anesthesia plus intracameral 1% preservative-free lidocaine or intracameral balanced salt solution.

MAIN OUTCOME MEASURES

Patient assessment of pain during delivery of the anesthesia, surgery, and after surgery using a visual analog pain scale was measured. Patients also recorded the degree to which they were bothered by tissue manipulation and the microscope light. Surgeon assessments of operative conditions, patient cooperation, and intraoperative complications were recorded. The attending anesthesiologist recorded any required supplemental intravenous sedation and any increase in pulse or increase in blood pressure.

RESULTS

There was no significant difference in patient-reported pain scores for delivery of anesthesia (P = 0.902), surgery (P = 0.170), or after surgery (P = 0.680). Patients in the lidocaine group reported being less bothered by tissue manipulation (P = 0.021). The surgeon assessment showed more patient cooperation in the lidocaine group (P = 0.043).

CONCLUSIONS

Both topical anesthesia alone and topical anesthesia plus intracameral lidocaine provide good operative conditions for the surgeon and comfortable surgical circumstances for the patient. Injection of intraocular lidocaine increases patient cooperation and decreases the degree to which patients are bothered by tissue manipulation, two outcomes that justify its use.

Simplified anesthesia technique for scleral tunnel phacoemulsification

A simplified anesthesia technique for sutureless scleral tunnel, small incision, one-port phacoemulsification is described. Step 1: Mild intravenous sedation is achieved with 1 mg of midazolam and 10 mg of propofol. Step 2: A tetracaine- or preservative-free-lidocaine-soaked Weck cell sponge is applied to the superior bulbar conjunctiva and the superior episcleral tissue for localized anesthesia. Step 3: Preservative-free lidocaine 1%, 0.75 cc, is injected into the anterior chamber for intraocular anesthesia. This technique can be used in the presence of all types of cataracts, requires about 10 seconds to complete, and can be used with all phacoemulsification techniques. Results of the technique in a study population are reported.

Combined topical-peribulbar anesthesia for cataract surgery

PURPOSE

To evaluate the anesthetic effect of single-point low-volume peribulbar anesthesia supplemented by topical anesthesia.

SETTING

Private ambulatory ophthalmic practice.

METHODS

Five hundred consecutive patients received 4 cc of lidocaine 2% with 200 units hyaluronidase as 1-point peribulbar anesthesia. This was supplemented by lidocaine 4%, 1 drop every 3 to 5 minutes for 3 instillations. Phacoemulsification and intraocular lens implantation were performed through a scleral tunnel or clear corneal approach. All patients were evaluated for intraoperative akinesia, lid closure, and anesthesia. One hour after surgery, the eye patch was removed and patients were evaluated for pain, discomfort, foreign-body sensation, diplopia, and lid closure.

RESULTS

All patients had no pain to mild discomfort during surgery; 34% had total and 58% partial akinesia; 78% had poor orbicularis action (lid closure); 12% had subconjunctival hemorrhage. Postoperatively, 42% of patients had foreign-body sensation caused by conjunctival coaptation by diathermy or corneal edema. Diplopia occurred in 32% of patients but resolved within 1 hour after eye-patch removal, and partial ptosis occurred in 58%, resolving within 2 hours of patch removal. All patients had normal lid closure when the eye patch was removed.

CONCLUSIONS

Low-volume 1-point peribulbar anesthesia supplemented by topical anesthesia was safe and effective and provided early visual recovery. Topical therapy can be started 1 hour postoperatively.

A randomized clinical trial of combined topical-intracameral anesthesia in cataract surgery

OBJECTIVE

To evaluate the level of patient discomfort during phacoemulsification and implantation of a foldable intraocular lens (IOL) while under topical lidocaine, alone or in combination with intracameral lidocaine.

DESIGN

A prospective, randomized, controlled trial.

PARTICIPANTS

Between January and July 1997, a total of 162 patients (162 eyes) scheduled for cataract surgery were randomly assigned to either the placebo group (topical anesthesia with intracameral balanced salt solution [group 1, n = 81]) or the interventional group (combined topical-intracameral anesthesia [group 2, n = 81]).

INTERVENTIONS

All patients underwent temporal clear corneal phacoemulsification and implantation of a foldable silicone IOL. All patients received a minimum total of five doses (two drops per dose) of 2% topical lidocaine hydrochloride. Three doses were administered before surgery into the superior and inferior cul-de-sac at 10 minutes, 5 minutes, and immediately before the initial corneal incision. One dose was administered before the commencement of phacoemulsification and another dose before implantation of the IOL. In addition, all patients received an intracameral injection immediately after entrance into the anterior chamber. Patients in group 1 received a 0.5-ml injection of balanced salt solution, and those in group 2 received a 0.5-ml injection of 1% lidocaine.

MAIN OUTCOME MEASURE

A 10-point visual analogue scale was used immediately after the surgery to assess each patient's overall severity of pain intraoperatively.

RESULTS

Ninety percent of patients in group 1 and 95% in group 2 assigned a score of 0 or 1 to the level of intraoperative discomfort. The mean pain score +/- 1 standard deviation for group 1 was 0.63 +/- 0.68 and for group 2 was 0.37 +/- 0.58. The difference between the pain scores for the two groups was statistically significant (P = 0.0053). A small but significant proportion (15%) of patients in group 1 expressed distress when the ciliary body was stretched or the iris was manipulated with instruments.

CONCLUSION

Although topical lidocaine alone provides adequate anesthesia for phacoemulsification and implantation of a foldable IOL, combined topical and intracameral administration of lidocaine can further minimize intraoperative discomfort.

Visual recovery after phacoemulsification using topical anesthesia

PURPOSE

To assess the speed of visual function recovery after phacoemulsification using topical anesthesia.

SETTING

Department of Ophthalmology, Royal United Hospital, Bath, United Kingdom.

METHODS

Twenty consecutive patients having routine sutureless clear corneal phacoemulsification with implantation of a Staar foldable intraocular lens were recruited in a prospective study. Visual acuity was assessed using a LogMAR chart and contrast sensitivity using a Pelli-Robson chart 1, 2, 4, and 16 hours postoperatively. A final examination and refraction were performed at 1 week.

RESULTS

Although return of visual acuity was slow during the first 2 hours, the mean LogMAR acuity had improved to 0.425 (Snellen equivalent 6/15) by 4 hours and 0.165 (Snellen equivalent of 6/9.5) by 16 hours. There was no postoperative ptosis or diplopia.

CONCLUSION

The absence of diplopia and rapid return of visual function with a mean acuity of 6/15 by 4 hours suggest that early patient discharge is relatively safe.

Toxicity of Xylocaine to rabbit corneal endothelium

PURPOSE

To assess the toxicity of lidocaine hydrochloride (Xylocaine) to the corneal endothelium.

SETTING

Department of Ophthalmology, Hôtel-Dieu Hospital, Paris, France.

METHODS

Rabbit corneas were excised and the endothelium was exposed to balanced salt solution (BSS), Xylocaine 1%, or Xylocaine 5% (5 corneas/group) for 20 minutes. The endothelium was then stained with trypan blue and alizarin red, and 5 photomicrographs were taken of each cornea at a standard magnification and analyzed with a digital imaging system (Biocom 200).

RESULTS

Xylocaine solutions produced changes in endothelial cell morphology, but there was no cell staining with trypan blue. Corneas exposed to Xylocaine 5% had more marked cell alterations. Small areas of cells were lost from all 15 corneas, mainly at the periphery, but the differences among the 3 groups of corneas were not significant.

CONCLUSION

Exposure of rabbit corneal endothelium to Xylocaine solutions in vitro was not associated with trypan blue staining of endothelial cells.

Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up

PURPOSE

To evaluate the results of topical plus subconjunctival anesthesia for phacotrabeculectomy surgery and postoperative glaucoma control over 1 year.

SETTING

Pacific Eye Center, Brisbane, Australia.

METHODS

In this retrospective study of consecutive patients with glaucoma and cataract, topical plus subconjunctival anesthesia was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy). Patients with proliferative diabetic retinopathy or neovascular glaucoma were excluded.

RESULTS

Thirty-eight eyes had phacotrabeculectomy using topical plus subconjunctival anesthesia over 2 years. Patients reported no discomfort intraoperatively or postoperatively, and none required intravenous sedation. Eighty-one percent of patients achieved a best corrected visual acuity of 20/40 or better 6 months after surgery. Mean drop in intraocular pressure (IOP) was 5.91 mm Hg at 3 months and 5.86 mm Hg at 12 months, at which time IOP was controlled without additional medication in 72% of patients. There were no serious complications postoperatively.

CONCLUSION

In this series, no patient reported intraoperative or postoperative discomfort and surgical results were excellent in terms of visual outcome and IOP control.

Evaluation of local anesthesia techniques for small incision cataract surgery

PURPOSE

To evaluate the surgical experiences and patient preference with 3 local anesthesia techniques for small incision cataract surgery.

SETTING

Department of Ophthalmology, Hjørring Hospital, Denmark.

METHODS

This prospective, randomized study included 66 patients having simultaneous bilateral cataract surgery. There were 3 test groups, each containing 2 of the following local anesthesia techniques: retro/peribulbar (RBA), sub-Tenon's (STA), or topical (TA). Each patient served as his or her own control. No medical sedation was used. Patient response to each anesthesia technique was evaluated by the surgeon based on surgical difficulties, a nurse using hand-holding tension and verbal interaction, and a visual analog pain score. Patients were also asked which of the 2 techniques they preferred and their reasons.

RESULTS

No local anesthesia techniques interfered with surgery. The order of a positive pain/discomfort response during surgery was TA > STA > RBA. Significantly more pain occurred with application of RBA than with STA or TA. No postoperative pain was recorded with any method. Fifty-six percent of patients said they preferred 1 technique over the other; 16% of patients having STA would not do so again, 19% would not have TA again, and 40% would not have RBA again. The main reasons for preferring STA and TA were fear of or pain from a retrobulbar injection. The main reasons for preferring RBA were less awareness, anxiety, and surgical pain. Immediate visual recovery seemed to be of minor importance in patients' choice of an anesthesia technique.

CONCLUSION

Although less discomfort/pain occurred during surgery with RBA, patients preferred STA and TA primarily because of the inconvenience or pain of the retrobulbar injection. Although medical sedation was not used in this study, the pain/discomfort ratio from surgery was not greater than in studies using intravenous sedation, indicating that the use of medical sedation should be re-evaluated.

Toxicity of intraocular lidocaine and bupivacaine

PURPOSE

To study the toxicity of intraocular lidocaine, bupivacaine, and a combination of the two anesthetics.

METHODS

The right eyes of 34 rabbits were divided into eight groups, and each was injected intravitreally with 0.2 ml of lidocaine hydrochloride in a 2%, 1%, 0.5%, or 0.25% concentration, or bupivacaine hydrochloride in a 0.75%, 0.5%, or 0.25% concentration, or a 1:1 mixture of lidocaine 2% and bupivacaine 0.75%. The left eyes of four of these rabbits received an injection of balanced saline solution. Electroretinograms were recorded before injection and 30 minutes, 90 minutes, 3 hours, 6 hours, 24 hours, and 1 week after injection. The amplitude and the implicit time were analyzed. The rabbits were killed 1 week after injection and the eyes evaluated histologically.

RESULTS

No adverse clinical reaction and no histologic abnormality was observed in any of the nine groups after injection. The a- and b-waves of the electroretinograms in the control group injected with balanced saline solution, and the a-waves of the experimental groups that received injections of lidocaine, bupivacaine, or the mixture, were normal. The b-waves of the experimental groups demonstrated a marked decrease in the amplitude and an increase (P < .05) in the implicit time after intravitreal injection. Electroretinogram responses recovered within 24 hours.

CONCLUSIONS

Intravitreal injection of 0.2 ml of lidocaine up to 2%, or of bupivacaine up to 0.75%, and the mixture of lidocaine 2% and bupivacaine 0.75%, induced reversible electroretinogram changes in the rabbit retina. No histologic abnormalities were observed.

Patient comfort during cataract surgery with modified topical and peribulbar anesthesia

PURPOSE

To evaluate patient comfort during cataract surgery performed using modified topical and peribulbar anesthesia.

SETTING

Sunderland Eye Infirmary Cataract Treatment Centre, Sunderland, United Kingdom.

METHODS

In this prospective study, 50 consecutive patients scheduled for cataract surgery with local anesthesia were randomly assigned to receive topical bupivacaine hydrochloride plus 0.1 mL subconjunctival lignocaine or standard peribulbar anesthesia. All surgery was performed by one surgeon using a scleral pocket bimanual phacoemulsification technique. Patients were asked to grade the pain experienced during administration of the anesthetic and during cataract surgery using a visual analog scale.

RESULTS

No statistically significant difference in patient comfort was demonstrated between the two groups during cataract surgery (P < .4, Wilcoxon rank-sum test), and all patients were satisfied with the anesthesia. However, administration of topical bupivacaine was significantly less painful than peribulbar injections (P < .001, Wilcoxon rank-sum test). In eight patients in the topical anesthesia group, the cataract in the fellow eye was removed using peribulbar anesthesia; seven of these patients stated a preference for the modified topical method, while one patient thought there was no difference between the two methods. There was no difference between the groups in surgical complications, but 24% of the peribulbar group had a minor subconjunctival hemorrhage at the needle entry site.

CONCLUSION

The modified topical technique provided satisfactory patient comfort during cataract surgery; it was comparable to the comfort achieved using peribulbar injections. The speed and ease of administering topical anesthesia coupled with the rapid visual recovery after surgery makes this method a suitable and safe choice for day-case phacoemulsification cataract surgery.