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Anesthesia For Cataract Surgery Recent Trends

Cataract Surgery And Anesthesia Types

Cataract Surgery | Inside the OR

The majority of cataract surgeries performed in the U.S. are done with a local anesthetic and IV sedation.

The local anesthesia may be accomplished in one of two ways: either an injection of anesthetic around the eye or anesthetic eye drops placed on the eye, often combined with an injection of a small amount of anesthetic into the front of the eye at the very beginning of surgery.

The injection of anesthetic around the eye generally produces a deeper anesthesia for the surgery than the topical method but it also comes with increased risk. There is a very small chance of potentially serious bleeding behind the eye and a rare chance of inadvertent penetration of the back of the eye with the injection needle.

The topical anesthesia has lower risk but does not provide quite as deep of an anesthesia, although the overwhelming majority of people having cataract surgery with a topical anesthetic do not experience any significant pain during the procedure.

The other difference between the two anesthesias is with that topical anesthesia you maintain your ability to move your eye around whereas with injection anesthesia the eye muscles are temporarily paralyzed so your eye doesnt move during the surgery. When you have topical anesthesia it is important for you to try to stare straight ahead at the light in the microscope above you. Most people accomplish this quite easily.

Patient Selection And Assessment

Older patients undergoing eye surgery frequently have coexisting diseases such as diabetes mellitus, hypertension, coronary artery disease, or cardiac insufficiency. A preoperative assessment should be routinely done to ensure that coexisting medical conditions are reasonably well controlled. Despite the low morbidity and mortality associated with local ophthalmic anesthesia, patients should be carefully screened for their eligibility for surgery. Patients with severe kyphosis or scoliosis pose obvious practical problems for microscopic surgery. Patients who may not be able to lie flat for the requisite period, due to cardiac or respiratory insufficiency, neurological disease, or dementia, are also challenging. Once draped, patients with profound deafness may be unable to respond to intraoperative commands unless carefully briefed preoperatively.

Principles Of Peribulbar Anesthesia

Single-injection versus multiple-injection technique: Increasing the injected volume of LA provides sufficient anesthesia. Additional injections are not needed. In addition, anatomic distortion following the first injection may increase the risk of complications associated with consecutive injections. As a rule of thumb, a second injection should be performed only as a supplement when the first injection has failed to provide effective anesthesia. Needle insertion sites: Needle insertion through the superior nasal site should be avoided. At this level, the distance between the orbital roof and the globe is reduced, theoretically increasing the risk of globe perforation.Additionally, the needle may injure the superior oblique muscle. The inferonasal approach or an approach through the medial canthus should be used instead. The needle is introduced at the medial junction of the lids, nasal to the lacrimal caruncle, in a strictly posterior direction to a depth of 15 mm or less. At this level, the space between the orbital wall and the globe is similar in size to that of the inferior and temporal approach and is free of blood vessels. Moreover, myopic staphyloma, an anatomical anomaly that represents a risk factor for perforation, is infrequently encountered on the nasal side of the globe.

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Anesthesia For Cataract Surgery: Recent Trends

Copyright and License informationDisclaimerCorrespondence:Copyright

The world has witnessed a significant evolution in surgical technique of cataract extraction in last few decades. After Ridley introduced the intraocular lens, the challenge was to reduce the size of incision. It was fulfilled by Kelman with the introduction of phacoemulsification and by Mazzocco with the introduction of foldable intraocular lens. Of course advances in phaco machines, phacotips, ophthalmic viscosurgical devices , etc. also have played a major role to reach todays faster, more controlled, and less traumatic cataract surgery.

As incisional size of cataract extraction has reduced, anesthesia techniques have also advanced significantly. General anesthesia was introduced in mid-19th century. Koller and Knapp can be considered the pioneers of local anesthesia for cataract surgery. Koller introduced topical cocaine in 1884 while Knapp introduced retrobulbar anesthesia in 1884. In the beginning of 19th century, orbicularis block was introduced by Van Lint, OBeriens, and Alkinson. In last 25 years, local anesthesia techniques have progressed from posterior peribulbar to no anesthesia techniques.

Wolters Kluwer — Medknow Publications

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The Volume Effect Of Injectionsbehind The Eye

Glam Derma

Any substantial injection behind the equator of the eye can significantly raise intraocular pressure and push the posterior segment forward, resulting in a crescent-shaped anterior chamber with decreased volume . This can make surgical conditions more challenging, and while this can mostly be offset by counter-pressure , some surgeons prefer techniques that retain a physiological anterior segment, and most surgeons prefer techniques that avoid large volumes of injectate in the orbit. On the other hand, in patients with significant enophthalmos, bringing the globe forward can improve surgical exposure.

FIGURE 7. Physiological anterior segment. The effect of increased retrobulbar volume.

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Local Anaesthesia In Cataract Surgery

Sagili Chandrasekhara Reddy, Thanigasalam Thevi

Sagili Chandrasekhara Reddy, Department of Ophthalmology, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, MalaysiaThanigasalam Thevi, Department of Ophthalmology, Hospital Melaka, Melaka, MalaysiaConflict-of-interest statement: The author declare that there is no conflict of interest regarding the publication of this paper.Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/Correspondence to: Sagili Chandrasekhara Reddy, Professor, Department of Ophthalmology, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia.Email: profscreddy@gmail.com

Anesthesia For Cataract Surgery

More than half of the respondents used topical with intracameral anesthesia for phacoemulsification. This leaves a cumulative 44.9% for the three types of regional anesthesia combined together .

Preferred anesthesia for phacoemulsification.

Of the respondents, 66.3% used retrobulbar anesthesia for ECCE procedure. A total of 92.1% used regional anesthetic for ECCE .

Preferred anesthesia for ECCE.

Patient cooperation, surgeon skill and experience, procedure safety and the type of procedure were the top four factors affecting the surgeons choice of anesthesia technique .

Facors determining choice of anesthetic.

Regarding giving sedation before the surgery, 62.6% did not give sedation before cataract surgery, while 26.6% sometimes used benzodiazepines for their patients. In the majority of cases , the respondent themself is the one who administers the anesthesia 70.1% of the respondents said that they had an anesthesia-trained person monitoring the patient during surgery.

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Ocular Anesthesia Trends Toward Fewer Needles No Pain

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Various innovations in technology and methods have revolutionized ocular surgery by maximizing outcomes and safety, shortening surgical time and reducing stress on patients.

Patient comfort and immobility are also critical to surgical success and safety, and anesthesia plays a key role. Currently, ophthalmic surgeons use intravenous sedation and topical or infiltration methods such as retrobulbar anesthesia, peribulbar anesthesia and subconjunctival anesthesia to achieve akinesia.

Patients expect less invasive and painless surgery, according to Melissa Toyos, MD, FACS.

Were dealing with people with higher levels of expectations. Theyre not necessarily willing or used to suffering in any way. They definitely want to be comfortable, she said. I think all of the trends are less invasive fewer needles, no pain.

In the past, ophthalmic surgeons would perform retrobulbar and peribulbar blocks, in which local anesthetic is injected behind the eye, according to John P. Berdahl, MD. The long-acting anesthetics would prevent the eye from moving and make the surgery painless. However, nobody really loves having a needle stuck behind their eye, he said.

Image: Toyos M

Practices and preferences

There are still pockets in the United States where people do a lot of retrobulbar blocks, but for the most part it is not common, he said.

Retina procedures

Pain Control During Cataract Surgery

Cataract Surgery in 2022 How I Do It.

All of the major classes of techniques reported yielded good or excellent intraoperative pain control. The evidence was strong that retrobulbar and peribulbar techniques produce equivalent pain control during cataract surgery, and there was moderate evidence indicating superior pain control with the use of subconjunctival/sub-Tenon’s approaches compared with retrobulbar block. There was insufficient evidence to determine whether peribulbar or subconjunctival/sub-Tenon’s anesthesia results in better pain control during surgery. There was strong evidence that retrobulbar block results in less pain during cataract surgery than topical anesthesia, moderate evidence that peribulbar block results in less pain during cataract surgery than topical anesthesia, and weak evidence that subconjunctival/sub-Tenon’s block results in less pain during cataract surgery than topical anesthesia.

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Rba: Is There A Future

Given the versatility and rising popularity of sub-Tenons Nerve blocks, and given that there is no situation in which a retrobulbar nerve block would be preferred over a peribulbar nerve block, it seems unlikely that retrobulbar nerve blocks will remain part of the repertoire of the modern anesthesiologist.

Role Of Anesthesia Practitioner For Sedation During Eye Surgery

Table 2. Options for Ophthalmologic Surgery

A retrospective review of 560 charts of cataract patients in a teaching hospital in Iowa by Pecka and Dexterfound at least one anesthesia intervention occurred after block placement in 33% of 560 cataract cases. These authors commented that there is no justification to decreasing the amount of time that anesthesiologist or nurse anesthetists spend caring for patients undergoing cataract extraction with a retrobulbar block.

A survey of international ophthalmologists conducted in 2002 illustrated significant differences in the reported use of an anesthesia-trained personnel for monitoring of patients undergoing eye surgery during local/regional anesthesia.Ninety-seven percent of Australian ophthalmologists and 96% of American ophthalmologists indicated routine use of monitoring by an anesthesia-trained professional. The lowest uses of anesthesia monitoring were reported by ophthalmologists from Malaysia and Thailand . An expert panel of surgeons and anesthesiologists was convened to assign preference values to anesthesia care and outcomes as well as to perform cost analyses of these strategies.The preferred strategy was intravenous sedation with block anesthesia and presence of an anesthesiologist during the case. The estimated costs of this strategy were considerably greater than the second most preferred strategy: oral sedation, block anesthesia, anesthesiologist available but not physically present .

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Some More Effects Of Mannitol

Due to hypertonicity osmotic effect of mannitol are Intracellular dehydration, Expansion of ECF volume Haemodilution and Diuresis due osmotic effects and ECF expansion. While non-osmotic effects of mannitol are decreased blood viscosity with Possible Cytoprotective consequence and cardiovascular consequences are subsequent to expanded intravascular volume .

Jeffrey J Fletcher et al., stated that Mannitol has been shown to damage endothelial cells and activate coagulation pathways leading to intravascular thrombosis. Dehydration and hemagglutination have also been associated with mannitol use, although the risk of clinically evident venous thromboembolism disease is not well-defined. In conclusion, despite a significant change in the pattern of osmotic therapy used at our institution, the proportion of patients with VTE remained unchanged. They found no evidence that mannitol use was associated with VTE compared to hypertonic saline alone.

Use of hypertonic mannitol as an osmotic agent was reported with success by Barry et al., in cases with functional renal failure and oliguria and has since then had been an accepted part of therapy. Mannitol was also found a very effective agent for reducing cerebro-spinal fluid pressure. Wise and Charter demonstrated, in anaesthetized dogs after ligation of renal arteries, that the cerebrospinal fluid hypotensive effect of mannitol was independent of its diuretic effect without secondary rebound overshoot of pressure.

Mannitol In Cataract Surgery

Osmotic agents like urea, mannitol, and glycerol have been effectively used earlier to lower both the cerebro-spinal pressure and intra-ocular pressure. Mannitol is a hexahydroxy alcohol related to mannose. It occurs as a white, crystalline powder and is soluble in water and stable at room temperature.

Intravenous administration of mannitol induces diuresis by elevating the osmotic pressure of the glomerular filtrate to such an extent that tubular re-absorption of water and sodium is hindered. Mannitol also promotes excretion of chlorides. It itself is excreted unchanged in the urine. In the present series, a study is made to evaluate the use of mannitol in cataract surgery. Reduction of intra-ocular pressure prior to cataract surgery is essential to keep vitreous in its physiological position after lens extraction and to minimise post-operative complications.

Virno and others studied oral glycerol efficacy in glaucoma cases and, found it most effective in reducing ocular tension in cases of acute angle closure glaucoma. The ease of oral administration, lack of – toxicity, promptness and intensity of action of glycerol made them recommend its use prior to cataract surgery. Jaffe and Light recorded 5.4 mm average fall ocular tension with glycerol as compared to 0.4 mm average fall of ocular tension in control series. Though the hypotensive effect of glycerol was moderate, unpleasant side effects like nausea and vomiting due to the bad taste of glycerol were quite frequent.

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Innervation Of The Orbit

Sensory innervation of the orbit and globe is provided mostly by the frontal and nasociliary branches of the ophthalmic nerve , which pass through the muscular cone , while some of the floor of the orbit is supplied by the infraorbital branch of the maxillary nerve .The trochlear nerve provides motor control to the superior oblique muscles, the abducens nerve to the lateral rectus muscle, and the oculomotor nerve to all other extraocular muscles, including the levator muscle. All except the trochlear nerve pass through the muscular conus.

FIGURE 4. Left orbit: lateral view. Lateral wall and lacrimal gland removed.

FIGURE 5. Extraocular muscles and innervation of the orbit at the level of the annulus of Zinn. Cranial nerves indicated by Roman numerals.

Primary Position Versus On

Complete paresis of all extraocular muscles renders the eye in the primary or neutral position. Usually, this corresponds with the surgeon having the pupil aligned with the axis of the surgical microscope . However, in cases of incomplete motor nerve block, or in patients who have significant spinal curvature or who are unable to lie flat, the resting position of the blocked eye may not correspond to an on-axis view. For this reason, many surgeons actually prefer to have a fully mobile eye for certain patients or certain procedures so that they can ask the patient to look at the light of the microscope, thereby bringing the eye on axis, or to look away, allowing greater access to more peripheral parts of the globe.

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Is Anesthesia Necessary For Cataract Surgery

Doctors sometimes get asked by patients if anesthesia is necessary for cataract surgery. The answer is yes.

The surgery, known as phacoemulsification, involves a tiny cut in your eye. The affected, cloudy lens is expertly removed from the eye, and a new, artificial lens is implanted in its place.

Because of the precision nature of the procedure, its imperative that the patient can tolerate needles and lasers operating on the eyes. No anesthesia leaves this up to chance, not something surgeons like to do. The risk of a patient moving or flinching during a delicate procedure can only help minimize the effect of the procedure.

The operation involves using an intraocular lens to correct the cloudiness in the eye. It is not an invasive procedure and can be performed with a laser. The doctor will first administer anesthesia to numb your eyes before conducting the procedure.

Doctors perform an estimated 10 million cataract surgeries a year worldwide, making it the most common medical procedure. It usually takes 15 to 60 minutes, and you can go home as soon after it is done.

Generally speaking, for cataract surgery, the medical team will want to use the least invasive procedure and the lowest dosage of medications and anesthesia possible. You and your doctor can work out a plan together for what is likely to be optimal for you.

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Availability Of The Full Report

The full evidence report from which this summary was derived was prepared for the Agency for Healthcare Research and Quality by the Johns Hopkins University Evidence-based Practice Center under contract 290-097-0006. It is expected to be available in 2000. At that time, printed copies can be obtained free of charge from the AHRQ Publications Clearinghouse by calling 1-800-358-9295. Requesters should ask for Evidence Report/Technology Assessment Number 16, Anesthesia Management During Cataract Surgery . Internet users will be able to access the report online at: .

AHRQ Publication No. 00-E015Current as of August 2000

Internet Citation:Anesthesia Management During Cataract Surgery. Summary, Evidence Report/Technology Assessment: Number 16. AHRQ Publication No. 00-E015, August 2000. Agency for Healthcare Research and Quality, Rockville, MD.http://text.nlm.nih.gov/ftrs/directBrowse.pl?collect=epc& dbName=catsum.

AHRQ Publication No. 00-E015

Nasocilary/infratrochlear/anterior Ethmoidal Nerve Block

The nasocilary nerve is a branch of the ophthalmic nerve and supplies, via its intratrochlear and anterior ethmoidal branches, sensation to the medial wall of the orbit, the proximal lacrimal sac, the proximal nasolacrimal duct, the mucosa of the nasal cavity, and much of the skin of the nose. This nerve is blocked via an injection of 23 mL of local anesthetic by a vertical insertion of a fine-gauge needle parallel to the medial wall of the orbit approximately in line with the bridge of the nose to a depth of about 25 mm. This corresponds with the foramen through which the anterior ethmoidal nerve exits the orbit. It is important that the needle descend freely to the point of injection, as the orbital wall is thin at this level, and perforation of the ethmoidal and even sphenoidal sinuses is quite possible.

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