Comparison of Regional vs. General Anesthesia for Surgical Repair of Open-Globe Injuries at a University Referral Center

Abstract

Purpose This study compares the clinical features and physician selection of either Regional Anesthesia (peribulbar or retrobulbar block) with Monitored Anesthesia Care (RA-MAC) or General Anesthesia (GA) for open globe injury repair. Design A non-randomized, comparative, retrospective case series at a University Referral Center. Participants All adult repairable open globe injuries receiving primary repair between January 1st, 2004 and December 31st, 2014 (11 years). Exclusion criteria were patients less than 18 years of age and those treated with primary enucleation. Methods Data was gathered via retrospective chart review. Main Outcome Measures Data collected from each patient was age, gender, injury type, location, length of wound, presenting visual acuity, classification of anesthesia used, duration of the procedure performed, months of clinical follow-up, and final visual acuity. Results During the 11 years study period, 448 patients were identified who had open globe injuries with documented information on zone of injury. Globe injury repair was performed using RA-MAC in 351/448 (78%) patients and general anesthesia in 97/448 (22%) patients. Zone 1, 2 and 3 injuries were recorded in 241, 135, and 72 patients respectively. The rates in specific zones, of RA-MAC versus GA were as follows: Zone 1 – 213/241 (88%) vs 28/241 (12%), Zone 2 – 104/135 (77%) vs 31/135 (23%) and Zone 3 – 34/72 (47%) vs 38/72 (53%). Open globe injuries repaired under RA-MAC had significantly shorter wound length (p<0.001), more anterior wound location (p<0.001) and shorter operative times (p<0.001). RA-MAC cases also had a better presenting and final visual acuity (p<0.001). Neither class of anesthesia conferred a greater visual acuity improvement (p=0.06). The use of GA did not cause any delay in the time elapsed from injury until surgical repair (p=0.74). Conclusions RA-MAC is a reasonable alternative to GA for the repair of open globe injuries in selected adult patients. RA-MAC was selected more often for Zone 1 and Zone 2 injuries. For eyes with Zone 3 injuries, there are equal selection ratio for RA-MAC and GA.

Guideline for the treatment of no light perception eyes induced by mechanical ocular trauma

“…Most doctors choose local anesthesia to treat the wounds in Zones I and II for patients whose physical conditions do not allow general anesthesia or in emergencies when the treatment time is urgent. However, general anesthesia should be considered in cases with large rupture wounds or cannot co‐operate with local anesthesia due to systemic diseases 52,53 . The purpose of primary surgery is to close the ocular wound, retain the eyeball, and restore IOP.…”

“…However, general anesthesia should be considered in cases with large rupture wounds or cannot co‐operate with local anesthesia due to systemic diseases. 52 , 53 The purpose of primary surgery is to close the ocular wound, retain the eyeball, and restore IOP. Intraocular tissue can be repositioned by filling it with a sterilized air bubble or viscoelastic agent after suturing, laying a good foundation for vitrectomy.…”

Open Globe Injuries: Review of Evaluation, Management, and Surgical Pearls

“…53,54 For low-risk anterior OGIs, regional blocks with monitored anesthesia care and small injected anesthetic volumes (3-4 mL) have comparable time-to-surgery and visual outcomes to general anesthesia but are rarely used. [55][56][57] Due to these issues, preoperative consultation with the anesthesia provider is highly recommended.…”

Anaesthetic considerations for the surgical management of ocular hypotony in adults

“…The choices of anaesthetic modality and the controversy of suxamethonium in open globe injury have been well described, debated and documented. [39][40][41]45,47 While general anaesthesia remains the mainstay technique, topical anaesthesia and ophthalmic block, with monitored anaesthesia care, have been used successful in many cases, especially in anteriorly located wounds and shorter wound length (<6.5 mm). In selected cases, it may be appropriate for the surgeon to perform an initial repair of the corneal wound using topical anaesthesia, then administer a gentle sub-Tenon's block 'on the table' before dealing with any more posterior trauma.…”

“…Many cases of mild-to-moderate ocular hypotony may be amenable to topical anaesthesia or regional ophthalmic block 9,[40][41][42] and these are particularly useful in medically unwell patients. 43,44 The authors are of the opinion that hypotony exacerbates pre-existing risk factors (Table 2) and further increases the risk of inadvertent globe injury with regional anaesthesia.…”