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REVIEW/UPDATE

Local anesthesia for cataract surgery


Adeela Malik, MBBS, Emily C. Fletcher, MRCOphth, Victor Chong, FRCOphth, Jay Dasan, FRCA

Various aspects of local anesthesia for cataract surgery, such as the anesthetic agents and their
interaction with ocular nerve supply, anesthesia requirements, available clinical techniques and
their inherent complications are reviewed. A comparative evaluation of clinical techniques in terms
of efficacy, akinesia, and patient-perceived pain during both anesthesia administration and intra-
operative cataract surgery is presented, along with the prevailing practice patterns of anesthesia
techniques among refractive surgeons in the United Kingdom and United States. More randomized
clinical trials are needed to facilitate statistical methods of metaanalysis to establish convincingly
the overall benefits and efficacy of the various local anesthesia procedures in cataract surgery. The
wide scope of the present review is of relevance in structuring ophthalmology and anesthesia spe-
cialist training programs for junior staff.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2010; 36:133–152 Q 2010 ASCRS and ESCRS

Significant changes in the techniques and instrumenta- complications, and illustration of practice patterns of
tion used for cataract surgery1 over the past 20 years use of various anesthesia techniques among the refrac-
have led to the development of the clear corneal su- tive surgeons in the United Kingdom and North
tureless phacoemulsification technique for cataract America are also included. Finally, a comparative
surgery.2,3 Progression of the surgical approach has evaluation of the various local anesthesia techniques
led to better outcomes in routine and complex cases. with respect to patient-perceived pain and their effec-
Along with this development has come an inevitable tiveness in promoting akinesia is presented, with
change in delivery of the accompanying anesthesia a view to identifying an optimum local anesthesia
from general to topical modalities.4–6 This article re- strategy for cataract surgery.
views the changes in anesthesia delivery and the evi-
dence behind these changes.
PROGRESSION AND HISTORICAL DEVELOPMENT OF
The article includes a brief description of the histor-
SURGICAL TECHNIQUES IN CATARACT EXTRACTION
ical developments in surgical techniques for cataract
extraction, typical anesthetic agents used in ocular sur- During the first half of the 20th century, intracapsular
gery, and the ocular nerves relevant to local anesthe- cataract extraction (ICCE) was the predominant form
sia. Discussion of anesthesia requirements for the of lens removal. It involved removal of the entire
safety and comfort of patients, description of the clin- lens and capsule using a large 180-degree limbal inci-
ical methodologies used for implementation of various sion aided by mechanical or chemical cleaving of zon-
local anesthesia modalities along with the associated ular attachments. In this procedure, vitreous loss,
hemorrhage, retinal detachment, chronic cystoid mac-
ular edema, and high astigmatism were common com-
Submitted: February 8, 2008. plications, with a prolonged recovery time. During the
Final revision submitted: September 29, 2009. second half of the 20th century, with the introduction
Accepted: October 1, 2009.
of the intraocular lens (IOL), ICCE was superseded
From the Department of Ophthalmology (Malik), Epsom & St. Helier by extracapsular cataract extraction (ECCCE).7–11
University Hospitals, Carshalton, Department of Ophthalmology This involved a smaller incision1,3 (10.0 mm to 11.0
(Fletcher, Chong,), Oxford Eye Hospital, Headington, and Depart- mm) and the lens nucleus was prolapsed out of the
ment of Anaesthesia (Dasan), King’s College Hospital, London, capsular bag, and eventually out of the eye, after an
United Kingdom. opening ‘‘capsulectomy’’ was created in the anterior
Corresponding author: Adeela Malik, MBBS, Department of Oph- capsular bag. The intact posterior capsule provided
thalmology, Epsom & St. Helier University Hospitals, Wrythe support for the IOL, and also reduced the risk for vit-
Lane, Carshalton, Surrey, United Kingdom, SM5 1AA. E-mail: reous loss. However, the remnant cortical material that
adeela15malik@gmail.com. could not be removed during the procedure resulted in

Q 2010 ASCRS and ESCRS 0886-3350/10/$dsee front matter 133


Published by Elsevier Inc. doi:10.1016/j.jcrs.2009.10.025
134 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

severe postoperative inflammation and dense poste- and development of the anesthesia technique ensures
rior membranous opacification. minimal risk from the anesthetic agent only if there
Improvements in automated irrigation/aspiration is minimal risk from the surgery as a whole.
systems,7 including capsulectomy techniques8 and In some of the literature, retrobulbar, peribulbar,
the advent of phacoemulsification,7,12 considerably and sub-Tenon anesthesia is referred to as intraconal,
improved ECCE techniques. Today, phacoemulsifica- extraconal, and parabulbar blocks, respectively; how-
tion with a small incision is the method of choice for ever, in this paper the former terminology is used.
most cataract surgeons. The procedure provides a
controlled, faster, and safer method of removing the ANESTHETIC AGENTS
nucleus with an intact posterior capsule. The small
The choice of a local anesthetic agent is optimal only
wound provides rapid visual recovery for the patient,
when its inherent properties meet both the characteris-
and also reduces intraoperative complications such as
tics of the surgical procedure and the requirements of
expulsive hemorrhage, high astigmatism, and trau-
the patient in terms of contraindications and perceived
matic wound rupture. However, in these procedures,
pain. The relative performance, efficacy, and underly-
attention to proper wound construction,10 capsulec-
ing complications of local anesthetic agents, including
tomy, ophthalmic viscosurgical devices, and nuclear
toxicity, have been discussed extensively.21,26–36 The
disassembly is important.
pharmacology and pathogenesis of toxicity of the var-
Phacoemulsification, which removes the lens with
ious agents are also well documented.29 Table 1 lists
ultrasonic energy, can be performed in the anterior
the properties of common anesthetic agents. Lido-
chamber, iris plane, or posterior chamber. Ophthalmic
caine, bupivacaine, and ropivacaine are the most pop-
viscosurgical devices1,9 have been instrumental in al-
ular traditional agents used for conduction blockades.
lowing the safe adaptation of phacoemulsification in
Levobupivacaine, articaine, and 2-chloroprocaine are
ECCE. During cataract surgery, endothelial cell loss
recent developments. Table 2 lists the typical agents
can occur from physical contact between the corneal
used for various anesthesia techniques, and Table 3
endothelium and IOL, damage from phacoemulsifica-
depicts the onset time to akinesia for the traditional
tion energy, loss of fluid during irrigation, air bubble
and newer agents.
damage, contact with nuclear fragments, or toxic ef-
The use of hyaluronidase in regional anesthesia is
fects from intracameral medication. Ophthalmic visco-
controversial. However, as an adjuvant in retrobulbar
surgical devices reduce mechanical trauma to the
and peribulbar anesthesia,6,9,42 it enhances the onset of
corneal endothelium as well as maintain intraocular
the block. It also improves the onset and quality of the
space, even when there is an incision in the eye.
block in the sub-Tenon procedure by promoting diffu-
Several methods of anesthesia are available for
sion to the periorbital and retroorbital tissue19,43–45
cataract extraction. General anesthesia was preferred
and alleviating the need for a facial nerve block, which
for ICCE procedures as these techniques involved sig-
can be painful.31,45 Hyaluronidase6 helps to prevent
nificant manipulation of the eye, and required several
a decrease in retinal circulation, an increase in intraoc-
corneal sutures to provide a watertight wound. Extrac-
ular pressure (IOP) and also reduce the risk for muscle
apsular cataract surgery1,7–10 also required a large cor-
toxicity from local anesthetic agents.
neal incision, but there was a trend toward local
Intracameral anesthesia (injection into the anterior
anesthesia such as retrobulbar,13,14 which allowed
chamber) is often used as an adjunct to topical anes-
quicker patient recovery and thus facilitated day-
thesia to enhance the anesthesia and thereby deal
case surgery.
with incremental pain that may arise during topical
With the introduction of foldable IOLs,15 small-
anesthesia alone. Ester-linked benoxinate (oxybupro-
incision surgery developed with phacoemulsifica-
caine), amide-linked lidocaine, and ester-linked tet-
tion.1,15–17 Initially, this was performed via a scleral
racaine (amethocaine) are the most commonly used
tunnel and thus required sutures, so retrobulbar and
topical agents6 for anesthesia of the cornea and
peribulbar anesthesia were preferred.13,18 Because
conjunctiva.
the corneal incision is inherently small, stepped, and
self sealing, very little manipulation is required and
this has allowed the use of sub-Tenon19–22 and topical ANATOMY AND OCULAR NERVE SUPPLY IN LOCAL
anesthesia.13,23–25 ANESTHESIA
Any anesthesia technique for cataract surgery must An understanding of the anatomy of the orbit and its
strive for patient safety, comfort, and the attainment of contents is essential for the safe practice of regional
safe conditions for the necessary surgery. Essentially, anesthesia, and these are adequately covered in the liter-
the anesthesia modality must be assessed on an indi- ature.46,47 Regional anesthesia can be broadly divided
vidual patient and surgeon basis. The progression into 3 categories: the first attains globe and conjunctival

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Table 1. Properties of popular local anesthetic agents used for ocular surgery.26,29,35, 36

Agent Type Onset Potency Toxicity Duration

Traditional
Procaine Ester Slow Low Low Short
2-chloroprocaine Ester Rapid Intermediate Low Short
Tetracaine Ester Slow Intermediate Intermediate Intermediate
(amethocaine)
Cocaine Ester Slow High Very high: Long
Benoxinate Ester Must be used in lowest possible dosage36 to avoid (1) lethal reactions in low cholinesterase
(oxybuprocaine) activities; (2) allergy to para-aminobenzoic moities; (3) absorption through nasal–lacrimal
apparatus or mucous membrane
Bupivacaine Amide Slow High High Long
Lidocaine Amide Rapid Intermediate Low Short
Ropivacaine Amide Slow Intermediate Intermediate Long
Etidocaine Amide Rapid High High Long
Newly developed
Articaine Amide Rapid d Low Long
Levobupivacaine Amide Slow d High Long
2-choloroprocaine Ester Rapid d Low Short
Proxymethacaine Ester Rapid d Low Intermediate

anesthesia; the second leads to globe, lid, and periorbital of the ophthalmic and maxillary division of the trigem-
akinesia; and the third gives rise to intraocular hypot- inal nerve,46,48,49 whereas globe akinesia requires con-
ony. The first category is particularly suited to a compli- duction blockade of the intraorbital portions of the
cated and prolonged surgery, and the other 2 are oculomotor cranial nerves III, IV, and VI. Mechanical
adequate for less stringent operating requirements. orbital compression devices are often used to attain
Globe and conjunctival anesthesia is achieved globe hypotony.36 Sensory innervation of the globe
through conduction blockade of the sensory functions and its internal structures is mainly via the long and
short ciliary division of the nasociliary nerve (Figure 1).
Table 2. Typical anesthetic agents for various conduction blocks The short ciliary nerve progresses anteriorly, provid-
and topical and intracameral anesthesia techniques. ing sensation to the globe and autonomic motor func-
tion to the iris. It also traverses the retrobulbar cone
Technique/Anesthetic Agent Remarks
and sub-Tenon space and is thus susceptible to block-
Regional/conduction block ade by local anesthesia.
(retrobulbar, peribulbar, Table 4 lists the various regions of the eye and the
sub-Tenon) subserving sensory nerve distribution. Figure 2 de-
Lidocaine 2% For short procedures picts the various extraocular muscles responsible for
Lidocaine 2% C bupivacaine For procedures lasting eye movement.46,49 The oculomotor nerve (cranial
0.75% or ropivacaine 1% 1 hour
nerve III) provides most of the motor innervation for
50%–50% mixture For rapid onset and long
the movements of the globe through all the extraocular
of lidocaine 2% and procedures
bupivacaine 0.75%
muscles, except the superior oblique and lateral rectus.
Topical The lateral rectus muscle is supplied by the abducent
Eyedrops d nerve (cranial nerve VI) and the superior oblique
Proparacaine d muscle, by the trochlear nerve (cranial nerve IV).
Tetracaine d The oculomotor nerve or cranial nerve III supplies
Lidocaine d the levator palpebrae muscle for opening the eyelid,
Bupivacaine d and the facial nerve or cranial nerve VII supplies the
Benoxinate d orbicularis oculi muscle for closing the eyelid.49 Facial
Viscous lidocaine gel d nerve block is used rarely as it is painful and causes
Intracameral
bruising. However, the orbicularis oculi can be
Mixture of preservative-free d
blocked easily from within the orbit, especially by in-
lidocaine 1% and
preservative-free bupivacaine
jecting into the nasal compartment and spreading the
0.5% eyedrops block using ocular compression devices.28,48 The ocu-
lomotor nerve enters the ‘‘bellies’’ of the recti muscles

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136 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

Table 3. Typical onset times and other properties of traditional (bupivacaine 0.5% C lidocaine 2%) and new (ropivacaine, levobupivacaine,
2-choloroprocaine, and articaine) local anesthetic agents.

Anesthetic Agent Onset Time* (Min) Remarks


26,37
Bupivacaine (peribulbar approach) Mean 7.2 G 5.7 (SD) (1) Cardiotoxic
50:50 mixture of bupivacaine 0.5% (with 1:200 000 (2) No adverse effects due to diplopia, although
epinephrine C 30 IU/mL hyaluronidase) some reports suggest diplopia not resolved
& lidocaine 2%) until next day

Ropivacaine38 (peribulbar approach)


Comparative study: Median 8.0 (both agents) (1) Ropivacaine: Less cardiotoxic with higher
Ropivacaine C lidocaine 2.0% C hyaluronidase threshold for central nervous system toxicity than
vs bupivacaine C lidocaine 2.0% C bupivacaine
hyaluronidase (2) Recovery of motor function after 15 min, 55% for
ropivacaine 0.50% and 82% for ropivacaine 0.75%;
after 60 min, 37% and 5%, respectively.
(2) Diplopia persists for 30 hours
for ropivacaine 1.00%
Levobupivacaine39 (sub-Tenon approach)
Comparative study (sub-Tenon approach) (1) Levobupivacaine less cardiotoxic
Levobupivacaine 0.75% C hyaluronidase 5.06 levobupivacaine (2) For (A) Onset difference between levobupivacaine
vs lidocaine 2.00% C hyaluronidase 3.02 lidocaine 0.75% and lidocaine 2.00% not clinically significant39
Median 2.0 both agents

Levobupivacaine (peribulbar approach)


Comparative study:
Levobupivacaine 0.75% C hyaluronidase
vs bupivacaine 0.75% C hyaluronidase

2-Choloroprocaine40 (peribulbar approach)


Comparative study: Full recovery of extraocular muscle
2-choloroprocaine 2% vs 2-choloroprocaine 3% !4 for 2% and 6 for 3% and eyelid motion !85 min for 2-choloroprocaine
(both preservative free) 2% and !100 min for 2-choloroprocaine 3%

Articaine41 (peribulbar approach)


Comparative study:
(A) Articaine 2% C 1:200 000 epinephrine Degree of ocular akinesia after 1 min, same with articaine 2.0% and bupivacaine
C hyaluronidase vs bupivacaine 0.5% 0.5%; after 5 min, greater with articaine 2.0% than with bupivacaine 0.5%;
C lidocaine 2.0%C hyaluronidase at discharge, extraocular motion regained quicker with articaine 2.0% than
with bupivacaine 0.5%.

Articaine (inferotemporal injection approach)


Comparative study:
Repeat of (A) Onset times same as for peribulbar approach

Atticaine (sub-Tenon approach)


Comparative study:
Articaine 2.0% vs bupivacaine 0.5% Onset times faster with articaine 2.0% than with bupivacaine 0.5%
C Lidocaine 2%

*To akinesia or time to start surgery

from the conal surface, and the local anesthetic agent avoided in these parts. Table 5 indicates the extent of
has to reach the exposed 5.0 to 10.0 mm segment of blockade achievable for various regional anesthesia in-
the motor nerves in the posterior intraconal space for jection approaches.36,41
conduction block of these nerves to promote akinesia
LOCAL ANESTHESIA REQUIREMENTS
in the associated muscles.
The apex and superomedial parts of the orbit are the Efficacy
most vascular areas, congested with nerves, blood ves- The efficacy of anesthesia partly depends on the ease
sels, and muscles; hence, needle penetration should be of irrigation and partly on its spread after injection. A

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Figure 1. Diagram of the division of the ophthalmic nerve. Left: Long and short ciliary division of the nasociliary branch. Right: Lacrimal and
frontal branches.

study using magnetic resonance imaging has exam- of various anesthesia modalities is discussed further
ined the distribution of local anesthesia solution in var- under ‘‘Comparative Evaluation of Various Local An-
ious modalities such as combined peribulbar and esthesia Techniques.’’
retrobulbar, superomedial retrobulbar, and sub-Tenon
injection modalities. It reported that for a combined Akinesia
peribulbar and retrobulbar block,50 a relatively large Many surgeons do not consider akinesia an important
volume of local anesthetic solution spreads through- requirement for cataract surgery, but some prefer to op-
out the orbit and a reliable anesthesia is achieved. erate under conditions in which eye movements are
For the superomedial retrobulbar or sub-Tenon injec- blunted if not completely paralyzed. Friedman et al.27
tions, the local anesthetic solution accumulates behind report that both retrobulbar and peribulbar blocks pro-
the globe, and good analgesia and slight akinesia are duce the same degree of akinesia. The same survey com-
achieved with a small volume of anesthetic solution. paring retrobulbar and sub-Tenon techniques reports
However, as discussed, the superomedial approach that akinesia was slightly less effective with sub-Tenon;
is not favored because of the close proximity to the but, the statistical evidence for this was poor. Topical
cluster of nerves and blood vessels. The effectiveness procedures, however, do not lead to akinesia.

Patient Preference (Pain Experience)


Table 4. Distribution of sensory nerve supply to various regions
of the eye and its structures. Significant pain during anesthetic administration,
intraoperative surgery, or after the cataract procedure
Region Nerves are the major reasons for low patient satisfaction.51
Sclera, cornea, ciliary Nasociliary branches: Perceived pain level thus determines patient’s prefer-
body, and iris short ciliary long ciliary ence for the anesthesia technique and is an important
Conjunctiva: factor in the selection of an optimum strategy for anes-
Superior Frontal branches: supraorbital, thesia management during cataract surgery. During
supratrochlear Nasociliary the anesthesia administration phase, topical anesthe-
branch: infratrochlear sia, unlike injection-type anesthesia modalities, is asso-
Inferior Maxillary branch: infraorbital ciated with minimal discomfort. However, with
Lateral Lacrimal Maxillary branch: topical anesthesia, only the trigeminal nerve endings
zygomaticofacial
in the cornea and the conjunctiva are blocked,52 leav-
Circumcorneal Long ciliary
ing the intraocular structures in the anterior segment
Periorbital skin Frontal branches: supraorbital,
supratrochlear Maxillary branch:
unanesthetized. Thus, manipulation of the iris or
infraorbital Lacrimal stretching of the ciliary and zonular tissues irritates
the ciliary nerves, resulting in discomfort. Injectable

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138 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

Figure 2. Extraocular muscles.

anesthesia overall provides a higher level of analgesia vision. Compared with a regional block, topical anes-
and akinesia than topical anesthesia, but the degree of thesia permits early visual rehabilitation, primarily be-
pain perceived by patients during anesthesia adminis- cause in this modality only a limited block or no block
tration and intraoperative surgery for individual retro- of the optic nerve is involved.
bulbar, peribulbar, or sub-Tenon modalities varies. The overall onset and duration times of any selected
The patient-reported pain for various anesthesia tech- anesthetic agent depends on its specific pharmacolog-
niques is discussed in detail under ‘‘Comparative ical properties, on the method of administration, the
Evaluation of Various Local Anesthesia Techniques.’’ mixture properties including hyaluronidase content
(Tables 1 to 3). The duration of the anesthesia deter-
Visual Recovery mines the postoperative recovery and assessment in
Rapid vision recovery is highly desirable in cataract most cases, but, as in other procedures, children or pa-
surgery and is extremely useful, especially in monocu- tients with learning difficulties are treated under gen-
lar patients having surgery in the better eye. Modern eral anesthesia.
ophthalmologic surgery is becoming faster and in
a typical ophthalmology clinic, an uneventful cataract Sedation
surgery may take 20 minutes or less; this allows the pa- Administration of an orbital block can result in
tient to be discharged without an eye patch and good a great deal of pain; consequently, some clinicians

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Table 5. Various regional anesthetic injection approaches and


the resulting blockade of relevant nerves.

Injection location Blockade

Inferotemporal approach Lacrimal, nasociliary, and


frontal (supraorbital and
supratrochlear) nerves
Medial approach (placed Medial branches of nasociliary
between the caruncle and (long ciliary) nerve;
the medial canthal angle) infratrochlear nerve and medial
components of supraorbital
and supratrochlear nerves
Superomedial approach Here the needle would be in Figure 3. Typical initial instrument entry/incision points (unfilled
contact with a path congested markers), and the associated terminal points for anesthetic delivery
with nerves, blood vessels, and (filled markers) within the orbit for various anesthetic techniques (cor-
muscles, and this approach is onal section, right eye). See also Tables 5 and 6.
therefore best avoided.
Superolateral approach This would avoid the
impediments encountered in
pocket expenses. In some European countries (eg,
the superomedial approach. Holland), the cost savings are estimated at about
The needle is placed through 20%. The survey also reports that the rate of outpatient
the skin of the upper lid as the cataract surgery in 10 European countries is influenced
relevant area of conjunctiva is mainly by acute-bed density, density of practicing
inaccessible. physicians, and public expenditure on health.60

use deep sedation. However, many believe the patient CHOICE OF ANESTHESIA DELIVERY
should not be sedated deeply so that he or she remains General Anesthesia
cooperative. In the UK, the use of sedation decreased
from 5.85 % in 1996 to 3.9% in 2002/2003.53,54 The Especially with the advent of day surgery, general
practice of sedation is, however, not recommended anesthesia is reserved for cases that are unsuitable
by the Royal College of Anaesthetists55 and thus for local anesthesia: patients (such as a child or a youn-
should be used to cover only anxiety, not inadequate ger adult) intolerant to the local anesthesia procedure,
blocks. Complications of sedation include excessive confused patients unable to comply, patients with
restlessness, sudden movement, and airway obstruc- marked uncontrolled tremor or jerky movements, pa-
tion, which can significantly increase the risk of the tients with a history of allergic reaction to local anes-
surgery.6,51,56 If the patient is sedated, monitoring is thesia, and patients who refused consent for local
required. The anesthetist should be present and re- anesthesia.
sponsible for the intravenous (IV) sedation. It is con-
sidered safer to abandon surgery than to convert to
general anesthesia, and to continue with general anes- Local Anesthesia
thesia only when the patient is fully prepared. ‘‘Con- Local anesthesia for cataract surgery promises a bet-
scious’’ sedation, which allows full cooperation of ter procedural safety profile6,28 and has allowed devel-
the patient, is recommended.57 The level of sedation opment of day-surgery cases and quicker patient
desired, the route of administration, and the choice recovery generally and visually; it is also a more viable
of drugs commonly used in ophthalmic anesthesia technique financially. Figure 3 illustrates the initial en-
have been reviewed elsewhere.58 try/incision and the final anesthesia-delivery points
for the cannula/needle tip for the various local anes-
Cost thesia techniques. A typical initial cannula entry/inci-
Literature on the economic evaluation of different sion point, the terminal anesthetic delivery point and
systems for cataract surgery and anesthesia is limited, the path traversed by the cannula tip are illustrated
and there is ongoing discussion of the most appropri- in Figure 3. Table 6 describes an appropriate entry lo-
ate methods that can be used.59 According to a survey cation for the cannula in this modality, including typ-
reported by Mojon-Azzi and Mojon,60 outpatient sur- ical procedural maneuvers involved, and the extent of
gery is more cost-effective, primarily because there the resulting anesthesia. Table 6 lists the typical proce-
are no costs for overnight stays and lower out-of- dural details for each technique.

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Table 6. Typical cannula entry/incision locations for various local anesthetic modalities, procedural techniques, and nature of anesthesia
achieved (see also Figure 3).

Technique Cannula Entry Point/Incision Location Procedure/Remarks

(1) Retrobulbar Avascular area inferotemporal quadrant The syringe needle is initially inserted horizontally in an axial direction
(or nasal side of medial rectus muscle) through the lower eyelid (just above the lateral orbit margin) up to the
eye–equator plane, and then the needle is inclined upward and pushed
posterior to the bulb. Both the motor and the sensory nerves are affected49;
the oculomotor (III) and abducent (VI) motor nerves paralyze all
extraocular muscles except the superior oblique. Ciliary ganglion is also
blocked. The entire globe is anesthetized as a result of blocking the
nasociliary and the long ciliary nerves (from Lipatka et al.62, Hamilton64,
and Freeman and Freeman65).
(2) Peribulbar Avascular area For the needle tip to end up beyond the equator plane, the syringe needle
Nasal side of medial rectus is inserted horizontally through the conjunctiva or the lower eyelid, in an
(or inferotemporal quadrant) axial direction above the infraorbital margin. It is angled upward for
delivery. Here the injectate is deposited within the orbit and does not
enter the geometric confines of the cone of the rectus muscle. 48 During
this procedure, local anesthesia affects the motor nerve supply of the
superior oblique muscle and also the orbicularis muscle due to the spread
of local anesthesia through the orbital septum (from Hamilton64, Freeman
and Freeman65, and Kumar and Fanning66).
(3) Sub-Tenon Incision of tented conjunctiva, A small incision is made inferonasally through the conjunctival and sub-
inferonasal quadrant Tenon layers. Using a sub-Tenon curved blunt cannula placed through
the incision to the sub-Tenon space; 3.5 to 5 mL of local anesthetic is
injected. Ocular massage is optional. Iris and anterior segment anesthesia
is achieved,48 and is better than subconjunctival injection alone. The
degree of abolition of extraocular muscle movement is proportional to the
volume and depth of the injectate. With age,19 the posterior Tenon capsule
degenerates and fenestration probably aids diffusion of anesthetic into
retrobulbar cone (from Canavan et al.19 and Kumar and Dodds63).
(4) Topical Drops administered to Drops or gel are/is applied to the surface of the conjunctiva and cornea
cornea and fornix preoperatively. Trigeminal nerve endings in the cornea and conjunctiva
only are blocked.52 Intraocular structures in the anterior segment are not
anesthetized (from Cass26 and Fichman67).
(5) Intracameral Injected though corneal Preservative-free anesthetic agent (usually lidocaine 1%) is injected into
incision during surgery the anterior chamber at the beginning of the operation through 1 of the
corneal incisions required for phacoemulsification. It provides sensory
blockage of the axis and the ciliary body (from Cass26 and Gills et al.68).

LOCAL ANESTHESIA TECHNIQUES 9% in 2003; and the procedure was used primarily for
Retrobulbar (Intraconal) Anesthesia longer operations in eyes with a less stable anterior
chamber.
The retrobulbar procedure achieves good ocular
akinesia and analgesia and generally requires an injec-
tion of 3.5 mL to 5.0 mL of anesthetic agent into the ret- Peribulbar (Extraconal) Anesthesia
robulbar space.14,32,61,62 According to Feibel,14 in this The peribulbar technique involves administration
technique, a shorter needle (31 mm versus 38 mm) is of several (up to 4) injections external to the muscle
introduced into the retrobulbar space by having the cone (Figure 3 and Table 6) and achieves good oc-
patient in primary gaze. Precision placement of the ular akinesia and anesthesia.13,18,70 An audit of peri-
needle is essential to avoid complications (Figure 3 bulbar blockade using short (15.0 mm), medium
and Table 6). (25.0 mm), and long (37.5 mm) needles (disregard-
In a survey of members of the American Society of ing the inherent safety aspects of the length of the
Cataract and Refractive Surgery (ASCRS),69 the per- needles in this particular study for teaching pur-
centage of respondents using retrobulbar anesthesia poses) concluded that the efficacy of peribulbar an-
with some facial block decreased from 76% in 1985 to esthesia depends on the proximity of the deposition

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of the local anesthetic solution to the globe or the that here the ‘‘minimal risk’’ of puncturing the eye is
orbital apex.71 Consequently, peribulbar anesthesia assured because of the clear visibility of the needle
can be classified as circumocular (sub-Tenon epis- tip at all times. Gray and Lucas20 point out that the
cleral), periocular (anterior, superficial), periconal needle tip is not clearly visible once under the conjunc-
(posterior, deep), and apical (ultra deep). Peribulbar tiva and in the event of hemorrhage, it would quickly
blockade can lead to significant reduction in pulsa- be obscured. Thus, Amin et al methodology has no
tile ocular blood flow and IOP, which may be of additional safety compared with the normal peribulbar
benefit in certain operations.72 technique.
Peribulbar anesthesia is the local anesthesia of
choice in complex cataract cases that need total aki-
nesia or iris manipulation. It provides superior aki- Topical Anesthesia
nesia and anesthesia, and in well-trained hands, For fast recovery and rehabilitation after surgery,
there is an extremely low risk for globe penetration. cataract patients are often managed under topical an-
However, an inherently large-volume injection re- esthesia, which can be supplemented with intracam-
quirements for peribulbar anesthesia leads to a rela- eral anesthesia6,13,24 oral or IV sedation.23 One bonus
tively higher chemosis compared to that in of topical anesthesia, especially in patients who have
retrobulbar anesthesia. vision in the operated eye only, is that visual recovery
is almost immediate.
Several methods of topical anesthesia are available,
Sub-Tenon (Parabulbar) Anesthesia but the use of eyedrops or viscous gels are the most
Sub-Tenon anesthesia has been popular.13,19,20,63,73 common modalities. Considerations such as corneal en-
The technique begins with instillation of topical anes- dothelial toxicity,81 patient comfort, and patient history
thesia. The Tenon capsule is then dissected, and a blunt of allergies to local anesthetic determine the choice of
cannula is introduced48 into the sub-Tenon space to suitable anesthetic eyedrops for use in any particular
administer the anesthetic agent. This produces ante- situation. Primarily, proparacaine, tetracaine, lidocaine,
rior segment and conjunctival anesthesia.19,63,73 Anes- bupivacaine, or benoxinate anesthetic eyedrops
thesia sets in rapidly, followed after a few minutes by (Table 2) into the fornix of the operative eye are used.
globe akinesia. Topical anesthesia has also been used with varying
The Tenon capsule is a fascial layer of connective tis- degrees of success for combined cataract and glau-
sue surrounding the globe and extraocular muscles.19 coma surgery, trabeculectomy,78 viscocanalostomy,
It is attached anteriorly to the limbus of the eye, ex- and secondary IOL transplantation.
tends posteriorly over the surface of the globe, and It has been demonstrated to be a safe and effective al-
fuses with the dura surrounding the optic nerve. The ternative to retrobulbar and peribulbar procedures, but
cavity is bound by the Tenon capsule and sclera. it does not provide akinesia and may even give inade-
The sub-Tenon technique has been used increas- quate sensory blockade for the iris and ciliary body.26
ingly for posterior segment eye surgery such as retinal Consequently, it is used for short surgeries and in
detachment surgery.74,75 However, the technique re- cooperative patients with low to medium anxiety. A sig-
quires a certain amount of skill to dissect into the nificant number of surgeons reckon that for routine
sub-Tenon space and correctly placing the anesthetic small-incision cataract surgery, ocular anesthesia with
agent, as well as competence to deal with an increased a topical anesthetic agent is sufficient.13,26,79
risk of conjunctival bleeding and chemosis. Topical anesthetic agents52 block trigeminal nerve
The incidence of conjunctival swelling associated endings in the cornea and the conjunctiva only, leav-
with the sub-Tenon block is around 39.4%.19,76 ing the intraocular structures in the anterior segment
Some of this is attributable to anterior leakage of unanesthetized. Thus, manipulation of the iris and
the injectate, and chemosis is exaggerated if the solu- stretching of the ciliary and zonular tissues during sur-
tion is administered incorrectly into the anterior gery can irritate the ciliary nerves, resulting in discom-
compartment of sub-Tenon space or the subconjunc- fort. For this reason, the addition of intracameral
tival space. The reported incidence of subconjuncti- anesthesia as an adjunct is popular.5,13,26,80
val hemorrhage is 32% to 56%.19,77 Cauterization of High or prolonged doses of local anesthetic agents
the conjunctival incision is often used to reduce are toxic to the corneal epithelium, and this prolongs
hemorrhage. wound healing and causes corneal erosion. Also, re-
Amin et al.74 suggest the use of a standard IV can- peated administration of drops can cause clouding of
nula (instead of the sub-Tenon cannula) to puncture the cornea, rendering surgery more difficult. Tetra-
the anesthetized and tented conjunctiva to reduce che- caine (an ester-type anesthetic agent) is the most irri-
mosis and subconjunctival hemorrhage. It is claimed tating of the eyedrops listed above and should be

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142 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

avoided in patients allergic to this particular family of preservative free lidocaine 1% is injected into the ante-
anesthetic agents.26 Proparacaine, although an ester rior chamber through the corneal incision at the begin-
type, does not metabolize to p-aminobenzoate moiety, ning of the operation. It probably provides sensory
and thus may be used safely in patients allergic to blockage of the iris and ciliary body and thereby re-
other ester-type anesthetic agents. lieves discomfort experienced during IOL placement.
An alternative to eyedrops for topical application is Intracameral lidocaine alone dilates the pupil well,87
the use of viscous lidocaine gel. The gel is often mixed and this is believed to be due to the direct action of
with dilating medications, antibiotics and nonsteroi- lidocaine on the iris, which in turn causes muscle re-
dal antiinflammatory agents. It is reported that 5 mL laxation. Preservative-free lidocaine 1% with 1:100 000
of lidocaine gel 2% mixed with 4 drops tropicamide, epinephrine enhances pupillary dilation more than
4 drops cyclopentolate 1%, 4 drops phenylephrine lidocaine 1% alone and thus obviates the need for
10%, 10 drops moxifloxacin, and 4 drops ketorolac, ap- preoperative dilating drops.88
plied to the operative eye twice before the surgery typ- Intracameral anesthesia has several advantages: in-
ically achieves excellent dilation and anesthesia.26 juries to ocular tissue or life-threatening systemic
However, drug absorption and corneal epithelial side-effects are minimal, the vision is restored in-
safety of this mixture have not been fully investigated. stantly after the operation, the undesirable cosmetic
A comparative clinical trial of topical anesthetic side-effects are avoided, the technique is economical,
agents in cataract surgery82 suggests that lidocaine and there is no need for an anesthetist to be present.
gel is a better agent than bupivacaine or benoxinate The efficacy of intracameral anesthesia with regard
drops. However, bupivacaine drops are effective in to possible retinal and corneal endothelial toxicity is
providing deep topical anesthesia. The reported verbal discussed in a report by the American Academy of
pain score (VPS) during surgery for lidocaine gel, bu- Ophthalmology.26,89 Some of the papers clearly indi-
pivacaine, and benoxinate drops was 1.6, 4.1, and cate the efficacy of intracameral anesthesia, whereas
7.1, respectively (using an arbitrary pain scale of 0 to others fail to support this conclusion. However, the
10 where zero represents no pain and a score of 10, report concludes that as topical anesthesia alone is
high pain). The VPS during application of the agent effective, intracameral anesthesia should be reserved
was 2.97, 1.53, and 1.03, respectively. to deal with incremental pain arising during the
Several studies have compared the relative perfor- procedure.
mance of topical anesthesia and regional blocks. One Short-term studies of the safety of intracameral an-
study shows that although the topical route is well tol- esthesia indicate that preservative-free lidocaine 1%
erated, there is greater overall satisfaction and less im- is well tolerated by the corneal endothelium, whereas
mediate and post-procedure pain with sub-Tenon higher concentrations are toxic.26 Although short-term
blockade.83 Another concludes that patient comfort studies indicate safety, the long-term effects are not
and surgery-related complications did not differ be- known.
tween topical anesthesia and peribulbar anesthesia Retinal toxicity can occur because of posterior diffu-
and that in view of the minimally invasive character sion of local anesthesia to the retina, and a temporary
of topical anesthesia compared with that of peribulbar loss of light perception has been reported after intra-
anesthesia, the use of topical anesthesia for routine cat- cameral anesthesia.26 Several in vitro studies suggest
aract surgery is justified.84 that both lidocaine and bupivacaine may be toxic to
A study comparing topical anesthesia and retrobul- the retina; therefore, a minimal concentration of local
bar anesthesia85 reports that phacoemulsification with anesthesia must be used.26 Although the toxic effects
topical anesthesia is more painful than retrobulbar an- of the commonly available topical anesthetic agents
esthesia and that in hypertonic patients and younger on the corneal epithelium have been studied exten-
patients more susceptible to pain, topical anesthesia sively,52 their effect on corneal endothelium as part
should be avoided or used in conjunction with seda- of intracameral anesthesia administration is not fully
tion. Yet, another study86 suggests that topical anesthe- understood. Preservative-free lidocaine 1% in doses
sia is justified as a means of improving safety without of 0.1 to 0.5 mL is not associated with corneal endothe-
causing discomfort to the patient even in complicated lial toxicity,26 but higher concentrations may be toxic.
cataract surgery cases. The Royal College of Anaesthe- Compared with lidocaine, intracameral bupivacaine is
tists55 recommends the presence of an anesthetist only not well studied, but it may be more toxic to corneal
when a sharp-needle block or sedation is undertaken. endothelium than lidocaine 1%. Thus, preservative-
free lidocaine 1% has been suggested as the local anes-
Intracameral Anesthesia thesia of choice for intracameral anesthesia.26
Intracameral anesthesia is a common adjunct to A study in rabbits shows that the preservative ben-
topical anesthesia in phacoemulsification.26 Normally zalkonium chloride (at a concentration of 0.025% to

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REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY 143

0.05%) in commercially available anesthetic agents


Table 7. Contraindications to local anesthesia.
may cause irreversible damage to corneal tissues.52 In-
jecting unpreserved lidocaine hydrochloric acid 4% Relative Contraindication Avoid
into the anterior chamber over a period of several
Prolonged complex surgery All local
days81 produced significant corneal thickening and
anesthesia techniques
opacification in rabbit models.
Uncontrollable neurological All local
Exposure time to the agent and the preservative in movements anesthesia techniques
the agent are important in determining the effect of li- Uncooperative mentally All local
docaine. However, a brief exposure (typically equal to debilitated patient anesthesia techniques
that needed for uneventful foldable IOL implantation) Highly myopic cases Retrobulbar and peribulbar
to unpreserved lidocaine is considered unlikely to in- techniques
jure the corneal endothelium. Allergy Topical anesthesia
Several incidents of visual sensations ranging from Nystagmus Topical anesthesia
light perception to increasing clarity have been re-
ported during surgery under topical anesthesia proce- Globe Perforation
dures.90 Many patients find this an unexpected and
Globe perforation is a rare complication, more likely
disturbing experience, but this fear may be reduced
to occur in myopic eyes (which are thinner and lon-
with adequate patient counseling.
ger), especially when carrying out retrobulbar and
peribulbar blocks.31,94 The reported incidence of globe
COMPLICATIONS OF ANESTHESIA TECHNIQUES
perforation ranges from 0 in 2000 to 1 in 16 224 for
Contraindications peribulbar procedures,95 3 in 4000 for retrobulbar,
The contraindications to various modalities are and 1 in 12 000 for a mixture of peribulbar and retro-
listed in Table 7. bulbar procedures.16 A significant proportion of globe
penetrations are not detected during administration of
Safety Considerations the anesthetic agent but are noticed following the de-
Safety considerations concern both the inherent velopment of hypotony, poor red reflex, and vitreous
safety of the anesthetic agent and also the modality hemorrhage during surgery.31
technique used. A UK-based survey concludes that po- During delivery of the anesthetic agent, patients are
tentially life-threatening complications exist with all often asked to move their eyes from side to side to en-
techniques except topical/intracameral local anesthe- sure that no contact with the globe has occurred. The
sia.53 This suggests that an anesthetist must be present risk with this is that a patient will move his or her
to deal with adverse events when intraocular surgery head instead and in doing so run the risk of deepening
is performed. Another UK-based survey54 showed the depth of penetration.
that in 1996, an anesthetist was present for 84% of The complication rate of globe perforation can be re-
the cases monitored and IV access was established in duced by correct knowledge of anatomy (especially if
60% of these cases. The UK-based survey53 also previous ocular surgery that may alter the anatomy
showed that from 2002 to 2003, potentially sight- has occurred), patient cooperation, and the use of
threatening complications were mostly associated blunt needles. Although perforation is less likely
with retrobulbar and peribulbar techniques. with blunt needles, in the event of a perforation,
more trauma is involved.28
Orbital Hemorrhage
Orbital hemorrhage can be reduced by avoiding in- Systemic Adverse Events
jection into the apex (vascular area), using fine and Systemic risk such as brainstem anesthesia can oc-
short needles (25-gauge and 25 mm needles). 31,48,91–93 cur with local anesthesia. For this reason, the patient
Fanning61 discusses a choice of needles for use in orbital must be monitored carefully after administration of
regional anesthesia. The use of needles longer than 31 the anesthesia and also during surgery. Symptoms
mm is not recommended. The use of retrobulbar and such as drowsiness and loss of or confused verbal con-
peribulbar anesthesia is decreasing primarily because tact often suggest brainstem anesthesia, which can
of the increased risk and severity of complications lead to respiratory and cardiac arrest.31 The onset usu-
such as globe perforation and retrobulbar hemorrhage, ally occurs within 8 to 10 minutes of local anesthesia
especially as other modalities have been found to be as delivery. Resuscitation equipment and personnel
effective. Delivery of the anesthetic agent with a blunt trained to use it must be available. The oculocardiac
needle, such as that used in sub-Tenon delivery, reflexdepisodes of bradycardia provoked by eye sur-
reduces this risk substantially. gery or eye manipulationdis blocked when the ciliary

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144 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

ganglion is anesthetized (Figure 1, left). The oculocar- rectus muscle, can occur as a result of the retrobulbar
diac reflex is rare with local anesthesia because block- technique.103,104 Muscle palsy (diplopia and ptosis)
ade of the ciliary ganglion ablates the afferent can be prevented by not using high concentrations of
oculocardiac reflex,28 but rapid distension of the tissues local anesthesia, which can become both neurotoxic
by volume or hemorrhage can occasionally provoke it. and myotoxic. Facial nerve blocks can lead to dyspha-
Death can result from local anesthesia as a conse- gia or respiratory obstruction31 from spread of the an-
quence of spread of the anesthetic agent along the op- esthesia to the glossopharyngeal nerve and should be
tic nerve sheath or intraarterial injection of the used only in the presence of severe blepharospasm.
anesthetic solution with retrograde flow, giving rise Adjuvant IV anesthetic agents for the reduction of
to systemic toxicity that causes brainstem anesthe- pain are normally associated with an increase in med-
sia.28,31 This is more likely to occur with retrobulbar ical events.105
anesthesia (0.1% to 0.3%); it rarely occurs with peribul- The incidence of perioperative myocardial ischemia
bar and short needles, as they avoid the cone of the ex- in elderly patients having cataract surgery is signifi-
traocular muscles. This risk is also reduced if short cantly less under local anesthesia than general anes-
needles are used in primary gaze to avoid rotation of thesia.106 High or prolonged doses of local anesthesia
the needle towards the nerve,13 which reduces the in- are toxic to the corneal epithelium; this prolongs
cidence of direct trauma to the optic nerve. In the UK wound healing and causes corneal erosion. Repeated
during the period 2002 to 2003, 7 of 8 reported neuro- administration of topical local anesthetic agents fre-
logical complications (consistent with brainstem) were quently sting and occasionally cause temporary cloud-
due to retrobulbar and peribulbar anesthesia.53 ing of the cornea, rendering surgery difficult.30,31
A study of the management of cataract in a predom-
inantly elderly female population exhibiting signifi-
COMPARATIVE EVALUATION OF LOCAL ANESTHESIA
cant systemic illness and coexisting advanced
TECHNIQUES
cataract, presenting for surgery in a typical public hos-
pital in New Zealand, reported adverse intraoperative Patient-Reported Pain
events of only 5%.96 Friedman et al.27 performed a systematic literature
search using PubMed and Cochrane Collaboration’s
Allergy database (Central) to synthesize the findings of vari-
ous randomized trials in regional anesthesia manage-
The adverse effects of some common drugs used in
ment strategies for cataract surgery,. They concluded
refractive surgery have been discussed in various
that because of the large heterogeneity in the
studies.29,31,97,98 Toxicity (arising because of overdose
contents, design, and outcomes of the studies, the
or intravascular injection) and allergic or vasovagal re-
scientific justification for the metaanalysis were not
actions are the most common complications associated
met and they instead used an unconventional con-
with local anesthesia and can lead to systemic
sensus-type approach to grade the outcomes based
complications.31
on the methodology proposed by Garbutt et al.107
There have been several case reports of allergy from
Recently, Alhassan et al.108 compared patient-per-
use of local anesthesia or proparacaine eyedrops.99,100
ceived pain during cataract surgery for retrobulbar
Although cross-sensitization between proparacaine
versus peribulbar interventions invoking metaanaly-
and other related topical ophthalmologic anesthetic
sis. Both studies reached the same conclusion that:
agents such as tetracaine is a rare occurrence, some
Retrobulbar and peribulbar blocks perform similarly,
studies100 suggest that allergic sensitization and possi-
and there is little difference between them in terms
ble cross reaction to topical anesthetic agents in oph-
of patient-perceived pain and anesthesia during cat-
thalmologists is an occupational hazard.
aract surgery.
The development of amide local anesthetic agents
The applicability of metaanalysis for the study un-
have effectively reduced allergic reactions, and amides
dertaken by Alhassan et al.108 is probably justified as
are now considered rare allergens; only about 1% al-
the number of patients in their study was large (N Z
leged reactions are believed to be caused by a truly im-
221) compared with the number in the study by
mune-mediated process.29 Hyaluronidase, an additive
Friedman et al.27 (N Z 40). Also, the statistical power
used to promote the onset and quality of the block,
of the study by Alhassan et al. exceeds that of the study
may rarely cause allergic reactions.101,102
by Friedman et al. However, as the available data for
the comparative study of the patient-perceived pain
Other Complications for most of the local anesthetic modalities are limited,
Persistent diplopia (overall incidence 0.25%), lasting it is prudent to be guided by the methodology adopted
over a month and due to direct damage to the inferior by Friedman et al.27 There is, however, a trend to use

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REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY 145

Figure 4. Global display of comparative patient-reported


pain between various pairs of anesthesia techniques dur-
ing anesthesia administration (compiled from data in
reference 27). The width of the horizontal bars represents
the patient-perceived pain level and a scheme of ‘‘more,’’
‘‘less,’’ or ‘‘equal’’ pain level representation is adopted
for any comparative pair of modalities. The degree of as-
sociated confidence (in descending order: A, B, C, and
‘‘poor’’), representing the strength of evidence, efficacy
of the intervention, and the choice of controls used is
also indicated. The modalities for any pair are arranged
to align along a fixed set of markers along the vertical
axis that represent the various modalities involved.
The modality-markers are arranged along the vertical
axis in a descending order and correspond to the mean
pain scores evaluated in the text (PB Z peribulbar; ST
Z sub-Tenon) (compiled from Friedman et al.27).

random-effect modeling to accommodate the signifi- versus sub-Tenon, and peribulbar versus topical
cant heterogeneity assumption and thereby justify and spans the period 1993 to 1998. The study of Al-
the use of metaanalysis, but the inherent weakness of hassan et al.108 is limited to the comparison of retro-
this method is that the sources of bias are not con- bulbar and peribulbar only and the data refers to
trolled by the method.109 the earlier period 1989 to 1991.
More randomized clinical trials of various local an-
esthesia procedures in cataract surgery are needed to
facilitate statistical methods of metaanalysis in order Patient-Perceived Pain During Anesthesia
to establish the relative merits of these procedures Administration
convincingly. The rationale is that a larger number Figure 4 is a global plot of superimposed data for
of studies and larger number of patients per study comparative patient-perceived pain during anesthesia
would reduce bias with proper statistical modeling
in metaanalysis and also overcome the problem of
any shortfall in the number of degrees of freedom.
The presentation of the results of the comparative
study by Friedman et al.27 for the assessment of pa-
tient-perceived pain for various modalities is a lengthy
narrative description, which is not easy to assimilate.
We present these descriptive findings selectively, as
a global superimposed graphical display and/or as
a table for easy comparative evaluation. Our presenta-
tions reveal the qualitative and, in some cases, even the
quantitative trends.
Alhassan et al.108 assert that some of the data
included by Friedman et al.27 (ie, Murdock110 and
Saunders et al.111) is ‘‘with high risk of bias,’’ imply-
ing that this probably led to the large observed ‘‘sta-
tistical heterogeneity’’ unjustifiably invalidating the
use of metaanalysis. We exclude these specific studies
from our data for the construction of Figures 4 to 7.
The work of Friedman et al.27 is extensive, as it
compares the parameters of interest for a number of Figure 5. Relative quantitative rating of patient-perceived pain for
comparative modalities such as retrobulbar versus various anesthetic modalities during anesthetic administration
peribulbar, retrobulbar versus sub-Tenon, peribulbar along an arbitrary (0 to 10) scale.

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146 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

Figure 6. Global display of comparative patient-reported


pain between various pairs of anesthesia techniques dur-
ing intraoperative cataract surgery (PB Z peribulbar; ST
Z sub-Tenon) (compiled from Friedman et al.27).

administration for the various pairs of anesthesia mo- of anesthesia by injection is relatively more painful
dalities. The global plot is constructed using the pain than that by topical procedures. A plot of the mean
scores reported by Friedman et al,27 and only the values for the various modalities yields the
data for pairs of modalities without sedation has
been included. Performing statistical averaging of the
tabulated pain scores27 for the various modalities in
different setups, the mean pain levels for retrobulbar,
peribulbar, sub-Tenon, and topical anesthesia is 2.25,
1.96, 1.8, and 0.1, respectively. The spread (range) of
the mean pain scores in different setups for retrobulbar
and peribulbar is (G2.2%  mean) and (G8.2% 
mean) respectively. The spread of the results for sub-
Tenon and topical anesthesia for different setups is
not known as only a single trial result is available for
these 2 modalities. However, an assumption is made
that the spread is probably of the same order as that
for retrobulbar or peribulbar modalities. As the range
(dispersion) may at least for one-half of the modalities,
considered is a mean pain level can be assigned to var-
ious modalities for quantitative purposes, within an
arbitrary scale 0 to 10, where zero score represents
no pain, 1 to 2 mild pain, 3 to 5 moderate pain, and
a score of more than 5 severe pain. However, here
some uncertainty remains mainly due to insufficient
data, especially for sub-Tenon and topical anesthesia.
The modality-markers in the global plot (Figure 4)
are arranged vertically in descending order of the
mean values, and this is used as a datum for the align-
ment of the various superposed comparative pairs of
modalities. Figure 4 shows that qualitatively, among
the injection types, the perceived pain least with the Figure 7. Relative qualitative rating of patient-perceived pain for
sub-Tenon approach and, generally, the application various anesthetic modalities during intraoperative cataract surgery.

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REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY 147

Table 8. Effectiveness of regional anesthesia.

Parameter Effectiveness of various modalities

Akinesia Retrobulbar and peribulbar anesthesia produce equally good akinesia.27,108


Addition of hyaluronidase Addition of hyaluronidase appears to increase the effectiveness of these blocks in
producing akinesia; however, the use of hyaluronidase in procedures other than
retrobulbar is controversial.
There is insufficient evidence to determine whether retrobulbar or peribulbar
blocks produce better akinesia than sub-Tenon block. Comparing between
retrobulbar and sub-Tenon procedures, akinesia is slightly less effective in sub-
Tenon procedure, but there is insufficient evidence to support this conclusion.
In summarizing above conclusions, the survey27 combined the qualitative
statements and the actual muscle movement measurements.
Patient-reported pain during anesthetic administration Application of anesthesia by injection is more painful than by topical means in
patients not receiving sedation.
Of the injection-type procedures, the sub-Tenon approach is the least painful.
There is weak evidence that peribulbar blocks are slightly less painful than
retrobulbar blocks.27
Patient-reported intraoperative pain Intraoperative pain is greater with topical anesthesia than with injection blocks.
Addition of intracameral nonpreserved lidocaine to topical anesthesia improves
the pain control of this modality.
Among injection-type procedures, pain during intraoperative surgery is less
with sub-Tenon procedure compared to retrobulbar or peribulbar procedures.
Duration of surgery is an important factor in assessing the intraoperative pain;
however, the effect of this on the above observations is not known27)
Visual recovery Retrobulbar, peribulbar, and sub-Tenon methods cause optic-nerve conduction
delay. Visual recovery is normally up to 6 hours postoperatively, whereas instant
recovery is attained under topical anesthesia.

quantitative grading of the patient-perceived pain is constructed using the data reported by Friedman
(Figure 5) during anesthesia administration. et al.,27 and the arrangement for plotting the various
components of the comparative modalities is the
same as that described for Figure 4, except that place-
Patient-Perceived Pain During Intraoperative ment of modality markers along the vertical axis is not
Surgery based on the mean values.
Figure 6 is a global plot of superimposed data for Statistical averaging of the tabulated data reported
patient-perceived pain during intraoperative cataract by Friedman et al.27 indicates a large spread (range)
surgery for various pairs of anesthesia modalities. It in the perceived pain levels for retrobulbar and

Figure 8. Trend in the use of various local anesthetic tech-


niques in the U.S. from 1995 to 2003 (compiled from
Leaming69).

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148 REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY

Table 9. Comparison of the trend and use of various anesthesia


order of sub-Tenon and topical anesthesia readily fall
techniques for ocular surgery in U.K. for the years 1996 and in place when the pair results are superimposed on
2002–2003 (based on references53,54). the global plot (Figure 6).
Qualitative grading of the various modalities as
Percentage
derived from Figure 6 is illustrated in Figure 7. It
Trend Trend in indicates that the patient-perceived pain during intra-
Technique in 1996 2002–2003 operative surgery was greater with topical anesthesia
than with injection blocks. For the injection types,
General anesthesia 24.2 4.1
Local anesthesia alone 70.0 92.1
pain was less with the sub-Tenon procedure than
Local anesthesia with sedation 5.8 3.9 with retrobulbar and peribulbar.
Retrobulbar 16.9 3.5
Peribulbar 65.6 30.6
Patient-Perceived Pain with Various Anesthetic Agents
Sub-Tenon 6.7 42.6
Topical 2.9 9.9 The VPS between 0 and 10 (zero represents no pain
Topical C intracameral 2.3 11.0 and 10, high pain) for pain during surgery for different
Subconjunctival 4.4 1.7 types of topical anesthetic agents such as lidocaine gel
2%, bupivacaine 5% drops, and benoxinate 0.4% drops
has been reported as 1.6, 4.1, and 7.1, respectively.82
peribulbar modalities in different comparative setups.
The spread around the mean value is G92.4%  mean
(mean Z 1.4) for retrobulbar and G60%  mean Akinesia and Effectiveness of Various Anesthesia
(mean Z 0.5) for peribulbar. The spread for sub-Tenon Modalities
and topical anesthesia is not known as only a single Table 8 summarizes the effectiveness of various re-
trial result was available for these 2 modalities. As gional anesthesia modalities in terms of akinesia, pa-
the spread (range) the mean for different setups of tient-reported pain during anesthetic administration,
the various modalities is large, it is inappropriate to as- patient-reported intraoperative pain, and visual recov-
sign mean values to the various modalities for quanti- ery. The results show that retrobulbar and peribulbar
tative purposes. Consequently, the global plot in procedures produce equally good akinesia, and sub-
Figure 6 is purely a qualitative display based on com- Tenon procedures produce slightly less akinesia, but
parative inference. The weighted pain level scores the supporting evidence for this is insufficient.
(taken as the product of the mean pain scores and The patient-reported pain results in Table 8 for ‘‘dur-
the percent of cases with severe pain) for both retrobul- ing anesthetic administration’’ and ‘‘intraoperative
bar and peribulbar are the same, indicating that the surgery’’ are consistent with the trends depicted in Fig-
perceived pain for these 2 modalities is the same; ures 4 to 7. Table 8 also indicates that visual recovery
and this is in agreement with the conclusions reached after topical anesthesia compared with retrobulbar,
by Friedman et al.27 Using this as a datum, the relative peribulbar, and sub-Tenon is relatively a lot quicker.

Figure 9. Relative changes in the use of various local an-


esthetic modalities in the U.S. from 1995 to 2003 (com-
piled from Leaming69).

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REVIEW/ UPDATE: LOCAL ANESTHESIA FOR CATARACT SURGERY 149

Figure 10. Relative changes in the use of various local an-


esthetic modalities in the UK for the years 1996 and
2002/2003 (GA Z general anesthesia; LA: local anesthe-
sia) (compiled from Eke and Thompson53,54).

Practice Patterns Among Refractive Surgeons in the blunt needle and topical treatments has improved
United Kingdom and the United States the safety profile of anesthesia delivery. Both modali-
The results of the practice-pattern survey of ASCRS ties appear acceptable for patient comfort during anes-
members69 (Figure 8) clearly indicates that from 1998 thesia delivery and intraoperative surgery. However,
to 2003, there was a significant decline in the use of ret- consideration of contraindications and the desired du-
robulbar anesthesia procedures and an increase in top- ration of anesthesia for the accomplishment of set sur-
ical procedures. The results also indicate a renewed gical objectives determine the choice between these 2
interest in sub-Tenon techniques. The survey suggests modalities. Other modalities have their place and
that the use of topical anesthesia varied according to should be considered if the surgery is complicated,
the surgical volume: In 2003, it was 38% for institu- likely to be of prolonged duration, or especially if the
tions with 1 to 5 procedures a month and 76% for insti- patient is intolerant of local or topical procedures.
tutions with more than 75 procedures a month. There is a need for more randomized clinical trials of
A 2002 European survey112 comparing anesthesia various local anesthesia procedures in cataract sur-
techniques and practices internationally suggested gery, to facilitate the statistical methods of metaanaly-
that peribulbar block was the most frequently used sis and thus establish the relative merits and efficacy of
technique and that topical anesthesia was used by these procedures. This would, in turn, prompt the in-
a sizeable minority of surgeons. However, the Ameri- clusion of relevant anesthesia strategies for cataract
can survey69 is considered more thorough and is also surgery within ophthalmology and anesthesia train-
more widely accepted. ing programs.
Table 9 lists the findings of UK-based studies (The
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