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Volume 15 | Issue 1 | January-March 2018

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JOURNAL OF CLINICAL SCIENCES
• VOLUME 15
•
ISSUE 1
•
JANUARY-MARCH 2017

ORIGINAL RESEARCH REPORTS

•
Pages 1-***

Regional anesthesia for small incision

cataract surgery: Comparison of subtenon
and peribulbar block.............................................1

Perception of spirituality, spiritual care, and

barriers to the provision of spiritual
care among undergraduate nurses in the
University of Lagos, Nigeria................................8

Undergraduate dental students' perception,

educational satisfaction, and attitude
regarding the use of rubber dam.......................13

Hypoxic-ischemic encephalopathy and the

Apgar scoring system: The experience in a
resource-limited setting.....................................18

Pattern of von Willebrand factor in

hypertensive patients in Lagos, Nigeria...........22

. .
NI
U

VE O
RSIT AG
IN Y OF L
DE H
ED AND IN TRUT

Official Publication of Faculty of Clinical Sciences,

College of Medicine, University of Lagos, Nigeria
 ORIGINAL RESEARCH REPORT

Regional anesthesia for small incision cataract surgery:

Comparison of subtenon and peribulbar block
Oyebola Olubodun Adekola, Olufisayo Temitayo Aribaba, Kareem Musa, John Olutola Olatosi,
Gabriel Kolawole Asiyanbi1, Adekunle Rotimi‑Samuel, Adeola Onakoya, Folasade B. Akinsola

Department of Anaesthesia and Ophthalmology, College of Medicine, University of Lagos and Lagos University Teaching Hospital,
1
Department of Anaesthesia, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria

Address for correspondence:
Dr. Oyebola Olubodun Adekola,
Department of Anaesthesia, College
of Medicine, University of Lagos
and Lagos University Teaching
Hospital, P.M.B 12003, Surulere,
Lagos, Nigeria.
E‑mail: oyebolaadekola@yahoo.
com, ooadekola@unilag.edu.ng
ABSTRACT
Background and Objective: The recent trend in cataract surgery is the use of regional
ophthalmic nerve blocks or topical anesthesia. We determined and compared the effect of
peribulbar and subtenon block on pain and patients’ satisfaction, following small incision
cataract surgery (SICS). Methods: This was age‑sex‑matched comparative study involving
462 ASA I‑III patients, aged 18 years and above scheduled for SICS. They were assigned to
receive either peribulbar block (Group P) or subtenon (Group ST). The pain score and patients’
satisfaction with the anesthetic experiences were recorded by a study‑masked anesthesiologist
during surgery and postoperatively at 30 min and 1, 2, 4, and 24 h. Results: The median numeric
rating score was significantly lower in the subtenon group than the peribulbar group: During
surgery, Group ST 1 (1) versus group P 1.5 (2.25), P < 0.001. At 30 min after surgery, Group ST
0 (1) versus Group P 1 (2.5) versus P < 0.001, and at 1 h after surgery, Group ST 0 (1) versus
group P 1 (2), P = 0.002. Ten patients had akinesia in the peribulbar group compared with one
in the subtenon group. Chemosis was significantly higher in the subtenon group 10 (3.2%)
than in the peribulbar group 0 (0%), P = 0.035. Similarly, a significant difference was not
with subconjuctival hemorrhage; subtenon 14 (4.5%) versus peribulbar 2 (1.3%), P = 0.105.
Conclusion: The use of subtenon block resulted in lower pain scores and higher patient’s
satisfaction than peribulbar block. However, subconjuctival hemorrhage and chemosis were
more common with subtenon block.
Key words: Complications, pain, peribulbar block, small incision cataract surgery, subtenon
block

INTRODUCTION ophthalmic, oculomotor, abducent, and trochlear nerves) as

Cataract surgery is the most common surgical procedure in
ophthalmology and is known to be the most cost‑effective
of all surgical procedures.[1] Cataract surgery has been
reported to have a good safety profile.[1,2] Eye surgeries
had been performed with little or no anesthesia for almost
a 1000 years until 1884 when cocaine hydrochloride was
discovered by Carl Koller.[3]
However, the global trend for anesthesia during cataract
surgery has shifted from general anesthesia, sedation, and
hospitalization to regional ophthalmic block (ciliary ganglion,
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well as topical anesthesia with day case management due
to the improvement in cataract surgical techniques. This
improvement in cataract surgical services is predicated on
reduced surgical wound size and self‑sealing architecture
as well as better intraocular lenses design, less tissue
manipulation, and modern instrumentation.[1,4‑6]
The operative technique includes extracapsular cataract
extraction, small incision cataract surgery (SICS),
phacoemulsification, and phacolaser methods.[1,4‑6]
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Adekola OO, Aribaba OT, Musa K,

DOI: Olatosi JO, Asiyanbi GK, Rotimi-Samuel A, et al. Regional anesthesia
10.4103/jcls.jcls_5_17
for small incision cataract surgery: Comparison of subtenon and
peribulbar block. J Clin Sci 2018;15:1-7.

© 2018 JOURNAL OF CLINICAL SCIENCES | PUBLISHED BY WOLTERS KLUWER - MEDKNOW Page | 1

 Adekola, et al.: The effect of subtenon and peribulbar block on pain during cataract surgery
The choice of regional block varies from retrobulbar or
peribulbar block to subtenon, subconjunctiva, intracameral,
topical anesthesia, or a combination of any of the blocks.[2‑5]
The needle tip remains outside the muscle cone with
peribulbar (extraconal) block technique. [7] The local
anesthetic agent is injected under the Tenon’s capsule
with subtenon space block.[7] Other nomenclature for
subtenon block includes parabulbar, pinpoint, or medial
episcleral block.[8] The use of subtenon block is on the
increase because of its simplicity and avoidance of needle
insertion into the orbit associated with reported low
complication rates, high patient satisfaction coupled
with adequate anesthesia.[7,9] Each technique has its own
risk/benefit profile and proven to be highly successful if
performed correctly. The choice of the technique should
be individualized based on specific needs of the patient,
nature and extent of eye surgery, and anesthesiologist’s
and surgeon’s preferences and skill.[3]
The incidence of intraoperative and postoperative pain
after regional ophthalmic block has been reported to be
13% and 37%, respectively.[5] The presence of pain during
and after cataract surgery has been associated with lower
patient’s satisfaction with their anesthesia.[5]
The incidence of postoperative nausea or vomiting
after regional ophthalmic block was 4.1%. [10] The
complications which may follow ophthalmic block have
been divided into sight and life‑threatening events.[10]
Such complications include corneal abrasion, chemosis,
subconjunctival hemorrhage, vitreous hemorrhage,
retrobulbar hemorrhage, globe penetration, and
perforation.[10,11] Others are extraocular muscle damage,
inadvertent intravenous or intrathecal injection, local
anesthetic agent toxicity, brainstem anesthesia, and
cardiorespiratory arrest.[9,10] Subconjunctival hemorrhage
and chemosis are not uncommon after subtenon block with
an incidence of 7%–100%.[8,11] In 2011, subtenon block was
introduced at our institution in accordance with approved
standard of care for ophthalmic regional anesthesia.[7,8] In
an attempt to improve the quality of ophthalmic anesthesia
and outcome following cataract surgery, we investigated
the effect of peribulbar and subtenon block on pain and
patients’ satisfaction following SICS.
Setting
The study was conducted at the Guinness Eye Centre of
the Lagos University Teaching Hospital, a 760‑bed hospital
located at Idi‑Araba, Lagos
PATIENTS AND METHODS
The study spanned from November 2012 to October 2014.
The Institutional Human Research Ethics Committee
approval and individual participant informed consent
were obtained. The American Society of Anesthesiologist
Page | 2 JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 1, January-March 2018
Physical status (ASA) I‑III patients aged 18 years and above
scheduled for SICS were recruited. The exclusion criteria
included patients with known sensitivity to lidocaine,
previous eye surgery, eye injury or inflammation in the eye
of interest, pupillary size less than 5 mm intraoperatively;
failure to understand the numeric rating scale, patients
who had planned or unplanned extracapsular cataract
extraction, and those that declined to participate at any time.
The preoperative review was done 24 h before surgery by
both the ophthalmologist and anesthetist. During the visit,
detailed information on the research protocol, consent form
administration, pain assessment score using numeric rating
scale, comfort score, and satisfaction score were explained
to each participant. Routine investigations included packed
cell volume, electrolytes, urea, and creatinine. Clinically
controlled hypertensive and diabetic patients received
their medication on the morning of surgery. For diabetic
patients, the fasting blood sugar level was measured on the
morning of surgery with OneTouch Glucometer (Life Scan,
Inc. 2005 Milpitas, California USA), and patients with
glucose level within the normal range (3.5–5.6 mmol/L)
were recruited. Consecutive patients scheduled for SICS
were allocated into the peribulbar (P) and subtenon (ST)
block groups, respectively, depending on the patients need
and ophthalmologist evaluation.
On arrival in the operating room, multiparameter patients
monitor (Datex Ohmeda Cardiocap 710, Metropolitan
Medical Services of NC. Inc., 15 Westside Drive, Asheville
North Carolina, USA) was attached. Oxygen saturation,
electrocardiogram, and noninvasive blood pressure were
monitored continuously every 10 min till the end of surgery.
Intravenous access was established with appropriate‑sized
cannula. All patients received 0.9% normal saline as per the
standard protocol. All ophthalmic nerve block (subtenon or
peribulbar anesthesia) was performed under strict asepsis
by consultant ophthalmologists with at least 3 years’
experience in SICS and regional block.
Technique of peribulbar block
The eyelid and periocular areas of the eye to be operated
upon were cleaned with 5% povidone iodine after which
the patient was instructed to look straight up to put the
eye in the primary position of gaze. Thereafter, the inferior
orbital rim was palpated and a 23‑gauge, 1/4 long needle
attached to a 5 ml syringe containing anesthetic solution
was inserted through the eyelid skin at the junction of the
medial two‑third and the lateral one‑third of the inferior
orbital rim with the bevel of the needle facing up. The
needle was advanced parallel to the floor of the orbit
and tangential to the eyeball until the hub touched the
skin. Thereafter, 4 ml of 2% lidocaine mixed with 1:1,000
adrenaline and 75 IU/ml hyaluronidase was injected after
ensuring a negative aspiration for blood. After the injection,
digital compression of the eyeball was done for 10 min to
aid the dispersion of the anesthetic agent during which
 Adekola, et al.: The effect of subtenon and peribulbar block on pain during cataract surgery
akinesia of the eyeball was assessed every 2 min. Ocular
compression was discontinued and patient released for
surgery if significant akinesia was achieved before 10 min.
However, if significant akinesia was not achieved after
10 min of injection, 2 ml of supplemental injection was
given between the caruncle and the medial canthus to a
depth of 20 mm after which digital ocular compression
was done for another 5 min.[11,12]
Akinesia was assessed by one of the anesthetists who have
previously been trained to measure the extent of ocular
motility in the superior, inferior, nasal, and temporal
quadrants with the aid of a transparent ruler using the
limbus of the respective quadrant as a landmark. Movement
of ≤2 mm or no movement from the primary position of gaze
in three or more quadrants was regarded as “significant
akinesia” while larger ocular movement (>2 mm) in two or
more quadrants was regarded as “no significant akinesia”
necessitating supplemental injection.[11,12]
Technique for subtenon space block
Two drops of tetracaine (0.5%) eye drops were instilled
into the eye to be operated upon after which the patient was
asked to close the eye for 3 min. The eyelid and periocular
areas were then cleaned with 5% povidone iodine after
which a wire speculum was inserted to part the eyelids and
ensure a good ocular exposure. Thereafter, the patient was
asked to look superotemporally to expose the inferonasal
quadrant. The inferonasal conjunctiva and tenon capsule
were picked up with a Moorefield forceps and a small
incision was made 5 mm from the limbus with a Westcott
scissors. A blunt dissection of the tenon capsule was done
with the scissors to expose the sclera and a 19‑gauge,
2.54‑cm long and curved subtenon cannula with a blunt
tip was inserted following the curvature of the globe. Four
milliliters of 2% lidocaine mixed with 1:1,000 adrenaline
and 75 IU/ml hyaluronidase was injected. After the
injection, digital compression of the eyeball and assessment
of akinesia was done as described above. Two milliliters of
supplemental injection was given through the same route
in patients with “no significant akinesia” after 10 min of
the initial injection. The study outcome was assessed by
the anesthetist a coinvestigator, who was not involved with
the regional block or surgery.[8,11,12]
Pain assessment
The pain and outcome were assessed by one of the
anesthesiologists. A 10‑point numeric rating scale
(0–10) was used for pain assessment during surgery
(during subconjunctival injection of antibiotics and steroid)
and at specific intervals in the postoperative period
(30 min and 1, 2, 4, and 24 h). If the patient complained
of pain more than once during or after surgery, only the
most severe was taken into consideration to determine the
severity of pain. No pain was described as 0, mild pain <5,
and moderate‑to‑severe postoperative pain  (score  ≥5).
JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 1, January-March 2018
Patients who experienced moderate‑to‑severe postoperative
pain (score ≥5) received oral paracetamol 1000 mg; if the
pain persisted thereafter, oral diclofenac 100 mg was
administered.
The patients’ comfort and satisfaction score of the regional
anesthetic technique were documented immediately after
surgery.
The primary outcome measure was the occurrence
and severity of intraoperative and postoperative pain
following SICS. The secondary outcome measures were the
occurrence of anesthetic complications and the degree of
patients’ satisfaction following SICS.
For this study, the following definitions were
used
Postoperative complications included postoperative pain,
postoperative nausea and vomiting, subconjunctival
hemorrhage and chemosis.
Sight‑threatening hemorrhage defined as hyphema,
vitreous hemorrhage, subterinal hemorrhage, and
moderate‑to‑severe choroidal hemorrhage.[13]
Patient comfort score
1. Complete absence of sensation in the operated eye
2. Sensation of the eye only such as irritation, but with no
discomfort present
3. Mild discomfort, but with the patient declining any offer
of further analgesia or with no obvious clinical need for
such further intervention
4. Patient expresses wish for additional analgesia or
exhibits an obvious clinical need for such intervention
such as a state of distress related to pain on further
questioning or requested for pain relief.[14,15]
Patient satisfaction with anesthesia
score (verbal)
1. Very dissatisfied
2. Slightly dissatisfied
3. Neither satisfied nor dissatisfied
4. Satisfied.[15]
Statistical analysis
Sample size calculation
Using a previous study [9] with difference in the
peribulbar (Group P) and subtenon (Group ST) proportion
of 20% suggesting no painful episode of 40% and 60%,
respectively, with assumed attrition rate of 15% and ratio
1:2, 156 subjects (Group P) and 312 subjects (Group ST)
to be able to reject the null hypothesis that the population
proportion of Group P and Group ST was equal with
probability (power) 90% and significance level of 0.05.
Statistical analysis was performed with the IBM SPSS
software version 22. Data were presented as mean ± SD,
Page | 3
 Adekola, et al.: The effect of subtenon and peribulbar block on pain during cataract surgery

median (IQR), frequency, and percentile, and the comparison Table 1: Patients characteristics
between the groups was determined with the students’ Variables Mean±SD P
independent t‑test for continuous and Chi‑Square for Peribulbar Subtenon
categorical variables. A P ≤ 0.05 was considered significant. (n=150) (n=312)
Age 61.03±14.50 62.57±15.08 0.30
RESULTS Male:female ratio (frequency) 1.2:1 1.2:1 0.55
Co‑existing medical disease (%) 41.3 46.5 0.30
A total of 462 patients were studied; 11 (2.38%) out of Weight 70.44±10.99 70.87±14.10 0.88
462 patients had bilateral cataract extraction performed, Height 1.82±0.067 1.72±0.67 0.65
while 226 (48.92%) and 225 (48.70%) were operated on the Body mass index 26.13±4.48 28.06±6.48 0.39
Duration of surgery (min) 28.25±17.16 26.98±16.07 0.66
right and left eye, respectively. The M:F ratio in Group P was
Dose of LAA (ml) 4.16±0.54 4.01±0.16 <0.001
1.2:1 and Group ST (1.2:1), P = 0.30. Among 207 (44.81%) Onset of pain (min) 17.50±14.43 74.92±64.27 <0.001
patients with systemic comorbidities; hypertension was the Duration of pain (min)±SEM 22.81±4.51 16.14±2.56 0.24
most common disease in 149 patients (71.98%), followed by Time of rescue analgesia 48.58±14.69 65.20±43.69 <0001
hypertension and diabetes in 27 (13.04%) patients [Table 1]. Data represents mean±SD, frequency, and proportion, P<0.05 is considered
significant. SD=Standard deviation, LAA=Local anesthetic agent, SEM=Standard
The mean duration of surgery was comparable; error of mean

Group P (28.25 ± 17.16) minutes versus

Group ST (26.98 ± 16.07) minutes, P = 0.66. The incidence Table 2: Distribution of numeric rating scale
of intraoperative pain in the two groups was comparable; between peribulbar and subtenon groups
Group P (8.67%) versus Group ST (7.05%), P = 0.66. Time of pain Groups NRS (%) df P
A similar observation was made with postoperative pain after surgery 0 1 2 3 4 5 6 7 8 9 10
Group P (53.3%) versus Group ST (47.1%), P = 0.308. 30 min P 54.7 0 20.7 10 4.7 5.3 1.3 0.7 2 0.7 0.7 6 <0.001
However, the onset of postoperative pain was significantly S 73.4 0 14.1 6.7 0.9 3.5 1.3 0 0 0 0
shorter in peribulbar group (17.50 ± 14.43) minutes than 1h P 68.7 0 15.3 6.7 2 6.7 0.7 0 0 0 0 9 0.021
in the subtenon group (74.92 ± 64.27), P < 0.001 [Table 1]. S 75.6 0 15.1 5.5 0.9 0.9 0.3 0 0 0 0
2h P 77.2 0 14.8 4.7 0.7 2.7 0 0 0 0 0 5 0.75
The median numeric rating scale (NRS) for pain was S 81.3 0 13.1 4.2 0.3 1 0 0 0 0 0
significantly higher during surgery, at 30 min, and 1 h after 4h P 82 0 10.7 3.3 2 1.3 0 0 0.7 0 0 6 0.12
surgery in the peribulbar group than the subtenon group, S 87.2 0 9.9 1.3 1 0.3 0 0 0 0 0
P < 0.05. However, at 2, 4, and 24 h, there was no significant 24 h P 67.4 0.7 2.7 0 0.7 0 0 0 0 0 0 6 0.14
S 57.6 0 3.6 1 0.3 0 0 0 0 0 0
difference in the pain score [Table 2].
Data represents proportion of patients with NRS from 0 to 10, degree of freedom,
P=0.05 was considered significant. P=Peribulbar anesthesia, S=Subtenon anesthesia,
A higher number of patients in the peribulbar group 3 (2%) NRS=Numerical rating scale
than the subtenon group 0 (0%), P = 0.034, required oral
diclofenac in addition to paracetamol [Table 3].
Table 3: The distribution of pain and rescue
Concerning patients comfort, more patients in subtenon analgesia
group had complete absence of pain (93.2%) than variables Frequency (%) P
peribulbar group (87.97), P < 0.001. 0.32% in the subtenon Peribulbar (n=150) Subtenon (n=312)
group required additional anesthesia compared with 7.33% Period of pain
in peribulbar group [Table 4]. However, more patients in Intraoperative 13 (8.67) 22 (7.05) 0.32
peribulbar group (98%) were satisfied with their block Postoperative 80 (53.33) 147 (47.12) 0.30
than (96.2%) in subtenon group, P < 0.001, Table 4. Rescue analgesia
Rescue paracetamol 14 (9.33) 19 (6.01) 0.32
Concerning the extent of akinesia more patients in Rescue diclofenac 3 (2) 0 0.034*
*Fischer exact. Data represents frequency and P values of the quality of regional
the peribulbar group 10 (6.67%) required additional ophthalmic anesthesia
anesthesia than the subtenon group 1 (0.32%), P < 0.001.
Subconjuctiva hemorrhage and chemosis were more
postoperative pain during cataract surgery than peribulbar
frequent with subtenon block; though no patient had
block. This is because more patients in the subtenon group
retrobulbar hemorrhage, globe perforation and globe
penetration in our cohort [Table 5]. compared with the peribulbar group had a median numeric
rating scale (NRS) less than 5 for pain intraoperatively.
Likewise, the maximum NRS was lower in the former
DISCUSSION
than the latter group. Our observation is in keeping with
In the present study, subtenon block was found to be previous reports that the pain score for subtenon block is
more effective in the management of intraoperative and usually low, except for occasional outliers.[8] The quality of

Page | 4 JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 1, January-March 2018

 Adekola, et al.: The effect of subtenon and peribulbar block on pain during cataract surgery

Table 4: Comfort score and satisfaction level compared to retrobulbar and topical groups. [10] The
Variables Frequency (%) P superior effect of subtenon block on quality of anesthesia,
Peribulbar Subtenon
and analgesia was also illustrated when it was compared
(n=150) (n=312) with either retrobulbar,[3,8,10] topical block,[13] or peribulbar
Comfort level block,[11,12,17] This observation may suggest that subtenon
Complete absence of pain 87.97 93.2 <0.001 block provides better anesthesia and analgesia for cataract
Sensation of eye only, no discomfort 4.7 5.5 <0.001 surgery than peribulbar block.
Mild discomfort 0 1.3 <0.001
Additional anaesthesia 7.33 0.32 <0.001 The incidence of intraoperative and postoperative pain is
Satisfaction level comparable between the groups in our study. However,
Satisfied 98.0 96.15 <0.001 the proportion of patients with intraoperative pain
Slightly dissatisfied 0.7 2.55 <0.001 was lower in the subtenon (7.05%) group than in the
Very dissatisfied 1.3 0 <0.001 peribulbar (8.67%). In a similar study, 6 patients (7.9%)
Neither satisfied nor dissatisfied 0 1.3 <0.001 had moderate pain in the peribulbar group while only
Values are proportions, a P<0.05 is considered significant
2 patients (2.6%) experienced moderate pain in the
subtenon group.[12] The proportion of intraoperative pain
Table 5: The distribution of complications after is, however, lower than 13% reported during regional
regional block ophthalmic blocks. [4] Similarly, fewer patients in the
Frequency (%) P subtenon group (47.12%) experienced postoperative pain
Peribulbar Subtenon when compared with the peribulbar block (53.33%). This is
(n=150) (n=312) in agreement with a previous study, in which the proportion
Akinesia 10 (0.67) 1 (0.32) 0.32* of patients with postoperative pain was less with subtenon
NRS <5 114 (76) 262 (83.97) 0.08 block.[12] However, the frequency in the two groups was
NRS ≥5 14 (9.33) 19 (6.09) 0.21 higher than 35% reported for regional ophthalmic blocks
Additional LAA 11 (7.33) 1 (0.32) <0.001 in a similar study.[4] The heterogeneity in the incidence of
Complications 2 (1.33) 23 (7.37) 0.007*
pain may not be unrelated to differences in patients’ cohort,
Orbital
pain assessment, choice of local anaesthetic agent and
Chemosis 0 10 (3.21) 0.035*
Conjunctivae Hemorrhage 2 (1.33) 14 (4.49) 0.01*
volume. The use of rescue paracetamol and diclofenac in
Others the postoperative period was commoner with peribulbar
Nausea 2 (1.33) 0 0.04* block in our study.
Vomiting 2 (1.33) 2 (0.64) 0.68*
*Fischer exact, a P<0.05 is considered significant. Data represents frequency and On the contrary, Al‑Yousuf[18] observed that intraoperative
P values of the quality of regional ophthalmic anesthesia. NRS=Numerical rating pain perception was similar in both groups; however,
scale, LAA=Local anesthetic agent
the subtenon block reduced ocular movement during
surgery.[18] The author concluded that subtenon anesthesia
block was better with subtenon block than peribulbar block is more effective in terms of ocular movement than
in our study. This is because complete absence of sensation peribulbar anesthesia. Similarly, Mushtaq et al.[19] reported
in the operative eye was noted in more patients in the no significant difference in pain during and 4 h after surgery
subtenon block group compared with the peribulbar block between subtenon and peribulbar block. It is important
group. It was also observed that only one patient in the to note that the sample size in their studies was relatively
former compared with ten in the latter group did not have small, which may influence the observation, unlike in
significant akinesia after the first injection necessitating other studies with a larger population.[4,8] However, both
supplemental injection. A similar observation was made researchers[18,19] agreed that subtenon anesthesia is safe,
by Datti et  al.[16] in relation to pain score, however; the and as effective as peribulbar anesthesia and is more
occurrence of akinesia was comparable.[16] They observed comfortable to the patient at the time of administration.[18,19]
that there were more patients in the subtenon group who
developed subconjunctival hemorrhage and chemosis, The observed patient satisfaction level in our study was
unlike peribulbar group with higher number of ptosis.[16] lower with subtenon block compared with peribulbar
In addition, a lower volume of anesthetic agent and shorter block. This is contrary to previous documentations that
duration of surgery was required in subtenon block. They subtenon provides better patients’ satisfaction than
concluded that subtenon block is a better alternative to peribulbar block.[9‑11] This may be because, in our study,
peribulbar in manual SICS.[16] the level of satisfaction was conducted immediately after
the cataract extraction. In the subtenon block, 5.5% had
In a study that compared the quality of analgesia between painful sensation in the eye, and 1.3% had mild discomfort
topical, retrobulbar, and subtenon’s techniques. The compared with 4.7% and 0%, respectively, in the
authors observed that a higher proportion of patients in the peribulbar block group during the operation. This was in
subtenon’s group had complete intraoperative analgesia contrast to previous observations that subtenon provided

JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 1, January-March 2018 Page | 5

 Adekola, et al.: The effect of subtenon and peribulbar block on pain during cataract surgery
better patients satisfaction compared with peribulbar,
retrobulbar, and topical block.[9‑11] Another study that
subtenon’s blocks with retrobulbar block.[9] The authors
observed that over 68% of patients had no discomfort at
all during performance of the block and less than 1.5%
reported more than mild to moderate pain.[9]
The rate of subconjuctival hemorrhage and chemosis
was higher with subtenon block than peribulbar block;
nevertheless, the rates were lower than 10% in both
groups. Similar observation was documented by Iganga
et al.[12] although the proportions were slightly more than
40% for the subtenon’s group.
In a group of cardiac patients on warfarin who had cataract
surgery under peribulbar and subtenon technique,[13]
the frequency of hemorrhage was significantly higher
in the subtenon group than the peribulbar group. [13]
However, the proportions of patients with subconjuctival
hemorrhage was similar, and there was no sight threatening
hemorrhagic complications. Pain was significantly lower
in the subtenon’s group. A majority of the patients
reported satisfaction.[13] The surgeons, however admitted
a significantly higher satisfaction with peribulbar than
subtenon block.[13] The authors recommended the use of
peribulbar block in patients on anticoagulants since the
frequency of hemorrhage was less. The higher frequency
of hemorrhage in the latter study when compared to the
present study may be related to the use of anticoagulants
by the patients.
In the present study, no patient developed sight threatening
hemorrhage, globe penetration, or perforation. This was
similar to the observations made by other researchers.[12,13]
This is not surprising as it has previously been reported
that the complication following subtenon is usually minor,
which include pain upon injection, reflux of local anesthetic,
chemosis, and conjunctival hemorrhage with varying
incidence.[7] Our finding was in agreement with a study in
the United Kingdom, where it was noted that the incidence
of sight‑threatening complications was lower with subtenon
than the other blocks; subtenon block (0.6/10,000)
versus peribulbar (2.9 per 10,000) versus retrobulbar
techniques (4.5 per 10,000).[9] Another study reported a
60% reduction in the incidence of serious complications
with subtenon (12 per 10,000) compared to peribulbar
anesthesia (5/10,000).[17] However, minor complications
in the subtenon group such as chemosis (2.03%) and
subconjunctival hemorrhage (1.99%) were more common
than in the peribulbar group.[17] They concluded that
subtenon block is continuing to gain popularity and is now
the most popular technique of regional orbital anesthesia
in many centers. It also provided extremely good analgesia
and operating conditions, while avoiding the passage of
sharp needles into the orbit.[19] It has been reported that
the risk of serious complications with subtenon block is
very low, and studies have shown that their incidence is
Page | 6 JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 1, January-March 2018
much lower than with other techniques of ocular regional
anesthesia.[8]
The occurrence of postoperative nausea and vomiting is
low with either subtenon (nausea 0% and vomiting 1.3%)
or peribulbar (nausea 1.33% and vomiting 1.33%) in the
present study. This is the general trend with postoperative
nausea and vomiting after local ophthalmic blocks.[15]
This study is limited by the fact that the block was
performed by three different consultant ophthalmologists
whose competence was comparable with respect to the
peribulbar and subtenon block as well as SICS. In addition,
the study was not randomized which may have resulted in
selection bias.
CONCLUSION
The use of subtenon block resulted in lower intraoperative
and postoperative pain scores and higher patients’
comfort than peribulbar block. However, subconjuctival
hemorrhage and chemosis were more common with
subtenon block. We recommend the use of subtenon
block for SICS in low‑risk patients, while in patients on
anticoagulants, peribulbar block is recommended since
the frequency of hemorrhage was less. There will be need
for further randomized controlled study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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