Pain during pars plana vitrectomy following sub-Tenon versus peribulbar anesthesia: A randomized trial

Abstract

Purpose To compare pain during pars plana vitrectomy (PPV) following topical lidocaine jelly and sub-Tenon anesthesia versus peribulbar anesthesia. Methods Prospective, single-center, randomized study. Patients scheduled for PPV for macular hole (MH) or epiretinal membrane (ERM) at the Retina and Vitreous Section of the Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo were randomly assigned to one of two groups in a 1:1 allocation ratio. Patients assigned to Group ST received topical anesthesia with 2% lidocaine jelly followed by sub-Tenon anesthesia with 2–4 ml of 1% ropivacaine. Patients assigned to PB received peribulbar anesthesia with 4–6 ml of 1% ropivacaine. After PPV, patients in both groups were asked to rate the level of pain they felt during the entire procedure (including anesthesia administration and PPV) by pointing at a 0–100 Visual Analogue Pain Scale (VAS). Data regarding demographics, patient characteristics and surgical features were also collected. Results Fifty-four patients were enrolled in the study (26 in Group ST and 28 in Group PB). Baseline characteristics, including age, gender, and presence of comorbidities, were similar in both groups. The surgery performed was PPV alone in 10 and 14 patients in the ST and PB groups, respectively, and combined phacoemulsification and PPV in 16 and 14 patients in the ST and PB groups, respectively (p = 0.39, Pearson). Surgery duration (mean ± SD minutes) was similar in the two groups (62 ± 12 for ST and 70 ± 20 for PB, p = 0.09, t-Test). No patients needed supplemental topical or intravenous anesthesia during surgery. No sight- or life-threatening complication was observed in either group. VAS score was significantly lower in the ST compared to the PB group (median (interquartile range) was 1 (2.25–0) in the ST group compared to 11.5 (29.75–5) in the PB group, p< 0.0001, Wilcoxon). Conclusion In this study of patients who underwent PPV for MH or ERM, topical followed by sub-Tenon anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia. Compared to peribulbar anesthesia which is administered with a sharp needle, sub-Tenon anesthesia administered with a blunt cannula may be associated with a reduced risk of such adverse events as globe perforation, retrobulbar hemorrhage, and inadvertent injection of anesthesia into the optic nerve sheath.

Adverse Events during Vitreoretinal Surgery under Adequacy of Anesthesia Guidance—Risk Factor Analysis

“…We also analyzed the possibility of coincidence between the two most common comorbidities of patients undergoing vitreoretinal surgeries, arterial hypertension and DM, in relation to the incidence of PONV [43][44][45]. Diabetic patients benefit from enhanced vision and improved lifestyle from the introduction of vitreoretinal surgeries [46].…”

“…First, all patients received a fixed volume of crystalloids (10 mL/kg of body weight) to balance the overnight fluid loss, which was estimated to be approximately 40 mL/hour. Intraoperatively, when the depth of anesthesia using spectral entropy EEG (SE) was fixed at [40][41][42][43][44][45] in all patients and the IRNA was kept under SPI guidance levels (in accordance with AoA regimen), the use of anesthetic agents had a presumably similar impact on the intraoperative fluid requirement in individual patients, despite the group allocation. We hypothesize that the intraoperative monitoring of the depth of anesthesia using SE and analgesia using SPI could have created comparable conditions for all patients to direct fluid challenge according to their needs based on the intraoperative hemodynamic changes in response to the anesthetic regimen required to perform PPV.…”

Efficacy and safety of trans-sub-Tenon's retrobulbar anesthesia for pars plana vitrectomy: a randomized trial

“…Therefore, to ensure that a sufficient amount of anesthetic reaches the retrobulbar space, peribulbar anesthesia requires a larger volume of anesthetic (up to 10 ml) with or without hylase to help spread the anesthetic [28][29][30]. Moreover, a randomized trial from 2020 comparing sub-Tenon's anesthesia (2-4 ml ropivacaine) and peribulbar anesthesia (4-6 ml ropivacaine) for PPV showed that sub-Tenon's anesthesia was more effective in controlling pain during the whole vitrectomy procedure than peribulbar anesthesia [24]. To date, there were few comparative clinical studies on the trans-sub-Tenon's ciliary nerve block anesthesia and transcutaneous retrobulbar anesthesia for vitreoretinal surgery.…”

“…Exclusion criteria: (1) history of previous vitreoretinal surgery; (2) history of ocular trauma; (3) the patient could not cooperate with the operation; (4) the patient was allergic to ropivacaine or any of its components or similar drugs; (5) the patient was pregnant or lactating female. The sample size was calculated based on previous literature review [13,17,24]. The estimated sample size was 120 patients (60 in each group) based on type I error (α) of 5%, and a power (1-β) of 90%.…”

A study to compare 0.5% hyperbaric bupivacaine with 0.5% isobaric ropivacaine intrathecally for elective lower limb surgery.

“…The newly introduced drug, i.e., ropivacaine, has a more specific effect on the motor nerve fibers [5][6][7] . Furthermore, this drug has lesser cardiac toxicity 8 . On the other hand, bupivacaine possesses a faster onset and regression of sensory and motor blocks.…”