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Keywords: Many patients presenting for V-R surgery are elderly with a high incidence of associated medical
Vitreo-retinal surgery conditions. Thorough preoperative assessment is essential especially for those scheduled for general
Local anaesthesia
anaesthesia.
General anaesthesia
Patients on anticoagulants and antiplatelet drugs scheduled for V-R surgery should continue their
routine medication. However, where there are specific concerns, the anaesthetist, surgeon and patient
should discuss the risks and benefits of continuing their routine medication to agree an acceptable
approach.
Local anaesthetic techniques are now far more commonly used than general anaesthesia for V-R
surgery. Clinicians must recognize the limitations and contraindications of both approaches.
Whenever local anaesthetic techniques are used, attention to small details can make a huge difference
to patient comfort. This often entails meticulous patient positioning and clear lines of communication
between patient and the theatre team. Sometimes, sedative drugs are beneficial to patient care.
Careful patient monitoring is recommended during V-R surgery because of the darkened theatre
environment, the age and associated medical conditions of many of these patients, and the risk of
precipitating abnormal cardiac rhythms from drugs and the oculocardiac reflex.
Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction the operation can stimulate the oculocardiac reflex under GA and if
there is an inadequate local anaesthetic block. A non-absorbable
Vitreo-retinal (V-R) surgery has evolved rapidly over the last 30 silicone sponge or solid explant is sutured to the globe and some-
years allowing the surgical treatment of a wide variety of diseases times sub-retinal fluid (SRF) is drained. If SRF is not drained, the
affecting predominantly the posterior segment of the eye. intraocular pressure (IOP) rises as the sutures securing the explant
Approximately 18,000 retinal surgical procedures were performed are tightened to raise an indent inside the eye. If the IOP rises above
in England between 2005 and 2006 (Department of Health Hospital the perfusion pressure in the central retinal artery (about
Episode Statistics). There are essentially 2 types of operation; one 70 mm Hg), it will be occluded. The surgeon ensures perfusion of
that approaches the problem externally (the cryo-buckle proce- the central retinal artery (CRA) either by ocular massage or para-
dure), and the other, internally (vitrectomy). centesis but it is essential that the anaesthetist maintains a normal
blood pressure so that the surgeon can rely on the perfusion
2. Scope of surgery and implications pressure in the CRA present at the end of the operation.
This operation has been used for more than 50 years for the A vitrectomy operation involves an internal approach to diseases
treatment of retinal detachment and may be undertaken under of the vitreous or retina. The operation is usually done under LA
local (LA) or general anaesthesia (GA). nowadays. Generally there is no traction on the extraocular muscles
The operation involves observing with the indirect ophthal- and therefore painful pulling on the globe does not occur. Three tiny
moscope to locate retinal holes and treating them externally with holes are made in the sclera so that instruments can enter the eye
cryotherapy. To enable easy movement of the globe, traction through the pars plana without damaging intraocular structures. A
sutures are placed round the recti muscles. Pulling on these during wide angle indirect viewing system is attached to the operating
microscope. The surgeon can then examine and treat the retina
* Corresponding author. Tel.: þ44 121 507 4343; fax: þ44 121 507 4349. directly so as to manage retinal detachment, severe diabetic reti-
E-mail address: k-l.kong@swbh.nhs.uk (K.L. Kong). nopathy and a variety of macular diseases such as macular holes and
0953-7112/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cacc.2009.11.008
K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179 175
The operation frequently involves the use of agents such as air, Absolute Patient refusal
airegas mixtures and silicone oils to tamponade the retina. Gases True allergy to local anaesthetic
used include air, sulphahexafluoride (SF6) and perfluoropropane Orbital infection
Inability of patient to cooperate with theatre staff (dementia, children
(C3F8). Sometimes these gases are used neat, in which case and those with learning disabilities)
expansion occurs slowly within the eye over 24 h to twice (SF6) and Inability to lie still (tremors, epilepsy, dystonic movements)
four times (C3F8) their volume. Often they are diluted with air in
Relative Inability to lie flat (cardiac or respiratory disease)
non-expansile concentrations to prolong the presence of an air Intractable cough
bubble in the eye. Patients with communication difficulties (profound deafness,
language difficulties)
2.3. Urgency of operation Prolonged surgery (greater than 2 h)
Claustrophobia
Previous surgery in the same eye (scleral buckling, excision of orbital
V-R surgery is required urgently in those patients whose macula tumours)
is still attached at presentation (macular-on retinal detachment) Deep set eyes
and in whom sub-retinal fluid is likely to extend rapidly, e.g., upper Nystagmus
Operations on the only one sighted or partially sighted eye
bullous retinal detachments. This is because, once the macula
Young patients
detaches, the chances of getting a good visual outcome are much
reduced. On the other hand, once the macular has detached, the
outcomes are similar provided the operation is performed within
the next seven days.1 1. Cardiac disease e Patient's condition should be stabilized or
optimized prior to surgery. Routine cardiac drugs must be
2.4. Treatment to the contralateral eye continued throughout the perioperative period. Ideally, elec-
tive surgery is deferred for three to six months after
Rhegmatogenous retinal detachment is often associated with a myocardial infarction. Antibiotic prophylaxis is not necessary
areas of weakness in the contralateral eye that could predispose in patients with valvular heart lesions undergoing V-R surgery.
that eye to the same condition. Therefore surgeons always examine 2. Hypertension e Although common in the elderly population,
the good eye preoperatively. If areas of lattice degeneration or other ‘white coat hypertension’ should be excluded by multiple
predisposing lesions are found, then commonly laser treatment readings. Patients with severe hypertension (stage 3) defined
will be applied around these areas using the indirect ophthalmo- as a systolic blood pressure of >180 mm Hg and/or a diastolic
scope laser at the time of surgery on the affected eye. If the patient pressure of >110 mm Hg should be treated prior to elective
is under general anaesthesia, this prolongs the operation by 15 min surgery. They are at risk of dangerous hypertensive crises
or so, and has important implications if the first operated eye has causing intracranial haemorrhage, acute left ventricular failure,
a gas bubble in it (see later). life-threatening ventricular arrhythmias or renal failure.3
3. Chronic obstructive pulmonary disease (COPD) e LA is ideal for
3. Preoperative assessment and preparation these patients provided they are able to lie flat and still for the
duration of surgery. In theory, GA may provoke dangerous
Many presenting for V-R surgery are older patients with bronchospasm or lead to postoperative sputum retention, chest
a higher incidence of associated systemic disease. Complication infection and respiratory failure. Fortunately, V-R surgery does
rates associated with anaesthesia correlate with the number of not interfere with the mechanics of breathing and most V-R
associated disease conditions.2 patients can be safely managed under GA. Whenever possible,
the chest should be optimized prior to surgery using bron-
3.1. History and examination chodilators, steroids or antibiotics, and the patient is advised to
stop smoking where appropriate.
When a local anaesthetic is planned, history taking and physical 4. Diabetes mellitus e Diabetes mellitus is also common in
examination must focus on issues that might preclude such an patients presenting for V-R surgery. LA has the advantage of
anaesthetic approach (See Table 1). minimal disruption of meals, drug treatment and blood sugar
Features such as deep set eyes and nystagmus make a local control. When assessing these patients, careful attention must
anaesthetic technique more challenging. General anaesthesia may be paid to the potential cardiac, renal and neurological
be indicated when the proposed surgery is on the patient's only eye complications of the disease.
because local anaesthetic often renders the eye sightless due to 5. Current drug therapy e As patients presenting for V-R surgery
temporary effect on the optic nerve, and an anaesthetized eye is have a higher incidence of associated systemic disease,
prone to corneal ulceration. Some patients who have had previous a complete list of current medication must be documented,
cryo-buckling procedures may also be better treated under GA allowing essential drugs to be continued perioperatively and
principally because the spread of local anaesthetic agents around potential drug interactions to be avoided.
the globe is hindered by the scarring induced after previous
surgery. In addition the anatomy is altered which may predispose
to globe perforation. True allergy to local anaesthetic drugs is 3.2. Investigations
fortunately very rare and previous adverse reactions to local
anaesthetics are most commonly due to the effects of adrenaline or As far as ophthalmic patients are concerned, no routine
overdosage, or the result of vaso-vagal effects. screening tests have been shown to be helpful or to improve the
Careful preoperative assessment is necessary for V-R patients outcome. A large multicentre trial4 showed that routine preoper-
especially those scheduled for a general anaesthetic due to the ative blood tests and electrocardiogram in cataract patients did not
higher incidence of associated medical conditions. Issues that increase the safety of surgery. The Joint Colleges' Guidelines (2001)5
require specific consideration include the following: for local anaesthesia recommend that tests should only be
176 K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179
even if surgery had not been planned. However, it also recommends Patient benefits Less or no postoperative nausea and vomiting
that the blood sugar in diabetic patients should be controlled and Superior postoperative analgesia
the international normalized ratio (INR) checked in those patients Minimal interference with diabetic control as
patients do not need to be starved
on warfarin. We recommend further investigations in the V-R Minimal postoperative cognitive dysfunction
patient undergoing LA should be ordered only when specifically Faster recovery from anaesthesia and discharge from
indicated and when the results of such investigations will make hospital
a positive difference to the perioperative management of the Anaesthetic and surgical No cardiovascular or respiratory depression
patient. considerations Partial or complete blockade of the oculocardiac
When GA is considered, most eye units adopt recommendations reflex
published by NICE in 2003.6 However, it is essential that ophthal- Suitable for patients at risk of general anaesthesia
such as sickle cell disease, malignant hyperpyrexia,
mology units develop and implement guidelines to ensure atypical cholinesterase, porphyria
consistency of care and minimize any disruption to patient care. Patients who need to posture postoperatively can
commence immediately
3.3. Patients on anticoagulants and antiplatelet medications Resource benefits Faster list turnover
Faster postoperative rehabilitation in
Of special concern are those patients on anticoagulants and a predominantly day case service
antiplatelet medications. Many presenting for cataract and V-R Minimal equipment required
Cost savings
surgery are on aspirin, warfarin or clopidogrel. These medications
are prescribed to reduce the incidence of potentially life-threat-
ening thromboembolic events in patients with cardiovascular
disease. It is therefore desirable to continue these medications the circumstances where local anaesthesia is contraindicated or
during the perioperative period provided that they do not a general anaesthetic preferred, especially in younger patients and for
adversely affect the safety of anaesthesia and the success of surgery. more complex procedures. These are listed in Table 1.
No randomized controlled trial that specifically addresses the
risks and benefits of anticoagulants and antiplatelet drugs during
4.1. Local anaesthetic techniques
ophthalmic surgery has been undertaken. However, large obser-
vational studies in cataract surgery7,8 found that it was safe to
Subconjunctival and topical anaesthesia are unsuitable for V-R
continue with these agents during the perioperative period
surgery since they do not provide adequate analgesia and immo-
without a higher incidence of potentially sight-threatening local
bility of the eye. Dangers of retrobulbar anaesthesia are now widely
anaesthetic or operative haemorrhagic complications. Similarly,
appreciated and consequently it is seldom used. Both peribulbar
results from smaller observational studies on V-R surgery
and sub-Tenon's anaesthesia provide excellent operating condi-
patients9,10 also suggest that no change in on-going anticoagulants
tions for the range of V-R procedures commonly carried out and are
or antiplatelet drugs is necessary. Until evidence to the contrary is
the local anaesthetic techniques of choice. However, a more
available, it seems sensible to continue these drugs in V-R patients.
profound block than that used for cataract operations is required in
For those on warfarin, the Royal Colleges of Anaesthetists and
V-R surgery, particularly when buckling and retinopexy procedures
Ophthalmologists5 advise that the INR should be checked and this
are anticipated. Good akinesia is more important for certain V-R
should be within the recommended therapeutic ratio determined
procedures such as membrane peeling. Local anaesthesia
by the condition for which the patient is being anticoagulated.
comprising a 50/50 mixture of 2% lignocaine and 0.75% bupivacaine
Where there are any specific concerns (e.g., complicated surgery or
with hyalase is often used. Intraoperatively, the surgeon must be
only eye surgery), there should be a discussion between anaes-
prepared to top-up the anaesthetic with a sub-Tenon's injection,
thetist, surgeon and patient regarding the risks and benefits of
particularly in patients undergoing scleral buckling procedures or
continuing anticoagulants and antiplatelet drugs to agree an
when surgery is either unexpectedly difficult or prolonged.
acceptable approach.
In cataract surgery under LA, the biometry measurement of axial
length is routinely available, however, this is mostly not the case in
4. Choice of anaesthetic technique
V-R surgery. Axial length is useful in determining those highly
myopic eyes which would be best anaesthetized using either sub-
There has been a major change in practice from general to local
Tenon's technique or the medial canthal peribulbar approach.
anaesthesia for vitreo-retinal surgery over the last 10 years, and this
Anaesthetists providing local anaesthetic should therefore check
trend of LA for V-R surgery is similar to that for cataract surgery.
with the surgeon or patient the degree of myopia and modify their
Some reasons for this increase of LA in V-R surgery are shown in
approach accordingly.
Table 2. In practice, the choice of anaesthetic technique is largely
governed by the general health of the patient, and the preferences
of both the patient and surgeon. 4.2. General anaesthesia
Perceived advantages of local anaesthesia for vitreo-retinal
surgery are presented in Table 3. However, it is important to recognise It should be remembered that whilst local anaesthetic tech-
niques have gained in popularity, they are not without risks. For
many years, general anaesthesia has proven to be very safe despite
Table 2 the general state of health and advanced age of many of these
Reasons for increased local anaesthesia rate for vitreo-retinal surgery. patients. Both inhalational and intravenous techniques are suitable
Safer and effective LA techniques (peribulbar and sub-Tenon's anaesthesia) and the aim is to achieve optimal operating conditions by avoiding
Reduction in in-patient hospital beds coughing, straining and vomiting both at induction and recovery
Patients more accepting of LA to avoid the disadvantages of GA from anaesthesia, and to maintain stable haemodynamics and
Efforts of anaesthetists in promoting LA
intraocular pressure.
K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179 177
5. Intraoperative considerations that anaesthesia using nitrous oxide does not adversely affect the
size of a C3F8 gas bubble as the gas kinetics would only apply to
5.1. Optimal operating conditions the closed eye situation. During vitrectomies, uncontrolled leakage
from sclerostomy sites is the predominant factor in determining
Surgical requirements for V-R surgery include a well anaes- bubble size. Moreover, the diffusion of N2O into intraocular gas
thetized eye that is still in the neutral gaze position. For patients bubbles is time dependent and if intraocular gas is introduced just
receiving a general anaesthetic, this requires the administration of before the cessation of surgery and anaesthesia, then the effects of
muscle relaxants and mechanical ventilation which also facilitates N2O would be negligible.
the control of end-tidal carbon dioxide concentrations. When The risk does arise however, in the situation where the surgeon
muscle relaxants are used, neuromuscular transmission should be has finished operating on one eye, closes it and then proceeds to do
monitored to avoid any sudden wearing off of relaxant and patient some procedure on the other eye. In this situation, N2O must be
movement. A continuous infusion of an appropriate muscle discontinued as soon as the first eye has been closed.
relaxant such as atracurium has its merits in avoiding the peak and A major danger arises if patients with intraocular gas are
trough concentration effects. A remifentanil infusion in place of subsequently subjected to general anaesthesia using N2O.12 Several
nitrous oxide during V-R surgery is gaining popularity. However, it case reports have described severe visual loss in those patients
is inadvisable to rely on a remifentanil infusion to provide immo- undergoing nitrous oxide anaesthesia in the presence of an intra-
bility as sudden patient movement has occurred during surgery and ocular gas bubble. Intraocular gas duration varies. Generally, larger
resulted in surgical instruments damaging the patient's eye. and more concentrated volumes of gases that are less soluble last
longer. Air is typically absorbed within a few days; SF6 lasts
5.2. Laryngeal Mask Airway (LMA) versus endotracheal tube (ETT) approximately 10 days and C3F8 about 6 weeks although durations
in excess of 70 days have been reported.
Airway access is limited during V-R surgery under general In an aircraft, during decompression, intraocular gas expands
anaesthesia, therefore it is essential to secure the airway prior to and can produce the same deleterious effects.
commencement of surgery, either with a LMA or an ETT. In the Patients who have had intraocular gas injections should be
absence of specific contraindications, the armoured/flexible LMA is advised of these risks and provided with a notification wristband
increasingly favoured by ophthalmic anaesthetists as the airway (Fig. 1) warning against both flying and the use of nitrous oxide
device of choice. It has the advantage of minimal change in systemic until the gas has been completely absorbed.
arterial and intraocular pressure during insertion and removal, and
a lower incidence of sore throat compared to endotracheal intubation. 5.5. The oculocardiac reflex
Fig. 1. Picture of wristband warning against flying and repeat nitrous oxide anaesthesia in patients with intraocular gas.
178 K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179
Many V-R units routinely use Mydricaine to ensure maximal and Whenever sedation is administered, the recommendations of
long lasting dilatation of the pupil. This drug is not listed in the the Joint Royal Colleges5 must be followed:
British National Formulary (BNF) or Monthly Index of Medical
Specialities (MIMS). It is administered by sub-conjunctival injec- Sedation should only be used to allay anxiety and not to cover
tion, usually at the start of the operation and is available in two inadequate blocks which would require further administra-
strengths. No.1 injection (used in children) supplied as 0.5 ml tion of local anaesthetics
ampoules contains procaine HCl 3 mg, atropine sulphate 0.5 mg, Sedation should not be used to manage patients with pre-
and adrenaline 108 mcg. No.2 injection (used in adults) supplied as existing mental confusion as this may well aggravate the
0.5 ml ampoules contains procaine HCl 6 mg, atropine sulphate condition
1 mg, and adrenaline 216 mcg. Intravenous sedation should only be administered under the
There have been several reports of the cardiovascular effects of supervision of an anaesthetist whose sole responsibility is to
this medication. Severe hypertension, cardiac arrhythmias and that list
myocardial infarction as well as prolonged sinus tachycardias A similar level of continuous monitoring should be used
have been reported. Tachycardia and transient myocardial during sedation as that used during general anaesthesia
ischaemia may develop in patients with no previous history of
ischaemic heart disease, and using a smaller dose of the less 5.9. Specific issues (ensuring patient comfort and tolerance)
concentrated Mydricaine No.1 solution is no guarantee against
side effects. It therefore follows that whenever Mydricaine is used, Attention to small details can make a big difference to patient
the surgeon must inform the anaesthetist and the patient closely comfort. The tolerance of patients during LA is often limited by the
monitored. comfort of the operating table rather than the surgery itself.
Therefore careful patient positioning prior to commencement of
5.7. The use of lasers surgery is essential.
It is imperative that patients are informed before hand that if
Argon Laser is commonly used during V-R surgery for reti- they experience any discomfort, they must alert the theatre team
nopexy or the treatment of ischaemic retina, for example, during and analgesia can be given. It is relatively simple for the surgeon to
surgery for advanced diabetic retinopathy. Laser treatment is perform a sub-Tenon's top-up of local anaesthetic when required
administered either via a fibre-optic probe inserted into the eye during the operation.
(endolaser) or externally using a specially adapted indirect As V-R surgery is not associated with significant blood loss or
ophthalmoscope. In both instances, the surgeon controls the firing fluid shifts, excessive infusions of intravenous fluids should be
of the laser using a footswitch. Clearly there is the possibility of avoided. It is also sensible to ensure an empty bladder prior to
inadvertent firing with consequent dangers for theatre staff, surgery as operations can last for an hour or longer.
therefore all those present must wear protective goggles at all
6. Postoperative care
times when the laser is switched on. Warning signs must be erected
at all portals of entry to the room and any windows or glass doors
6.1. Postoperative posture
occluded.
Patients may need to posture postoperatively, to ensure that the
5.8. Role of sedation during local anaesthesia
bubble in the eye is in the best position to close the retinal break. If
the retinal break is superior, the best position for the patient is
Time spent establishing a good rapport with the patient is
upright and if the hole is posterior (e.g., in a macular hole) this
usually more effective in allaying anxiety than the use of phar-
would be face down.
macological agents. However, there remains a proportion of
LA has the advantage that patients can posture immediately.
patients undergoing V-R surgery who would benefit from seda-
After GA, the patient will need to have recovered sufficiently first.
tion. Common indications for this include patient's request,
The length of time the patient has to posture varies with their
allaying anxiety, controlling claustrophobia, long and complex
condition and the duration of the gas bubble, but is often for 5e10
surgery, and attenuating the undesirable cardiovascular reactions
days. Patients are allowed 10e15 min off per hour to prevent deep
to stress.
vein thrombosis (DVT) and stiffness and a reasonable time for
There is a suggestion that as more V-R surgery is being per-
meals. At night, sleeping left or right semi-prone is usually suffi-
formed under LA, the use of sedation has increased with it. Costen
cient as more complicated positions are not compatible with
et al. (2005)13 reported that the use of sedation in V-R surgery
comfortable sleep.
increased from 7.8% in 2001 to 20.2% in 2005 following a rise in LA
rate for V-R procedures from 82% to 92% over this period of time. In 6.2. Pain relief
general, younger patients having scleral buckling procedures are
more likely to benefit from sedation than elderly patients having Following V-R surgery, mild to moderate pain is common and is
vitrectomies. Several drugs are available for this purpose, the most effectively treated with combinations of paracetamol, non-
popular being a small dose of midazolam (1e2 mg in 0.5 mg steroidal anti-inflammatory analgesics and codeine phosphate.
increments) or propofol (10e20 mg given in 5 mg increments). Strong opioid analgesics such as morphine sulphate may cause
The main problem with the use of sedatives during V-R surgery nausea, vomiting and sedation and are rarely indicated. If post-
(particularly vitrectomies) is sudden patient movement especially operative pain is so severe that strong opioid analgesics are
when patients wake up with a start having fallen asleep. Other required, surgical complications such as an unacceptable rise in
potential complications include respiratory depression, falling intraocular pressure must first be excluded. It is well recognized
oxygen saturations and excessive restlessness. The majority of eye that the use of local anaesthesia as part of the general anaesthetic
patients are elderly and the doses and effects of sedative drugs in technique for V-R surgery contributes to improved postoperative
these patients can vary markedly. Fine judgement is therefore patient comfort and recovery from anaesthesia. In our hospital,
required to select the correct drug and dose to produce a calm a sub-Tenon's injection of local anaesthetic is routinely given for
sedated patient who remains both awake and cooperative. patients undergoing a general anaesthetic.
K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179 179