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A Comparison of Topical Anaesthesia and Retrobulbar Block for Cataract Surgery

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A Comparison of Topical Anaesthesia and Retrobulbar Block for Cataract Surgery A COMPARISON OF TOPICAL ANAESTHESIA AND RETROBULBAR BLOCK FOR CATARACT SURGERY 2 1 D. M. JOLLIFFE\ M. N. ABDEL-KHALEK and A. C. NORTON Boston SUMMARY PATIENTS AND METHODS It is possible to remove a cataract and insert an This study was approved by the local ethics intraocular lens under topical anaesthesia (lignocaine committee. 4% preservative-free eye drops) with a van Lint block. This study was performed to evaluate this anaesthetic Patients technique. Nineteen patients having cataract surgery Patients made the choice between general and local with topical anaesthesia and a van Lint block were anaesthesia for their cataract surgery after discussion compared with 21 patients who received a retrobulbar with the ophthalmic nurses. Those choosing local block and a van Lint block. There were no significant anaesthesia were studied prospectively but eyes differences between the two groups in patient char­ which had been operated on before, for any reason, acteristics, mean cardiovascular stress of the procedure, were excluded. A record was kept of the age, gender experience of pain during the operation or willingness and ASA (American Society of Anesthesiologists) to have the same anaesthetic technique again. Topical status of the patients. A patient who is ASA I is well anaesthesia with a van Lint block is feasible for cataract and healthy, ASA II has mild to moderate systemic surgery and is potentially safer than other regional disease, ASA III has severe systemic disease that anaesthetic techniques. limits activity, or ASA IV has incapacitating systemic disease that is life-threatening. In an attempt to evaluate topical anaesthesia for cataract surgery, two groups of patients were studied Anaesthesia prospectively and compared. One group had topical Pre-operatively the patients were not starved and anaesthesia and the other had regional anaesthesia after assessment were all given oral diazepam 5 mg, with a retrobulbar block. All patients also received a promethazine hydrochloride 10 mg and chlorproma­ van Lint block. In all cases a recently developed l zine hydrochloride 10 mg, an hour and a half before modifiedsurgical technique was used. The quality of surgery. The eyes to be operated on were prepared anaesthesia was evaluated subjectively by asking the with a standard regimen of mydriatic and antibiotic patients post-operatively about any pain or discom­ eye drops. fort experienced in theatre. Patients were also asked In the anaesthetic room ECG, non-invasive blood whether they would agree to have the same pressure (Dinamap) and pulse oximetry monitoring anaesthetic technique if they were to require another were established. Venous access was secured in the eye operation. An objective comparison of the two dorsum of the left hand using a 20 gauge intravenous techniques was made by quantifying the rate cannula inserted without local anaesthesia. Patients pressure product (RPP) at defined points in the were randomised by year of birth. Those born in procedure. As the RPP correlates with myocardial even years received topical anaesthesia with 0.5 ml oxygen demand and cardiac work, the area under the preservative-free 4% lignocaine eye drops. After RPP/time graph reflects the total cardiovascular instillation of the drops into the conjunctival sac, the stress. This indicator was compared between the eyelids were held apart for about a minute to groups. maximise contact between the local anaesthetic solution and the corneal and conjunctival surfaces 2 From: Departments of 1 Anaesthesia and 0phthalmology, and to soak the nerve endings. Patients born in odd Pilgrim Hospital, Boston, Lincolnshire, UK. Correspondence to: M. N. Abdel-Khalek, Pilgrim Hospital, years received a retrobulbar block using 3 ml of a 10 Boston, Lincolnshire PE21 9QS, UK. ml mixture containing 7 ml 0.75% bupivacaine, 3 ml Eye (1997) 11,858-862 © 1997 Royal College of Ophthalmologists TOPICAL ANAESTHESIA VS RETROBULBAR BLOCK FOR CATARACT SURGERY 859 2% lignocaine and 1500 IV hyalase. All patients when the superior rectus suture was inserted (6), the received a zygomatic nerve block (van Lint) with 2 nucleus delivered (7), the lens implanted (8), the ml 2 % lignocaine injected deep along the upper and corneo-limbal incision sutured (9) and the subcon­ lower orbital rims and along the superior edge of the junctival injection given (10). For each patient the zygomatic arch. No injection was given to fixate the measurements of heart rate and systolic blood superior rectus muscle. All regional anaesthesia was pressure were used to calculate the rate pressure given by the surgeon (M.A.-K.) as this promotes the product (RPP) at the 10 defined events points during best chance of observing an orbital haemorrhage or the procedure. The timing of these measurements other complication before draping the patient and reflected either baseline conditions (1,5) or points in incising the eye? the procedure when the patient was most likely to In theatre monitoring of the patient's ECG, blood feel pain. The area under the curve (Aue) of RPP pressure and pulse oximetry were continued and all (y-axis) plotted against time (x-axis) was then patients received supplemental oxygen. During the calculated for each patient. procedure any arrhythmias were noted. Post-operatively on the ward all the patients were interviewed by the anaesthetist and asked whether Surgery they had experienced any pain or discomfort in theatre (i.e. after the regional anaesthesia had been All the operations were performed by the same instituted). Responses were graded on a five-point surgeon (M.A.-K.) using the same technique? This scale: 0, no feeling; 1, aware of the steps of the modifiedtechnique enables a cataract to be extracted procedure; 2, discomfort; 3, tolerable pain; 4, and an intraocular lens inserted under topical intolerable pain. Satisfaction was assessed by asking anaesthesia. The effectiveness of the van Lint block whether the patient would choose to have the same in reducing the strength of the palpebral reflex was anaesthetic technique again should they require assessed by the ease with which a Barraquer's one­ another eye operation. Any comments were noted. piece wire speculum was inserted. A corneo-limbal incision from 10 o'clock to 2 o'clock was made with a diamond knife in a two-step fashion. Firstly a Statistics perpendicular incision in the superficial half of the In planning the study, the authors concluded that a cornea was made and then a deep slanting incision 30% difference in mean RPP between the two towards the pupil to enter the anterior chamber. A groups would constitute a clinically important differ­ wide 'can-opener' capsulotomy was used to allow ence. The sample size for each study group was easy delivery of the nucleus and avoid pain caused by estimated by a comparison of two means method3 stretching the zonules in the ciliary body. Phaco­ assuming an 80% power of detecting a 30% emulsificationof the nucleus was not employed. The difference in mean RPP assuming a standard devia­ equatorial area of the lens bag was flushed with tion of 3000 in RPP calculations in each group. This balanced salt solution through a curved 26G lacrimal method estimated a sample size of 19 patients in each needle. This 'equatorial flush' helped to break the group. attachments of the lens fibres and enabled the lens RPP data were analysed according to the method cortex to be rapidly aspirated. A rigid 12.00 mm of Matthews et al.4 for the analysis of serial diameter intraocular lens implant was inserted into measurements in biomedical research. The AuC the capsular bag and the corneo-limbal incision was calculations as the summary measure were subjected sutured closed with 10/0 continuous nylon. At the to significance testing with one-way analysis of end of the operation a subconjunctival injection of variance (ANOVA). Responses to patient assess­ gentamicin and betamethasone was given. to ments of intra-operative pain and willingness undergo the �rocedur� ag in were analysed using Assessment chI-squared. (X ) � tests WIth gIven degrees of freedom All the assessments were made by the same observer (d.f.). (D.M.J.). Baseline m�asurements of each patient's heart rate and systolIc, mean and diastolic blood RESULTS pressures were made after their arrival . in the Initially 44 patients were included in the study but 4 anaes!hetIc room (1). These readings were . repeated were subsequently excluded from the analysis. In after msertlOn ?f the venous cannula (2), instillation each group one patient was excluded because the ?f ey� drops (m the topical anaesthesia group) or lens was inserted into the anterior chamber. This is a lllsertlOn of the retrobulbar block needle (3) and more pamful. procedure than insertion into the aft�r th� van Lint block was performed ' . (4). On postenor cha ber because iridectomy is necessary. arnvmg m theatre further readings of � . the patient's Two other patIents who received topical anaesthesia heart rate, systolIc, mean and diastolic blood wer excluded, one for anaesthetic and one for pressures were taken (5), and these were � repeated surgIcal reasons. One patient complained of 860 D. M. JOLLIFFE ET AL. Table I. Patient characteristics RPP Retrobulbar Local drops 14000 n = (n = 21) ( 19) 12000 Mean age (range) 77.8 (67-93) 78.1 (70-91) 10000 Gender M:F 7:14 7:12 8000 ASA status I:II:III 3:15:3 2:12:5 6000 4000 Table II. Total time (minutes) for anaesthesia and cataract 2000 Time (minI surgery o Retrobulbar Local drops Fig. 2. Graph of rate pressure product (RPP) versus time. Mean ± SD 32.67 ± 6.55 33.47 ± 5.52 Range 23-50 24-42 so the total cardiovascular stress is not significantly different between the two techniques. intolerable pain on insertion of the superior rectus Table IV documents the patients' post-operative suture.
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