Vitreoretinal Research Articles

Comparison of sub-Tenon’s block with i.v. fentanyl for paediatric vitreoretinal surgery

Vitreoretinal (VR) surgery is associated with moderate to severe pain and significant postoperative nausea and vomiting (PONV). The study aimed to assess the effectiveness of sub-Tenon's block for providing perioperative analgesia in children undergoing VR surgery. In a randomized, observer-blinded trial, after obtaining institutional ethical committee approval and parental consent, 200 ASA grade I-II children aged 5-16 yr were allocated to receive either a sub-Tenon's block (Group SB) or 2 microg kg(-1) i.v. fentanyl (Group F) after induction of anaesthesia and topical anaesthesia of the conjunctiva with proparacaine 0.5% drops. Patients in Group F received fentanyl 0.5 microg kg(-1) and those in Group SB were given a corresponding volume of normal saline i.v. every hour from preloaded syringes. Increases in heart rate or mean arterial pressure by more than 20% of baseline were treated with additional 0.5 microg kg(-1) i.v. fentanyl boluses in both groups. The incidence of oculocardiac reflex (OCR), need for additional analgesics, postoperative pain, and PONV were recorded for the first 24 h after surgery. More patients in Group F (47.96%) had moderate to severe pain in the first 24 h when compared with Group SB (31.36%) (P=0.023). The need for postoperative ibuprofen was higher in Group F (66.3%) compared with Group SB (47.95%) (P=0.012). The incidence of OCR was significantly higher in Group F (31.6%) compared with Group SB (5.1%) (P<0.001). The incidence of PONV was similar in both groups. Sub-Tenon's block provides more effective analgesia than i.v. fentanyl for paediatric VR surgery.

Macular hole surgery : Maiden experience

Macular holes (MHLs) first described over a century ago by Noyes [1], have seen a renewed interest in their pathophysiology and management in the last two decades. They occur following trauma, laser treatment, cystoid macular edema, retinal vascular disorders, retinal detachment (RD) or may not have any detectable cause. Most MHLs occur as age-related primary idiopathic entities. Full thickness MHLs were once considered untreatable and were treated only when there was an accompanying extensive RD. Initially MHLs were treated with achieving strong vitreo-retinal (VR) adhesions around the MHL but with refinement of VR techniques and emphasis on tangential traction being responsible for the MHL, retinal surgeons are attempting treatment with vitrectomy, membrane peeling and intra-ocular gas tamponade.

Risk management, adverse events and litigation in vitreoretinal surgery

Using data from the UK National Reporting and Learning System and the National Health Service Litigation Authority, this paper assesses trends in patient safety incidents and litigation in relation to ophthalmic surgery generally and vitreoretinal (VR) surgery in particular. Examples of human error and equipment-related incidents in VR surgery are discussed. Data from incident reporting and litigation should be interpreted with care as these are influenced by many factors. An open culture, improved reporting and prioritisation of patient safety will help provide further insight into the prevalence and causes of patient safety incidents in VR surgery.

Feasibility of day-case vitreoretinal surgery

The indications for vitreoretinal (VR) surgery are increasing as equipment and techniques available improve. In order to decrease demand on limited health resources, day-case surgery would be beneficial in many cases. This study combines a retrospective and prospective arm to examine the feasibility and safety of routine day-case VR surgery. One hundred consecutive patients (50 retrospective and 50 prospective) undergoing VR surgery within the Royal Berkshire NHS trust were included. The retrospective arm aimed to identify the frequency and type of acute ophthalmic or medical intervention during postop overnight stay and the results were used to alter management in the prospective group. The prospective group consisted of patients undergoing a mixture of overnight stay and day-case surgery. All patients in the prospective group had routine subtenon marcaine anaesthesia together with prophylactic pre-operative intravenous acetazolamide. Patients deemed fit postoperatively were offered overnight ward discharge, with obligatory next-day review. In the retrospective arm, 56% required oral nonsteroidal analgesia on the day of surgery and one patient required narcotic analgesia. Twenty-two per cent patients required intraocular pressure (IOP) control on the day of surgery and one patient required medical intervention in the form of urinary catheterisation. Nineteen patients required intervention on next-day review. In the prospective arm, 86% preferred day case and were suitable, 6% were suitable for day-case but preferred overnight stay and 8% were deemed not fit for discharge. No patient required narcotic analgesics. No patient discharged returned as a casualty overnight. Only one patient required topical beta-blocker for the control of IOP on next-day review. These data suggest that many patients who are hospitalised overnight for VR surgery could be safely treated as day cases. Such a shift in the pattern of care for VR surgery could provide a significant improvement in health-care efficiency and minimise patient inconvenience.

Office-based anaesthesia for vitreoretinal surgery

The objectives of this study were to consider the effectiveness of local anaesthesia (LA) for office-based vitreoretinal (VR) surgery, the requirement to supplement the anaesthetic blockade, the demographic pattern of the sample and the acceptance of LA by patients. This prospective observational audit involved 111 patients that had undergone 128 VR procedures. Assessment data included: patient’s information, details of type of anaesthetic, and pain during surgery. A clinical audit was also carried out with telephone survey to establish the postoperative use of analgesics, the frequency of nausea, emesis, and insomnia. Results suggest that VR surgery can be carried out effectively and safely with LA, in an office-based surgery, provided that experienced surgeons exist. We noted a high degree of patient acceptance, a reasonable level of postoperative pain and a low frequency of nausea and vomits.

Usefulness of pre-emptive peribulbar block in pediatric vitreoretinal surgery: A prospective study

Background and Objectives: Vitreoretinal (VR) surgery with or without scleral buckling is associated with significant postoperative pain and emesis in adults, and recent studies have addressed the effect of retro or peribulbar block on these parameters. VR surgery in children has received little attention regarding the incidence of pain and emesis, and the role of regional anesthesia in modifying these parameters. In this study, we compared peribulbar block with conventional opioid analgesia in children undergoing VR surgery. Methods: In a prospective, randomized, single-blind study, 85 children (ages 6 to 13 years) were allocated to receive peribulbar block (n = 42) or intravenous meperidine 1 mg/kg (n = 43) after induction of general anesthesia. Parameters compared were: intraoperative incidence of oculocardiac reflex and requirement for additional analgesic; postoperative pain intensity; incidence of postoperative emesis; time to first analgesic, total number of postoperative analgesic supplements; and parental assessment of the child's postoperative comfort at 24 hours. Results: The incidence of intraoperative oculocardiac reflex was significantly less in the peribulbar group (P = .0001). Significantly more children receiving peribulbar block were pain free on awakening (P = .0004) and throughout the postoperative period. The number of children requiring opioid was significantly lower with peribulbar block (P = .008), and a significant number of children did not vomit throughout the postoperative period (P = .001). Conclusions: Peribulbar block appears to be a safe and clinically superior alternative to intravenous opioid for pediatric VR surgery. Reg Anesth Pain Med 2003;28:43-47.

Arrangements for the management of urgent retinal detachments in the United Kingdom and Eire in the year 2000: results of a survey.

To ascertain the current provision of facilities for the management of vitreo-retinal (V-R) emergencies, and attitudes of V-R surgeons towards the management of V-R emergencies within the United Kingdom and Eire. To obtain this information, all 82 consultant members of the Britain and Eire Association of Vitreo-Retinal Surgeons (BEAVRS) were requested to complete a 14-part postal questionnaire in the year 2000. Seventy-eight questionnaires were completed and returned. Data from the questionnaires were collated on a Microsoft Access Database and then statistically analysed using SPSS. The Student's t-test was used to assess relationships between continuous variables, and the Chi-squared and Fisher's Exact tests were used to compare non-parametric data. Analyses of the first 13 parts of the questionnaire are presented in this report. The majority of V-R surgeons (59%) practise in teaching hospitals. There are greater numbers of V-R surgeons per unit in teaching hospitals as compared to District General Hospitals (DGHs). Ophthalmic theatre and ophthalmic theatre staff availability are theoretically high (92.3% and 84.6% respectively) and evenly distributed between teaching hospitals and DGHs, but in reality, access may be difficult. Most V-R surgeons take part in an on-call rota with general ophthalmology colleagues. This formal commitment may be infrequent. Only a small proportion of V-R surgeons (28.3%) officially provide a continuous fixed on-call V-R rota, though in practice, a larger proportion do seem to provide this type of cover informally. Most V-R fellows are located in teaching hospitals (89.5%), and are usually on either a formal or informal on-call rota. Only one unit has a formal continuous on-call rota for fellows allowing no more than 72 hours duty per week. The mean time given in response to the question as to the ideal time within which surgery of an acute macula on supero-temporal retinal detachment should be carried out was 29 hours. Most V-R surgeons would not support, in court, a colleague whose patient lost vision through delay in treating a macula on detachment. The findings of this survey have important implications for providing a reliable service and for proper cover for doctors in training.

UK survey of attitudes to local anaesthesia for vitreoretinal surgery.

The use of local anaesthesia (LA) for vitreoretinal (VR) surgery is growing although surgeons in the UK traditionally use general anaesthesia. To assess the use and attitudes towards local anaesthesia for VR surgery among the members of the British and Eire Association of Vitreo-retinal Surgeons (BEAVRS). A questionnaire was sent to members of BEAVRS. Use of LA was assessed for the following procedures: macular hole; diabetic vitrectomy; vitrectomy; cryopexy and gas; buckling and re-buckling procedures. Attitudes of surgeons generally using LA for primary retinal detachment surgery (> 50% of cases) were compared with those generally using general anaesthesia (GA) (> 50% of cases). 33.6% of surgeons preferred LA for macular hole; 26.2% for diabetic vitrectomy; 23.3% for vitrectomy, cryopexy and gas; 21.4% for buckling procedures; and 9.35% for re-buckling procedures. When surgeons routinely using LA were compared with those regularly using GA they considered LA less stressful for patients and surgeon, patients tolerant to longer operations, and buckling or redo surgery no more difficult under LA. However, both groups considered surgery on young patients and teaching relatively more difficult under LA. The use of LA may convey benefits for VR surgery and faster rehabilitation for patients. However, we identified wide variations in the use of and attitudes to LA for VR surgery in British surgeons.

Local anaesthesia for vitreoretinal surgery: a case-control study of 200 cases.

In the United Kingdom the majority of vitreoretinal (VR) surgery is performed under general anaesthesia (GA). The aim of this study was to demonstrate the scope of local anaesthesia (LA) for VR surgery, to measure the acceptance of LA to patients and surgeons and to compare the surgical outcomes, complication rates and duration of the surgical procedures under LA and GA. A case-control study was undertaken to compare 100 cases performed under LA with 100 matched cases performed under GA. The matching of cases was based on multiple criteria such as configuration and complexity of retinal detachment, the involvement of the macula, the number and site of retinal tears, presence and severity of proliferative vitreoretinopathy, experience of the surgeon and the type of the surgical procedure. A clinical audit was also carried out on 65 successive patients using a questionnaire to determine the acceptability of LA to patients and surgeons. Anatomical and visual success rates, and intra-operative and post-operative complications, were similar in cases carried out under LA and GA. The mean duration of the surgery (excluding anaesthetic time) was significantly shorter for LA than GA procedures (p < 0.001). The acceptance for LA was high for both patients and the operating surgeons. We found that VR surgery can be safely and efficiently performed under LA. Adoption of LA has increased our throughput.