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Anaesthesia for Cataract Surgery

Anaesthesia for Cataract Surgery

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REVIEW ARTICLE

Drugs Aging 2010; 27 (1): 21-38 1170-229X/10/0001-0021/$49.95/0

ª 2010 Adis Data Information BV. All rights reserved.

Anaesthesia for Cataract Surgery
Emmanuel Nouvellon,1 Philippe Cuvillon,1 Jacques Ripart1,2 and Eric J. Viel1
ˆmes, France 1 Anaesthesia Service and Pain Clinic, University Hospital Caremeau, Nı ˆmes Medical School, Montpellier I University, Montpellier, France 2 Montpellier-Nı

Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Anaesthesia in the Elderly Patient: Specific Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Concomitant Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Continuation of Usual Treatment or Not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Requests from the Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Anatomical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Regional Anaesthesia (RA): Conventional Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Complications of Needle Blocks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Retrobulbar Anaesthesia (RBA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Peribulbar Anaesthesia (PBA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 RBA versus PBA Controversy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Recent RA Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Topical Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Perilimbal (Subconjunctival) Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Sub-Tenon’s Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.1 Needle Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.2 Surgical Approach with a Blunt Cannula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Local Anaesthetics and Adjuvant Agents for Eye Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Controversy: Who Should Perform the Block? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Supporting Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Controversy: General Anaesthesia versus RA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Future of Cataract Anaesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 22 23 23 24 24 25 25 26 26 28 28 28 29 29 30 30 31 32 32 33 34 34

Abstract

Cataract surgery is the most frequent surgical procedure requiring anaesthesia in developed countries. It is performed mainly in elderly patients, who present with many coexisting diseases that induce subsequent hazards from general anaesthesia. Cataract anaesthesia is performed following various techniques of regional anaesthesia, which are detailed in this review. Needle block carries a low but real risk of complications, mainly because of needle misplacement. Correct teaching and training are mandatory to prevent complications. The main patient risk factor for inadvertent globe perforation is the presence of a myopic staphyloma. Retrobulbar block has been progressively phased out and replaced by peribulbar block, sub-Tenon’s block (STB) or topical anaesthesia (TA). The requirement for very deep block with total akinesia has greatly decreased with the use of phacoemulsification for cataract surgery, allowing for use of TA or low-volume STB. However,

choice of local anaesthetics and adjuvant agents and. Anesthesia & Analgesia. general anaesthesia (GA) versus RA – suffers from a lack of well designed comparative studies. i. American Journal of Ophthalmic Surgery. some surgeons still express a need for a more efficient block. This has resulted in the development of alternative techniques such as peribulbar. Regional Anesthesia and Pain Medicine. but does not totally prevent complications. classical (retrobulbar and peribulbar) needle block techniques together with their efficacies and complications. phakoemulsification. Various local anaesthetics may be used. Increasing the anaesthetic volume provides reproducible akinesia. Moreover. A greater knowledge of anatomy and of the various techniques will enable the anaesthesiologist to choose the best technique to match each situation. 27 (1) . When deep anaesthesia is required. Eye and Archives of Ophthalmology. British Journal of Anaesthesia. requests from surgeons for total akinesia and lowered intraocular pressure (IOP) have decreased. and elderly patient. Literature searches were conducted on MEDLINE and EMBASE from 2000 to 2009 using the following keywords: cataract surgery. the relevant anatomy. general anesthesia. The ª 2010 Adis Data Information BV. However. Anaesthesia in the Elderly Patient: Specific Considerations The topic of anaesthesia in the elderly patient is sufficiently large in itself as to require a separate Drugs Aging 2010. A surgical approach to accessing sub-Tenon’s space avoids needle block. performed using either the needle technique or a surgical approach. providing total globe akinesia and anaesthesia of the globe. and these cannot be extensively detailed here. The most useful adjuvant to local anaesthetic is hyaluronidase. Ophthalmic surgery is the most frequent surgical procedure requiring anaesthesia in developed countries. the complications of conventional RBA have been extensively described.[1-3] Eye block has historically been limited to retrobulbar anaesthesia (RBA) performed by the surgeon alone with monitored anaesthesia care or without any anaesthesiologist’s assistance at all. Anaesthesiologists are now increasingly becoming involved in ophthalmic RA. In addition. which have the potential to result in surgical complications. low-volume STB. the aim of which is to improve safety. appears to be the technique of choice in terms of efficacy. Ophthalmology. We also searched a cumulative personal database based on monthly issues of the following journals published since 1994: Anesthesiology. under regional anaesthesia (RA). This review briefly discusses anaesthesia in elderly patients and the condition of the eye requested by the surgeon. non-ophthalmic complications of cataract surgery are so rare that the outcome does not significantly differ between those patients who have been operated on and those who have not. about 500 000 patients in France and nearly 2 million patients in the US. non-akinesia techniques may give rise to impaired surgical conditions.e.22 Nouvellon et al. Whether anaesthesia influences patient outcomes has been the topic of many publications.e.[4] At the same time. regional anesthesia. Each year. finally. emerging techniques and their relative ‘pros’ and ‘cons’. eye surgery. anesthesia. albeit at the price of imperfect akinesia. depending on their availability and respective properties. but focuses particularly on RA. All rights reserved. As surgical practice evolves following widespread use of the phacoemulsification (PKE) technique. also called ‘eye block’. some ongoing controversies. the debate between GA and RA is developed. for some difficult procedures and certain patients. cataract surgery is performed on more than 300 000 patients in the UK. 1.[1] The vast majority of procedures are performed in a 1-day surgery setting. controversy over the choice of anaesthesia technique – i. intraocular lens replacement. and the need for greater safety during eye block has been emphasized. lowvolume sub-Tenon’s block (STB) and topical anaesthesia (TA). Journal of Cataract & Refractive Surgery.

which can be found elsewhere (e. angina and myocardial infarction (14%). diabetes and corticosteroid therapy are classical causes of cataracts. the patient’s usual treatment should be given on the morning of surgery.1 Concomitant Diseases 1. carotid stenosis or coronary drug-eluting stents.[6] As in all elderly patients. non-tissue prosthetic heart valves. for example. These risks include cerebral ischaemic stroke. gastrooesophageal reflux (19%). or (ii) the morning insulin dose is avoided. When choosing the eye block. two options are possible: (i) as for any other surgery. cataract patients may have multiple concomitant diseases. The most debated problem is whether to continue anticoagulants/antiplatelet therapy. On the other hand. relative overdosage and subsequently delayed recovery or prolonged residual effect with mental dysfunction. myocardial infarction and death.[14] Therefore. those with atrial fibrillation. observed a 97% rate of pre-existing risk factors for intraoperative adverse events requiring medical intervention in patients undergoing cataract surgery. deeper hypotension induced by GA or delayed wakening). the median patient age was 75 years.[10] Therefore. On the one hand. In a prospective study.e. discontinuing those therapies may unacceptably increase the risk for thrombosis in at-risk patients. the usual insulin is continued. Sharwood et al. cataract surgery is a totally ‘bloodless’ procedure and can be performed safely in patients taking any anticoagulant/antiplatelet agents. because of the risk of a rebound effect.Anaesthesia for Cataract Surgery 23 review.g.  Effects of anaesthesia such as arterial hypotension may be less well tolerated in the elderly patient because of multiple underlying diseases (e. when the patient is fasted. Concerning insulin treatment of diabetic patients. myocardial or cerebral infarction resulting from coronary or carotid stenosis).[12. subconjunctival or palpebral haematoma). the option of TA must be taken into account. Kelly observed that up to 63% of cataract patients have a significant underlying disease. 1. The elderly have also specific characteristics that may interfere with anaesthetic agents. and moreover for b-adrenoceptor antagonists (b-blockers) in particular. In fact. All deep blocks (both needle block and cannula STB) carry a low risk for haematoma.[9] Indeed.[5]). ‘‘the INR [international normalized ratio] should be within the therapeutic ratio which is determined by the Drugs Aging 2010.13] However. When the patient is not fasting. continuing such treatments is frequently thought to increase both the risk for surgical bleeding and the risk of haematoma from eye block puncture. In a series of >55 000 cases.[8] The most frequently described co-morbidity is cardiovascular disease. particularly GA. to produce exaggerated adverse effects:  Decreased drug elimination may lead to accumulation. This is especially true for antihypertensive agents. especially in patients given GA. As with any other surgical procedure. All rights reserved. This discussion is limited to the most important points. Most of them are benign with only short-term aesthetic consequences (i. are also reported.[11] So these drugs should generally be continued. Cohendy et al.2 Continuation of Usual Treatment or Not? Cataract is mainly an elderly patient’s health concern. diabetes (13%) and asthma (9%). but neurological or metabolic diseases or conditions.[7] Stupp et al. because the patient is fasting.  Increased susceptibility to anaesthetic agents may lead to more pronounced drug effects than in healthy adults with the same dosage (e. the golden rule is not to change a patient’s usual treatment if he or she is stable on it. discontinuation of anticoagulant/antiplatelet therapy for a deep block is no longer routinely recommended.  Polymedication may lead to significant drug interactions with anaesthetic agents. 27 (1) . reported the following incidences: hypertension (51%). including diabetes mellitus or chronic corticosteroid therapy.g. 1 mL/g/h). it appears that anticoagulants/antiplatelets do not significantly increase the risk of such a haemorrhage.g. the exception being the classical but very infrequent compressive retrobulbar haemorrhage. ª 2010 Adis Data Information BV. British guidelines state that. the normal insulin dose is given as usual under the cover of an intravenous glucose infusion (glucose 50 g/L.

The four rectus muscles of the eye are inserted anteriorly near the equator of the globe. a potential space with no actual volume.[15] and French guidelines recommend continuation of aspirin (acetylsalicylic acid). The orbit is filled mainly by adipose tissue. condition for which the patient is being anticoagulated’’. there is no need for any suture and the duration of the procedure is reduced to as little as 3–5 minutes in easy cases. for instance. 27 (1) . The four rectus muscles delimit the retrobulbar cone. and this only rarely. Tenon’s capsule is perforated by the tendons of the oblique and rectus muscles before they insert into the sclera. All rights reserved.[4] This procedure consists of fragmentation of the lens nucleus with an ultrasound probe and evacuation of the fragments by an irrigation-aspiration system. Some authors assimilate it into the articular capsule of the globe. they are inserted together. at the apex. as the lens is free of any sensory innervation.[16] Canadian practice appears to be similar. Many major structures are located in the muscular conus and are therefore vulnerable to the risk of needle injury. as with any other open globe surgery. with its apex posterior and its ª 2010 Adis Data Information BV. through which the optic nerve enters the orbit.[18] The surgeon may also require that other general conditions be prevented. 2. may cause catastrophic choroidal expulsive haemorrhage. Anteriorly. injecting local anaesthetic inside the cone can logically be expected to provide anaesthesia and akinesia of the globe and of the extraocular muscles. which passes through the muscular cone. the first branch of the trigeminal nerve (cranial nerve [CN] V). for cataract surgery. In this case. sensory and motor innervation of the globe.24 Nouvellon et al. and the globe is suspended in its anterior part. Posteriorly.[17] The only drug for which there are no recommendations is clopidogrel. on the Zinn tendinous annulus. All these nerves except the trochlear nerve pass through the muscular conus. methods have radically changed. a decision must be taken on an individual basis. although fluid can be injected into it. It delimits the episcleral space or sub-Tenon’s space. A small incision (3–4 mm) is sufficient to allow a foldable prosthetic lens to be introduced. PKE is possible for selected patients without any anaesthesia at all. most of the arteries of the orbit. meaning lowering the IOP is much less important. and the oculomotor nerve (CN III) provides motor signals to all the other extraocular muscles. these include the optic nerve with its meningeal sheaths. base corresponding to the anterior aperture. which requires a large (6–8 mm) incision to remove the entire lens. for obvious reasons. Indeed. and the autonomic. By contrast. Near the equator. Tenon’s capsule merges with the bulbar conjunctiva before both insert together into the corneal limbus. Anatomical Considerations The orbit is a cavity in the shape of a truncated square pyramid. Acute peak arterial hypertension. because the ultrasound probe allows immobilization of the eyeball. Drugs Aging 2010. Akinesia is rarely if ever required. Because the small incision is self-sealing. only the corneal incision may be painful. which can impair surgery and therefore must be prevented. the abducens nerve (CN VI) does the same to the lateral rectus muscle. The facial sheath of the eyeball – also called Tenon’s capsule – is a fibroelastic layer that surrounds the entire scleral portion of the globe. the request from the surgeon is for analgesia. 3. Only the motor command of the orbicularis muscle of the eyelids has an extraorbital course. Requests from the Surgeon Classically.[19. Coughing gives rise to very acute and high peak IOP. Therefore. As the small incision is obturated by the ultrasound probe. akinesia and hypotonia of the eyeball.20] Sensory innervation of the globe is supplied by the ophthalmic nerve. Finally. with the development of PKE. PKE can be considered a ‘closed eye’ procedure. At this point there is a continuity between Tenon’s capsule and the fascial sheath of the muscles. Tremor or restlessness may impair the procedure. The trochlear nerve (CN IV) provides the motor command to the superior oblique muscles. This remains true for the traditional extracapsular cataract extraction (ECE) technique. arising as it does from the superior branch of the facial nerve (CN VII). which is not sealed by any intermuscular membrane.

1 Complications of Needle Blocks The most common cause of needle block complications is needle misplacement. or total spinal anaesthesia with tetraparesis. The complication has a poor prognosis. Firstly. long eyeball). Symptomatic treatment (oxygen supply. if required. in most cases. Retrobulbar haemorrhage results from an inadvertent arterial puncture.Anaesthesia for Cataract Surgery 25 4. Surgical decompression may be required. so that. bradycardia and eventually respiratory and cardiac arrest. if required. confusion and restlessness.[25. surgery can be continued. high pressure due to injection into the muscle sheath.26] Risk factors are classically inexperience of the physician and a highly myopic eye (i. rather than clotting disorders. progressive.[27] Moreover. an inadvertent intraarterial injection may reverse blood flow in the ophthalmic artery up to the anterior cerebral or the internal carotid artery. Edge and Navon observed that myopic staphyloma was the greatest risk factor for scleral perforation.23] Katsev et al. Secondly. have demonstrated that the apex of the orbit may be reached with a 40 mm long needle. All rights reserved. and. tracheal intubation for mechanical ventilation with muscle relaxants) usually allows rapid recovery without after-effects. staphyloma is more frequently located at the posterior pole of the globe (accounting for perforations after RBA) or in the inferior area of the globe (accounting for perforations after inferior and temporal punctures. CN palsy with sympathetic activation. symptomatic treatment (oxygen supply. ultrasound measurement of the axial length of the globe (biometry) should be performed. a retractile scar develops. and. but. As a result. the choice of needle is largely based on efforts to prevent complications. this contraindication may be circumvented if B-mode ultrasound is conducted to assess the presence and location of a staphyloma.[12] The main risk factor is arterial fragility (diabetes and atheroma). Regional Anaesthesia (RA): Conventional Blocks As all needle blocks can be used for cataract surgery.[26] In a series of 50 000 cases. Venous puncture leads to noncompressive haematoma. and finally. Injury to an extraocular muscle may cause diplopia and ptosis. all that is needed is postponement of surgery.[21] such that an injected volume as small as 4 mL can produce seizures. or myotoxicity of the local anaesthetic. Spread of anaesthesia in the CNS may involve two mechanisms. at least in myopic patients and ideally in all patients. Drugs Aging 2010. In such cases. then it appears to recover. Several mechanisms can be involved: direct injury by the needle resulting in intramuscular haematoma. However. arterial hypotension. which can threaten retinal perfusion. the main risk factor is poor training and limited experience of the physician performing the block. brainstem anaesthesia. 4. Using ultrasound imaging.[22.e. This complication may lead to a compressive haematoma. injected antiepileptic drugs such as thiopental sodium or benzodiazepine. A highly myopic eye (axial length >26 mm) remains the classical contraindication to eye block. both peri. tracheal intubation and ventilation) should result in total recovery within hours. in most cases. the consequences of which are much less severe. Inadvertent globe perforation and rupture is the most devastating complication of eye blocks. possibilities include bilateral block. Although some anatomical features may increase the risk of complications. 27 (1) . This causes partial or total. particuª 2010 Adis Data Information BV. Vohra and Good observed that the probability of staphyloma is greater in highly myopic than slightly myopic eyes. vasopressors.or retrobulbar).[28] The injury may progress in three steps: initially the muscle is paralysed. as myopic staphyloma occurs only in myopic eyes. larly in cases of delayed diagnosis. The incidence is between 1/350 and 7/50 000 cases.[24] Depending on the dose and volume of local anaesthetic spreading towards the brainstem. face mask ventilation. an inadvertent injection under the dura mater sheath of the optic nerve or directly through the optic foramen may result in subarachnoid spread of the local anaesthetic.[25] This suggests that isolated high myopia may not be a risk factor per se. but acts as a confounding factor.

A large volume is required to allow the local anaesthetic to spread into the entire corpus adiposum of the orbit. However. a technique that is theoretically less hazardous.3 Peribulbar Anaesthesia (PBA) b Fig. PBA consists of introducing the needle into the extraconal space. The long-used technique of peribulbar anaesthesia (PBA) was highlighted by the work of Bloomberg.36] The main reason for use of this technique is to reduce the risk of injury to major structures in the intraconal space. where the nerves to be blocked are ª 2010 Adis Data Information BV. and the second superiorly and nasally (figure 1). advances in PBA techniques may be summarized in terms of a few guidelines: 1. one inferiorly and temporally at the same site as for RBA. Conventional peribulbar injection: (a) inferior and temporal injection and (b) superior and nasal injection. RBA is used less frequently nowadays because of its complications. Using a single injection technique. 27 (1) .[30] The main hazard of RBA is the risk of injury to the globe or one of the many vulnerable elements located in the muscular cone. these structures are packed in a very small volume and are fixed by the tendon of Zinn.[29] 4. The most classical PBA technique involves two injections. 1. Many alternative techniques have been described and these cannot be extensively reported here. RBA was formally described only in 1936. As the space where the local anaesthetic spreads is unique.[31. thereby avoiding the need for additional eyelid block. Additionally. some authors have proposed avoiding introduction of a needle into the muscular cone.2 Retrobulbar Anaesthesia (RBA) a Historically. which appears to be less hazardous. The volume of local anaesthetic injected is larger than that with an RBA injection (up to12 mL).[35] confirmed that this increases the risk of optic nerve injury.[30] An additional facial nerve block is required to prevent blinking.26 Nouvellon et al. located. which prevents them from moving away from the needle. RBA has been the gold standard of eye block and is achieved by injecting a small volume of local anaesthetic agent (3–5 mL) inside the muscular cone. Direct optic nerve trauma by the needle is very rare but causes blindness. The resulting potential complications are detailed in section 4.[31. such a large volume allows an anterior spread to the eyelids. To prevent such complications. providing a block of the orbicularis muscle of the eyelids. 4.[33] The Atkinson ‘up and in’ position of the gaze was abandoned after Liu et al. Drugs Aging 2010.32] Although used from the beginning of the twentieth century. All rights reserved. including the intraconal space. CT scan imaging usually shows optic nerve enlargement due to intraneural haematoma. with the technique that is most frequently used being the van Lindt eyelid block.1.[32] Davis and Mandel.[34] and Unso ¨ ld et al. Near the apex. and prefer to keep the needle in the extraconal space.

[25. (3) semilunaris fold of the conjunctiva.32] vessels. Additionally.Anaesthesia for Cataract Surgery 27 increasing the injected volume is sufficient to provide efficient anaesthesia. which increases after injection. shortbevelled needles need more pressure to perforate the sclera on cadavers. because of the very low incidence of perforation.[31. Compression has not been shown to enhance the quality of the block. This fact probably explains the occurrence of complications such as optic nerve injury after an attempted peribulbar injection. Increasing the depth of needle insertion is expected to change a peribulbar into a retrobulbar injection. a long needle introduced totally into the orbit may reach the apex of the orbit. Katsev et al. this has a similar efficacy to a 25 mm depth. as the first injection may impair identification of anatomical landmarks. At this level. All rights reserved. An alternative site of puncture for PBA is the medial canthus (figure 2).[43] However. Inferior and temporal puncture remains the gold standard. 2. the superior oblique muscle may be injured by the needle. so that the extraconal space totally disappears and becomes virtual.32. nasally to the lachrymal caruncle. and is free from blood ª 2010 Adis Data Information BV. (4) medial canthus episcleral anaesthesia. in a strictly posterior direction. Sites of needle introduction for the most frequently used blocks: (1) medial canthus peribulbar anaesthesia. 2 3 1 4 5 Fig.36. Drugs Aging 2010. the distance between the orbital roof and the globe is reduced. an anatomical anomaly that represents a risk factor for perforation.44] This poor reproducibility in block efficacy is the main disadvantage of PBA. leading to the need to increase the injected volume to prevent an imperfect block.[37] Moreover. At this level.[42] The needle is introduced at the medial junction of the eyelids. demonstrated that inserting the needle up to a 40 mm depth will result in an injection directly through the optical foramen in 11% of cases.[41] 3. Using a thin needle (25 gauge) to limit pain. Depending on the surgeon’s request for akinesia. myopic staphyloma. Avoiding the superior and nasal site of puncture.[39] Some ‘posterior PBAs’ are in fact inadvertent retrobulbar injections. 5. the space between the orbital wall and the globe is as large as with the inferior and temporal approach.[24] More recently. Using compression to lower IOP. it has been suggested that the second injection may lead to complications more frequently than the first. 2. spreading of local anaesthetics in the corpus adiposum of the orbit remains somewhat unpredictable. A 30 mmHg pressure applied for 10–15 minutes is sufficient. Posteriorly to the globe.[38] A second injection should be performed only as a supplement when the first injection has failed.[43-79] and (5) inferior and temporal peribulbar anaesthesia. Moreover.27] 4. this has not been confirmed in patients. Use of short-bevelled needles should presumably enhance safety by increasing the tactile perception of resistance to be overcome during needle insertion. Comparative studies have confirmed that. For example. provided the injected volume is sufficient.[40] In an anatomical study. In all cases. limiting the needle insertion to a 15 mm depth was proposed. Limiting the depth of needle insertion (usually 25 mm). Moreover. a hazardous zone. the single injection technique is as effective as the double injection technique. the rectus muscles are in contact with the orbital walls.[42] (2) lachrymal caruncle.[31. is infrequently located on the nasal side of the globe. 27 (1) . an additional injection is required in 1–50% of cases. at a depth of 15 mm (no more). theoretically increasing the risk of globe perforation.

[46. However. retrobulbar haemorrhage) because of intraconal introduction of the needle.[46] As it does not require deep insertion of a sharp needle.[19. thus allowing cataract surgery by PKE when akinesia is not required. In (a). Schematic of spread of local anaesthetic for (a) both retrobulbar and peribulbar block or (b) sub-Tenon’s injection. All rights reserved. http://lww.[45] This can be explained by the fact that there is no intermuscular membrane that separates extraconal from intraconal spaces. the efficacy ª 2010 Adis Data Information BV.47] In our opinion. 27 (1) . theoretically. it appears that – provided a sufficient volume of local anaesthetic is injected – both techniques have similar efficacies.1 Topical Anaesthesia b Instillation of local anaesthetic eyedrops provides corneal analgesia.[1-3.. 3. TA is the technique of choice for patients receiving anticoagulant or antiplatelet therapy.[4] It is quick and simple to perform and avoids the potential hazards of needle techniques. Fig. 4. However. subTenon’s injection corresponds to a very specific space that guides the local anaesthetic all around the globe. brainstem anaesthesia. thereby explaining the very good akinesia (reproduced from Ripart et al.[80] with permission from Lippincott Williams & Wilkins. the similar efficacy of the two techniques and the possibly higher risk of complications with RBA compared with PBA should result in discontinuation of use of RBA. when the injected volume is increased (>4 mL). 5. RBA. Inhomogeneous spreading because of small septa explains why retrobulbar and peribulbar anaesthesia may produce incomplete blocks.28 Nouvellon et al. it is important to note that local anaesthetic spreads through the whole corpus adiposum of the orbit regardless of whether the injection is peribulbar or retrobulbar anaesthesia. By contrast.4 RBA versus PBA Controversy a Although RBA is classically assumed to be more efficacious than PBA. carries a higher risk of complications (optic nerve injury. accounting for up to 60% of procedures in some series but remaining at around 20% in some others. so that both form a unique space for spreading of local anaesthetic (figure 3).20] If efficacy is similar. This may be because of the very low rate of complications and the subsequent lack of power of comparative studies – including large series or meta-analyses. the expected greater safety of PBA has never been confirmed. in (b).com).49] Some surgeons prefer TA for routine PKE in >90% of their procedures. the rate of complications with RA is so low that it was never possible to confirm a decrease in the RA-related sight-threatening complication rate with TA. thus explaining the very reproducible anaesthesia of the globe.46. Because there is a continuation between Tenon’s capsule and the muscle sheath. The figures show coronal sections passing through the globe. excess local anaesthetic flows towards the rectus muscles. the only basis on which to choose one technique over the other is safety. Recent RA Techniques 5. However.[48] This technique is increasingly being used for cataract surgery worldwide. Drugs Aging 2010. except when compared with RBA.

which were originally designed for use in urology.3 Sub-Tenon’s Block Also called episcleral or parabulbar anaesthesia. namely.[18. Firstly. The efficacy of sponges soaked with local anaesthetic inserted into the conjunctival fornices and soluble local anaesthetic inserts needs further documentation. it would have acted as a barrier.[57] Therefore. a surprising decrease in vitreous issue rate in the TA group (0.[58. In a randomized. non-blind.Anaesthesia for Cataract Surgery 29 of TA is limited. TA should be limited to planned easy procedures performed by experienced surgeons in selected patients.[73] This might explain why TA has been associated with a 3.[63. the lack of akinesia and IOP control associated with the short duration of the procedure may theoretically make surgery more hazardous. thereby resulting in insufficient eye disinfection. TA is associated with a 2-fold increase in posterior capsule rupture requiring anterior vitrectomy. STB is achieved by injecting into the episcleral space. which appears to be no more effective than no anaesthesia at all in selected cases involving an experienced surgeon.76] 5. thereby achieving high-quality analgesia of the whole globe with injection of relatively Drugs Aging 2010.4% vs 2. the investigators observed a nonsignificant increase in iris prolapse (1.[70.[55] At the same time. Patients randomly subjected to RBA or TA for one eye and the other technique for the other eye preferred RBA (71% vs 10%).5%).[52. comparative study of unselected patients. intracameral injection cannot be recommended.[4] This may be the case in institutions where PKE is not available for technical reasons. Jacobi et al. The safety of this technique in relation to local anaesthetic ª 2010 Adis Data Information BV. Thus.[62] This entails injecting small volumes (0.[54] Similarly.59] Efforts have been made to improve TA efficacy in many ways. the problem is probably the wrong sequence of application rather than the jelly itself.1 mL) of local anaesthetic in the anterior chamber at the beginning of surgery. 27 (1) . However. observed only one significant difference between TA and RBA.[69] For these reasons. when compared with STB. Use of long-acting local anaesthetics such as levobupivacaine or ropivacaine appears more efficacious than lidocaine (lignocaine).81] than with TA.[77] but has not gained wide popularity. preventing disinfectant applied later from reaching the conjunctiva.[74] The most plausible explanation for these cases is that if the jelly was applied first on the eye.[50] Intraoperative comfort is more consistently obtained with RBA[50-52] or sub-Tenon’s[53.4%).69.7% vs 0. akinesia is still required and TA is questionable. has been confirmed. Specifically designed topical lidocaine or tetracaine jellies should replace current jellies. lidocaine jelly has been associated with an increase in postoperative incidence of endophthalmitis. analgesia may be incomplete. In a 2382case survey. observed an acceptably low rate of surgical complications of cataract surgery performed under TA. For manual ECE.8-fold increase in endophthalmitis rate compared with RBA.71] Instilling lidocaine jelly instead of eyedrops appears to clearly enhance the quality of analgesia of the anterior segment.54] Only one study has observed an advantage for TA in terms of the surgical complication rate.2 Perilimbal (Subconjunctival) Anaesthesia Subconjunctival injection of local anaesthetic may provide analgesia of the anterior segment without any akinesia. Shaw et al. All rights reserved.[56] By contrast.[75. This allows the local anaesthetic to spread circularly around the scleral portion of the globe. 5.72] and is being increasingly used.[60. which is not able to regenerate. toxicity to corneal endothelium. a more recent meta-analysis has shown that.64-68] This is not surprising. possibly reflecting eye hypertonia due to the lack of akinesia in the TA group.61] Intracameral injection of local anaesthetic has been proposed to enhance analgesia.64] but any significant analgesic benefit of intracameral injection versus simple TA has never been established by properly designed trials. as described by the French sanitary agency in 2004. TA was identified as a risk factor for displacement of nuclear fragments into the vitreous.[18] Secondly. as analgesia is not correlated with intracameral local anaesthetic concentration.[53.

83] Chemosis (subconjunctival spread of the local anaesthetic) occurs frequently after injection of such large volumes[81.[13] One inadvertent perforation Drugs Aging 2010.[44.[3] Under TA. we encountered no serious complications. as with all needle techniques. the needle is slightly shifted medially and advanced strictly posteriorly. low volumes (usually 3–5 mL) [figure 3].[84] However. Sub-Tenon’s space may be injected using either a needle technique or surgical dissection followed by introduction of a blunt cannula.2 Surgical Approach with a Blunt Cannula Use of a blunt cannula was first proposed as an intraoperative complement to RBA. 5.[3] In a 6000-case series. with a 2.78.1 Needle Technique In the needle technique. 5–10 mm away from the limbus. Finally.84] and is easily explained by anatomical features. Similarly. After it has encroached on the conjunctiva. ultrashort metallic cannulas.[82] Being a non-akinesia technique. it has been identified as a risk factor for displacement of nuclear fragments into the vitreous. To obtain acceptable akinesia. It remains to be assessed on a large scale. have been described. lowvolume STB carries the same limitations as TA.78. Therefore. Some complications of STB. Its occurrence confirms the sub-Tenon’s location of the injection and may require compression to be resolved. with only one case requiring cancellation of surgery. such that preoperative compression of the globe may be unnecessary. the risk of misplacement of the needle and its subsequent complications must be kept in mind.83] the needle is introduced into the fornix between the semilunaris fold of the conjunctiva and the globe. eyeball perforation and sepsis.[44. Nevertheless. with acceptable safety of use. nique has subsequently been proposed as a sole anaesthetic technique. episcleral injection of a small volume of local anaesthetic may be used for an open globe.[83] However. because it avoids the blind introduction of a needle in the orbit. and the results are more reproducible than with classical PBA. the bulbar conjunctiva is grasped with a small forceps.83. Blunt Wescott scissors are used to open a small buttonhole into the conjunctiva and Tenon’s capsule to gain access to the episcleral space.82. 5.3. despite its proven safety record in large series. a short intravenous catheter (18 or 20 gauge) without its needle can be used. it is the technique of choice as a supplemental injection when required intraoperatively. any needle block complication may occur after STB.79] In addition. which results in directing the gaze medially.79. Guise reported that 6% of cases had chemosis and 7% had subconjunctival haematoma.[86] This techª 2010 Adis Data Information BV.[85] This technique might be considered as a blend of needle and cannula techniques. Several types of cannulas have been proposed: smooth curved metallic cannulas. All rights reserved. the globe returns to its primary gaze position.[88.[57] Another limitation is the relatively high rate of minor incidents.79. thereby pulling on the globe. STB efficacy is excellent for globe analgesia: 96% of the blocks were scored as perfect or good. In our experience of 2000 cases. use of a larger volume (up to 8–11 mL) means the local anaesthetic will spread to the extraocular muscle sheaths. At a 10–15 mm depth. the injected volume must be increased to 11 mL. This technique has not been widely used outside France. including strabismus. Moreover. A variant technique using only forceps and a ‘pencil-point’ needle instead of scissors and cannula was recently proposed by Allman et al. and silicon or plastic cannulas. tangentially to the globe (figure 2). 27 (1) . which provides good globe analgesia but only partial akinesia of the globe and lids. thus allowing injection. although rare. Using a large volume (5–10 mL) with this technique results in good globe and lid akinesia.3.[78. the main advantage of the technique is its safety.89] When no specific cannula is available. This technique is usually used with injection of low volumes (2–5 mL) of local anaesthetic. use of small volumes causes a very small increase in IOP. This serves as a depth marker.[44] This technique is simple to learn and perform.3-fold increase compared with RBA and PBA having been observed.[87] and has been used in up to 50% of cases in the UK. producing an effective and reproducible akinesia (figure 3). A blunt cannula is then inserted into the episcleral space to allow the injection.30 Nouvellon et al. after a small loss of resistance (‘click’) is perceived. Indeed.

taking into account particularly the requirement for quick onset (lidocaine. this problem should be prevented by more effective purification[105] or. mepivacaine. STB appeared to cause a lower incidence of serious complications than RBA and PBA. possibly due to synechias between the sclera and Tenon’s capsule in a previously operated eye.[109] Other benefits of hyaluronidase include a smaller intraoperative increase in IOP. This may cause orbital oedema or a pseudotumoural orbitopathy. 25–50 IU/mL can be proposed. Doses varying from 3. 27 (1) .111] Other adjuvants are less frequently used. which is available in the US. either alone or as a mixture of two agents.[95. ª 2010 Adis Data Information BV.[107] This may be because of use of varying concentrations in different studies. usually used more by dental surgeons than anaesthesiologists.96] Articaine is also considered to cause less myotoxicity and diplopia than other drugs.Anaesthesia for Cataract Surgery 31 occurred during dissection.75 to 300 IU/mL of local anaesthetic have been reported.92] but is only slightly superior to PBA in this respect. for instance. The choice of local anaesthetics should be based on the pharmacological properties and availability of the drugs. ropivacaine and mepivacaine. bupivacaine) and akinesia (higher concentration).[108] Given the wide range of concentrations used and the absence of clear dose-efficacy ranging data. in large series.[91. which may otherwise dramatically hinder surgery.[84] In the series of 375 000 procedures by Eke and Thompson. STB was associated with a 2. with a subsequent rise in IOP that may mimic an expulsive choroidal haemorrhage[99] or lead to surgical complications (posterior capsule rupture or vitreous loss).[93] 5. clonidine does not increase the incidence of systemic adverse events such as hypotension or excessive sedation. although this difference was significant only for life-threatening (not sight-threatening) complications. by use of recombinant hyaluronidase. although very rare. complications of STB are very rare. All rights reserved. and these cannot be detailed here. with only a tendency towards a greater benefit with higher doses. possibly by limiting local anaesthetic myotoxicity because of a quicker spread. Clonidine.[100-104] As it is probably not due to hyaluronidase itself. Adrenaline (epinephrine) is sometimes added to increase the duration of eye block. Many publications have compared various local anaesthetic mixtures and concentrations.[112] Moreover.[106] However. articaine).5-fold decreased risk in serious complications compared with needle techniques.[3] Sub-Tenon’s anaesthesia also leads to higher patient and surgeon satisfaction than RBA and TA. At a dose of 0. the literature is somewhat controversial. Guise reported no serious complication in 6000 cases. ideally. Articaine.[46] In the British database series of >55 000 cases. showing a limited magnitude of benefit concerning akinesia. bupivacaine. systemic toxicity is not a major concern. enhances intraoperative and postoperative analgesia when added to local anaesthetic. As the volume of local anaesthetic injected is usually small (3–10 mL).[90] However.[97] There is no definitive ‘magic bullet’ in terms of the ideal local anaesthetic for eye block.4 Local Anaesthetics and Adjuvant Agents for Eye Blocks All available local anaesthetics have been used for eye block.[94] The main differences found between these local anaesthetic combinations are in accordance with their known pharmacological properties. complication of hyaluronidase administration is immediate or delayed allergy. Hyaluronidase is an enzyme that facilitates wider spreading of local anaesthetics. Use of hyaluronidase is classically assumed to shorten the onset of the block and enhance its quality. postoperative residual block for analgesia (ropivacaine. postoperative pain is not a major concern after cataract surgery and the Drugs Aging 2010. prolonged effect.5–1 mg/kg.[98] The only significant. clonidine may help to prevent intraoperative arterial hypertension and may lower IOP. or a combination of two of these.[110. Use of hyaluronidase also permits a decrease in the amount of local anaesthetic required to achieve the same efficacy. The most frequently used local anaesthetics are lidocaine.[108] The last consideration in terms of the benefits of hyaluronidase is its ability to decrease the incidence of postoperative strabismus. has also been proposed for both PBA and STB because of its quick onset and short duration. However.

[115] Warming the local anaesthetic may decrease pain on injection and enhance block efficacy. Excessive sedation and Drugs Aging 2010.[44.32 Nouvellon et al. anaesthesiologists are increasingly performing the blocks.[126] The role of preoperative fasting remains controversial. The most frequently used drugs include benzodiazepines. depending on the payment system. there are very great differences in anaesthesiologists’ involvement in eye blocks both between and within countries. the local anaesthetic may precipitate when there is excessive alkalinization. especially cataract surgery. However. some standard safety measures such as monitoring.84] However. a preoperative assessment to ensure coexisting diseases are properly controlled appears well advised.[3. All rights reserved. Some reports have emphasized complications after blocks performed by ‘‘anesthesia personnel’’. has very little impact on perioperative morbidity and mortality. hydroxyzine.83] Care must be taken in patients with mental confusion and restlessness attributable to benzodiazepines or any other drug overdosage.42. Old patients undergoing eye surgery frequently have coexisting disease. When complications occur or there is a need to convert to GA. Finally. provide monitored anaesthesia care and manage life-threatening complications. are sometimes circumvented for eye blocks.83. In some institutions. but no clinically relevant benefits appear to occur.[131] Short sedation for performing the block might include small amounts of propofol or opioids. in which situation the antibacterial will be chosen for its intraocular penetration properties. A fluoroquinolone is a standard choice. 27 (1) . and surgeons have to manage the block themselves. as with other RA techniques. The cost effectiveness of this practice may vary among various institutions. Alkalinization has been proposed to decrease pain during injection and to accelerate block onset.121] Eye block is associated with lower perioperative morbidity than GA for ophthalmic surgery. provided that no heavy sedation is added. such as France and the UK.[119] In fact. ª 2010 Adis Data Information BV. The optimal concentration of bicarbonate is difficult to determine because of the large pH range of local anaesthetic solutions provided by pharmaceutical firms. relatively safe but potentially dangerous. On the other hand. anaesthesiologists provide only monitored anaesthesia care while the surgeon performs the block. some of these complications were associated with blocks performed by nurse anaesthetists or operating room nurses directly supervised by surgeons. anaesthesiologists have become increasingly involved in eye blocks that were previously undertaken by surgeons.[121-125] As a result. but concern has been expressed about their potential risk for systemic effects.5 Controversy: Who Should Perform the Block? anaesthesiologists have demonstrated their ability to perform eye blocks. anaesthesiologists are not available.[116] 5.118] In other areas. Provided that they have been correctly taught and trained. fasting and preoperative evaluation. like any other RA. dexmedetomedine and melatonin. Anaesthesiologists should theoretically be the most appropriate persons to perform eye blocks. but has limited efficacy. strict fasting is uncomfortable and may be considered too heavy-handed given the very low incidence of such situations. clonidine.[127-130] Antibacterial prophylaxis is limited to sepsis highrisk situations such as in the treatment of diabetic patients. in many countries.[114] Opioids do not appear to be more efficient when administered via a regional ophthalmic route than by systemic administration. which are considered basic recommendations for other types of block.6 Supporting Therapies Since the 1980s. Moreover. Premedication is frequently used but should be utilized cautiously so as not to prevent early discharge because of residual excessive sedation in an ambulatory setting. availability of a new long-acting local anaesthetic has become the focus of less interest. a full stomach may constitute an aggravating factor.[117. Therefore. anaesthesiologists are not available for eye block everywhere. It must be stressed that eye blocks are.[120. Eye surgery.[113] Small doses of muscle relaxant may enhance akinesia. 5. Practices appear to vary widely among different countries.

[140] Postoperative cognitive dysfunction (POCD) in the elderly patient remains an unsolved problem after GA for major surgery and is a predictive factor for mortality.[141] Both anaesthesia duration and the technique used for postoperative analgesia (particularly avoidance of RA. without enjoying widespread use. with sufficient space to allow free breathing. Controversy: General Anaesthesia versus RA Anterior segment ophthalmic surgery is the only human surgical procedure that has no detectable impact on patient survival. Therefore.137] Continuous infusion of dexmedetomedine or midazolam has also been proposed.[138] To avoid excessive sedation. continuous epidural or peripheral nerve blocks) may play a role in increasing POCD.139] 6. Anxiety and residual pain occur relatively frequently during eye surgery under local anaesthesia.g. patients’ age was greater in the RA group. were not able to show any difference in short-term mortality and morbidity between GA and RA in elderly patients (age >90 years).[5] This is an argument for avoiding GA for cataract surgery. Most cataract surgeries are performed under RA.e. deafness.[123] There is a lack of well conducted prospective large studies comparing GA and RA for cataract surgery.[137. in the context of the very large amount of cataract surgery performed each year.[134] Even if their incidence is low. given the underlying co-morbidities in many patients. Patient immobility is required during surgery. Intraoperative sedation can be used to limit anxiety and pain. possibly because physicians more frequently chose elderly and disabled patients. Quigley was not able to demonstrate any difference in mortality rate between GA and RA. some physicians advise against any intraoperative monitoring or monitored anaesthesia care.[132] Because perioperative systemic adverse events of supporting therapies are so rare that their incidence cannot be measured. which are titrated before the patient is draped. the ability to perform resuscitation is essential. heavy sedation has been associated with an increase in complications such as restlessness or hypoxia. adverse events are possible. pulse oximetry and automated noninvasive blood pressure measurement.[125] However.[122] Excessive sedation can be avoided by cautious use of sedatives (if needed). Neurological diseases and psychiatric disorders (e.[121] However.[133] However. as in French practice. i. Only Glantz et al. 27 (1) . trying to impose use of RA in all cases is probably pointless. Although this assumption seems logical for many. In the authors’ opinion. Light planes of GA may lead to eye divergency with subsequent eccentric eye position and impaired surgical access to the globe. Various British guidelines are less strict and recommend only continuous monitoring of ventilation and circulation by clinical observation and pulse oximetry. in addition to or instead of premedication. Intravascular access is clearly required. Additional fresh air flow is preferable to oxygen as a means of improving ventilation in a confined atmosphere. In a 20-year noncomparative survey. ª 2010 Adis Data Information BV. ECG. observed fewer myocardial ischaemic events after RA than after GA. i. and has even been associated with increased mortality. Parkinson’s disease or mental confusion) may impair patient cooperation and the ability to lie Drugs Aging 2010.e. it is based on very weak evidence or none at all. However. Hoskings et al. in this series. the patient should be positioned as comfortably as possible. which typically is totally painless postoperatively. intraoperative monitoring should include basic monitoring. The most frequently used drugs are small doses of propofol or remifentanil infusion. and the presence of drapes over the head may increase anxiety. being convinced that RA is safer for fragile patients. the absolute value of such events is probably significant.Anaesthesia for Cataract Surgery 33 subsequent mental confusion have been claimed to have caused patient movement during performance of RA with subsequent eyeball perforation.135] In patients with life-threatening complications.[136. patient-controlled or patienttarget-controlled infusion have been proposed. All rights reserved. and the same guidelines recommend that ‘‘there should always be at least one person present who has Advanced Life Support (ALS) training or equivalent’’.[15. a choice based on the assumption that this is less hazardous to elderly patients. again without achieving great popularity.[124] Similarly.

7. Roberts TV. Johnston RL. Over the last 20 years. References 1. The authors acknowledge Serge Albertini for his English editing of the article. appears to be the technique of choice. Cuvillon P. Johnston RL. Stupp T. STB. Future of Cataract Anaesthesia Cataract anaesthesia in the elderly is achieved mainly by RA or TA. Brougere A. Anaesthesia in the older patient. Eye 2009. 1991: 95-105 8. New York: Oxford University Press. Sharwood PL. The Cataract National Dataset electronic multicentre audit of 55 567 operations: risk stratification for posterior capsule rupture and vitreous loss. Hassouna I. Similarly. Narendran N. RBA is being progressively replaced by PBA. which require two-hand experience. in the absence of any airway access. sleeping and snoring. All rights reserved. Research should continue the quest for the ‘Holy Grail’ that will provide analgesia (PKE) and total akinesia when required (other surgical techniques). and further efforts should be made to make it – including the recombinant form – more available. et al. Curr Opin Clin Nutr Metab Care 2005. The Cataract National Dataset electronic multicentre audit of 55 567 operations: anaesthetic techniques and complications. is not available in many countries. Acknowledgements No sources of funding were used to assist in the preparation of this review. most anaesthesiologists are unfamiliar with cannula techniques. STB appears to be the gold standard. Mavrakanas NA. 27 (1) . Leaming DV. 23: 50-5 4. or to respiratory depression. Br J Ophthalmol. However. Sedation is frequently presented as a solution but excessive sedation may lead to restlessness. Correct teaching and training are required to prevent complications. Cohendy R. 8: 17-21 6. 30: 892-900 2. rheumatic pain or prostate adenoma dysuria may prevent the patient from lying immobile under RA. Adverse medical events associated with cataract surgery performed under Drugs Aging 2010. although useful. The fourth New Zealand cataract and refractive surgery survey: 2007. The required time of immobility is around 15 minutes. UK EPR User Group. supine quietly during surgery under RA. El-Hindy N. place for TA or low-volume STB. Needle block carries a low but real risk of complications. Jaycock P. Pick ZS. The requirement for very deep block with total akinesia has greatly decreased with the use of PKE for cataract surgery. In: Mostafa SM. Use of a surgical approach to gain access to sub-Tenon’s space avoids needle block. GA might be considered as a first choice.. performed either by the needle technique or using a surgical approach. Schutz JS. mainly due to needle misplacement. which. The main patient risk factor for inadvertent globe perforation is the presence of a myopic staphyloma. Practice styles and preferences of ASCRS members: 2003 survey. may be catastrophic. The AstraZeneca. et al. 36: 604-19 3. Because of safety considerations. depending on the surgeon’s skill and the characteristics of the cataract. anaesthesiologists have played an increasing role in performing eye blocks. Conclusion Cataract surgery is the most frequent surgical procedure requiring anaesthesia in developed countries. Elder MJ. France. J Cataract Refract Surg 2004. Clin Experiment Ophthalmol 2008. Specific local anaesthetic jelly mixtures for TA should be developed. Soppart K. et al. and Air Liquide Sante other authors have no conflicts of interest that are directly relevant to the content of this review. Kelly JM. expanding the ª 2010 Adis Data Information BV. TA prevents anaesthesia complications but some concerns may still be expressed over surgical difficulties caused by the absence of akinesia. 8. Leaming DV. In terms of efficacy. What degree of anaesthesia is necessary for intraocular surgery? It depends on whether surgery is ‘‘open’’ or ‘‘closed’’. In press 5. Systemic adverse events: a comparison between topical and peribulbar anaesthesia in cataract surgery. Eye 2009.34 Nouvellon et al. rather than RA combined with hazardous heavy sedation. 221: 320-5 9. Hyaluronidase. When deep anaesthesia is required. Ophthalmologica 2007. Thomas D. enabling procedures to be carried out in absolute safety. In cases where intraoperative immobility cannot be guaranteed. Jaycock P. Preoperative assessment and medication. 23: 31-7 7. needle techniques will probably continue to lose popularity in the future. but does not totally prevent complications. editor. Anaesthesia for ophthalmic surgery. but may be longer. France. Jacques Ripart has acted as a consultant to ´ .

57: 428-33 Nicoll JMV. Papworth DP. Taboada J. Vohra SB. 14. 107: 1751-3 42. Respiratory arrest following peribulbar anesthesia for cataract surgery: case report and review of the literature. 25: 1237-44 Duker JS. A comparison of peribulbar and retrobulbar anesthesia ª 2010 Adis Data Information BV. 18. Nikki P. Curr Drug Targets. Zangrillo A.org/pdf/aapconfexp. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. Anesthesiology 2001. Cataract surgery under systemic anticoagulant therapy with coumarin. Navon S. Werner L. Sub-Tenon’s anesthesia with aspirin. Ophthalmic Surg Lasers 1997. 31: 991-6 Pandey SK.rcoa. et al. 2001 [online]. 27 (1) . 8: 184-7 41. 28: 998-1001 38. Eur J Ophthalmol 1998. Reverse arterial blood flow as a pathway for central nervous system toxic responses following injection of local anesthetics. Central nervous system complication after 6000 retrobulbar blocks. Hamilton RC. 12: 677-9 ´ brale transitoire provoque ´e 33. de La Coussaye JE. 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