Pain during pars plana vitrectomy following sub-Tenon versus peribulbar anesthesia: A randomized trial.

Jefferson A S Ribeiro,Ingrid U Scott,Rodrigo Jorge,João Abrão,Daniel S Ribeiro,Luciano Quaranta

doi:10.1371/journal.pone.0236624

Abstract

PurposeTo compare pain during pars plana vitrectomy (PPV) following topical lidocaine jelly and sub-Tenon anesthesia versus peribulbar anesthesia.MethodsProspective, single-center, randomized study. Patients scheduled for PPV for macular hole (MH) or epiretinal membrane (ERM) at the Retina and Vitreous Section of the Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo were randomly assigned to one of two groups in a 1:1 allocation ratio. Patients assigned to Group ST received topical anesthesia with 2% lidocaine jelly followed by sub-Tenon anesthesia with 2–4 ml of 1% ropivacaine. Patients assigned to PB received peribulbar anesthesia with 4–6 ml of 1% ropivacaine. After PPV, patients in both groups were asked to rate the level of pain they felt during the entire procedure (including anesthesia administration and PPV) by pointing at a 0–100 Visual Analogue Pain Scale (VAS). Data regarding demographics, patient characteristics and surgical features were also collected.ResultsFifty-four patients were enrolled in the study (26 in Group ST and 28 in Group PB). Baseline characteristics, including age, gender, and presence of comorbidities, were similar in both groups. The surgery performed was PPV alone in 10 and 14 patients in the ST and PB groups, respectively, and combined phacoemulsification and PPV in 16 and 14 patients in the ST and PB groups, respectively (p = 0.39, Pearson). Surgery duration (mean ± SD minutes) was similar in the two groups (62 ± 12 for ST and 70 ± 20 for PB, p = 0.09, t-Test). No patients needed supplemental topical or intravenous anesthesia during surgery. No sight- or life-threatening complication was observed in either group. VAS score was significantly lower in the ST compared to the PB group (median (interquartile range) was 1 (2.25–0) in the ST group compared to 11.5 (29.75–5) in the PB group, p< 0.0001, Wilcoxon).ConclusionIn this study of patients who underwent PPV for MH or ERM, topical followed by sub-Tenon anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia. Compared to peribulbar anesthesia which is administered with a sharp needle, sub-Tenon anesthesia administered with a blunt cannula may be associated with a reduced risk of such adverse events as globe perforation, retrobulbar hemorrhage, and inadvertent injection of anesthesia into the optic nerve sheath.

Highlights

Ocular anesthesia began with the demonstration of the anesthetic effect of topical cocaine for eye surgery in 1884 by Koller [1]
In this study of patients who underwent pars plana vitrectomy (PPV) for macular hole (MH) or epiretinal membrane (ERM), topical followed by sub-Tenon anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia
Compared to peribulbar anesthesia which is administered with a sharp needle, sub-Tenon anesthesia administered with a blunt cannula may be associated with a reduced risk of such adverse events as globe perforation, retrobulbar hemorrhage, and inadvertent injection of anesthesia into the optic nerve sheath

Summary

Introduction

Ocular anesthesia began with the demonstration of the anesthetic effect of topical cocaine for eye surgery in 1884 by Koller [1]. During the early part of the 20th century, cataract surgery was performed under topical cocaine anesthesia in order to reduce the risk of complications related to orbital or general anesthesia [2]. In the 1990s, the development of ophthalmic procedures, such as modern phacoemulsification techniques, allowing safe and rapid cataract extraction [2], and topical anesthesia made this option a favorite of many surgeons [3], intraconal or peribulbar blocks may be preferred for other anterior segment surgeries, such as trabeculectomy or penetrating keratoplasty [2]. The use of sharp needles to perform local anesthesia is associated with such complications as retrobulbar hemorrhage and injection of anesthesia into the optic nerve sheath which may result in death [10,11,12]

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