Ophthalmol Clin N Am 19 (2006) 233 237

Choosing Anesthesia for Cataract Surgery

Joselito S. Navaleza, MDa, Sagun J. Pendse, MDa, Mark H. Blecher, MDb,T
b a Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA Cataract and Primary Eye Care Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA

Advances in cataract surgery techniques have presented surgeons with new options for ocular anesthesia. As cataract removal has become faster, safer, and less traumatic, the need for akinesia and anesthesia has declined significantly. The use of general anesthesia or retrobulbar block has largely been replaced with other safer and equally effective means of local anesthesia, including peribulbar, sub-Tenons, and topical. These newer and less invasive methods have not only reduced the potential for catastrophic surgical complications, but also increased the efficiency of cataract surgery and hastened the process of visual rehabilitation. Today there are numerous modes of anesthesia from which a surgeon can choose. There is not one type of anesthesia right for all cases. The best choice varies from surgeon to surgeon, and patient to patient. The goal of this article is to review the current choices for ocular anesthesia, compare their efficacies, and provide a framework, helping to select the most appropriate type of anesthesia for each patient. Although general anesthesia was first used in surgery in 1846 by William Morton, it was not used for cataract surgery until 1954 [1]. Retrobulbar block was first described in 1884 by Knapp who injected 4% cocaine before enucleation surgery [2]. The modern technique used by most ophthalmologists today was described by Atkinson in 1948, and until recently served as the most commonly used technique for intraocular surgery [3]. Davis and Mandel are credited with introducing the peribulbar block in

T Corresponding author. Cataract and Primary Eye Care Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107. E-mail address: mhbmd@earthlink.net (M.H. Blecher).

1986 as a less dangerous alternative to retrobulbar anesthesia [4]. The decision between retrobulbar anesthesia and peribulbar anesthesia presents the surgeon with a choice between speed and safety. With a retrobulbar block a surgeon can ensure that adequate akinesia and anesthesia will result for cataract surgery; however, a blind injection into the orbit poses several potential complications, including, but not limited to retrobulbar hemorrhage, globe perforation, optic nerve damage, and brainstem anesthesia. Peribulbar anesthesia, involving the injection of local anesthetic external to the muscle cone, is thought to decrease the likelihood of optic nerve and globe perforation while maintaining the desirable qualities of excellent akinesia and anesthesia. However, the potential need for reinjection, the higher volume of injectate required, and the longer duration of onset associated with peribulbar blocks may make it a less attractive alternative. In a prospective, randomized controlled trial involving 100 patients undergoing elective cataract surgery, Whitsett and colleagues compared retrobulbar anesthesia with one injection site peribulbar anesthesia [5]. They evaluated the two methods based on three criteria that were considered critical to intraocular surgery: lid akinesia, globe akinesia, and ocular anesthesia. Following administration of the block, an independent observer rated each of these. The authors concluded that one injection site peribulbar anesthesia appeared to have a similar range of efficacy in all three categories as compared with standard retrobulbar anesthesia. There were no anesthetic-related complications in either group. As documented by Leaming [6] in his annual surveys of ASCRS members, the current trend for cataract surgery has shifted away from retrobulbar and peribulbar anesthesia toward topical anesthesia.

0896-1549/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ohc.2006.02.001

ophthalmology.theclinics.com

234

navaleza et al

Karl Koller was the first to describe the use of cocaine as a topical anesthetic for ocular surgery in 1884 [7]. Topical anesthesia, however, did not gain popularity until recently when it was reintroduced in the early 1990s by groups that used topical medications. Subsequently, topical anesthesia was modified by Gills and colleagues in 1997 with the introduction of nonpreserved intracameral lidocaine [8,9] and by Barequet et al [10] with the introduction of lidocaine gel. Given the recent trend toward the use of topical anesthesia, perhaps of more significance would be a comparison of retrobulbar and topical anesthesia for cataract surgery. In 1993, Kershner evaluated 100 patents undergoing cataract surgery with topical anesthesia and concluded that topical anesthesia was safe, decreased complication rates, and hastened patients return to normal vision [11]. However, the following year, however, Fukasaku and Marron [12] compared topical and retrobulbar anesthesia and found that patients had unacceptable amounts of intraoperative pain with the topical technique and abandoned its use altogether. They, however, did not mention the use of preoperative counseling or IV sedation. Patel and collegaues completed a randomized controlled trial comparing the clinical efficacy of retrobulbar versus topical anesthesia in patients undergoing temporal clear corneal cataract extraction [13]. Patients were given IV sedation (Midazolam) in this study. They used a visual pain analog scale to evaluate patient discomfort preoperatively, intraoperatively, and postoperatively, and concluded that the degree to which patients experience pain is only marginally higher for the topical group during the administration of the anesthetic, intraoperatively, and postoperatively. There was no statistically significant difference in pain scores ( P = .35). They also concluded that no statistically significant ( P = .5) difference in operative conditions were experienced by the surgeon because of lack of globe akinesia. The importance of careful patient selection with regard to patient anxiety and cooperation was emphasized. In a follow-up study by Crandall and colleagues, the efficacy of topical anesthesia with and without intracameral lidocaine was assessed [14]. In this study no intravenous sedation was used. The authors found that there was no statistically significant difference in patients assessments of pain preoperatively, intraoperatively or postoperatively between those who received intracameral lidocaine and those in the control group. There did exist, however, a statistically significant difference in patients perception of tissue handling ( P = .021). This outcome measure did not incorporate pain, but rather the

sensation that the eye or surrounding tissue is being manipulated. Of perhaps greatest importance was the finding of a statistically significant difference in the surgeons assessment of patient cooperation (P = .043) between the two groups. Those patients who received intracameral lidocaine more readily followed surgeon commands. It was postulated that this ability to cooperate was a result of the patient being less bothered by tissue manipulation. The authors argue that this finding alone justifies the use of intracameral lidocaine to enhance topical anesthesia given the importance of patient cooperation to successful topical cataract surgery. And to take the current trend of less anesthesia to its most absolute, Pandey and associates compared no anesthesia to topical and topical with intracameral and found that for a highly experienced surgeon, with a carefully selected patient population, the pain scores for all three groups were the same. The only difference was the discomfort level of the surgeon [15]. In the most recent published study of the practice styles and preferences of ASCRS members [6], it was found that retrobulbar block without facial block was used by 11% of surgeons and retrobulbar injection with facial block by 9% (down from 76% in 1985, 32% in 1995, and 14% in 2000). The peribulbar block was used by 17% of surgeons (down from 38% in 1995). Topical anesthesia was used by 61% (up from 8% in 1995 and 51% in 2000). Of those surgeons electing to use topical, 73% of surgeons also used concomitant intracameral lidocaine. The use of topical also varied with surgical volume. Those performing 1 to 5 cataract procedures per month used topical 38% of the time and those doing more than 75 procedures used it in 76% of cases. Clearly the trend has been to transition from retrobulbar anesthesia to topical, and this pattern parallels the increase in the use of temporal clear corneal incisions. Given the choices for ocular anesthesia today, one thing remains clear: no single mode of anesthesia can serve as a universal choice for all patients and all surgeons. The literature reveals that each of the major modes of ocular anesthesiaretrobulbar, peribulbar, and topicalare essentially equally effective in controlling patient pain and allowing a surgeon to have a successful surgical outcome. The decision to choose one of these methods ultimately falls on the surgeon, and the surgeon should carefully tailor his or her approach to each individual patient. The decision of which type of anesthesia to use is not only dependent on a number of patient factors, but is also dependent on the surgeon and the surgeons level of expertise and facility with the surgery to be performed. With this in mind, we present a short discussion that

choosing anesthesia for cataract surgery

235

addresses the decisions involved in choosing the mode of anesthesia best suited for each patient. The ideal surgery is conducted under the safest conditions, is cost- and time-efficient, and ultimately results in excellent outcomes as well as patient satisfaction. These are our goals with regard to the use of anesthesia for cataract surgery as well. We group anesthesia into three categories: general, regional (retrobulbar, peribulbar, and sub-Tenons), and topical (with and without intraocular anesthetics).

Risks and benefits General anesthesia provides excellent anesthesia, analgesia, and akinesia. In addition, the duration of anesthesia can be varied to accommodate the length of surgery. This provides the most controlled environment for surgery and may result in fewer ocular complications and, ultimately, a satisfied patient. Systemic risks include malignant hyperthermia, hemodynamic fluctuation, postoperative nausea and vomiting, and allergic reactions. There may also be increased risk of cardiac complications under general anesthesia. In 1980, Backer and colleagues [16] published a study suggesting elderly patients with a history of myocardial infarction were at a higher risk for another myocardial infarction under general anesthesia. Lang [17] did not find similar results in their review of 15,000 cases between 1977 and 1979 comparing regional with general anesthesia. There was one death in each group and the only two myocardial infarctions occurred in the regional group. Lynch and colleagues [18] found similar rates of mortality and major complications including vitreous loss with general and regional anesthesia in 2217 consecutive patients. Ocular complications such as intraocular pressure fluctuation, Valsalva retinopathy, corneal abrasions, and chemical injury also occur more frequently. General anesthesia requires more medication, equipment, and personnel than topical anesthesia. As a result, it is the most costly form of anesthesia. The time required for induction, intubation, and extubation also contributes to its inefficiency. Modern health care, where time and cost efficiency are significant factors, renders general anesthesia unlikely for the bulk of cataract surgeries. Regional anesthesia also provides excellent anesthesia, analgesia, and akinesia. The duration of effect varies with the anesthetic mixture used but can easily last for most cataract surgeries. While the eye is not able to move, the patient may still move, as a result, it is not quite as controlled as general anesthesia. The

cost of the medications and equipment are much less than with general anesthesia. Injections themselves take very little time, making this method more time and cost efficient than general anesthesia. There are systemic risks such as allergic reactions, brainstem anesthesia, and oculocardiac reflex. In addition, the complications of a blind injection into the orbit present additional risks discussed earlier. The incidence of retrobulbar hemorrhage has been reported as low as 0.44% of cases [19], up to 3% of cases [20]. Peribulbar anesthesia, involving the injection of local anesthetic external to the muscle cone, is thought to decrease the likelihood of optic nerve and globe perforation while maintaining the desirable qualities of excellent akinesia and anesthesia. However, the higher volume of injectate required and the longer duration of onset may make it a less attractive alternative. Sub-Tenons injections with blunt cannulas have an even lower risk of local complications [21]. With all orbital block anesthesia, cosmetic complications such as localized swelling, bruising, and subconjuctival hemorrhage may lead to reduced patient satisfaction. In addition, eye movement and vision are affected for some time after surgery. Topical anesthesia is the most cost and time efficient. Topical does not affect vision or motility, so patients may have improved and useful vision almost immediately after surgery. There are also minimal cosmetic changes. As a result, if patients have no pain or discomfort during surgery, patient satisfaction may be improved. Topical also avoids the systemic risks of general anesthesia and the risk of local trauma that occurs with regional blocks. Rare local allergic reactions do occur. The disadvantage to topical anesthesia is that it provides the least controlled environment for cataract surgery. Patients are able to move their eyes as well as any other part of their bodies. They perceive visual phenomena as the case proceeds. Pain and pressure may be experienced with intraocular pressure changes as the lens iris diaphragm move. These sensations may be reduced with intravenous sedation or analgesia, maneuvers such as entering the eye with low bottle height, or with the use of intracameral anesthetics [22]. However, even with all of the above, patients may still experience some discomfort. In addition, the duration of anesthetic effect is typically less than an hour. Even in uncomplicated cases there may be a loss of effect by the end of a case.

Choosing anesthesia It is essential that the surgeon, patient, and anesthesia staff work together and be involved in

236

navaleza et al

the selection and execution of anesthesia during the surgery. Involving the patient in this decision by describing the patient experience before and during surgery is critical. Fear and anxiety result when things are unknown or unexpected. If patients are prepared, they are better equipped to cope with the sensations they may feel during and after surgery. Anesthesia staff, whether a physician or nurse anesthetist should also be involved and know the patient. Modulation of intravenous sedation can play a key role during surgery. Increasing sedation as needed during surgery can reduce discomfort, provide akinesia, and ultimately may result in some amnesia that can result in better outcomes. This may be particularly important with topical anesthesia, and the degree of intravenous sedation may vary widely from surgeon to surgeon, and from case to case. Some of the indications for general anesthesia for cataract surgery include pediatric patients, patients who are unable to cooperate, lengthy procedures (> 3 hours), and patient or surgeon preference. Most surgery in children is performed under general anesthesia. Patients with psychiatric disorders, dementia, tremor, and inability to lie flat are at risk to move or even attempt to sit up during surgery. Longer procedures may exceed the duration of action of regional blocks; some complex anterior segment surgeries such as suturing lenses can take hours in some hands. Patients may ultimately feel that they will not be able to cooperate during surgery and request general anesthesia. Finally, the surgeon may choose general anesthesia for certain patients. Again, general does provide the most controlled environment. This may be ideal for the beginning surgeon. In teaching institutions, it would also allow the attending surgeon and the resident surgeon to communicate more freely during surgery. General and topical anesthesia should also be considered in patients on anticoagulation treatment; general is preferable when complete ocular akinesia is desired. Patients with nystagmus may not be able to fixate and ocular akinesia can only be attained with regional or general anesthesia. Anatomic abnormalities such as an abnormally long axial length may make topical or general anesthesia a safer alternative. There are patients in which general anesthesia is contraindicated or should be undertaken with caution. Myotonic dystrophy patients develop cataracts at a younger age; these patients are at risk of cardiac and respiratory complications under general anesthesia [23,24]. Marfans patients are subject to lens subluxation and dislocation; they are also at increased risk of cardiac and pulmonary complications under general anesthesia [25,26]. Other modes of anesthesia

should be considered in patients with a family history of malignant hypertension. Thorough review of medications is necessary, because some ocular medications may interfere with general anesthesia. Topical epinephrine used to treat glaucoma may interact with halogenated hydrocarbon anesthetics leading to ventricular fibrillation [27]. Echothiophate, which in the past was used to treat glaucoma, inhibits plasma pseudocholinesterase, which also metabolizes anesthetics including succinylcholine leading to overdosing [28]. Regional blocks provide some benefit over topical for patients who are unable to follow directions, such as when the patient is hearing impaired or there is a language barrier. It obviously does not prevent patient movement. The ocular akinesia and longer duration of effect make it a more ideal mode of anesthesia in cases in which the primary surgeon is a physician in training. Topical anesthesia provides the least controlled environment for cataract surgery. The surgeon must be able to tolerate some ocular motility, the patient should be able to follow directions, and the anesthesia staff must be willing to modulate intravenous sedation. Topical has the shortest duration of action. If the surgeon anticipates that he or she can complete the case in a reasonable time frame and the other conditions are met, topical anesthesia may ultimately be the safest mode of anesthesia as it avoids the systemic risks of general anesthesia and the risk of local trauma that accompanies regional blocks. For many patients and surgeons this mode of anesthesia fulfills all of the goals of anesthesia in cataract surgery. This is perhaps the reason that it has become the most popular form of anesthesia. It seems every few years we further perfect the cataract operation. We make it safer, faster, better, and more atraumatic. And just when we think we cannot improve it any more, we do. Hand in hand with our evolving surgical technique has come concepts in ocular anesthesia that bring these surgical advances to our patients in the safest and most efficient manner. While it seems unbelievable that we can further reduce the stress of cataract surgery and cataract surgery anesthesia any further, our history should tell us otherwise.

References
[1] Esser A. The first cataract surgery under general anesthesia. Klin Monatsbl Augenheilkd 1954;125(5): 610 4. [2] Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol 1884;18:402 48.

choosing anesthesia for cataract surgery [3] Atkinson WS. Local anesthesia in ophthalmology. Am J Ophthalmol 1948;31:1607 18. [4] Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986;12:182 4. [5] Whitsett J, Baleyat H, McClure B. Comparison of oneinjection-site peribulbar anesthesia and retrobulbar anesthesia. J Cataract Refract Surg 1990;16:243 5. [6] Leaming D. Practice styles and preferences of ASCRS members2003 survey. J Cataract Refract Surg 2004; 30:892 900. [7] Koller C. On the use of cocaine for producing anaesthesia on the eye. Lancet 1884;2:990 2. [8] Fichman R. Use of topical anesthesia alone in cataract surgery. J Cataract Refract Surg 1996;22:612 4. [9] Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine to control discomfort during cataract surgery using topical anesthesia. J Cataract Refract Surg 1997; 23:545 50. [10] Barequet IS, Soriano ES, Green WR, et al. Provision of anesthesia with single application of lidocaine 2% gel. J Cataract and Refract Surg 1999;25:626 31. [11] Kershner R. Topical anesthesia for small incision selfsealing cataract surgery. A prospective evaluation of the first 100 patients. J Cataract Refract Surg 1993;18: 290 2. [12] Fukasaku H, Marron J. Pinpoint anesthesia: a new approach to local ocular anesthesia. J Cataract Refract Surg 1994;20:468 71. [13] Patel B, Burns T, Crandall A, et al. A Comparison of topical and retrobulbar anesthesia for cataract surgery. Ophthalmology 1996;103:1196 203. [14] Crandall A, Zabriskie N, Patel B. A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine. Ophthalmology 1999;6:60 6. [15] Pandey SK, Werner L, Apple DJ, et al. No-anesthesia clear corneal phacoemulsification versus topical and topical plus intracameral anesthesia: randomized

237

[16]

[17]

[18]

[19]

[20]

[21] [22] [23]

[24]

[25] [26] [27]

[28]

clinical trial. J Cataract Refract Surg 2001;27(10): 1643 50. Backer CL, Tinker JH, Robertson DM, et al. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth Analg 1980;59:256 62. Lang DW. Morbitity and mortality in ophthalmology. In: Bruce RA, McGoldrick KE, Oppenheimer P, editors. Anesthesia for ophthalmology. Birmingham (AL)7 Aesculapius Publishing; 1982. p. 195. Lynch S, Wolf GL, Berlin I. General anesthesia for cataract surgery: a comparative review of 2217 consecutive cases. Anesth Analg 1974;53:909 13. Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. Anesth Analg 1993;76(5): 1019 22. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology 1988;95:660 5. Greenbaum S. Ocular anesthesia. Philadephia7 W B Saunders Company; 1997. p. 1 57. Fichman RA. Topical anesthesia. Ophthalmol Clin North Am 1998;11:60. Luntz MH. Clinical types of cataracts. In: Duane TD, editor. Clinical ophthalmology. Philadelphia7 JB Lippincott; 1988. p. 14. Aldridge LM. Anaesthetic problems in myotonic dystrophy: a case report and review of the Aberdeen experience comprising 48 general anesthetics in a further 16 patients. Br J Anaesth 1985;57:1119 30. Wells DG, Podolakin W. Anesthesia and Marfans syndrome: case report. Can J Anesth 1987;34:311 4. Mostafa SM. Anaesthesia for ophthalmic surgery. Oxford7 Oxford University Press; 1991. Janssens ML, Cockx F. A case of ventricular fibrillation during halothane anesthesia caused by eye drops. Acta Anaesthesiol Belg 1979;30(4):273 5. DeRoeth A, Dettbar WD, Rosenberg P. Effect of phospholine iodide on blood cholinesterase levels. Am J Ophthalmol 1963;59:586 92.