Eyeworld

few cases, Dr. Myers uses 1% lido- caine with epinephrine. Dr. Sikder reserves the regional technique mainly for those on anticoagulation therapy, as she would rather avoid a bleed in these patients. Scott Greenbaum, MD, Greenbaum Eye Associates, and clinical assistant professor of oph- thalmology, New York University Medical Center, New York, favors a sub-Tenon's approach for all of his patients. He views safety and speed as the only advantages of the topical approach. "The downsides are inadequate analgesia requiring additional IV sedation and a greater dependence on IV sedation in general in compar- ison to sub-Tenon's," Dr. Greenbaum said, adding that this is the view supported by Certified Registered Nurse Anesthetists. He said that there is added risk and cost in the use of IV sedation that accompanies the topical approach—an issue that is apparent but rarely discussed. With retrobulbar and peribulbar regional techniques, meanwhile, he worries about the safety with sharp instruments. He uses a flexible, blunt plastic cannula (Greenbaum Anesthesia Cannula, Alcon, Fort Worth, Texas), which he finds much safer. "Needles have been proven to perforate the sclera, orbit blood ves- sels, nerve sheaths and extra ocular muscles," he said. "Why continue using them in 2014?" Dr. Greenbaum has successfully performed cataract surgery, glau- coma surgery, and even corneal transplants using blunt cannula sub-Tenon's anesthesia since 1992. The same medications relied on with other regional techniques are used here. To further enhance safety, he patches the eye for a minimum of 4 hours postop—an approach he credits to Randall Olsen, MD, who showed that this was advisable in his work at the University of Utah. "Patching significantly reduced risk with any anesthesia technique," Dr. Greenbaum noted. Going forward, Dr. Greenbaum thinks that the sub-Tenon's ap- proach will continue to grow in popularity as topical and needle delivered techniques slowly fade. Dr. Sikder disagrees. She views use of topical anesthesia as on the rise. "It's popular and it's conven- ient," Dr. Sikder said. "But I think it's important that surgeons be aware of what their other choices are because at the end of the day, the right choice may make all of the difference in the success of the surgery." EW Editors' note: Drs. Greenbaum and Sikder have no financial interests re- lated to their comments. Dr. Myers has financial interests with Leiter's Com- pounding Pharmacy (San Jose, Calif.). Contact information Greenbaum: thecannula@aol.com Myers: wmyers2020@gmail.com Sikder: ssikder1@jhmi.edu June 2014 Magenta, Y 00 Remove contact lenses prior t These reactions were reported in 3 to 8% of patients. U mg/ s. S as e Anesthesia continued from page 14 Use of intracameral phenylephrine as part of the anesthesia regimen may head off signs of IFIS, such as the anterior iris streaming pictured here. Source: William G. Myers, MD 11-19 News_EW June 2014-DL_Layout 1 6/3/14 12:16 PM Page 17

• Cover