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A Comparison of Topical and

Retrobulbar Anesthesia for


Cataract Surgery

Bhupendra C. K. Patel, MD, FRCS, FRCOphth,l Thomas A. Burns, MD, 2


Alan Crandall, MD,1 Samuel T. Shomaker, MD,z Nathan L. Pace, MD,z
Akira van Eerd,l Thomas Clinch, MDI

Purpose: To evaluate and compare the efficacy of topical and retrobulbar anesthesia
for cataract extraction with intraocular lens implantation.
Methods: One hundred thirty-eight patients prospectively were assigned to the
topical (group 1 ; n= 69) or retrobulbar (group 2; n = 69) anesthesia groups by permuted
block restricted randomization. Group 1 received topical 0.75% bupivacaine and intra-
venous midazolam and fentanyl for anesthesia. Group 2 received intravenous metho-
hexital followed by retrobulbar block with an equal mixture of 2% lidocaine and 0.75%
bupivacaine plus hyaluronidase (150 U). A visual pain analogue scale was used to assess
the degree of pain during the administration of anesthesia, during surgery, and post-
operatively. The degree to which eye movement, touch, and light caused patient dis-
comfort was assessed. Complications and surgical conditions were recorded.
Results: There was no difference in the surgical conditions (P = 0.5) or pain during
surgery (P = 0.35) between the two groups. There was more discomfort during admin-
istration of topical anesthesia (P < 0.0001) and postoperatively (P < 0.05) in the topical
group. Chemosis, subconjunctival hemorrhage, and eyelid hemorrhage were seen almost
exclusively in the retrobulbar group. One patient in group 2 had a retrobulbar hemorrhage.
Although eyeball movement and squeezing of the eyelids were present more frequently
in the topical group, neither was a problem to the surgeon.
Conclusion: Topical anesthesia can be used safely for cataract extraction. The
degree of patient discomfort is only marginally higher during administration of the anes-
thesia and postoperatively. However, surgical training and patient preparation are the
keys to the safe use of topical anesthesia. Ophthalmology 1996; 103: 1196-1203

Originally received: October 30, 1995.


Local anesthesia has become preferable to general anes-
Revision accepted: April 29, 1996. thesia for cataract surgery due to improvement in tech-
I John A. Moran Eye Center, University of Utah School of Medicine,
niques and instrumentation. The advantages of local
Salt Lake City. anesthesia are well known and include more rapid am-
2 Department of Anesthesia, University of Utah School of Medicine, bulation, the ability to perform the procedure as an out-
Salt Lake City. patient, avoidance of complications of general anesthesia,
Presented at the American Academy of Ophthalmology Annual Meeting, and quicker surgery.
Atlanta, Oct/Nov 1995. Methods of local anesthesia for cataract extraction
Supported in part by a grant from Research to Prevent Blindness. Inc, currently include retrobulbar, I peribulbar,2-5 subcon-
New York, New York, to the Department of Ophthalmology, University junctival, 6 and sub-Tenon application oflocal anesthetic
of Utah. Salt Lake City, Utah.
solution. 7 Retrobulbar anesthesia has been associated with
The authors have no proprietary interest in any of the materials used in
this study. a number of potentially serious complications, including
Reprint requests to Bhupendra C. K. Patel, MD, FRO;, FRCOphth,
inadvertent globe perforation, retrobulbar hemorrhage,
Moran Eye Center, 50 North Medical Dr, University of Utah School of orbital infection, central retinal artery occlusion, chronic
Medicine, Salt Lake City, UT 84132. mydriasis, contralateral amaurosis, damage to the optic

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Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery

nerve, intravascular or intrathecal injection, respiratory nously and an additional two drops bupivacaine 0.75%
depression, apnea, and death. 8- 18 Other more common were placed in the eye. Surgery was undertaken after a
complications include postoperative diplopia, ptosis, routine preparation and draping. The protocol established
nausea, and systemic hypertension. 19 ,2o for breakthrough pain, if it should occur, during surgery
Peri bulbar anesthesia eliminates the risk of optic nerve was as follows. If the patient is in pain, an additional two
trauma and lessens the chance of retrobulbar hemorrhage. drops bupivacaine 0.75% would be placed in the eye. If
However, the risk of globe perforation still remains. 21 The this is not effective within 2 minutes, the patient would
peribulbar technique is time-consuming and requires a receive additional fentanyl (0.5 JLg/kg) intravenously, to
greater volume of anesthetic than the retrobulbar tech- be repeated in three minutes, if necessary. Finally, if the
nique. 22 pain persisted, a peribulbar or retrobulbar block would
The use of intercapsular phacoemulsification and in- be used.
traocular lens implantation has introduced the opportu- The patients randomized to the retrobulbar group were
nity to perform cataract surgery with less-invasive anes- brought to the operating room where they received con-
thetic techniques. Topical anesthesia, using clear corneal tinuous nasal prong oxygen 4 lfminute, and vital signs
and scleral tunnel approaches, has been suggested for cat- were recorded. After 2 minutes of additional pre-oxygen-
aract extraction. However, reports suggest that careful pa- ation with 100% oxygen by face mask, the patients were
tient selection is important. Anxious and uncooperative given methohexital 1% (Brevital) titrated to unconscious-
patients should be excluded. 23 ,24 Although Kershner25 re- ness (approximate dose required, 0.5-1 mg/kg). A retro-
ported encouraging results with topical anesthesia for cat- bulbar block was performed with a 23-gauge retrobulbar
aract extraction, Fukasaku and Marron 23 found unac- needle using a solution oflidocaine 2% (2 ml), bupivacaine
ceptable levels of discomfort during surgery and they 0.75% (2 ml), and hyaluronidase (Wydase) 150 U. Surgery
abandoned the technique in favor of a peribulbar tech- was undertaken after a routine preparation and draping.
nique. We designed a prospective randomized study to No ocular compression was performed. Facial nerve or
compare the effectiveness of topical and retrobulbar anes- eyelid blocks were not used. If the patients in the retro-
thesia for cataract extraction. bulbar group had breakthrough pain, a protocol similar
to the topical group was followed.
The methods of sedation used in the two groups were
Patients and Methods different. Methohexital with retrobulbar anesthesia briefly
brings the patient to unconsciousness while the block is
Approval was obtained from the University of Utah In- being placed. These patients are amnestic for the block
stitutional Review Board. Consecutive patients under- placement and rarely receive additional sedation or an-
going elective cataract extraction and intraocular lens im- algesia for the remainder of the procedure. With the small
plantation were entered into the study between March doses of midazolam and fentanyl used for the topical
and July 1995. Informed consent was obtained, and the group, patients are awake and cooperative, with total recall
patients prospectively were assigned to either the topical of the procedure. We designed the study to compare the
or the retrobulbar anesthesia group by permuted block accepted standard of retrobulbar anesthesia using me-
restricted randomization. The patients included in the thohexital with the form of topical anesthesia and light
study were between 45 and 85 years of age and American intravenous sedation that we have found useful. If the
Society of Anesthesiology (ASA) physical status class 1, same doses of midazolam and fentanyl had been used for
2, or 3. Patients with communication difficulties, mon- retrobulbar anesthesia, we would have had an unaccept-
ocular patients, and patients taking anticoagulation med- ably high incidence of pain and recall during the place-
ication were excluded. All types of cataracts (posterior ment of the block.
subcapsular, nuclear sclerosis, dense brunescent, etc.) were All surgical procedures in this study were performed
included in this study. Preoperatively, baseline vital signs by one surgeon. A wire speculum was placed. Patients in
were taken in all patients, and an intravenous line with the topical group were asked to look down. No superior
Ringer lactate solution was placed. Each patient received rectus sutures were used in either group. The patients in
topical diclofenac sodium 0.1 % (Voltaren), two drops ev- the topical group were informed that they would be aware
ery 20 minutes times two; phenylephrine hydrochloride of the sensation of touch and would be able to move their
2.5% (Mydfrin), one drop every 5 minutes times three; eyeballs. A 3.2-mm, 400-JLm groove was made in clear
and cyclopentolate hydrochloride 1% (Cyclogyl), one drop temporal cornea. A stab incision was made for insertion
every 5 minutes times three. of a second instrument at the 10 o'clock position in the
The patients randomized to the topical group received, right eye and at the 4 o'clock position in the left. A 1.75-
while still in the preoperative area, two drops of bupiva- mm entry incision was made into the clear corneal groove
caine hydrochloride (Marcaine) 0.75% every 5 minutes with a diamond knife. A 5-mm wide capsulorrhexis was
times three, beginning 20 minutes before the procedure. performed. Hydrodissection was performed with balanced
In the operating room, all patients received continuous salt solution using a curved cannula. A divide and conquer
nasal prong oxygen 4 lfminute, and baseline vital signs type ofphacoemulsification technique was used. Amvisc+
were obtained. The patients in the topical group were was injected into the capsular bag. Foldable implants were
given midazolam hydrochloride (Versed) 0.015 mg/kg inserted and included plate lenses (Starr [Monrovia, CAl
intravenously and (Sublimaze citrate) 1 JLg/kg intrave- and Chiron [Huntington, WV]) and acrylic and silicone

1197
Ophthalmology Volume 103, Number 8, August 1996

Unbearable pain 1 0 lution. A collagen shield soaked in dexamethasone and


cephalexin was placed on the cornea at the end of the
procedure. Patients in group I did not receive a patch,
whereas an eye patch was applied to patients in group 2
until the following morning. The operating microscope
light was kept at its lowest level and gradually increased
9 in intensity. The level was up to the usual operating levels
after the hydrodissection.
After the surgery, the patients were taken to the post-
operative area where vital signs were obtained, and one
constant observer collected patient assessment responses.
8 Questions were presented to the patients from a stan-
dardized written form . Each patient was shown a lO-point
visual analogue graphic pain scale with numeric and de-
Severe Pain scripti ve ratings 26 (Fig I) and asked to grade the level of
discomfort or pain at the time of administration of anes-
7 thesia, during surgery, and postoperatively on separate
scales. If the patients were unable to see the scale or read
the accompanying text, the scale was described and a ver-
bal score was obtained. Patients also were asked to assess
the degree to which they were bothered by the ability to
6 move their eyes, by the sensation of touch, and by the
operating microscope light. The degree to which each of
these bothered the patient was graded as "none," "a little,"
or "a lot." The patients were kept in the recovery area for
a minimum of 30 minutes. The surgeon also completed
a questionnaire on the surgical conditions, complications,
Moderate Pain 5 and need for supplemental anesthesia. The surgeon rated
surgical conditions on an analogue scale, with 10 repre-
senting excellent, 7.5 good, 5 fair, 2.5 poor, and 0 being
extremely poor.
Comparisons between the topical and retrobulbar
4 anesthesia groups for the surgical conditions, pain during
administration of anesthesia, pain during surgery, and
postoperative pain was by a linear rank test. The Per-
mutation test with exact non parametric inference was
used from the StatXact statistical package (CYTEL Soft-
3 ware Corp, Cambridge, MA). Dichotomous comparisons
were performed by Fisher's exact test. The null hypothesis
Mild Discomfort was rejected for P < 0.05.

2 Results
Sixty-nine patients were entered into each group. Surgery
averaged 16.6 minutes (range, 11-21 minutes) for the
topical group (group I) and 15.8 minutes (range, 10-19
1 minutes) for the retrobulbar group (group 2; P> 0.05).
The surgical conditions and complications are given in
Table I. No patients in either group required supplemental
periocular anesthesia or a superior rectus suture. A wick
was required for pooling of fluid in two patients in group
No pain 0 I and in five in group 2 (P > 0.05). The surgeon noted
squeezing of the eyelids during surgery in 14 and 2 patients
Figure 1. A descriptive and numerical visual pain analogue scale.
in groups I and 2, respectively (P < 0.005). The degree
of squeezing was noted as mild in all patients and did not
interfere with the surgery. Eyelid injections were not re-
three-piece foldable lenses (Alcon [Ft. Worth, TX] and quired for any of these patients. Both groups rarely re-
AMOT [Irvine, CA]). The Amvisc+ was r~moved, and quired supplemental anesthesia. One patient in the topical
the anterior chamber was injected with balanced salt so- group required topical bupivacaine and one patient re-

1198
Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery
70
Table 1. Surgical Conditions and Complications
60
Group 1 Group 2
Topical Retrobulbar 50
(n = 69) (n = 69)
40
Supplemental periocular anesthesia 0 0
Number 01
Superior rectus suture required 0 0 Patients
30
Need for a wick (%) 2 (3) 5 (7)
20
Squeezing of eyelids present (%) 14 (20) 2 (3)
Iris prolapse 0 0 10
Miosis 0 0
Inadvertent movement (%) 22 (32) 4 (6) 0
0 2 3 4 5 6 7 8 10
Capsule rupture (%) 1 (1.5) 0 Pain level
Vitreous loss 0 1 (1.5)
Figure 3. Pain scores recorded for surgery. Solid bars = topical; hatched
Retrobulbar hemorrhage 0 1 (1.5) bars = retrobulbar.
Globe perforation 0 0
Chemosis (%) 0 48 (70)
Eyelid hemorrhage (%) 0 28 (41)
There was no significant difference (P = 0.35) between
Subconjunctival hemorrhage (%) 1 (1.5) 12 (17) the two groups regarding level of pain during surgery. 1 he
Successful IOL insertion (%) 69 (100) 69 (100) median and mean pain scores were 0 and 1.13, respec-
Cooperation (%) tively, for group I and 0 and 0.203 group 2, respectively
Excellent 64 (93) 66 (96) (Fig 3). Fifty-seven patients (S3%) in group I and 63 (91 %)
Good 3 (4.5) 1 (1.5) in group 2 scored 0 (P > 0.05). There was one patient
Poor 2 (3) 1 (1.5)
who scored a 5 (moderate pain) in the topical group.
10L = intraocular lens. There was more discomfort postoperatively in ' he top-
ical group (P < 0.05). The median and mean pain scores
were 0 and 0.406 for group I and 0 and 0.OS7 for group
2 (Fig 4). The postoperative pain levels were scored as 0
quired topical bupivacaine and fentanyl (0.5 1g/kg). In by 56 (SI %) patients in group I and 66 patients (96%) in
the retrobulbar group, one patient required topical bu- group 2 (P < 0.05). Thirteen patients had mild discomfort
pivacaine during surgery. in the topical group compared with three in the retro-
There was more discomfort in patients in group I while bulbar group. The patients in the topical group described
anesthesia was administered (P < 0.00 I). Visual analogue an aching feeling.
pain scores produced a median score of I and a mean Inadvertent movement of the eyeball was noted by the
score of 1.13 for applying anesthesia in patients in group surgeon in 22 patients in group I and 4 in group 2 (P <
I, and a median and mean of 0 and O.ISS, respectively, 0.00 I). This movement of the eyeball was a problem to
for patients in group 2 (Fig 2). Twenty-eight patients (41 %) the surgeon during surgery in only two patients in group
in group I and 66 (96%) in group 2 (P < 0.000 I) reported I and I patient in group 2. The surgeon was able to make
no pain during delivery of anesthesia. all patients in the topical group move the eyeball and this

70 70

60 60

50 50

40 40
Number 01
Number 01 Patient.
Patients 30 30

20 20

10 10

0 0
0 2 3 4 5 6 7 8 9 10 0 2 3 4 5 6 7 8 9 10
Pain level Pain level

Figure 2. Pain scores recorded for delivery of anesthesia. Solid bars = Figure 4. Pain scores recorded for postoperative period. Solid bars =
topical; hatched bars = retrobulbar. topical; hatched bars = retrobulbar.

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Ophthalmology Volume 103, Number 8, August 1996
70
was noted to be helpful in 52 patients (75%) by the sur-
geon.
60
There was one case of radial anterior capsule rupture
in a patient in group 1. The tear did not extend posteriorly,
50
and no further intervention was required. Intraocular lens
insertion was uneventful. The one patient with vitreous
40
loss associated with a capsular rupture in group 2 was
treated with anterior vitrectomy and intraocular lens in-
30
sertion into the capsular bag without need for any further No. of
periocular anesthesia. Patients
20
Patient cooperation was good or excellent in 67 (97%)
patients in each of the groups 1 and 2. Two patients in 10
the topical group showed poor cooperation. Both of these
were elderly patients requiring repeated instruction during o
the course of surgery. One patient in the retrobulbar group None Little Lot None Little Lot None Little Lot
had poor cooperation. This patient was slightly disorien- Eye movement Touch sensation Light

tated and moved during surgery. Surgery was uneventful. Figure 6. Patient perception of eye movement, touch sensation, and
The overall surgical conditions in the two groups as as- microscope light during surgery. Patients were asked at assess whether
sessed by the surgeon were comparable (P> 0.5; Fig 5). each of these bothered them "a lot, a little, or not at all." Solid bars =
The degree to which patients were bothered by eye topical; hatched bars = retrobulbar.
movement, sensation of touch, and microscope light is
shown in Figure 6. Twelve patients (17%) in group 1 and
1 in group 2 were bothered a little by the ability to move patient in group 2 with limited retrobulbar hemorrhage.
their eyes during surgery (P < 0.01). Seventeen patients Surgery was uneventful.
(25%) in group 1 were bothered a little by touch sensation Twenty patients had cataract extractions performed on
during surgery, the majority identifying the lid speculum both eyes during the course of the study. Three patients
as the source of the sensation. One patient in the topical had bilateral retrobulbar nerve blocks, 4 had bilateral top-
group also had "a lot of" discomfort (level 5 on the pain ical procedures, and 13 patients had one eye that had
analogue scale), again related to the lid speculum. Seven undergone with each technique. Of these 13 patients, 8
patients (10%) in the retrobulbar group also had some preferred the topical procedure and 5 preferred the ret-
discomfort from touch sensation. Seven patients (10%) in robulbar technique.
the topical group and one in the retrobulbar group indi-
cated that the microscope light was a little uncomfortable
(P> 0.05). Discussion
Eyelid hemorrhage and chemosis were seen exclusively
in group 2 (41% and 70%, respectively). Subconjunctival
The first successful use of topical anesthesia for cataract
hemorrhage defined as hemorrhage over one quadrant of
extraction was reported by Knapp27 in 1884. He used
the conjunctiva was seen superiorly in one patient in group
frequent drops of 5% cocaine. Topical anesthesia has been
1 and in 12 (17%) patients in group 2. There was one
used recently for strabismus surgery.28 Shule~9 reported
the use of topical anesthesia without intravenous sedation
for phacoemulsification cataract extraction with intra-
60 ocular lens implantation in a patient with a history of
retrobulbar hemorrhage. He advocated the use of topical
50 anesthesia in such patients with a high risk of complica-
tions associated with needle anesthesia. Kershne~5 eval-
40 uated 100 patients undergoing cataract extraction under
topical anesthesia and concluded that topical anesthesia
No. of 30 was safe, decreased intraoperative and postoperative
Patients
complications, and allowed rapid return of vision. How-
20 ever, when Fukasaku and Marron 23 compared topical
anesthesia with retrobulbar anesthesia, they found more
10 intraoperative pain with the topical technique. They found
that a sub-Tenon technique in the superior temporal
0 quadrant with instillation of I ml local anesthetic gave
2 4 6 7 8 9 10 better intraoperative pain control than topical anesthesia.
Operation Conditions Fukasaku and Marron 23 did not mention preoperative
Figure 5. Operating conditions rated by the surgeon pn an analogue patient counseling or using intravenous sedation.
scale, with 10 representing excellent, 7.5 good, 5 fair, 2.5 poor, and 0 Stevens26 has advocated one quadrant sub-Tenon in-
extremely poor. Solid bars = topical; hatched bars = retrobulbar. filtration anesthesia in preference to retrobulbar or peri-

1200
Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery

bulbar anesthesia. However, he noted more conjunctival These fibers pass through the ganglion and provide sen-
chemosis than usually seen with peribulbar or retrobulbar sation from the cornea, iris, and ciliary body. 3D Intraocular
anesthesia. Subconjunctival hemorrhage extending to manipulation and, in particular, iris manipulation would
more than one quadrant occurred in 32% of his patients, be expected to be uncomfortable for the patient with top-
and 46% required an additional Van Lint facial block ical anesthesia.
immediately before surgery. Advantages of his technique There was a greater level of pain reported during the
include reduced likelihood of injury to the vortex vein in administration of anesthesia with the topical group. This
the inferior nasal quadrant where the vortex vein is more is not surprising because the patient is rendered uncon-
posteriorly situated than the inferior temporal quadrant, scious by the methohexital during the course of giving
avoidance of damage to the superior conjunctiva, delivery retrobulbar anesthesia. Also, the mean and median levels
of adequate anesthesia, and akinesia. There is risk of of pain in the topical group were only I (a level just above
hemorrhage, especially in patients receiving anticoagu- the no pain level). The two patients who reported pain at
lants. In addition, there is a theoretical risk of spread of level 5 in the retrobulbar group both had pain during
infection via the conjunctival and sub-Tenon incision to intravenous administration of medications rather than
the retrobulbar space. during retrobulbar injection. However, pain during ret-
To achieve akinesia, the nerve supply to the extraocular robulbar injection is certainly possible because titration
muscles should be inhibited. This is generally regarded as of methohexital to induce unconsciousness occasionally
desirable for safe intraocular surgery. Akinesia of the globe can be difficult to judge.
is not achieved with topical anesthesia, which only affects During surgery, all except one patient in the topical
the trigeminal nerve to the cornea and the conjunctiva. group graded the pain at level 3 or lower (mild discomfort
However, none of our patients undergoing topical anes- or less) on the pain analogue scale. One patient had pain
thesia required a superior rectus suture. Twelve patients at level 5 (moderate discomfort). As expected, most pa-
stated that they were "a little bothered" by movement of tients with retrobulbar anesthesia had no pain during sur-
the eye during surgery. It is surprising that most of the gery, with six patients reporting mild discomfort (levels
patients (83%) were unaware of eye movement during 3 or less). The speed with which phacoemulsification can
surgery. However, the use of midazolam may have con- be performed and the minimal intraocular manipUlations
tributed to the lack of recollection regarding movements. involved may explain the minimal discomfort reported
The surgeon noted movement of the eyeball during sur- in the topical group. In the topical group, we had no in-
gery in 22 patients. Of these patients, the movement was cidence of miosis, iris prolapse, or vitreous loss requiring
helpful because the patient was able to assist in positioning iris manipulation. The one incidence of capsular rupture
the eyeball in all except two patients. In two patients, the was an anterior radial tear which did not extend poste-
movement was a problem and the eye was stabilized by riorly and did not require any further intervention. This
using forceps at the limbus. It is our belief that with ad- tear was not related to ocular movement. It is possible
equate preoperative explanation, movement of the eyeball that in the presence of any of the above complications,
is not a concern to the patient and can be useful to the intraocular manipulation may be uncomfortable for the
surgeon. The overall surgical conditions, as assessed by patient requiring supplemental peribulbar anesthesia.
the surgeon, were comparable in the two groups. However, However, Kershner 5 reported two incidences of capsular
as the surgeon was aware of the type of anesthesia being rupture requiring vitrectomy with topical anesthesia. He
used, there remains a risk of bias in this assessment. did not require supplemental anesthesia and was able to
With topical anesthesia, the globe may rest more pos- successfully perform a vitrectomy and insert an intraocu-
teriorly because there is no retrobulbar fluid volume. lar lens into the capsule in each patient.
Kershner25 found that the use of a wick during the pro- Postoperative pain was more common in the topical
cedure was necessary because of pooling of fluid in "sev- group. However, the median and mean scores were 0 and
eral patients." We required the use of a wick in fewer 0.406, respectively, at levels just above the no-pain level
patients using topical anesthesia than with retrobulbar on the analogue scale. It is not surprising that as patients
anesthesia. A number of other factors, including globe recover from the topical anesthesia, they have some degree
size (high hypermetropes with small eyes, etc.), deep-set of discomfort. Although patients were kept in the recovery
eyes, and a prominent supraorbital ridge necessitate the room for up to I hour, some patients would have had
need for a wick because of pooling. We did not attempt more discomfort several hours later when the retrobulbar
to identify the individual predisposing factors in our pa- anesthesia had worn off.
tients. Although we did not use any compression of the None of the patients were severely bothered by the op-
eyeball, the Honan balloon is used commonly with ret- erating microscope light. More patients (10%) were mod-
robulbar anesthesia. With the Honan balloon, the eyeball erately bothered by the light with topical anesthesia. Most
tends to return to its resting place in the absence of a of these patients were bothered by the light initially but
retrobulbar hemorrhage; therefore, one would not expect none had discomfort throughout the procedure. As
a greater degree of pooling of fluid in the topical anesthesia Kershner 5 indicated, manipUlation of the eyeball gen-
group. erally moves the light off the visual axis, accounting for
To eliminate pain sensation, pain fibers exiting from the low incidence of discomfort reported by patients.
the eye must be blocked. Ocular pain sensation is me- Keeping the light intensity low initially also helps avoid
diated by the long sensory root of the ciliary ganglion. discomfort. As a result of our experience with lower light

1201
Ophthalmology Volume 103, Number 8, August 1996

intensities, we tend to use lower intensities for patients References


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munication with the patients is vital for the topical tech- blockade. Anesthesiology 1985;63:688-90.
nique to be used successfully. Patients need to be informed 17. lavitt lC, Addiego R, Friedberg HL et al. Brain stem anes-
that they will be able to move their eyes and also have thesia after retrobulbar block. Ophthalmology 1987; 94:718-
24.
some sensation in their eyes during surgery. It is apparent 18. Nicoll 1M, Acharya PA, Ahlen K, et al. Central nervous
from this study that intraocular procedures can be per- system complications after 6000 retrobulbar blocks. Anesth
formed without akinesia. The degree to which intraocular Analg 1987;66:1298-302.
manipulation can be safely undertaken remains unan- 19. Kaplan LJ, laffe NS, Clayman HM. Ptosis and cataract sur-
swered by this study because we had no complications gery. A multivariant computer analysis of a prospective
requiring such manipulations. We currently are prospec- study. Ophthalmology 1985; 92:237-42.
tively evaluating the use of topical anesthesia in combined 20. Rainin EA, Carlson BM. Postoperative diplopia and ptosis.
trabeculectomy and cataract extraction. A clinical hypothesis based on the myotoxicity of local an-
As with adoption of any new technique, the true in- esthetics. Arch Ophthalmol 1985; 103:1337-9.
cidence of complications as well as other undescribed 21. Kimble lA, Morris RE, Witherspoon CD, Feist RM. Globe
complications will present themselves over time as more perforation from peribulbar injection [letter). Arch
Ophthalmol 1987; 105:749.
experience is gained. Surgery in this study was undertaken 22. Bloomberg LB. Anterior periocular anesthesia: five years
by surgeons who had experience with topical anesthesia. experience. 1 Cataract Refract Surg 1991; 17:508-11.
The difficulties and complications that would be encoun- 23. Fukasaku H, Marron lA. Pinpoint anesthesia: a Anew ap-
tered by a surgeon converting to the use of topical anes- proach to local ocular anesthesia. 1 Cataract Refract Surg
thesia currently are being evaluated. 1994; 20:468-71.
Acknowledgments. The authors thank Deborah Harri- 24. Gills lP, Hustead RF, Sanders DR, eds. Ophthalmic Anes-
son for her assistance in the design of this study. thesia. Thorofare, Nl: Slack, 1993; 187-202.

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Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery
25. Kershner RM. Topical anesthesia for small incision self- 28. Diamond GR. Topical anesthesia for strabismus surgery. J
sealing cataract surgery. A prospective evaluation of the first Pediatr Ophthalmol Strabismus 1989; 26:86-90.
100 patients. J Cataract Refract Surg 1993; 19:290-2. 29. Shuler JD. Topical anesthesia in a patient with a history of
26. Stevens JD. A new local anaesthesia technique for cataract retrobulbar hemorrhage [letter]. Arch Ophthalmol 1993;
extraction by one quadrant sub-Tenon's infiltration. Br J 111:733.
Ophthalmol 1992; 76:670-4. 30. Abelson MB, Mandel E, Paradis A, George M. The effect
27. Knapp H. On cocaine and its use in ophthalmic and general of hyaluronidase on akinesia during cataract surgery.
surgery. Arch Ophthalmol 1884; 13:402-48. Ophthalmic Surg 1989; 20:325-6.

Centennial Advertisement
From Soemmerring S. Abblidungen des menschlichen auges, Frankfurt, 1801. Soemmerring's work
is known for its accurate and detailed plates on the structure of the eye. Soemmerring's text was
translated later into French and, along with the plates, published by A. P. Demours in 1818.*

* Centennial advertisement provided courtesy of the Museum of Ophthalmology, Foundation of the American Academy of
Ophthalmology, San Francisco, California

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