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Methods of Applying Pressure After Retrobulbar Block

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Methods of Applying Pressure After Retrobulbar Block METHODS OF APPLYING PRESSURE AFTER RETROBULBAR BLOCK BYJose Berrocal, MD WITH THE INCREASING POPULARITY OF INTRAOCULAR LENS IMPLANTATION, THE IM- portance of obtaining a soft eye during surgery has been recognized. Emphasis has been placed on applying low levels of pressure on the eye for a prolonged period, both before and after the retrobulbar block. Several different apparatuses have been utilized recently in an effort to obtain a soft eye. '3 Unfortunately, while attempting to obtain these optimum conditions, significant and permanent visual loss has occurred in a number of these cases due to impaired blood supply to both the retina and the choroid during the ocular compression phase. The purpose of this study was to compare the efficacy of two different methods of applying pressure after a retrobulbar block before cataract extractions. Two methods of applying pressure were used in this study: manual cycling pressure using the super pinkie rubber ball and automatic cycling pressure using the Keeler autopress unit. First, we selected the super pinkie rubber ball, since it had been the most frequently used compression apparatus in the United States over five years until the Honan instrument was introduced two years ago. Second, eight months ago, we selected the new Keeler autopress unit (Fig 1) and attempted to compare its results with those obtained using the super pinkie rubber ball method. The following parameters were compared between these two groups: 1) Reduction in intraocular pressure following cycling compression4 2) Completeness of the extraocular muscle paralysis 3) Incidence of vitreous loss5 4) Air trapped in the anterior chamber following cataract extraction 5) Incidence of optic atrophy Preoperative medication administered by the anesthesiologist con- sisted of oxymorphone Hcl (Numorphan) 0.5 mg IM and triflupromazine (Vesprin) 25 mg IM or hydroxyzine pamoate (Vistaril) 100 mg IM for the majority of the patients in this study. During surgery thiopental sodium TR. AM. OPHTHI. Soc. vol. LXXIX, 1981 Retrobulbar Block 201 (Pentothal) 25 mg IV was used immediately after the retrobulbar block but prior to the modified Van Lint akinesia. In addition, Vistaril 50 mg IV, diazepam (Valium) 2.5 mg IV, and Pentothal 25 mg IV were used as required in order to keep the patient immobile. The retrobulbar block consisted of 3 cc of 4% lidocaine (Xylocaine) using an Atkinson retrobulbar needle, followed by 4 cc of intravenous Pentothal. Half a minute later, 10 cc of 2% Xylocaine were injected for the orbicularis muscle block. Post operatively the patients were unable to recall the orbicularis muscle block. The manual cycling pressure method used consisted of cycles of 20 seconds of pressure with a super pinkie rubber ball, followed by eight seconds of release or no pressure. These cycles were repeated for a total of seven minutes of alternating pressure. For the automatic cycling pressure method we used the automatic autopress unit from Diversatronics (Keeler). This machine allowed us to utilize exactly the same cycle as in the manual method. In addition, we were able to regulate precisely the amount of pressure exerted. This unit automatically applies regulated cycling pressure giving the surgeon exact control and monitoring over pressure height, duration of cycles, and total length of compression time. The ocular circulation is restored fully be- tween compression phases for full retinal reoxygenation (8 seconds). With a built-in, "fail safe" mechanism, the unit turns itself off auto- matically in the event the pressure-on phase exceeds 25 seconds for any reason and it decompresses immediately if electrical current is inter- rupted. Compression and decompression proceed automatically and when the compression time is reached, the machine turns itself off and a signal bell rings. The compression balloon is made of soft expandable rubber material and is well tolerated by the patient. No leakage of air has been en- countered since the company changed the design of its original balloon. The balloon remains accurately positioned by means of an adhesive sub- stance applied to this surface. This adhesive portion adheres to the rubber strip on the headband that also has an adhesive surface. We selected 70 millimeters of mercury as the pressure to apply, hope- fully trying to remain under the systolic pressure of the central retinal artery and, at the same time, above the diastolic pressure. In an effort to determine the pressure exerted with the rubber ball in the manual method, in several cases we substituted for the rubber ball both the Honan pressure regulator and the soft rubber compression balloon used with the automatic Keeler unit. We were satisfied that the pressure applied by these two techniques was essentially the same. With both techniques we obtained readings above 120 mm Hg. 202 Berrocal MATERIAL AND METHODS In 100 patients undergoing cataract surgery, the manual technique was used, in another 80 cataract patients, the automatic unit was used. All cataract patients over an 18-month period were included in this study except those patients with glaucoma or any other preoperative com- plication. One hundred eighty consecutive cases ofcataract surgery were included in this study. In the manual group, there were 43 men and 57 women while in the automatic group, 36 were men and 44 were women. Schi0tz tonometry was performed before the retrobulbar block and after seven minutes of cycling pressure utilizing either one of the two methods. The following results were recorded: 1) Reduction in intraocular pressure following cycling compression. An average reduction in intraocular pressure of 7 mm Hg (a decrease from 17 to 10 mm Hg) was obtained using the automatic method as compared to a reduction of 10 mm Hg (from 18 to 8 mm Hg) using the manual technique. Even more important was the finding that in 80% of the eyes in the manual group, the final pressure obtained was equal to or less than 10 mm Hg as compared to 60% ofthe eyes when using the automatic technique. 2) Completeness of the extraocular muscle paralysis. Extraocular muscle paralysis was complete in 90% ofthe eyes-on which the manual technique was used as compared with 80% of the eyes, on which the automatic method was used. 3) Incidence of vitreous loss. Vitreous loss occurred in 3% of the eyes on which the manual tech- nique was used as compared to an incidence of 4% in the automatic group. 4) Air captured in the anterior chamber after the extraction. Air was captured in the anterior chamber in 68% of the eyes in the manual group as compared with 50% in the automatic group. 5) Incidence of optic atrophy following surgery. In 2% ofthe eyes subjected to the manual technique, optic atrophy was seen six weeks after surgery. There were no cases ofoptic atrophy in the eyes on which the automatic method was used. No abnormal pigmenta- tion was noticed in the periphery of the fundus. In one case, a 58-year-old man in good health, the best corrected vision obtained was 20/100. In the second case, an 82-year-old woman also in good health, the best corrected vision obtained was 20/400. Visual fields performed on both patients revealed an altitudinal field defect. Retrobulbar Block 203 COMMENTS 1) Both methods accomplished an adequate reduction in the intra- ocular pressure. The difference here was not statistically significant. 2) In both groups a high percentage of eyes obtained complete extra- ocular muscle paralysis. The difference here, also was not statistically significant. 3) The incidence of vitreous loss was maintained relatively low with either method. The difference was not statistically significant. 4) The manual technique was significantly more effective than the automatic method in capturing air inside the anterior chamber following cataract removal. 5) Unexplained optic atrophy following cataract surgery occurred only with the manual method (in two out of 100 eyes). Manual application of pressure is the most common procedure used throughout the world. However, manual pressure will vary depending upon the strength, weight, and technique ofthe physician or his assistant. The probability of the pressure applied exceeding the systolic pressure when using the manual technique might account for the occurrence of optic atrophy in these two cases. CONCLUSION Both the manual method and the automatic method proved to be similar and consistent in obtaining an adequate retrobulbar block. However, we prefer to use the automatic method because of the two cases of optic atrophy that we encountered when using the manual method. The findings of this study has alerted us to the danger of inducing permanent visual loss due to impaired retinal and choroidal circulation when compressing the eyeball with the super pinkie rubber ball with an unregulated amount of pressure. REFERENCES 1. Shepard D: Shepard ocular compressor, in Emery J, Jacobson A: Current Concepts in Cataract Surgery, Sixth Biennial Cataract Surgical Congress, St Louis, CV Mosby Co, 1980, pp 257. 2. Buys NS: Mercury balloon reducer for vitreous and orbital volume control, in Emery J, Jacobson A: Current Concepts in Cataract Surgey, Sixth Biennial Cataract Congress, St Louis, CV Mosby Co, 1980, pp 258-259. 3. Gills JP: Techniques of controlling intraocular pressure and reducing vitreous loss, in Emery J, Jacobson A: Current Concepts in Cataract Surgery, Sixth Biennial Cataract Congress, St Louis, CV Mosby Co, 1980, pp 260-262. 204 Berrocal 4. Jaffe NS: Digital pressure, in Jaffe NS: Cataract Surgery and Its Complications, St Louis, CV Mosby, 1981, pp 37. 5. Jaffe NS: Measures to prevent loss of vitreous, in Jaffe NS: Cataract Surgery and Its Complications, St Louis, CV Mosby Co, 1981, pp 256-258. DISCUSSION DR A. EDWARD MAUMENEE. Undoubtedly one of the most important steps in intra- ocular surgery, expecially cataract surgery is the reduction of vitreous pressure.
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