When people think about anesthesia it often elicits the image of an individual in major surgery,

intubation tubes rising from their mouth, as nervous family members sit anxiously in the
waiting room

for a favorable outcome to the devastating situation.

Unlike scenes from fictional television shows, many of the surgeries
done on a daily basis are not as dramatic, and not all require general
anesthesia. As a matter of fact, most fields of medicine use more
several types of anesthesia and ophthalmology (eye care) is no
different.
Ophthalmic Anesthesia - Topical
Topical agents are the most common form of ophthalmic
anesthesia, and are used for a wide variety of things ranging from
preventing discomfort during an eye exam to refractive eye surgery
such as LASIK. Topical ophthalmic anesthetic agents can be
delivered to the cornea in the form of an eye drop, ointment, or
medication soaked pledget. The cornea and surrounding tissues of
the eye are extremely sensitive and contain the more nerves than
any other part of the body, and it is because of this sensitivity that
most diagnostic testing and/or procedures done in ophthalmology
will require anesthesia of some kind.
All topical ophthalmic agents used to numb the surface of the eye
work almost immediately, and are administered by placement in the
cul-de-sac of the lower eyelid (the small pocket made when the
lower lid is pulled down and slightly away from the eyeball).
Common uses for topical anesthesia in ophthalmology are:
applination tonomety (measurement of eye pressure), Schirmer's
testing (measurement of tear production), relief from minor
scratches and/or foreign body sensations, and some refractive
surgeries of the cornea like LASIK.
Many different medications can be used to numb the surface areas
of the eye, however, Proparacaine and tetracaine are the most
widely used. They can be administered as a liquid eye drop or in a
thick ointment form. Less common is the use of Xylocain (lidocaine)
as a topical agent by soaking it into a small cotton pledget and
placed in the cul-de-sac of the eyelid. This is primarily done to

prepare the conjunctiva (tissues around the eyeball) for injection of

a stronger local anesthesia.
As a rule topical ophthalmic anesthetics do not last as long as other
forms of anesthesia, on average ten to thirty minutes depending on
the medications used. They are preferred for minor procedures and
testing because they offer little or no complications. Occasionally
patients may develop an allergy and should be treated according to
severity. The main concern with topical ophthalmic anesthetic
agents is abuse of use. Overuse can result in a change in the corneal
surface and decrease in tear film, but more concerning is the
possibility of developing a severe and painful condition called
chronic keratitis. Patients with keratitis, as a result of the misuse of
ophthalmic anesthetic topical agents, become dependant on the
medications to mask the pain of the condition. This causes more
damage to the eye and with it more pain. A vicious cycle is created
and will require intervention from an ophthalmologist and possibly
a therapist to correct any addictive/dependant behaviors.
Ophthalmic Anesthesia - Local
Local anesthesia in ophthalmology is similar to other fields. It is
used to block nerves in a specific areas of the body to prevent any
feeling for an allotted amount of time. In ophthalmology, local
anesthetic agents are administered to the eye by injection.
The medication, typically xylocaine (lidocaine) or Marcaine
(bupivicaine) can be injected into the conjunctival tissues around
the eye to allow the excision of chalazions (styes) and other minor
in-office procedures, or can be injected around the eye to block, not
only eye pain, but movement of the eye muscles. Blocks (peribulbar
or retrobulbar) are used for invasive eye surgeries like cataract or
retinal detachment repair. Typically in invasive eye surgeries a
combination of local anesthesia and sedation will be used. The
sedation, often referred to as "twilight sedation", allows a patient to

relax enough to lie still for the duration of the surgery while the
local anesthesia will prevent pain and the movement of the eye.
If sedation is used in conjunction with local anesthesia, it is
commonly referred to as Monitored Anesthesia Care (MAC). With
MAC, a trained anesthesiologist, or nurse anesthetist must be
present to control and monitor the intravenously administered
medication. An advantage of MAC is the addition of more sedation
medications adjusted though the IV should it be required. Most
patients feel very little, if any, pain from the combination of local
anesthesia MAC. The majority of patients sleep through the surgery
and awaken with little or no memory of the event. The largest
concern with MAC is the inability to control a patient's airway,
risking the possibility of aspiration or obstruction. Extra care and
examination of a potential patient's health should be taken if MAC
is being considered.
As with any form of anesthesia, local anesthesia is not without risk.
With just a simple injection into the sensitive tissues around they
eye, there is a risk of allergic reaction, hematoma, and possibility of
infection at the injection site. With more complex local anesthetic
injections, such as a block, the risk increases because the needle
used for the injection is placed closer to the eyeball (globe), running
the risk of penetration of the globe and/or nerve paralysis.
The effects of local anesthesia without sedation may last for several
hours depending on the anesthetic agent and amount used. For
most minor in-office procedures, the effects often have worn off
before the patient returns to home, work or school. Patients that
have undergone invasive surgery where MAC sedation in addition to
local agents were used, the effects may last 6-8 hours, and should be
evaluated before leaving the hospital or surgery suite.
All forms of local anesthesia administered in ophthalmology can be
painful. Physicians can reduce the discomfort to the patient by
combing the injection with another type of anesthetic agent, such as

a topical for minor procedures, and both topical and sedation for
invasive surgeries. While the probability of problems resulting from
local anesthesia administered by a trained ophthalmologist is low,
there is a risk none-the-less and should be discussed at length prior
to proceeding with any procedure.
Ophthalmic Anesthesia - General
General anesthesia is utilized in all medical fields to render a
patient completely unconscious. It can be administered by either
inhalation (breathing in) - such as nitrous oxide - or intravenous
delivery (IV) - such as propofol. This type of anesthesia is not
commonly used in ophthalmology, but could be considered if: an
invasive surgery case may require an extended amount of time, a
patient is unable to remain still or lie on their back for the duration
of the surgery, or if general anesthesia is requested by the patient.
Loss of consciousness due to use general anesthesia may cause a
reduction in the protective response (coughing and/or gag reflex)
and could result in suffocation by obstruction. It is because of this
that when general anesthesia is used, control of the airway is
essential. It is typically controlled by use of an endotrachel tube or
other "breathing tube". As with MAC, general anesthesia requires
the presence of an anesthesiologist or nurse anesthetist to monitor
the amount of anesthetic medications used along with the vital signs
of the patient throughout the procedure.
After effects from general anesthesia may last longer than those
experienced by patients who have undergone MAC, local, and/or
topical anesthesia. It is not uncommon for a "groggy" feeling to be
present for several hours after the procedure, and in addition a
patient may feel nauseated and light headed. Commonly sore
throats and a raspy voice are reported after the removal of the
breathing tube. General anesthesia often has a more systemic effect
on the body than topical, local or MAC, and complete examination
of a patient's health and medical history should be considered,
however, for some patients, the advantage of being completely

unaware during the procedure out way the risks.

Ophthalmic Anesthesia - Patient Responsibility
No matter what ophthalmic anesthesia is chosen for a patient's
procedure or surgery, all risks and benefits should be reviewed
before a final decision is made. There are advantages and
disadvantages to each of the type anesthesia, and patients should be
encouraged to take an active roll in their eye care and discuss any
concerns or apprehensions they may have. Additionally, once a
choice in anesthesia has been made, it will be the responsibly of the
patient to comply with pre-operative instructions such as refraining
from eating or drinking after midnight the evening before their
scheduled surgery.In addition, full disclosure of medical heath and
history will be essential in preventing complications and allowing
for the best possible outcome. This is true not only from an
anesthetic perspective but for the procedure as a whole.

Published by Melissa Habrat

Jun 3, 2010
http://www.associatedcontent.com/article/5429952/ophthalmologys_3_most_com
mon_forms_pg4.html?cat=5
accessed 15 mei 2011 14.00