In 1884, Koller l-5 introduced
a revolutionary technique: the use of topical cocaine analgesia for cataract
surgery. During World War 1, Van Lint and O'Brien 6 produced motor akinesia of
the facial nerve, and in 1928, Elshnig7 proposed his technique of retrobulbar
injection. Since then, we have come full circle: Some have advocated the use of
general anesthesia and, recently, Fichman and others have investigated the use
of topical anesthesia in cataract surgery. Today, a diversity of anesthetic
techniques has become the source of a lively controversy in ophthalmology. 9 ,
10
I have developed a deep, topical
anesthesia technique that combines the safety, comfort, ease of administration,
and rapid onset of topical anesthesia with the deep, extensive anatomical
distribution of retrobulbar anesthesia. An absorbent pledget is soaked with a
high concentration of anesthetic, placed deep in the fornices, and pressurized
to encourage absorption of the anesthetic into adjacent tissues and
posteriorly, thus inducing a nerve block.
TECHNIQUE
I performed this technique in 81
consecutive patients who were not preselected. Two patients (three eyes) with
Fuch's dystrophy, one of whom also had systemic and ocular albinism, were
excluded from the statistical analysis.
Prior to receiving the
anesthetic, most patients received intravenous midazolam (Versed6) titrated by
the anesthesiologist to allow the patient comfort and sufficient alertness to
communicate with the surgeon and follow commands.
Several drops of tetracaine or
proparacaine were instilled into the superior and inferior fornices of all
patients. After a few moments, a neurosurgical 0.5 X 1.5 inch cottonoid or the
cut-off tip of a Weck cell sponge was soaked in lidocaine 4%. The patient
was asked to look down, and this pledget was placed deep in the superior fomix.
This was repeated in the inferior fornix. A Honan balloon was applied, inflated
to 30 to 35 min Hg, and left in place during the surgeon's scrub, 8 to 15
minutes. The sponges were removed during the prep, and prior to surgery the
surface anesthetic effect was tested by grasping the limbus with a 0.12
forceps.
Seventy-seven procedures
were performed with a 5 min or 6 min scleral tunnel, standard continuous tear
capsulorhexis, and phacoemulsification within the
capsular bag, with a divide and
conquer, flip and chip, or phacochop technique, using sodium hyaluronate
(Healon@ or Healon GV@). A single-piece poly(methyl methacrylate)
intraocular lens (IOL) was placed in the capsular bag. A clear corneal incision
and implantation - of a foldable IOL were
used in four patients whose anticoagulants were not
discontinued for surgery.
In the first cases, acetylcholine (Miocholg) were instilled
at the end of the procedure, but this was later discontinued as smaller
capsulorhexes were used and the IOLs were found to be stable in the bag. Also,
a few patients experienced ciliary spasm 15 to 20 minutes after the conclusion
of the procedure, which I attributed to the use of Miochol.
Postoperatively, all patients used prednisolone
(Inflamase Forteg), ciprofloxacin hydrochloride (Ciloxang) or tobramycin
(Tobrex), and betaxolol hydrochloride (Betoptic S).
Visual acuity was measured within 15 minutes of the
completion of surgery. On the first day postoperatively, I measured visual
acuity, cell and flare, and corneal appearance. Each patient was asked about
his or her experience of pain or other sensation. Six patients who had had
cataract surgery in the fellow eye were asked to compare the two experiences.
RESULTS
Intraoperatively, one patient who did not complain
of pain but could not tolerate the sensation of eye movement was given
supplemental peribulbar anesthesia. One patient was given supplemental
subconjunctival anesthesia.
No supplemental sedation or intravenous analgesia
was needed during scleral incision or IOL insertion with the use of bipolar
eraser cautery or with manipulation of the iris. This was true even in one case
in which a small posterior capsular tear required toileting vitreous from the
iris surface and anterior vitrectomy and in several small pupil cases in which
contact with the iris surface was inevitable. One case in which zonular
dehiscence in a hypermature lens occurred during the first phase of
phacoemulsification had to be converted to an extracapsular incision. Deep,
topical anesthesia was used without supplementation of local anesthetic or
additional sedation and without patient discomfort. Patients showed little or no
discomfort from the microscope light as it was gradually increased at the
beginning of the procedure.
Visual acuity results immediately after surgery and
one day postoperatively are shown in Figure 1. Cell and flare on the first day
postoperatively are shown in Figure 2. Nine percent of patients were noted to
have mild superficial punctate keratitis (SPK) on the first postoperative day.
In only two of these cases, both with pre-existing tear film deficiency,
did the SPK persist for more than a week.
Postoperatively, most patients needed only a single
dose of acetaminophen. One patient received ketorolac tromethamine (Toradol IM)
for analgesia.
No postoperative ptosis was observed. Two patients
had superior rectus paresis immediately following surgery; this lasted
approximately one half hour. Eyelid
Fig. 1. (Rosenthal) Best corrected visual acuity results
immediately after surgery and one day postoperatively. Nine percent of patients
were not tested.
Fig. 2.
(Rosenthal) Postoperative cell and flare results one day postoperatively.
hypokinesia, partial lid block, was observed in most
patients.
None of the six patients who had had retrobulbar or
peribulbar anesthesia for the cataract surgery in their fellow eye noticed any
difference in the intraoperative experiences.
DISCUSSION
The relative risks and benefits of retrobulbar
anesthesia have been discussed. 10-36 Briefly, "deeper"
retrobulbar anesthesia is thought to produce more profound anesthesia and
akinesia, maintaining globe stability during surgery and allowing free
manipulation of the internal as well as external anterior segment structures.
Topical anesthesia, on the other hand, allows more rapid onset without the
risks of injection, but most reports mention some degree of patient sensation when
incisions are made in the sclera (such as a scleral tunnel) and when the iris
and ciliary body are
31,31
manipulated.
The new technique draws on Thornton's concept of
"deep topical anesthesia" for radial keratotomy, 39,40 in which
proparacaine (Ophthaineg) is carefully instilled in the superior and inferior
conjunctival fornices. Thornton emphasizes that the patient is comfortable
during administration since no anesthetic is dropped directly onto the more
sensitive cornea,~ instead, it "washes" gradually onto it as the
patient blinks.
I postulated that placing the anesthetic in the
fornix is also more neuroanatomically and pharmacologically sound since the
fornix is contiguous to the peribulbar
space. Placement in the fornices allows absorption
by the nerve trunks subserving the conjunctiva as they radiate across it. At
the same time, by being absorbed posteriorly into the peribulbar (and possibly
transconally into the retrobulbar) space (Figure 3, a), the posterior ciliary
nerves, which supply the anterior sclera, anterior conjunctiva, and limbus as
well as the iris and ciliary body, are anesthetized at their nerve
41,42 roots. The addition of external pressure with
the Honan balloon enhances the absorption of medication across the conjunctiva
because the tissue pressure created is additive, with both passive and active
transport mechanisms. The fornix is also a logical place for direct absorption
across Tenon's capsule and the sclera to the scleral nerves (Figure 3, b)
because the fornix overlies the area in which the branches of the posterior
ciliary nerve destined for the ciliary body and iris root travel
intrasclerally,43 making them accessible to direct drug absorption. There is
also likely to be absorption into the lid, producing some degree of lid
akinesia (Figure 3, c). As in Thornton's technique, the anesthetic can
"wash" over the conjunctival surface in a "slow-release"
fashion while draining from the sponge. My technique differs from Thornton's,
however, because in theory (except for its local effect on the conjunctiva), it
affects the nerves near or at their roots and is therefore a type of nerve
block as opposed to infiltration anesthesia.
The use of a high concentration of lidocaine on a
retentive vehicle such as a sponge or cottonoid also enhances anesthetic
penetration. Cellulose sponges designed for cleaning instruments seemed to
produce the best drug concentration with the easiest insertion and least
irritation to the forneal tissues. Recently, I began using Xylocaine 4%-MPF
(methylparaben-free lidocaine hydrochloride), which is available in
sterile 5 cc ampules. This preservative-free preparation seems to produce
even quieter eyes with no corneal punctate keratitis. I have also informally
observed that the anesthetic seems to achieve the greatest depth and most
prolonged effect when it is applied at least 10 to 15 minutes before onset of
the procedure. The patient often receives the anesthesia in the holding area
prior to entering the operating room.
The presence of lid hypokinesia, the ability to
manipulate the iris freely without pain, and the few cases of superior rectus
paresis strongly suggest an anesthetic effect that goes well beyond its local
application. In contrast to studies using topical anesthesia 37,38
alone, propofol or
other sedatives or analgesics were not used or required in lieu of proper depth
and scope of anesthesia; sedation was used only if patient restlessness or
Anxiety was observed. I was also impressed that the microscope light did not
bother patients (even the one albino patient) and that bipolar eraser
cautery, which has been reported to create dis-
comfort with straight topical
application, was painless for all patients. Some investigators think that the
nerve endings responsible for temperature sensation in the cornea lie deeper in
the stroma and are therefore more difficult to ablate than pain fibers 44,
suggesting that the deep, topical technique produced a profound degree of
anesthesia in certain tissues.
As with traditional topical
anesthesia techniques, deep, topical, nerve-block anesthesia has less
motor neuron effect than retrobulbar anesthesia; however, some globe and lid
"hypokinesia" was seen. For the surgeon with experience, the
patient's voluntary eye movement becomes a very natural and desirable feature
of the procedure. Patient cooperation was excellent in most cases and obviated
stretching the extraocular muscles to produce the desired globe position; for
example, the patient could look directly into the microscope during
capsulorhexis and phacoemulsification and downward during incision and IOL
insertion. The lack of stretching may account for the absence of postoperative
ptosis. Patients who have trouble self-positioning their eye may be
coached: The surgeon gently grasps and moves the eye to the desired position
(with the patient's cooperation) and then asks the patient to maintain that
position. The eye is never forced into position, however.
Although 'no controls using
injectible anesthetic technique were specifically studied, my overall
impression was that with deep, topical, nerve-block anesthesia the eyes
had better initial postoperative acuity with more rapid healing and were
quieter than eyes in my previous experience that had had similar surgery using
retrobulbar or peribulbar anesthesia.
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