Intracameral Anesthesia Research Articles

Efficacy of topical plus intracameral anesthesia for cataract surgery in high myopia: Randomized controlled trial

To assess the efficacy of intracameral lidocaine supplementation of topical anesthesia during cataract surgery in eyes with high myopia. Department of Ophthalmology, Ospedale San Pietro-Fatebenefratelli, Rome, Italy. This prospective double-blind study comprised 120 highly myopic eyes with an axial length (AL) greater than 26.0 mm scheduled for routine cataract surgery. Cases were divided into 2 groups of 60 eyes each. One group received a placebo of balanced salt solution (BSS) (control group) and the other group, a supplement of 0.1 mL preservative-free lidocaine hydrochloride 1% injected in the capsular bag during hydrodissection (lidocaine group). Intraoperative pain was assessed by recording spontaneous patient reports of sensation of pain or ocular discomfort during 3 surgical stages: phaco tip insertion, irrigation/aspiration (I/A) system insertion for cortical aspiration, I/A system insertion for ophthalmic viscosurgical device removal after intraocular lens implantation. Postoperative pain was assessed on a visual analog scale (range 0 to 10). Data were compared by chi-square and Mann-Whitney U tests. The overall mean AL was 28.58 mm (28.57 mm control group; 28.50 mm lidocaine group). Fewer patients in the lidocaine group reported intraoperative pain, ocular discomfort, or tissue manipulation (odds ratio=0.36; 95% confidence interval, 0.16-0.80; P= .019). The mean postoperative pain score was 1.88+/-2.17 (SD) in the control group and 1.36+/-2.02 in the lidocaine group; the difference was not statistically significant (P= .21). Intracameral lidocaine supplementation for cataract surgery may improve intraoperative comfort under topical anesthesia in highly myopic eyes.

A Comparison of Methods of Local Anaesthesia used for Cataract Extraction

This paper will discuss the various techniques used for the instillation of local anaesthetics (LA) during intraocular (10) cataract extraction. It will be limited to a comparison of peribulbar block, sub-Tenons block and topical plus intracameral anaesthesia alone, as these are those most frequently used at the author's place of work. It will focus on both the surgeons' preferences and the patients' perceptions and comfort pre-, peri- and postoperatively. A description of each technique and the drugs available will be followed with a discussion of the patients' perceptions and pain levels. Included will be a summary of the patients' anxiety levels and the benefits of any sedation. Throughout, general and specific complications will be debated. All will be supported by current, relevant literature.

Sub-tenon anesthesia in the operation of cataract using phacoemulsification technique

Already in 1884, Knapp reported a successful cataract operation using 5% of cocaine in eyedrops.Today, different methods of local anaesthesia in the operation of cataract are used, such as retrobulbary, peribulbary, subconjunctival, sub-tenon, topical and intracameral anaesthesia. Phacoemulsification is a modern approach to the operation of cataract that is increasingly applied in our country. Aiming to eliminate the risk of severe complications caused by retrobulbary anaesthesia, in our patients undergoing surgery to treat cataract we applied sub-tenon anaesthesia. The aim of this work was to establish the efficacy and the safety of subtenal anaesthesia in the operation of cataract using phacoemulsification technique. We examined 85 patients who were operated for cataract under sub-tenon anaesthesia. The operation was performed using phacoemulsification technique. The surgeon injected about 2 ml of the mixture of lidocaine (2%) and bupivacaine (0.5%) in equal proportions into the bottom of the fornix at 11 o'clock or 1 o'clock position into one of the two upper eye quadrants. After phacoemulsification and the placement of intraocular lenses, the patients were asked to reply to the questions according to a standardized protocol. Priory, the patients were informed about the test and the pain scale ranging from 1 to 10, with 1 indicating the absence of pain and 10 unbearable pain. Eighty-five patients underwent surgery for cataract using phacoemulsification technique and in whom posterior chamber intraocular lenses were placed under sub-tenon anaesthesia. During the application of anaesthesia, subjective pain experience was at the level of mild discomfort or non-existent in 3/4 of the patients. In relation to pain experience during surgery, it ranged from mild inconvenience to pain absence in 4/5 of the patients. The most frequent complication during surgery was eye rolling occurring in every 10th patient. In 4/5 patients the overall surgical course was assessed by the surgeon as excellent or outstanding. Sub-tenon anaesthesia applied at one point of the upper quadrant using during modern approach in the surgery of cataract, namely the phacoemulsification technique, offers good comfort to the patient during anaesthesia introduction, as well as during surgery, with a relatively low complication rate occurring during the operation, and also offering good comfort to the surgeon.

Supplementary Intracameral Lidocaine for Phacoemulsification under Topical Anesthesia: A Meta-analysis of Randomized Controlled Trials

We consider a meta-analysis of randomized controlled trials (RCTs) comparing topical anesthesia alone with topical and intracameral anesthesia for phacoemulsification.Topical anesthesia has become an increasingly popular option for day-case cataract surgery. Many surgeons now use supplementary intraoperative intracameral lidocaine, but the evidence base for the supplementary use of intracameral anaesthetic during cataract surgery has never been reviewed systematically.The primary objective is to compare intraoperative pain for phacoemulsifications under topical anesthesia with and without intracameral anesthesia. The secondary objectives are to assess both adverse effects and complications attributable to choice of anesthesia and the need for additional anesthesia during surgery. Searches were made from the Cochrane Central Register of Controlled Trials, Medline, Excerpta Medica database, and Latin American and Caribbean Health Science Information Database up to and including June 8, 2006.Eight RCTs, recruiting a total of 1281 patients, were identified. Our data comparison showed significantly lower intraoperative pain perception in patient groups using supplementary intracameral lidocaine. No significant difference in intraoperative adverse events, corneal toxicity, or the need for supplemental anesthesia was identified.Intraoperative pain during cataract surgery under topical anaesthetic is reduced by intracameral lidocaine. Possible adverse effects of intracameral lidocaine cannot be excluded due to significant heterogeneity in outcome measures between different RCTs. Although a statistically significant reduction in intraoperative pain has been demonstrated, it is not yet possible to recommend this additional intervention without reservations.

Topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsification

Cataract is defined as loss of transparency of the natural lens and is usually an age-related phenomenon. The only recognized treatment available for cataract involves surgery. An ideal anaesthetic should allow for pain-free surgery with no systemic or local complications. It should be cost effective and should facilitate a stress-free procedure for surgeon and patient alike. Topical anaesthesia involves applying anaesthetic eye drops to the surface of the eye prior to and during surgery. This has found large acceptance especially in the USA where it is used by 61% of cataract surgeons. Many surgeons who perform cataract surgery under topical anaesthesia also use intraoperative supplementary intracameral lidocaine (injected directly into the anterior chamber of the eye). The benefits and possible risks of intracameral lidocaine have been assessed by a number of randomized controlled trials, but the results have been conflicting and many of the endpoints have been heterogeneous. The primary objective of this systematic review was to assess pain during surgery and patient satisfaction with topical anaesthesia alone compared to topical anaesthesia with intracameral anaesthesia for phacoemulsification. The secondary objectives were to assess adverse effects and complications attributable to choice of anaesthesia and the need for additional anaesthesia during surgery. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006) and LILACs (1982 to 3 May 2006). We also searched the reference lists of the identified studies and the Science Citation Index. We did not have any language restriction. We included only randomized controlled trials (RCTs) comparing topical anaesthesia alone to topical anaesthesia with intracameral lidocaine. Two authors independently assessed trial quality and extracted data. For dichotomous outcomes data were presented as odds ratios. For continuous outcomes the weighted mean difference was employed. A random-effects model was used unless there were fewer than three trials in a comparison, where a fixed-effect model was used. We explored heterogeneity between trial results using a chi-squared test. A total of eight trials comprising of 1281 patients were identified for analysis. Our data comparison showed a significantly lower intraoperative pain perception in patient groups using supplementary intracameral lidocaine, although the difference was small. No significant difference was demonstrated between the groups receiving topical anaesthesia alone and topical combined with intracameral anaesthesia in terms of the need for supplemental anaesthesia, intraoperative adverse events or corneal toxicity. The use of intracameral unpreserved 1% lidocaine is an effective and safe adjunct to topical anaesthesia for phacoemulsification cataract surgery.

Frühe visuelle Rehabilitation nach Kataraktoperation in kombinierter topischer und intrakameraler Anästhesie

Topical anaesthesia in cataract surgery permits early visual rehabilitation due to the reduced impact on the optic nerve function. In this prospective study, we evaluated the course of visual improvement after surgery. 45 consecutive patients with senile cataract and no concomitant eye disease were included in the study. Cataract surgery by clear corneal phacoemulsifaction was performed with insertion of a foldable IOL in the capsular bag under topical anaesthesia. For anaesthesia topical lidocaine gel (2 %) and intracameral injection of 0.15 ml lidocaine (1 %) was used. Uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) were measured in decimal fractions within 4 hours after surgery and 1 day postoperatively. The average preoperative UCVA was 0.23 +/- 0.39 and BCVA was 0.38 +/- 0.23 SD. Four hours postoperatively UCVA and BCVA improved significantly to 0.48 +/- 0.24 and 0.68 +/- 0.18, respectively. One day after surgery, the average UCVA was 0.65 +/- 0.15 and the BCVA was 0.89 +/- 0.07. 75 % (34) of the patients improved to a UCVA of 0.5 or better. The visual acuity improved in all patients one day after surgery, with 60 % (27) of the patients achieving a BCVA of 0.9 or better one day postoperatively. The postoperative corneal function had a significant influence on visual recovery (p = 0.01). A significant visual improvement was observed immediately after cataract surgery using the combination of topical and intracameral anaesthesia. 75 % of the patients reached a UCVA, which permitted sufficient visual function for mobility and orientation. Thus, the rapid recovery of visual function suggests an increased safety, particularly for out-patient surgery.

Safety and efficacy of topical anesthesia combined with a lower concentration of intracameral lidocaine in phacoemulsification: Paired human eye study

To assess the safety and efficacy of phacoemulsification under a topical anesthesia combined with intracameral lidocaine 0.5%. Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, China. A prospective randomized double-blind study was designed in which patients had phacoemulsification performed under topical anesthesia (4 drops of nonpreserved lidocaine 2%) with 0.15 mL intracameral placebo (balanced salt solution) in 1 eye (Group 1) and topical anesthesia with intracameral nonpreserved lidocaine 0.5% in the other eye (Group 2). Endothelial changes, including cell density, coefficient variation of cell size, and percentage of hexagonal cells, were measured by noncontact specular microscopy. Preoperative and postoperative best corrected visual acuity was also documented. The degree of pain throughout surgery was ranked on a 10-point visual analog pain scale. Thirty-three patients were recruited. There was no significant difference in preoperative and postoperative mean endothelial parameters between the 2 groups. Furthermore, mean endothelial cell loss was similar. Mild or no pain (score 0 to 1) was reported by 48.5% in Group 1 and 90.9% in Group 2. Patients reported less pain with combined topical and intracameral lidocaine anesthesia (P = .001, Mann-Whitney test). Vision was significantly improved in both groups. However, 1 patient in Group A developed vitreous loss as a result of involuntary eye movement. Combining topical anesthesia with intracameral lidocaine 0.5% [corrected] anesthesia was safe and effective in phacoemulsification with intraocular lens implantation.

Pain Induced by Phacoemulsification Performed by Residents Using Topical Anesthesia

To evaluate patient-reported pain induced by phacoemulsification performed by residents using topical anesthesia. This prospective study comprised 81 eyes of 76 consecutive patients having phacoemulsification under topical anesthesia. Surgery was performed by an experienced surgeon (group 1; n=41 eyes) or by two residents (group 2; n=40 eyes). No sedation or intracameral anesthesia was used in either group. Eighty eyes had clear corneal phacoemulsification with foldable acrylic posterior chamber intraocular lens implantation. Patients were asked postoperatively to grade the pain they experienced during the procedure using a visual analog pain scale from 0 to 10. The median pain score for the overall pain was 1.59 +/- 1.43 (range: 0 to 6) in group 1 and 1.95 +/- 1.64 (range: 0 to 7) in group 2 (P = .291). The mean pain score for the maximum pain perceived was 2.39 +/- 1.86 (range: 0 to 7) in group 1 and 2.53 +/- 1.67 (range: 0 to 7) in group 2 (P = .734). There was no significant correlation between the duration of surgery and the overall pain score (r = 0.102, P = .365). Topical anesthesia had sufficient analgesic effects in selected patients undergoing phacoemulsification cataract surgery by resident surgeons. The pain felt during the operation was low and tolerable.

Irisnahtfixation bei dezentrierter Intraokularlinse

Most revisions after intraocular lens (IOL) implantation are due to an insufficiency of the zonular apparatus. Frequently, an inferior decentration can be seen ("sunset syndrome"). In this clinical study, suture refixation of the haptics to the iris was assessed. Functional and morphological results were considered. 21 eyes with subluxation of the IOL were treated with iris sutures for refixation. The operation was performed under topical and intracameral anaesthesia. Refixation was achieved by suturing one or both haptics to one or two fixation points in the outer periphery of the iris. Complete zonular dialysis made it necessary to suture at two fixation spots. All eyes were examined preoperatively, at one day and three months postoperatively considering functional results and postoperative IOL centration. In 15 eyes (71%), the IOL was optimally centred postoperatively. In 5 eyes (24%), a revision had to be performed due to instable centration. In one further case the IOL was minimally decentred, but its position was stable. Best corrected visual acuity was 0.3 +/- 0.2 preoperatively and 0.5 +/- 0.2 after three months. The mean refraction was stable in the postoperative course and astigmatism did not change significantly. There were no major complications intraoperatively or postoperatively, but a localised iris atrophy at the haptic fixation points was noted. In the presence of a partially intact zonular apparatus, iris sutures are a safe and minimally invasive method for fixing a decentred IOL. Postoperative centration and functional results were stable after 3 months.

Cytotoxicity of Lidocaine or Bupivacaine on Corneal Endothelial Cells in a Rabbit Model

To investigate the corneal endothelial cytotoxicity of commercial formulations of agents used for intracameral anesthesia in cataract and other ocular surgery. Cultured corneal endothelial cells (CECs) of New Zealand White rabbits were exposed for 1 minute to balanced salt solution (control); Xylocaine (lidocaine) 1% E (with epinephrine), 2% E, 2%, or 4%; or Marcaine (bupivacaine) 0.5% or 0.5% spinal heavy. The degree of cytotoxicity was determined by in vitro staining with trypan blue and light microscopic evaluation of cell morphology. The effect of longer exposure (up to 16 minutes) to lidocaine 1% E was also investigated. CECs were not significantly damaged by 1-minute exposure to lidocaine 1% E or 2% E; however, significant cytotoxicity was seen after 1-minute exposure to lidocaine 2% or 4% or bupivacaine 0.5% or 0.5% spinal heavy. Exposure to lidocaine 1% E showed a trend toward time-dependent cytotoxicity that reached significance at 16 minutes. One-minute exposure to lidocaine 1% E or 2% E appears to be safe for cultured rabbit CECs, although longer exposures could cause time-dependent cytotoxicity, which should be considered in planning cataract or other ocular surgery. Because bupivacaine 0.5% and 0.5% spinal heavy cause cytotoxic effects within the first minute of contact with CECs, they should be used with great caution, if at all, in the anterior chamber of human eyes.

Treatment of acute postoperative endophthalmitis without hospital admission: Do we dare?

We report the successful management of a culture positive case of APE, without the need for hospital admission and discuss the merits of this strategy. A 79-year-old lady underwent uncomplicated cataract surgery in her left eye using phacoemulsification under topical and intracameral anaesthesia. She reported to eye casualty four days later, with pain and vision reduced to 6/60 in the left eye. A diagnosis of acute postoperative endophthalmitis was made. A vitreous biopsy was performed and antibiotics injected intravitreally on the same day. The patient was discharged on oral and topical antibiotics on the same day and reviewed subsequently in the clinic as an outpatient. Vision steadily improved and at one month following intravitreal injection her vision had improved to 6/9 unaided. The cornea remained clear, with a quiet anterior chamber and a clear view of the fundus. Current management of acute postoperative endophthalmitis in the UK includes a vitreous biopsy, administration of antibiotics into the vitreous cavity, admission of patients to a hospital ward and daily review. It is our opinion that under the circumstances where patients are fit and well, without significant co-morbidity, hospital admission is not necessary as demonstrated by the patient in our report.

Lidocaine Gel versus Combined Topical Anesthesia Using Bupivacaine, Oxybuprocaine and Diclofenac Eyedrops in Cataract Surgery

Purpose: To assess the safety and efficacy of two topical anesthesia regimes for cataract surgery. Methods: 21 patients received a combination of 4 times bupivacaine 0.5, oxybuprocaine and diclofenac eyedrops, 18 patients were given a single topical application of lidocaine gel 2%. A single intracameral injection of lidocaine 1% was administered to all subjects. Results: The extent to which the surgeon was bothered by patient motility was graded as low in about two thirds of all procedures. Patients reported lower intraoperative pain levels with a single application of lidocaine gel supplemented with intracameral lidocaine than with a fourfold application of the combination topical anesthesia plus intracameral anesthesia. Conclusions: A single application of lidocaine gel 2% combined with intracameral anesthesia provides at least as good analgesia than multiple administration of combined topical anesthesia supplemented with intracameral anesthesia and is equally safe.

Contact-Topical Plus Intracameral Lidocaine Versus Peribulbar Anesthesia in Combined Surgery

To compare the efficiency and safety of contact-topical anesthesia versus peribulbar injection anesthesia for phacotrabeculectomy. A total of 80 patients undergoing combined cataract and glaucoma surgery were randomly allocated to receive either contact or peribulbar anesthesia. No systemic sedatives were used in either group. Patients were asked to rate their pain level on a 5-point scale for 4 periods: during administration of the anesthetic agent; during surgery; immediately after surgery; and 24 hours postoperatively, while the surgeon recorded his subjective assessment of ease of surgery using a standardized template. The patients' general condition during surgery, as well as the results and short-term complications, were assessed. The injected anesthesia group showed higher rates of discomfort and pain, and 37 patients reported pain ranging from mild to severe during anesthetic administration. The difference between groups was statistically significant (P < 0.001). During surgery, there were no differences in vital signs, patients' subjective pain evaluation, or surgeon stress. We found no differences between pain rates after surgery. Complications included prolonged chemosis, and we also noted that conjunctival hemorrhage occurred more frequently in the peribulbar group than in the contact anesthesia group. Both anesthetic methods provide high levels of pain control without additional sedation during surgery. The use of contact-topical anesthesia avoids pain and reduces the possibility of complications during administration of anesthetics.

Combined topical and intracameral anesthesia in penetrating keratoplasty.

The standard of care for penetrating keratoplasty (PKP) is either retrobulbar or peribulbar anesthesia combined with seventh cranial nerve akinesia or general anesthesia. These methods are known to be associated with rare but potentially serious adverse ocular and systemic events. To determine the safety and efficacy of combined topical and intracameral anesthesia in addition to intravenous sedation for repeat penetrating keratoplasty (PKP). Tertiary-care university hospital. In this prospective study, combined topical tetracaine 0.5% and 0.2 cc intracameral 1% lidocaine along with i.v. sedation with midazolam and fentanyl were used for patients undergoing repeat PKP in 15 eyes of 15 selected patients. The indication for surgery was failed corneal graft. Verbal pain scale (VPS, 0-3) was recorded preoperatively, intraoperatively at 3 time-points (after trephination, after placing 8 interrupted sutures, and after placing the running suture), and postoperatively (1 hour postoperatively, overnight pain, and 1 day postoperatively). Patient and surgeon satisfaction were assessed postoperatively using a scale (1-5). After surgery patients were asked for their preferences comparing the current use of topical anesthesia compared with retrobulbar anesthesia used for their initial PKP. The mean intraoperative VPS score was 0.51 +/- 0.32 (range 0-1.33), and the mean postoperative VPS score was 0.47 +/- 0.50 (range 0-1.67). There were no serious intraoperative or postoperative complications. All patients reported high mean satisfaction score of 4.67 +/- 0.49 (range 4-5). The mean satisfaction score reported by the surgeon was 4.47 +/- 0.63 (range 3-5). All patients but 1 (93.3%) preferred combined topical over retrobulbar anesthesia, which they had in their previous surgery. We found combined topical and intracameral anesthesia to be safe and effective in our selected group of patients undergoing repeat PKP, and it may provide a satisfactory alternative anesthetic modality for patients in whom general, retrobulbar, or peribulbar anesthesia may be contraindicated.

Unexplained Surface Sensations with Intracameral Anesthesia in Phacoemulsification

Claoué, Charles MD, DO, FRCS, FRCOphth, FEBO; Uppal, Gurmit Singh MBBS; Jain, Saurabh MRCOphth Author Information

Vergleichende Verlaufsbeobachtung der Tetracaintropfanästhesie gegen Lidocaingelanästhesie bei der Kataraktoperation

in addition to intracameral anaesthesia, drop anaesthesia with tetracaine drops has been established for topical anaesthesia in cataract surgery. Anaesthesia with lidocaine gel is less established. We compared pain sensitivity of patients undergoing surgery with drop anaesthesia to patients who underwent surgery with gel anaesthesia. In a questionnaire-based survey in which patients assessed their sensitivity to pain during cataract surgery, we compared the sensitivity to pain of 49 patients during surgery with gel anaesthesia to 62 patients who consecutively underwent surgery with drop anaesthesia. Patients assessed pain intensity postoperatively by checking off a 10-graduation pain scale. Lidocaine gel (2 %) was applied once while tetracaine drops (1 %) were applied three times. All interventions were carried out by two surgeons as phako emulsifications with implantation of a posterior chamber lens via posterior-limbal access. In addition to pain sensitivity we also considered the patients' age, duration of surgery and surgical complications. The data for the patients' age, the duration of surgery and the assessment of intensity were not normally distributed so that a Mann-Whitney-rank-sum test was performed. No differences were observed between tho two groups, neither regarding age (P = 0.63) nor the duration of the surgical intervention (p = 0.43). However, in patients treated with tetracaine drops pain sensitivity was reported as being significantly less (mean 1,77) than in patients treated with lidocaine gel (mean 2.22; P < 0.043). 73.5 % of patients with gel anaesthesia and 83.9 % of those with drop anaesthesia reported "negligible" pains. There were no intra-operative complications. Both gel anaesthesia and drop anaesthesia are suitable methods for cataract surgery under local anaesthesia. According to patients' assessment, drop anaesthesia with tetracaine is better suited for pain elimination.

Simultaneous bilateral cataract surgery

Purpose To evaluate the safety and outcomes of simultaneous bilateral cataract surgery (SBCS). Setting York Finch Eye Associates and Humber River Regional Hospital, Toronto, Ontario, Canada. Methods This retrospective study reviewed the results of 1020 consecutive patients (2040 eyes) who had SBCS by endolenticular phacoemulsification through a clear corneal incision on the corneal steep axis with foldable posterior chamber intraocular lens implantation. The surgeries were performed by the same surgeon from January 1996 to January 2002 as 2 consecutive independent procedures under topical and intracameral anesthesia. Outcome measures included intraoperative and postoperative complications, postoperative uncorrected and best spectacle-corrected visual acuities, refractive error, and patient satisfaction. Results Complications were few and would not likely have been prevented had the surgery been performed monocularly. Conclusions Simultaneous bilateral cataract surgery did not lead to an increased incidence of intraoperative or postoperative complications. The visual acuity results were good, and the patients were pleased. No complications were observed that could be attributed to the procedures being done bilaterally.

THE EFFECTS OF INTRACAMERAL ANESTHESIA ON THE CORNEAL ENDOTHELIUM IN RABBITS

Newer methods of ocular anesthesia have emerged to complement the advanced techniques and instrumentation of modern - day cataract surgery. Local anesthesia has become preferable to general anesthesia for cataract surgery. The advantages of local anesthesia are well known and include: more rapid arnbulation, the ability to perform the procedure an outpatient. avoidance of complications associated with general anesthesia, and quicker surgery (Patel et al., 1996).Methods of local anesthesia for cataract extraction include: retrobulbar, peribulbar.subconjunctival, and sub-Tenon application of local anesthetic solution (Ducker et al., 1991). Retrobulbar anesthesia has been associated with a number of potentially serious complications including inadvertent globe perforation, retrobulbarhemorrhage, orbital infection, central retinal artery occlusion, damage to the optic nerve, intravascular or intrathecal injection, postoperative diplopia and ptosis (Morgan et al., 1988). Peribulbar anesthesia eliminates the risk of optic nerve trauma, and lessens the chance of retrobulbar hemorrhage. However, the risk of globe perforation still remains (Kimble et al., 1987). Topical and intracameral anesthesia are new options for pain control in modern cataract surgery. Topical anesthesia has been shown to be a safe and effective alternative to retrobulbar and p«.ibulbar anesthesia (Duguid et al., 1995). Topical anesthesia provides adequate anesthesia for phacoemulsification, with immediate recovery of visual acuity after surgery. However, the significant downfall of this technique lies in its failure to provide adequate motor and sensory anesthesia, when only topical drops are used. This may lead to an increased risk of intraoperative complications due to unrestricted eye movement and insufficient pain control. The lack of optic nerve blockade may also result in intolerance of the microscopic light (Fukasaku and Marron, 1994; Kreshner, 1993). Subconjunctival and peribulbar anesthesia have been recommended as supplements to topical anesthesia. (Anderson, 1995).

Acute suprachoroidal hemorrhage during clear corneal phacoemulsification using topical and intracameral anesthesia

Shallowing of the anterior chamber and hardening of the eye occurred just before commencement of irrigation/aspiration of cortex in an 80-year-old man having temporal clear corneal cataract surgery under topical and intracameral anesthesia. Nucleus removal had been completed and was uneventful. Intraoperative fundus examination with the indirect ophthalmoscope disclosed a choroidal hemorrhage. The wound was immediately closed with sutures, and intravenous mannitol was administered. The hemorrhage remained localized. The red reflex remained unchanged at all times, and there was no prolapse of intraocular contents. A high index of suspicion is critical to the early diagnosis and management of choroidal hemorrhage.

Patient Comfort with Combined Anterior Sub-Tenon's, Topical, and Intracameral Anesthesia Versus Retrobulbar Anesthesia in Trabeculectomy, Phacotrabeculectomy, and Aqueous Shunt Surgery

To assess patient comfort using combined anterior sub-Tenon's, topical, and intracameral ("Blitz") anesthesia versus retrobulbar anesthesia in glaucoma surgery. In this study, 139 consecutive patients who received retrobulbar anesthesia and 139 consecutive patients who received Blitz anesthesia during glaucoma surgery were evaluated in a prospective fashion. The retrobulbar group included 49 trabeculectomies, 36 aqueous shunts, and 54 phacotrabeculectomies. The Blitz group included 49 trabeculectomies, 30 aqueous shunts, and 60 phacotrabeculectomies. Patients were asked to assess their level of ocular pain operatively and postoperatively on a 10-point visual analog scale. The operative and postoperative pain scores and postoperative sedation of patients receiving retrobulbar anesthesia were compared with those of patients receiving Blitz anesthesia during trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery, separately. No statistically significant difference was found in the mean operative or postoperative pain scores between the two groups during trabeculectomy, phacotrabeculectomy, or aqueous shunt surgery. Blitz anesthesia offers a reasonable alternative to retrobulbar anesthesia for trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery.