Retrobulbar Anesthesia Research Articles

Comparison of analgesia and akinesia between sub-Tenon's capsule anesthesia and trans-Tenon's capsule retrobulbar anesthesia in vitrectomy.

We compared the effects of sub-Tenon's capsule anesthesia (STA) and trans-Tenon's capsule retrobulbar anesthesia (TTRBA) in 68 patients with epiretinal membrane. Either STA or TTRBA was induced with 3mL of lidocaine (2%) before vitrectomy combined with phacoemulsification and aspiration (phacovitrectomy). Akinesia was evaluated by range of eye movement (ROEM) in upward, downward, nasal, and temporal directions at 4, 10, and 30 minutes after injection. Analgesia was evaluated with a visual analogue pain score, which ranged from 0 to 10. The mean cumulative ROEMs were 1.44±1.02 corneal diameters (CDs) at 4 minutes, 0.55±0.76 CDs at 10 minutes, and 0.26±0.33 CDs at 30 minutes in patients who received STA; these values were 0.39±0.35 CDs at 4 minutes, 0.22±0.30 CDs at 10 minutes, and 0.13±0.29 CDs at 30 minutes in patients who received TTRBA. At both 4 and 10 minutes, the cumulative ROEMs in all directions, as well as the temporal ROEMs, were significantly larger in patients who received STA than in patients who received TTRBA. Pain scores did not significantly differ between groups at any time point. STA and TTRBA produced identical degrees of analgesia, but akinesia was slower in patients who received STA. TTRBA might be preferable for patients undergoing brief vitrectomy.

Surgical Treatment of Refractory Medium Macular Hole with Autologous Lens Capsular Flap Transplantation: A Case Report.

To report the clinical results of lens capsular flap (LCF) transplantation in a patient with refractory medium macular hole (MH). Case report. A 66-year-old female myopic patient with a history of medium macular hole (MH) was previously unsuccessfully treated by vitrectomy surgery, internal limiting membrane (ILM) peeling and air-fluid exchange followed by 12% C2F6 tamponade into the vitreous cavity and face-down positioning. After the first surgery, the patient's visual acuity of the left eye remained only 20/400 on the Snellen scale, and a persistent medium MH (290 µm) was observed on optical coherence tomography. Cataract of the left eye was also noted. A second surgery, combined cataract-vitrectomy surgery, was carried out to seal the MH, performed under retrobulbar anesthesia. Because there was insufficient ILM tissue to perform the ILM flap procedure, we decided to use another technique involving an autologous LCF. The patient underwent LCF placement onto the MH along with gas tamponade. At 6 months, the MH was sealed, and the patient's vision had improved to 20/32 on the Snellen scale. This is the first case report to describe the use of LCF to treat persistent medium MH. LCF seems to be effective in sealing small macular holes and was well tolerated by the patient.

Evaluating the effectiveness of localized sub-Tenon's anesthesia in 23-gauge vitreoretinal surgery.

To evaluate the effectiveness of localized sub-Tenon's anesthesia for pain control during 23-gauge vitreoretinal surgery. Eighty patients were randomly divided into two groups as localized sub-Tenon's (group 1, n = 41) and retrobulbar (group 2, n = 39) anesthesia groups. In group 1, a small volume of anesthetic was injected into the sub-Tenon's capsules at the trocar entry sites. The 23-gauge vitreoretinal surgery was performed in all patients. In both groups, the pain levels during the surgical steps were evaluated using the visual analog pain scale. Patients in group 1 experienced less pain than group 2 patients did during placement of the trocars and scleral depression (p = 0.041, p = 0.029). Pain during laser photocoagulation was higher in group 1 (p = 0.008). There was no serious complication due to anesthesia or surgery. Localized sub-Tenon's anesthesia is as effective as retrobulbar anesthesia in many steps of vitreoretinal surgery for providing pain control. It can be considered an alternative form of local anesthesia.

Outcome of Conventional Trabeculectomy in Terms of Intraocular Pressure and Visual Acuity in Primary Open Angle Glaucoma

Purpose: To determine the outcomes of conventional trabeculectomy in terms of decrease in Intra Ocular Pressure (IOP) and improvement in visual acuity in patients of primary open glaucoma, coming to a tertiary care hospital.
 Study Design: Retrospective case series.
 Place and Duration of Study: Ophthalmology department of a tertiary care hospital from January 2017 to December 2018.
 Methods: Patients undergoing trabeculectomy for Primary open angle glaucoma were included. Patients with repeated trabeculectomy, failed argon laser trabeculoplasty, advance cataract, corneal opacities and absolute glaucoma were excluded. All the trabeculectomies were done under retrobulbar anaesthesia after taking all aseptic measures. Primary outcome measures were preoperative and postoperative visual acuity, intraocular pressure, number of antiglaucoma medications and failed or successful trabeculectomy.
 Results: Total 52 patients underwent trabeculectomy. There were 36 (69.2%) males and 16 (30.8%) females. Mean age was 56.73 years ± 10.9 SD. Mean preoperative IOP was 30.96 ± 6.71 mm Hg, post operatively IOP at 1 year it was 15.6 ± 4.2 mm Hg. P value was <.000. Mean number of antiglaucoma medications was 3.03 and 1.19, pre and post-operatively respectively (p value <.000). Improvement in visual acuity after trabeculectomy was seen in 32 (61.5%) patients. Complete Surgical success was seen in 28 (53.8%) and qualified success in 21 (40.4%) patients. Failed trabeculectomy was seen in 3 (5.8%) patients.
 Conclusion: Conventional trabeculectomy is effective in lowering IOP in primary open angle glaucoma patients. It maintains IOP within normal range with and without anti-glaucoma medications at 1 year follow-up. Trabeculectomy significantly reduces number of anti-glaucoma medications.
 Key Words: Intraocular pressure, Primary open angle glaucoma, Trabeculectomy.

Continuation of aspirin therapy before pars plana vitrectomy: Safe or not?

To assess the safety of pars plana vitrectomy (PPV) in patients undergoing systemic treatment with aspirin. This prospective study enrolled consecutive patients undergoing PPV under percutaneous retrobulbar anesthesia between February 2016 and July 2018. Sixty-seven eyes from 67 patients on regular aspirin therapy were randomized into two groups: the continuation group (33 eyes), with aspirin continued during the perioperative period; and the discontinuation group (34 eyes), with aspirin discontinued for 3 to 7 days before surgery. Forty-three eyes from 43 patients who had no antiplatelet/anticoagulant therapy were used as a control group. There was no significant difference in the incidence of hemorrhagic complications or the need for additional operations due to hemorrhagic complications among the three groups (p = 0.740 and p = 0.324, respectively). None of the patients in these three groups suffered from thromboembolic events during the follow-up period. Except for one case (3.0%) of lid ecchymosis in the continuation group, no eye experienced bleeding complications associated with the retrobulbar local anesthesia. In the continuation group, three eyes (9.1%) demonstrated postoperative hyphema that resolved spontaneously. In the discontinuation group, two eyes (5.9%) suffered from postoperative vitreous hemorrhage, of which one eye required secondary surgery and the other cleared spontaneously. One eye (2.9%) in the discontinuation group demonstrated postoperative hyphema that absorbed spontaneously. Three eyes (7.0%) in the control group experienced hyphema that absorbed spontaneously. The outcomes of our study indicate that PPV under retrobulbar anesthesia can be safely performed without discontinuing systemic aspirin therapy.

Quantitative analysis of Gamma Knife stereotactic radiosurgery for uveal melanoma

Abstract The purpose of the study was to analyze single fraction Gamma Knife stereotactic radiosurgery (SRS) for uveal melanoma (UM). In the treatment of UMs, the dose distribution exhibited by an irregular eye surface has more calculation uncertainty. A tissue-equivalent bolus was placed on the left eye surface of a human head-shaped phantom. It was assumed that the treated eye is fixed using retrobulbar anesthesia and suture on extraocular muscles for phantom study. Leksell stereotactic frame was fixed around phantom’s head and the stereotactic computed tomography (CT) was performed. Two sets of scans were acquired (a) without bolus and (b) with a bolus of 1.0 cm thickness. These scans were transferred into a treatment planning system (TPS). The skull contouring was performed using stereotactic CT images. The target, visual pathways, and eye lens were delineated in stereotactic CT space created on TPS. A clinical relevant plan was designed on the CT study set “a” to deliver a radiation dose of 30Gy at tumor margin. The plan superimposed over CT study set “b” and compiled for convincing treatment strategy. The tumor coverage was 95% at 50% prescription isodose line. The conformity index, selectivity and the gradient index were 1.27, 0.80 and 3.28 respectively. The left optic nerve and eye lens received a maximum dose of 11.1 Gy and 11.0 Gy respectively. The treatment plan overlay showed similar planning indices and critical organ doses. The plan comparison showed: an irradiated volume received the radiation dose > 15 Gy varies < 1.0% whereas the volume received < 15 Gy were larger (> 1.0%) in the study set “b”. The distant lateral points from the target volume which describe the phantom’s eyelid showed a radiation dose of 3.2 Gy - 2.5 Gy. The doses to these points were misled and ignored in the CT study set “a”. The eye bolus provides better dosimetric information in the estimation of low dose areas which is commonly misled on TPS in SRS planning for UMs.

A New Two-Step Anesthesia for 23- or 25-Gauge Vitrectomy Surgery: A Prospective, Randomized Clinical Trial

Objective: To investigate the safety and efficacy of topical anesthesia combined with subconjunctival anesthesia (termed two-step anesthesia) for 23- or 25-gauge pars plana vitrectomy or other posterior segment surgery. Methods: Patients (n = 90) requiring 23-/25-gauge vitrectomy or other posterior segment surgery were randomized into 3 groups. Group 1 received peribulbar anesthesia, group 2 received retrobulbar anesthesia and group 3 received two-step anesthesia. A 5-point visual analog pain scale (VAPS) was used to measure self-report of patient pain. Complications were recorded for subsequent analysis. Results: VAPS scores for overall intraoperative pain ranged from 0 to 3 (1.07 ± 1.07) in group 1, from 0 to 2 (0.69 ± 0.93) in group 2 and from 0 to 3 (1.06 ± 0.98) in group 3. Assessment of surgeon discomfort score ranged from 0 to 2 (0.31 ± 0.66) in group 1, from 0 to 3 (0.38 ± 0.82) in group 2 and from 0 to 2 (0.47 ± 0.62) in group 3. Both scores reveal no significant difference among the 3 groups. While there were no complications noted in group 1, there was an ocular perforation in group 2. Additionally, there were no complications in group 3 related to the anesthetic technique. Conclusions: Results suggest that two-step anesthesia is a safe and effective anesthetic approach for selected patients undergoing 23- or 25-gauge pars plana vitrectomy or other posterior segment surgeries. It may offer a viable alternative to peribulbar anesthesia and retrobulbar anesthesia for carefully selected 23- or 25-gauge cannular-access ocular surgeries.

Retrospective analysis of complications associated with retrobulbar bupivacaine in dogs undergoing enucleation surgery

ObjectiveTo investigate complications associated with, and without, bupivacaine retrobulbar local anesthesia in dogs undergoing unilateral enucleation surgery. Study designRetrospective, observational study. AnimalsA total of 167 dogs underwent unilateral enucleation surgery via a transpalpebral approach. MethodsRecords from 167 dogs that underwent unilateral enucleation surgery that did (RB) or did not (NB) include retrobulbar bupivacaine anesthesia were reviewed, including anesthetic record, daily physical examination records, surgery report, patient discharge report and patient notes within 14 days of the surgery. Specific complications and severity were compared between RB and NB using the Wilcoxon rank-sum test. A ‘complication burden’ (0–5) comprising five prespecified complications was assigned and tested using rank-sum procedures. Statistical significance was set to 0.05. ResultsGroup RB included 97 dogs and group NB 70 dogs. Dogs in NB had a 17.0 percentage points (points) greater risk for a postoperative recovery complication (38.6% versus 21.6%; 95% confidence interval: 3.0–30.6 points; p = 0.017). There was inconclusive evidence that dogs in group RB had a lower risk of requiring perioperative anticholinergic administration (12.4% versus 22.9%; 10.5 points; p = 0.073). Other complications were similar between groups RB and NB with risks that differed by <10 points. The risk of hemorrhage was similar between groups RB (22.7%) and NB (20.0%) with no significant difference in the level of severity (p = 0.664). Conclusions and clinical relevanceIn this retrospective study, the use of retrobulbar bupivacaine for enucleation surgery in dogs was not associated with an increased risk of major or minor complications.

Preoperative upper lid skin tear: a rare and unique complication of retrobulbar anesthesia before cataract surgery

Retrobulbar anesthesia is commonly administered before cataract surgery or other intraocular and intraorbital ophthalmic procedures. The main benefits of retrobulbar anesthesia include rapid onset of action, low volume required to achieve analgesia, and complete akinesia. Retrobulbar anesthesia has a low risk for complications, and those complications are well known and have been extensively documented. A unique complication of an upper lid skin tear secondary to a retrobulbar block is presented.

The effect of retrobulbar anesthesia for cataract surgery on the retinal nerve fiber layer thickness.

The aim of this study was to evaluate the effect retrobulbar and topical anesthesia on optic nerve by measuring retinal nerve fiber layer (RNFL) thickness before and after phacoemulsification cataract surgery using optical coherence tomography (OCT). A total of 126 eyes of 108 patients were included in the study. Retrobulbar anesthesia was used in 61 eyes of 53 patients, and topical anesthesia was used in 65 eyes of 55 patients. OCT scans were done 1week before the surgery and 4weeks after surgery, and the results were evaluated. The average RNFL thickness increased postoperatively in both groups (p < 0.001 for topical anesthesia group and p = 0.001 for retrobulbar anesthesia group). The preoperative and postoperative average and quadrant RNFL thickness and the change in RNFL thickness were not significantly different between the two anesthesia groups (p > 0.05). Our results suggest that retrobulbar anesthesia has no unfavorable effect on the retinal nerve fiber layer.

Iatrogenic ophthalmic artery occlusion and retinal artery occlusion.

Iatrogenic ophthalmic artery occlusion (IOAO) is a rare but devastating ophthalmic disease that may cause sudden and permanent visual loss. Understanding the possible etiologic modalities and pathogenic mechanisms of IOAO may prevent its occurrence. There are numerous medical etiologies of IOAO, including cosmetic facial filler injection, intravascular procedures, intravitreal gas or drug injection, retrobulbar anesthesia, intraarterial chemotherapy in retinoblastoma. Non-ocular surgeries and vascular events in arteries that are not directly associated with the ophthalmic artery, can also cause IOAO. Since IOAO has a limited number of treatment modalities, which lead to poor final visual prognosis, it is imperative to acknowledge the information regarding medical procedures that are etiologically associated with IOAO. We accumulated all searchable and available IOAO case reports (our cases and previous reported cases from the literature), classified them according to their mechanisms of pathogenesis, and summarized treatment options and responses of each of the causes. Various sporadic cases of IOAO can be categorized into three mechanisms as follows: intravascular event, orbital compartment syndrome, and increased intraocular pressure. Embolic IOAO, which is considered the primary cause of the condition, was classified into three subgroups according to the pathway of embolic movement (retrograde pathway, anterograde pathway, pathway through collateral channels). Despite the practical limitations of treating spontaneous (non-iatrogenic) retinal artery occlusion, this article will contribute in predicting and improving the prognosis of IOAO by recognizing the treatable factors. Furthermore, it is expected to provide clues to future research associated with the treatment of retinal artery occlusion.

Seizures during Pars Plana Vitrectomy Surgery with Retrobulbar Anesthesia: A Case Report

We are presenting a patient who experienced generalized tonic-clonic seizures after retrobulbar injection of 2% lidocaine and 0.75% bupivacaine before pars plana vitrectomy surgery. Airway control was achieved and oxygen was given manually via a face mask. He recovered spontaneous ventilation five minutes later but did not remember experiencing the seizures. The patient had no personal or family antecedents of epilepsy. A computed tomography scan of brain was normal. As seizures are rare and serious complications which can occur during locoregional anesthesia, the mechanisms involved in this complication and possible methods of prevention should be discussed clinically.

Effect of hyaluronidase addition to retrobulbar local anesthesia for phacoemulsification on intraocular pressure

Purpose The aim of this study was to evaluate the effect of adding hyaluronidase to local anesthetic agents on intraocular pressure (IOP) following retrobulbar anesthesia for patients scheduled for routine phacoemulsification.Patients and methods This is a prospective comparative study that included patients scheduled for routine phacoemulsification. Patients were classified into two groups: group A patients were planned to have retrobulbar blocks with lidocaine 2% and hyaluronidase 20 IU/ml, and group B patients were planned to have retrobulbar blocks with lidocaine 2% only without hyaluronidase. IOP was measured immediately before and 2, 5, and 10 min after retrobulbar anesthesia administration in both groups using a calibrated Tono-pen.Results The study included 60 eyes of 50 patients. The mean preinjection IOP in group A patients (hyaluronidase group) was 16.38±2.41 mmHg, whereas the mean 10-min postinjection IOP was 18.17±3.54 mmHg (P>0.05). The mean preinjection IOP in group B patients (nonhyaluronidase group) was 15.41±2.63 mmHg, whereas the mean 10-min postinjection IOP was 24.34±5.25 mmHg (P<0.001). The mean change in IOP in group A before and after retrobulbar anesthesia (IOP rise) was 1.79±2.96 mmHg, whereas in group B, the mean IOP rise was 8.93±4.74 mmHg (P<0.001).Conclusion Although the addition of hyaluronidase to lidocaine 2% before cataract surgery had no IOP-lowering effect, it also did not cause any significant rise of postinjection IOP and did keep it within the range of the preinjection IOP.

Strabismus and oculomotor disorders induced by injection anesthesia for cataract surgery

To analyze diagnostic and treatment outcomes in patients with strabismus and oculomotor disorders induced by injection anesthesia for cataract surgery. The study included 11 patients (7 women and 4 men) aged 61 to 85 years (the mean age of 66±7.1 years) who complained of diplopia in the early post-op period after cataract phacoemulsification and elastic IOL implantation under retrobulbar anesthesia. Prior to further surgical treatment, all of the patients underwent functional multispiral computer tomography of the orbits. Prismatic spectacle correction was also used independently or in addition to surgical treatment. Eight out of eleven patients underwent one- or two-step surgical treatment (3 and 5 cases, respectively). In 2 patients, hypotropia did not exceed 10 prism diopters, and thus, diplopia could be compensated with prismatic spectacle correction alone. In 5 cases, binocular vision was achieved throughout the whole field of gaze. In 3 cases, surgical treatment enabled elimination of heterotropia in the primary gaze and compensation of diplopia within a radius of 40º from the center of gaze and within the entire horizontal range of eye-movement in the downward gaze. The limitation of ocular mobility decreased from 2.36 to 0.55 points leading to an associated decrease in the area of binocular diplopia - from 98% to 29%. In one case, spectacle occlusion was used. The inferior rectus restriction is the morphological substrate of anatomical and functional changes induced by retrobulbar anesthesia. As treatment options for restrictive vertical strabismus and binocular diplopia, both surgical (extraocular muscle surgery) and optical (prismatic correction, occlusion) methods should be considered.

Unintentional brainstem anesthesia after prolonged sub-tenon block. Сase report

A 64-year-old ASA 2 woman, with left eye retinal detachment was admitted for pars plana vitrectomy. There were no any neurological diseases, stroke, angina, myocardial infarction, epilepsy and allergy in her medical history. There aren’t clinical significant changes in her blood tests and ECG. General anesthesia was induced and maintained with inhalation of sevoflurane on target value of MAC 0.9–1.1. Analgesia was maintained by prolonged Sub-Tenon block — 1 % lidocaine 2 ml/h through catheter. The duration of surgery was 215 minutes. Sevoflurane and lidocaine were stopped immediately after the end of the surgery. The effective spontaneous breath has been noted by the first minute after surgery. However, the delayed recovery wasn’t allowing to discharge the patient from operating room within 50 minutes and the drowsiness was persisted 1.5 hours more after this. There wasn’t any neurological deficiency, the hemodynamic was stable and the patient had an effective breath during this time and later in postoperative period. With the exception of a possibility of inadvertent intravenous introduction of local anesthetic and development of systemic toxicity, the most probable cause of this complication was the brainstem anesthesia. The possibility of brainstem anesthesia in ophthalmology is well described when using retrobulbar and peribulbar anesthesia. The described cases of this complication of Sub-Tenon block are single. Our case presented a serious adverse event of prolonged Sub-Tenon block without life treating symptoms and neurologic consequences.

Alternative technique for insertion of Eva Dorc® infusion cannula in vitreoretinal surgeries

Abstract This paper provides a fast and inexpensive technique to prevent slippage of the infusion cannula from the EVA DORC® 27-gauge system. After the usual retrobulbar anesthesia, antisepsis and asepsis, a 2% hydroxypropyl methylcellulose drop is placed around the infusion cannula in the trocar to hold it in position. This technique prevents the slippage of the infusion cannula and both the surgical time and creation of the first sclerotomy in the eye can be shortened slightly. Alternative technique for insertion [...]

Ocular Anesthesia-Related Closed Claims from Ophthalmic Mutual Insurance Company 2008–2018

To evaluate the types of anesthesia-related closed claims and their contributing factors, using data from the Ophthalmic Mutual Insurance Company (OMIC). Retrospective analysis of preexisting data. Plaintiffs who filed a professional liability claim or suit (written demand for money) against OMIC-insured ophthalmologists, ophthalmic practices, or surgicenters in which the surgical case occurred. Plaintiff claims were collected from the OMIC database from 2008 to 2018 using search queries for terms associated with known complications of ophthalmic anesthesia. Number and types of anesthesia-related injuries and claims, who administered the anesthesia, the outcomes of the claim or suit, cost to defend, and payments made to plaintiffs. Sixty-three anesthesia-related claims or suits were filed by 50 plaintiffs. Anesthesia-related injuries included globe perforation (n= 17), death (n= 13), retrobulbar hemorrhage (n= 7), optic nerve damage (n= 4), vascular occlusions (n= 2), pain (n= 2), eye or head movement resulting in injury (n= 2), and 1 case each for numbness, diplopia, and tooth loss during intubation. All but 1 patient who died had preexisting, significant comorbidities. Two deaths were related to brainstem anesthesia. Regarding the type of anesthesia in the closed claims, retrobulbar and peribulbar anesthesia were the most common types (n= 16 each), followed by local infiltration around the lids and facial nerve (n= 6), topical anesthesia (n= 5), and general anesthesia (n= 5). In 2 cases, the exact type of anesthesia was unknown but not general. The 5 topical with sedation anesthesia-related claims were due to inadequate pain control (n= 2), ocular movement resulting in capsular rupture (n= 2), or death (n= 1) allegedly related to excessive or inadequate monitoring of sedation. There were 5 claims related to general anesthesia including 4 deaths and 1 tooth loss during intubation. Sedation was alleged to be a factor in 5 cases resulting in death. Anticoagulants were a factor in 3 retrobulbar hemorrhage cases. Although claims and suits were infrequent given the large number of insured ophthalmologists and the large number of surgical cases requiring various types of anesthesia performed over the 10.5-year study period, severe injuries can occur.

Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events

BackgroundVitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra- and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy (PPV) under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients with an interruption in this therapy before surgery.MethodsNinety-six patients will be randomly assigned to either the control group, in whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group in whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated.DiscussionThis trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy.Trial registrationClinical Trials Register EudraCT, 2018–000753-45. Registered on 11 November 2018.

Vitrectomy for Idiopathic Macular Hole in Patients Aged 80 Years or Older: Efficacy and Safety

ABSTRACTPurpose: To assess the efficacy and safety of idiopathic macular hole (MH) surgery in elderly patients (≥ 80 years of age).Methods: Prospective study enrolled consecutive patients who underwent pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling under retrobulbar anesthesia between February 2016 and May 2018. Twenty-eight eyes of 28 patients aged 80 years or older were classified into the elderly group, a matched group of 56 eyes from 56 younger patients as the control group. The main outcome measures included best-corrected visual acuity (BCVA) and intraoperative and postoperative complications.Results: Statistically, there was no significant difference in visual acuity improvement and incidences of complications between the elderly group and the control group (p = .784 and p = .712, respectively). No operation in either group was postponed or canceled due to complications associated with retrobulbar anesthesia, or physical discomfort before and during the operation. Moreover, no case suffered from myocardial infarction, stroke or death during the perioperative period. Except for one case of retinal detachment postoperatively in the control group, no case required a secondary surgery. All complications were successfully resolved or managed.Conclusions: The results from our study indicate the efficacy and safety of vitrectomy for idiopathic macular hole in patients aged 80 years or older, and idiopathic MH surgery should not be denied on basis of patient age alone.

Stepwise Decreasing of Vitreous Pressure by Anterior Vitrectomy: A Novel Method for Preventing Positive Vitreous Pressure During Penetrating Keratoplasty.

This study evaluates the clinical effects of the stepwise anterior vitrectomy on the prevention of positive vitreous pressure (PVP) during penetrating keratoplasty (PKP). PKP in conjunction with stepwise anterior vitrectomy was performed on 15 eyes of 15 patients under retrobulbar anesthesia. A preset vitrectomy trocar-cannula was inserted into the vitreous cavity before PKP. During the opening of the anterior chamber, intermittent vitrectomy and corneal incision expansion were performed alternately to keep the lens or artificial intraocular lens (IOL) and iris flat until the entirety of the pathological cornea had been dissected. The main outcome measures include visual acuity, crystalline lens rise (CLR), corneal curvature and diopter, and corneal endothelial cell loss. All surgical procedures were performed successfully without any PVP-related intraoperative complications. The mean time of the stepwise vitrectomies was 3.1 ± 0.7s, the duration of each vitrectomy was 8.1 ± 5.3s, and the duration of the total surgery was 60.5 ± 5.3min. The anterior segment reaction was mild and the shape of the pupil remained normal 1day after surgery. The mean preoperative and mean 3-month postoperative CLR values were 0.48 ± 0.09mm and - 0.16 ± 0.04mm, respectively (p < 0.0001). The mean preoperative endothelial cell density in donor buttons was 2570 ± 171cells/mm2, and the mean 6- and 12-month postoperative endothelial cell density in donor buttons was 2207 ± 127cells/mm2 and 2000 ± 198cells/mm2, respectively. The novel and stabilized PKP procedure, performed in conjunction with the stepwise anterior vitrectomy, effectively avoided the PVP during open-sky surgery. Chinese Clinical Trial Registry, ChiCTR1900021227.