Eyeworld

EW CATARACT 36 October 2018 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer ent types of anesthesia, topical, in- tracameral, and sub-Tenon's, found that while intracameral lidocaine provided sufficient pain suppressive effects in eyes without high myopia, sub-Tenon's anesthesia was found to be better in eyes with high myo- pia. 3 This study substantiated that a deeper, more far-reaching anesthetic approach might be required in high- ly myopic eyes. The majority of patients pre- senting for cataract surgery are older than 70 years of age, and many have preexisting medical conditions. Regional anesthesia may therefore be preferable, allowing good eye immobilization and pain blocking effects, while still allowing minimal disruption to patients' daily routine. "Using peribulbar local anesthesia for phacoemulsification in patients with axial myopia is an effective technique. It causes immobility, which is important in complicated cases," Dr. Stavropoulou said. EW References 1. Hay A, et al. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology. 1991;98:1017–24. 2. Duker JS, et al. Inadvertent globe per- foration during retrobulbar and peribulbar anesthesia. Patient characteristics, surgical management, and visual outcome. Ophthal- mology. 1991;98:519–26. 3. Hosoda Y, et al. A comparison of patient pain and visual outcome using topical anesthesia versus regional anesthesia during cataract surgery. Clin Ophthalmol. 2016;10:1139–44. Editors' note: Dr. Stavropoulou has no financial interests related to her comments. Contact information Stavropoulou: stavropouloudora1@gmail.com Other options Overall, infiltration anesthesia is contraindicated in uncooperative patients. The retrobulbar approach involves injection of anesthetic into the intraconal eye compartment, while peribulbar anesthesia is inject- ed into the extraconal eye compart- ment, which helps in avoiding most of the complications associated with the retrobulbar approach, such as ocular perforation, retrobulbar hem- orrhage, oculo-cardiac reflex, and optic nerve damage, among others. Peribulbar is technically easier to place, is less painful, and is associat- ed with less IOP rise than retrobul- bar anesthesia. It is more difficult to achieve the same complete anesthe- sia as with retrobulbar anesthesia, but it is still widely used given its lower complication rate. Some of the complications asso- ciated with peribulbar block include spread of local anesthetics to the contralateral eye, periorbital ecchy- mosis, and transient blindness. According to Dr. Stavropoulou, even the small setbacks of surgery that she experienced with this ap- proach were easy to overcome. "The rise of the intraocular pressure was not a problem, since after the injec- tion we put some pressure over the globe, so the majority of the liquid was absorbed. We usually wait about 20 minutes before proceeding to the operation," she explained. "Also, in the group of patients without ade- quate ocular immobility, the surgery continued as per normal, with some cooperation from the patients." Other options to achieve adequate anesthetic and analgesic effects for this patient group include topical and intracameral anesthesia. A study that compared the level of pain during phaco and IOL implan- tation in 301 eyes using three differ- Anesthesia was administered by the same surgeon, who was experienced with peribulbar injections. The results showed that ade- quate akinesia developed within 15 minutes in 70% of the patients. Adequate analgesia developed in almost all patients, except for two in which intracameral anesthesia was added. The cataract surgeries were otherwise uneventful, involving IOL implantation, and no globe perfora- tions or other major complications from the anesthetic injection. Dr. Stavropoulou noted 25/40 patients with posterior staphylomas. Axial myopia: Risk factor Regional anesthesia of the eye, such as peribulbar block, is generally safe and reliable, however, complications can include needlestick injuries to the globe, which can be sight-threat- ening. A study that examined the charts of 23 patients who expe- rienced needle perforations from retrobulbar or peribulbar injections reported that risk factors for globe penetration included high myopia, previous scleral buckling procedures, injection by a non-ophthalmologist, and poor patient cooperation during the injection. They showed that 70% of perforations were from sharp needles, and 30% were from blunt needles. 1 In another, unrelated series of 20 eyes in which there was inadver- tent perforation of the globe during retrobulbar or peribulbar anesthesia, investigators calculated that needle damage in patients with high my- opia of equal to or greater than 26 mm axial length was 30 times more common with an inferior temporal- ly placed peribulbar block, com- pared with eyes that had normal axial lengths of 23 mm or less. 2 Peribulbar anesthesia generally involves two injections roughly 20 minutes before surgery, placed above and below the orbit. It blocks the ciliary nerves, which prevent movement of the globe, but not the optic nerve. "Peribulbar is not complicated to place, indeed we use the inferior temporal approach," Dr. Stavropoulou said. "The biggest risk is perforation of the eye, especially in eyes with high axial length. The surgeon needs to be experienced and proceed carefully while admin- istrating the injection." Peribulbar anesthesia provided adequate analgesia, sensory anesthesia, and akinesia in highly myopic patients with no serious complications T he choice of ocular anes- thesia for cataract surgery largely depends on the surgeon's personal pref- erence, skills, and the patient's cooperation. Akinesia and anesthesia of the globe, lids, and adnexa need to be achieved, as well as adequate postoperative analge- sia. Local anesthesia of the eye is divided into topical, intracamer- al, and infiltration (regional), the last of which includes retrobulbar block, peribulbar block, sub-Tenon's block, and subconjunctival block. Topical anesthesia is today's main- stay, however, in patients in whom topical anesthesia may not do the trick, cataract surgeons need to consider more reliable approaches. A new study attests to the safety and efficacy of the peribulbar approach in patients with axial myopia. The aim of this study was to evaluate the efficacy of peribulbar anesthesia for phacoemulsification in 40 patients with axial myopia. The patients were monitored for major or minor complications and both surgeon and patient satisfac- tion was assessed. According to Theodora Stav- ropoulou, MD, Department of Ophthalmology, Athens University Clinic, Athens, Greece, who was the first author of the study that was presented as an e-poster at the 2017 ESCRS Congress, peribulbar anesthe- sia is an important tool for the eye surgeon to have for highly myopic patients. "Peribulbar anesthesia pro- vides immobility of the eye, some- thing needed in more complicated surgeries, as surgery in the high myopic can be. In our clinic, we rec- ommend this type of anesthesia for more demanding cataract surgeries, although the majority of surgery happens under eye drop anesthe- sia," Dr. Stavropoulou said. The study included 40 patients with axial myopia. Dr. Stavropou- lou and her team used lidocaine and ropivacaine 1:1, 4 ml in total, through a 23-gauge, 0.5 mm needle. Peribulbar anesthesia in patients with axial myopia for phacoemulsification " Using peribulbar local anesthesia for phacoemulsification in patients with axial myopia is an effective technique. " —Theodora Stavropoulou, MD

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