Eyeworld

P • Increased bleeding of ocular tissues Printed in USA US/PRA/13/0044(1)b 9/13 P o Magenta, Y EW NEWS & OPINION 14 Eyeing the latest trends I t is a question that is certainly on many patients' minds coming into cataract surgery: What sort of anesthesia will be used to keep them comfortable during the procedure? The answer depends on the particular practi- tioner's views. Shameema Sikder, MD, assis- tant professor of ophthalmology, Johns Hopkins University School of Medicine, and medical director, Wilmer Eye Institute, Bethesda, Md., sees the topical anesthetic approach as benefitting the majority of cataract patients. "I think that it offers patients very swift recovery, and it's less invasive," she said. "You're also less likely to have subconjunctival hem- orrhage that can happen both with retrobulbar and sub-Tenon's." Topical routines "I think that the patients start the road to recovery much sooner," Dr. Sikder said. While she still fre- quently patches patients for a couple of hours after surgery, even with the topical approach, she feels they are ahead of the game. "I take off their patch and get started on their drops the day of surgery," she said. "When they come see me the next day in clinic, they've already been off the patch and on the drops for quite some time, and they're pleased because their vision is starting to reach the final stage." By contrast, she finds that with a sub-Tenon's or retrobulbar injec- tion, patients need to be patched overnight. "If they come into the clinic and I have to take the patch off there, there's extra corneal edema, which makes their vision poor and in general makes patients a little less excited about their postoperative vision," Dr. Sikder said. Still, if a resident is handling the case and is new to surgery, Dr. Sikder does not hesitate to recommend a sub-Tenon's block. She finds that this can take away the resident's concern about possibly causing the patient discomfort during the proce- dure. In addition, for those with a history of trauma, she may opt for a sub-Tenon's block. "I don't want to go through the case and find a surprise like a signifi- cant zonular loss or posterior capsu- lar rupture and then have to do supplemental in the middle of the case," she said. But otherwise, she finds the topical approach preferable. Dr. Sikder begins her topical reg- imen as soon as the patient comes into the operating room, even while blood pressure is being tested and EKG leads put on. "I put in a couple drops of proparacaine and a couple drops of 5% betadine, then I do Xylocaine [lidocaine, AstraZeneca, London] jelly," she said. "I like to do that as soon as the patient comes into the room because the Xylocaine jelly has the opportu- nity to sit on the surface of the eye for a few minutes before the patient gets prepped." She finds that the thicker con- sistency of the jelly allows for a good coating of the ocular surface and in general makes patients more com- fortable as they get started with the case. Also, she finds that this works well from the practitioner's perspec- tive. "By the time the prep is com- plete and I put the drapes on and the speculum in, the jelly has com- pletely cleared the eye," she said. "I find that it's nicer to start operating on a clean surface [rather than] hav- ing to wash all the goop off myself." Right after making her paracen- tesis, Dr. Sikder injects a combina- tion of lidocaine and epinephrine. "I like to use that combined mix because it's more efficient in allow- ing things to dilate and to get initial discomfort addressed, so the rest of the case is easier for the patient," she said. William G. Myers, MD, assis- tant professor of ophthalmology, University of Chicago, attending, NorthShore University HealthSys- tem, Skokie, Ill., likewise views the topical approach as advantageous. "The patient becomes your first assistant," he said. "If they're prepped adequately they know to look at the microscope light, and you can redirect them to a position that you find favorable for making incisions." Or if you need them to look to one side or the other, they can do so, he said. "Secondly, you don't have to worry about patching the eye or protecting it when the lids aren't moving properly," Dr. Myers said. The IFIS angle Dr. Myers uses intracameral phenyle- phrine with lidocaine on all of his patients, something that he finds has the added benefit of helping to forestall intraoperative floppy iris syndrome (IFIS). "I've been doing intracameral anesthesia since 2003, and I have never seen a full-blown case of IFIS," Dr. Myers said. He cited a study by Ramon Lorente, MD, published in the Oc- tober 2012 issue of Ophthalmology, as substantiating this. In the study, patients receiving tamsulosin were randomized to receive either intra- cameral phenylephrine or balanced salt solution at the start of surgery. Results indicated that approximately 88% of the eyes receiving balanced salt solution alone experienced signs of IFIS, while no such signs were seen in those receiving the phenyle- phrine, Dr. Myers said. When using intracameral phenylephrine, it is important to be sure that the solution is prepared by a reputable compounding pharmacy, he emphasized, adding that this is not something that practitioners should attempt to mix up on their own, as phenylephrine drops contain preservatives toxic to the corneal endothelium. Dr. Myers' topical regimen includes use of lidocaine and povidone iodine. He repeats the application of this about 3 times before surgery and then again in the operating room. If he used tetracaine instead of lidocaine, this would not be necessary, he said. In an unpublished study that Dr. Myers conducted, he found that tetracaine lasts 45 minutes as opposed to lidocaine, which lasts 18 minutes. Still, he shies away from using tetracaine topically because he finds that it is more toxic to the ep- ithelium. He also finds that the lido- caine helps with dilation, something that Robert Cionni, MD, described back in 2003, Dr. Myers said. He only opts for a regional block for those patients who in- tensely squeeze their eyes. In those June 2014 by Maxine Lipner EyeWorld Senior Contributing Writer Anesthesia assist Putting Xylocaine jelly on the eye for a few minutes before the patient gets prepped makes the patient more comfortable and gives it time to clear the eye before the practitioner gets started. Source: Shameema Sikder, MD continued on page 17 Pharmaceutical focus 11-19 News_EW June 2014-DL_Layout 1 6/3/14 12:16 PM Page 14

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