ANAESTHESIA FOR CATARACT

SURGERY AND ITS COMPLICATION

Sunil Kumar
TECHNIQUE OF ANAESTHESIA FOR CATARACT
SURGERY
General anaesthesia
Retrobulbar anaesthesia
Peribulbar anaesthesia
Parabulbar anaesthesia
Topical anaesthesia
Cataract surgery has evolved from an
inpatient procedure under general
anesthesia to a day-care procedure
usually done under local or topical
anesthesia
PRACTICE PREFERENCES OF OPHTHALMIC
ANAESTHESIA FOR CATARACT SURGERY
SINGAPORE MED J. 2007; 48(4):287-90
A nationwide questionnaire survey of all cataract
surgeons in singapore - august 2004
Response rate - 61.1 percent (88 out of 144 eligible
ophthalmologists surveyed).
For phacoemulsification anaesthesia technique of
choice
Peribulbar anaesthesia - 43 percent,
Topical anaesthesia - 42 percent,
Retrobulbar anaesthesia - 13 percent
Sub-tenons and general anaesthesia - 1% each
For extra-capsular cataract extraction, the preferred
anaesthetic technique was
Peribulbar anaesthesia for 69 percent,
Retrobulbar anaesthesia for 30 percent
Sub-tenons anaesthesia for one percent of the respondents.
GENERAL ANAESTHESIA

Cataract surgery is usually performed under local
anaesthesia.
General anaesthesia is required under special
circumstances
Pediatric cataract surgery
Communication barrier
Very anxious or psychiatric patient
Patient refusal despite adequate explanation
Intractable coughing
Tremor or abnormal body movements
Orthopnoea or inability to lie flat
Claustrophobia
Previous complication with local anaesthesia
Allergy to the local anaesthetic agents.




ADVANTAGES AND DISADVANTAGES OF GENERAL
ANESTHESIA
ADVANTAGES
Patient comfort
Ideal operating conditionsa quiet, immobile patient and soft
eye
The method of choice for difficult cases
No risk of any of the complications associated with local
anesthetic blocks
No residual paralysis of the eye when the patient is awake
Better conditions for teaching

DISADVANTAGES
Slightly slower turnaround times, if only one anesthetist is
available
More expensive
More morbidity


RETROBULBAR ANAESTHESIA
Also called intraconal anaesthesia, local
anaesthetic is injected in the posterior intraconal
space
The aim is to block the oculomotor nerves before
they enter the four rectus muscles in the posterior
intraconal space. Some activity may be retained in
the superior oblique muscle because of its
extraconal course.

RETROBULBAR ANAESTHESIA
POSITION OF THE EYE
The primary gaze - as the optic nerve
is directed away from the path of the
needle toward the medial side of the
midsagittal plane.
SITE OF THE INJECTION
The injection site is immediately above
the inferior orbital rim, junction of
lateral one-third and medial two-third.
NEEDLES
A sharp 25- or 27-gauge needle is
used, no more than 31mm in length to
avoid piercing the optic nerve.


LOCAL ANESTHETIC AGENT.

Most common - bupivacaine 0.75% plus lidocaine
2% plus hyaluronidase 150u
Epinephrine (adrenaline) 5g/ml
Improves duration of the block.
Should be avoided in patients who have ischemic heart
disease, tachycardia, and hypertension.
TECHNIQUE OF INJECTION.

With the globe in primary gaze, the needle is
inserted at the lower orbital margin, at the
junction of lateral one-third and medial two-
third
The needle is passed posteriorly parallel to
the plane of the orbital floor until the tip
passes the equator of the globe. This
corresponds with the middle of the needle
being in the plane of the iris.
Then the needle is directed slightly upward
and medially, when the hub of the needle
reaches the plane of the iris, the tip should
be in the intraconal space, 45mm behind
the globe if it is of normal axial length
After aspiration, the local anesthetic is
injected slowly.
Any movement of the globe is noted, as this
is indicative of possible scleral puncture.

COMPLICATIONS ASSOCIATED WITH
RETROBULBAR BLOCK
Retrobulbar hemorrhage
Ocular perforation (<0.1% incidence, but 1 in 140
injections in highly myopic eyes)
Subarachnoid or intradural injection, leading to
brainstem anesthesia
Respiratory depression or arrest
Optic nerve injury
Retinal vascular occlusion
Muscle complications: ptosis, diplopia
RETROBULBAR HAEMORRHAGE
Incidence - 0.44 to 1.7%
Vary in severity
Venous haemorrhage
Limited
Spreads slowly
Arterial haemorrhage
Rapid and taut orbital swelling
Marked proptosis
Tense globe
Inability to separate the eyelids
Massive ecchymosis of the lids and conjunctiva
Impede vascular supply to optic nerve and globe
severe visual loss
RETROBULBAR HAEMORRHAGE
Management
Limited venous haemorrhage
Digital massage
Surgery can be performed soft eye, lids are easily separable
and there is no proptosis
Massive arterial haemorrhage
Lateral canthotomy
Digital massage
Osmotic diuresis
Paracentesis ?
OCULAR PERFORATION
Risk Factors -
Long eye, axial length >26mm; patients with axial myopia
have a 30 times greater risk
Posterior staphyloma
Enophthalmos
Faulty technique
Uncooperative patient
Unnecessarily long needle
No appreciation of risk factors
Suspect
Hypotony
Poor red reflex
Poking through sensation
Marked pain at the time of perforation
MANAGEMENT
Laser photocoagulation or cryopexy - treatment of
breaks when visible and not obscured by vitreous
hemorrhage. Laser is easier in posterior lesions
while cryopexy is easier in peripheral ones.

Vitrectomy with silicone oil/gas tamponade - dense
vitreous hemorrhage and/or RD. Early vitrectomy
helps to treat the retinal breaks and clear vitreous
hemorrhage.
ADVANTAGES AND DISADVANTAGE OF RETROBULBAR
BLOCK

ADVANTAGES
A retrobulbar block is reliable for producing excellent
anesthesia and akinesia
The onset of the block is quicker than with peribulbar; it
usually occurs within 5 minutes
Low volumes of anesthetic result in a lower intraorbital
tension and less chemosis than with peribulbar blocks

DISADVANTAGE
The main disadvantage of retrobulbar blocks is that the
complication rate is higher than for peribulbar blocks
the reason for the development of the peribulbar block


PERIBULBAR BLOCK

The principle of this technique is to inject the local
anesthetic outside the muscle cone and avoid
proximity to the optic nerve.
This utilizes high volumes of anesthetic and the
application of a pressure device.
The local anesthetic agents do not differ from those
used in retrobulbar block, but typically shorter
needles are used.

TECHNIQUE.
The volume varies from 510ml; Again, the eye is in
primary gaze.
The initial injection is at the inferotemporal lower orbital
margin, midway between the lateral canthus and the
lateral limbus. The 27- or 25-gauge needle is then
advanced parallel to the plane of the orbital floor and
injected at a depth of about 2.5 cm from the inferior
orbital rim (in an eye of normal axial length).
ADVANTAGES AND DISADVANTAGES OF
PERIBULBAR BLOCK


ADVANTAGES
The risk of complications is less as compared to
retrobulbar block

DISADVANTAGES
The quality of akinesia and anesthesia may not be as
good as with retrobulbar block
Volume requirement is greater
Often more than one injection is required
The block takes much longer to work
Postinjection orbital pressure is greater
Periorbital ecchymoses and conjunctival chemosis is
more

SUB-TENON'S BLOCK
Technique for sub-Tenons local anaesthetic.
Topical local anaesthetic drops are administered.
5% povidine drops are administered.
The periocular skin and lids are cleaned with povidine
and a lid speculum inserted.
The conjunctiva and Tenons capsule is incised
approximately 5-7 mm posterior to the inferonasal
limbus.
The sub-Tenons pocket is enlarged.
The blunt cannula is inserted into the sub-Tenons
space, advanced, and local anaesthetic injected.

ADVANTAGES AND DISADVANTAGES OF SUB-
TENON'S BLOCK

ADVANTAGES
It is less painful than a retrobulbar block
No serious complications are associated with this
technique
No increase in intraocular pressure occurs with the
administration of local anesthetic
Surgery can begin almost immediately
Lasts for 60 minutes and supplemental anesthetic agent
can be given
Low dose and low volume of anesthetic agent are used

DISADVANTAGES
Increased incidence of conjunctival chemosis and
haemorrhage
Potential of damaging one of the vortex vein
Supplemental injection may be necessary

TOPICAL ANESTHESIA

The first modern use of topical anesthesia was by
Koller in 1884 with cocaine
Currently the most frequently used agents are
tetracaine 0.5% and proparacaine 0.5%; both are
short acting (20 minutes) and are the least toxic to
the corneal epithelium.
Lidocaine 4% (lignocaine) and bupivacaine 0.5%
and 0.75% have a longer duration of action but an
increased associated corneal toxicity.

CONTRAINDICATIONS TO TOPICAL ANESTHESIA
Relative contraindications
Difficult or extended surgery
Language barrier, deafness
Uncooperative patient
Absolute contraindications -
Allergy to local anesthesia
Nystagmus.

TECHNIQUE
The aim is to block the nerves that supply the superficial
cornea and conjunctiva; namely, the long and short
ciliary, nasociliary, and lacrimal nerves.
The patient should be warned that application of the
drops on the surface of the cornea.
Drops are administered before the placement of the
drapes.
Preparation of the unblocked eyelid requires the patient
to keep the eye closed, but the eye is kept open when
the plastic drape is applied in order to secure the lid and
lashes.
As visual perception is not lost, the patient is asked to
focus on the source of the light
Topical anesthesia may be combined with intracameral
or subconjunctival anesthesia.
ADVANTAGES AND DISADVANTAGES OF TOPICAL
ANESTHESIA


ADVANTAGES
No risk associated at needle insertion
No risk of periocular hemorrhage or hyphema with clear corneal
incisions; systemic anticoagulation can be continued without any
worry
Functional vision is maintained; advantageous for uniocular
patients
No postoperative diplopia or ptosis
Patients are fully alert

DISADVANTAGES
An awake and talkative patient can be distracting for the surgeon
No akinesia of the eye
If difficulties or problems occur the anesthesia may not be adequate

ADVERSE EFFECTS OF TOPICAL OCULAR
ANESTHETICS
Direct corneal effectsalteration of lacrimation and tear
film stability
Epithelial toxicityhealing has been shown to be
delayed when an epithelial defect occurs
Endothelial toxicitythis occurs when penetrating
trauma is present and appears to be related to the
preservative benzalkonium
Systemic effectslethal toxicity (this is only a problem
with cocaine)
Allergy and idiosyncratic reactionscontact dermatitis is
the most common and occurs with proparacaine most
frequently

INTRAOCULAR LIDOCAINE.

Recently, intraocular lidocaine has been used to provide
analgesia during surgery.
The solution used is 1% isotonic, nonpreserved
lidocaine 0.3ml administered intracameral
At present, no side effects have been reported, except
for possible transient retinal toxicity if lidocaine is
injected posteriorly in the absence of a posterior
capsule.
Its use obviates the need for intravenous and regional
anesthetic supplementation in most patients.
Adequate anesthesia is obtained in about 10 seconds.
As with all topical techniques, the ability of the patient to
cooperate during surgery is desirable
CONCLUSION
The aim of anaesthesia for cataract surgery should be
to make the procedure as safe and as pleasant as
possible.
Advances in anaesthesia and surgery now permit
cataract extraction to be performed with minimal
physiological upset to the patient.
In addition to safety, analgesia, amnesia, anaesthesia,
and akinesia are all factors to be considered