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

Abstract

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.

Globe penetration during loco-regional anesthesia: prevalence and review of cases

“…The majority of eye surgeries are performed under regional anesthesia. This type of anesthesia includes different sub-types, such as topical anesthesia [13][14][15] , subconjunctival anesthesia [16][17][18] , retrobulbar anesthesia, peribulbar anesthesia, sub-Tenon's anesthesia [9,[19][20] , medial canthus epiescleral anesthesia [21] and facial nerve block. Topical anesthesia has become a common form of anesthesia; however, it requires that the surgery is performed quickly and efficiently to minimize stress on the patients [22] , patient cooperation [23] , experienced surgeon [10] and it doesn't provide the same level of pain relief as peribulbar anesteshia [24][25] .…”

Topical Vs Pribulbar Anesthesia in Patients Undergoing 23 Guage ,Three Ports Removal of Sillicone Oil

“…9 Recent studies have shown that local anesthetics that include lignocaine , amethocaine and bupivacaine are effective in providing topical and local anesthesia for intraocular surgery and Instillation of these local anesthesia decreases intraocular pressure (IOP) transiently . 12,8,5,13 As the duration of anesthesia and analgesia is very brief by these drugs , it requires repeat instillation of drops in the conjuctival sac after every 30 minutes but long-term use of these topical drugs is associated with ocular surface toxicity as they contain preservatives like benzalkonium chloride Most of the patients were in their fifth and sixth decade of life when they underwent 23 gauge three port pars removal of sillicone oil. The peribulbar technique for local anesthesia is a type of block that has been introduced and developed as ocular and periocular anesthetic technique for surgical procedures recently.…”

“…The peribulbar technique for local anesthesia is a type of block that has been introduced and developed as ocular and periocular anesthetic technique for surgical procedures recently. 7,8,4 The needle for peribulbar block is entered directly and is much shorter in length as compared to the previous technique of retro bulbar block as the later is associated with risk of complications like perforation of the globe and damage to optic nerve. The use of 26G ,25 mm needle for peribulbar block is much safer and this modified technique is the use of 23G needle that is associated with effective block and less rate of comlications.…”

“…Mahajan et al have studied the effect of topical versus peribulbar anesthesia for patients undergoing pars plana vitrectomy for vitreous hemorrhage and found that the pain score between the two groups was almost similar with the only difference that in topical anesthesia group the maximum pain during the procedure is felt at the time of trocar insertion whereas in the peribulbar block it is felt at the time of local anesthesia being given but the topical anesthesia does not cause lie edema and conjuctival chemosis that is seen in routine patients with peribulbar anesthesia. 7,8,6 The rationale of our study was to determine the safety and efficacy in term of analgesia provided by both topical and peribulbar techniques for the procedure of three ports 23 gauge pars plana removal of silicone oil using visual analogue scale on patient pain perception and to draw conclusion about the safety of both procedures , no such study has been done before in our population .By application of these methods in vitreo retinal procedures like 3 port 23 gauge ROSO we can determine a safe and efficient route of anesthesia for these patients that can both save time and is less expensive. 11,23…”

Anesthesia for ophthalmic surgery

“…It is important to note that relying solely on topical analgesia may not achieve ocular akinesia and requires special attention, particularly in macular surgery. [64,65] In cases of general anesthesia, the use of nitrous oxide (N 2 O) should be avoided. Given the potential for pain during the procedure, alternative analgesics, including opioids, should be considered.…”