British Journal of Anaesthesia 84 (1): 89–91 (2000)

Comparison of 1% ropivacaine with 0.75% bupivacaine and 2%

lidocaine for peribulbar anaesthesia
G. Nicholson*, B. Sutton and G. M. Hall

Department of Anaesthesia and Intensive Care Medicine, St George’s Hospital Medical School,
Cranmer Terrace, London SW17 0RE, UK
*Corresponding author

We have compared the efficacy of 1% ropivacaine with a mixture of 0.75% bupivacaine and
2% lidocaine for peribulbar anaesthesia in cataract surgery. We used the time to adequate
block for surgery, and ocular and eyelid movement scores at 8 min after block as clinical end-
points. Ninety patients were allocated randomly to receive 7–10 ml of a mixture of equal parts
of 0.75% bupivacaine and 2% lidocaine or an equal volume of 1% ropivacaine alone. Hyaluronidase
15 iu ml–1 was added to both solutions. There were no differences between groups in clinical
end-points. Median time at which the block was adequate to start surgery was 8 min
(interquartile range 4–10 min) in each group. Median eyelid movement scores were similar in
both groups, but the bupivacaine and lidocaine mixture produced a significantly decreased
ocular movement score at 2, 4 and 6 min (P⬍0.05). There was no difference between groups
in the incidence of minor complications. Based on clinical end-points, time to adequate block
for surgery and median ocular and eyelid movement scores at 8 min, 1% ropivacaine as the
sole agent for peribulbar anaesthesia was comparable with a mixture of 0.75% bupivacaine and
2% lidocaine.
Br J Anaesth 2000; 84: 89–91
Keywords: anaesthetics local, ropivacaine; anaesthetics local, bupivacaine; anaesthetics local,
lidocaine; anaesthetic techniques, regional, peribulbar
Accepted for publication: August 31, 1999

Regional anaesthesia with peribulbar block is the technique
of choice for most patients undergoing cataract surgery.1 A
mixture of bupivacaine and lidocaine is the most frequently
used local anaesthetic, lidocaine providing a rapid onset
and bupivacaine a long duration of action.2
Ropivacaine is a new aminoamide local anaesthetic agent
with a greater margin of safety than bupivacaine for
cardiotoxicity and central nervous system toxicity.3 4 We
have shown recently that 1% ropivacaine is an effective
alternative to 0.75% bupivacaine when used with 2%
lidocaine for peribulbar anaesthesia.5 We found that,
although ocular movement scores were not significantly
different between groups at 2, 4, 6 and 8 min, eyelid
movement scores were significantly less in the ropivacaine
group at 2, 6 and 8 min (P⬍0.05). The earliest time at
which the block was considered adequate to start surgery
was 8 min for each group.
However, if ropivacaine is used as a single agent for
peribulbar anaesthesia, onset of block may be delayed. In
this study, we have compared the rapidity of onset and
efficacy of peribulbar block produced with 1% ropivacaine
alone with the traditional mixture of equal volumes of
0.75% bupivacaine and 2% lidocaine; hyaluronidase was
added to both solutions. The major clinical end-points were
ocular and eyelid movement scores at 8 min, and time to
adequate block for surgery.
Methods and results
After obtaining approval from the Local Research Ethics
Committee and written informed consent, we studied 90
patients presenting for cataract surgery under local
anaesthesia. This study had a 95% chance of detecting a
statistically significant (P⬍0.05) difference of two points
for the sums of the ocular movement scores. Patients were
excluded if they were unwilling to take part, if there were
communication problems or if there was a history of
allergy to amide-type local anaesthetic agents. Patients were
allocated randomly to one of two groups using sealed
envelopes. Sealed unmarked envelopes that contained the
name of the anaesthetic to be administered were randomized
by shuffling. One group received a mixture of equal volumes
of 2% lidocaine and 0.75% bupivacaine, with hyaluronidase
15 iu ml–1, while the other group received an equivalent
volume of 1% ropivacaine to which hyaluronidase 15 iu
ml–1 was added. The anaesthetic solution was warmed to

© The Board of Management and Trustees of the British Journal of Anaesthesia 2000
 Nicholson et al.

body temperature using a fibrinotherm (Ernst Biegler Ges. Table 1 Median (interquartile range) ocular and eyelid movement scores and
number of patients who required supplementary anaesthesia or developed
mbh, Austria). complications in the two groups. *P⬍0.05 between groups
Patients were not fasted and did not receive any pre-
medication, perioperative sedation or supplementary Bupivacaine 0.75% and Ropivacaine 1%
2% lidocaine (n ⍧ 45) (n ⍧ 45)
oxygen. On arrival in the induction room, baseline eyelid
and globe movements were assessed. Topical anaesthesia Ocular movement scores
of the conjunctiva and cornea was achieved by administering 2 min 5 [3–7]* 7 [5–8]
4 min 3 [2–6]* 5 [3–7]
2–3 drops of 0.4% oxybuprocaine. Standard monitoring 6 min 2 [1–5]* 4 [2–6]
was started and i.v. access established. Peribulbar block 8 min 2 [0–4] 2 [1–5]
was carried out by one of two consultant anaesthetists via Eyelid movement scores
2 min 1 [1–2] 1 [1–2]
a single inferolateral, transcutaneous or transconjunctival 4 min 1 [0–2] 1 [0–2]
injection using a 25-gauge, 25-mm needle. After test aspira- 6 min 0 [0–2] 1 [0–2]
tion, 7–10 ml of the local anaesthetic mixture was injected 8 min 0 [0–1] 0 [0–1]
Supplementary anaesthesia 9 14
over 30–40 s. Different volumes of local anaesthetic were Complications
used depending on the degree of filling of the orbit observed Haematoma – 1
during injection and the rate of onset of ptosis. Manual Chemosis 7 6
Pain 11 13
compression and gentle massage of the eyeball were per-
formed after which a Visitec intraocular pressure reducer
inflated to 40 mm Hg was applied between scoring to
was 19:26 in the bupivacaine group and 15:30 in the
facilitate spread of the anaesthetic solution and to lower
ropivacaine group.
intraocular pressure. Patients were assessed for eyelid and
Median eyelid movement scores were not significantly
ocular movements at 2-min intervals using the scoring
different between groups at any time. Ocular movement
system of Brahma and colleagues.6 Scoring was carried
scores were significantly decreased in the bupivacaine group
out by a trained observer who was blinded to the local
compared with the ropivacaine group at 2 min (P⫽0.011),
anaesthetic used.
4 min (P⫽0.022) and 6 min (P⫽0.047), but there was no
Ocular movements were scored for each direction of
significant difference between groups at 8 min (P⫽0.13)
gaze in the superior, inferior, medial and lateral directions
(Table 1). Median time at which the block was considered
with a maximum score for each direction of three points
adequate to start surgery was 8 min (interquartile range
and a possible total maximum score of 12 points. Ocular
4–10 min) for each group.
and eyelid movements were assessed at 2, 4, 6, 8 and
Twenty patients in the bupivacaine group and 13 in the
10 min until the block was considered adequate for surgery
ropivacaine group had ocular movement scores 艋1 at 8 min.
(eyelid movement score⫽0 and ocular movement score
One patient in each group had an ocular movement score
艋2). If after 10 min block was inadequate, supplementary
of 12 at 8 min (total failure of the block). Fourteen patients
anaesthesia was provided with another injection of up to
in the ropivacaine group and nine in the bupivacaine group
5 ml of the test solution using the same technique. Time to
required supplementary analgesia, but surgery was delayed
adequate surgical anaesthesia was noted in addition to the
in only one patient in each group. Minor complications
need for supplementary anaesthesia. It was assumed that,
occurred in seven patients in each group: seven patients in
when motor block had been achieved, adequate sensory
the bupivacaine group and six in the ropivacaine group had
block was already present as this usually precedes motor
subconjunctival chemosis and one patient in the ropivacaine
block. Complications during or after injection were recorded
group developed a periorbital haematoma, which was small.
and patients were questioned specifically about pain during
All cases of chemosis had resolved by the start of surgery.
insertion of the block or during surgery.
Thirteen patients in the ropivacaine group complained of
The main outcome criteria were difference in median
slight pain during insertion of the initial block compared
ocular and eyelid movement scores at 8 min and time
with 11 patients in the bupivacaine group. None of the
needed to obtain adequate block to start surgery. Differences
differences was statistically significant.
between groups were analysed using the Wilcoxon rank
sum test. The number of patients who reached an ocular
movement score of 艋1, need for further injections, delay Comment
to the start of surgery and occurrence of complications were We have shown that 1% ropivacaine alone is an effective
compared using the chi-square or Fisher’s exact test, as alternative to 0.75% bupivacaine and 2% lidocaine for
appropriate. Statistical analysis was carried out using SPSS peribulbar anaesthesia. Although the bupivacaine and lido-
for Windows version 8. caine mixture resulted in significantly lower ocular move-
There were 45 patients in each group and all patient data ment scores at 2, 4 and 6 min, at 8 min both anaesthetic
were included in the statistical analysis. Mean age in the solutions provided similar anaesthesia. The faster onset in
bupivacaine group was 75 (range 51–92) yr and 73 (41– the bupivacaine and lidocaine group was probably the effect
98) yr in the ropivacaine group. The male:female ratio of lidocaine.

90
 Ropivacaine vs bupivacaine vs lidocaine for peribulbar anaesthesia
We were unable to assess the duration of motor block as
patients’ eyes were bandaged and covered after operation
and they were discharged home 1–2 h after surgery. If a
shorter duration of motor block occurs with ropivacaine,
this could be advantageous as prolonged paralysis from local
anaesthesia leaves the eye vulnerable to drying and trauma.7
Peribulbar anaesthesia requires relatively large volumes
of local anaesthetic and concerns have been expressed
about the potential for systemic toxicity. The incidence of
peribulbar blocks requiring supplementary anaesthesia has
been reported to be as high as 54%.8 Huha and colleagues
recently compared the clinical efficacy of 1% ropivacaine
alone with 0.75% bupivacaine and found no difference in
perioperative analgesia or duration of akinesia.9 Those
patients who received 1% ropivacaine had higher maximum
serum concentrations of local anaesthetic compared with
the group who received 0.75% bupivacaine. However, no
drug-related adverse effects were observed in either group.
Ropivacaine is less toxic to the myocardium and central
nervous system, which is a theoretical advantage in elderly
patients who frequently have co-existing cardiac disease.
Acknowledgement
We gratefully acknowledge the support of Astra Pharmaceuticals who
provided supplies of ropivacaine.
91
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