What's new in ophthalmic anaesthesia?

Vellore Govindaraj Venkatesan and Andrew Smith

Purpose of review There have been many changes in ophthalmic anaesthesia in the past few years. This review charts recent trends in practice. Recent findings Topical anaesthesia is gaining widespread use for ophthalmic surgery, but readers need to be aware that definitions vary widely; some `topical' techniques also include intracameral injections and adjunctive sedation. There is now evidence on the relative effectiveness of different types of local anaesthesia from large systematic reviews. Furthermore, the notion is emerging that the traditional distinction between peribulbar and retrobulbar blocks may not be as clear-cut as previously thought. A new area of investigation is the effect of local blocks on pulsatile ocular blood flow. However, the risk of ocular ischaemia has yet to be quantified. Local anaesthesia has also been tried for posterior segment surgery with apparently successful results. The management of patients taking anticoagulants and anti-platelet agents has been examined, and it appears that there are risks not only in continuing therapy but also in stopping it peri-operatively. The decision thus has to be taken on the balance of risks. Summary There have been significant further gains in our understanding of local anaesthetic eye blocks and the management of patients undergoing such procedures. Keywords ophthalmic surgery anticoagulation, peribulbar block, ophthalmic topical anaesthesia, retrobulbar block
Curr Opin Anaesthesiol 15:615620.
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Introduction

Ophthalmic anaesthesia has undergone signicant changes in the past 10 years or so. The widespread use of the surgical technique of phacoemulsication has simplied cataract surgery and is a reason for the shift from general to local anaesthesia. Hospital admission has given way to ambulatory (day-case) care for most patients. Local anaesthetic blocks are now frequently performed by anaesthetists rather than surgeons and we need to be familiar with the benets and drawbacks of these techniques. Particular areas of current debate are the relative merits of peribulbar, retrobulbar and subTenon's blocks, and how to manage the patient on anticoagulants or anti-platelet agents. There have been a number of large-scale studies and systematic reviews in ophthalmic anaesthesia in the past couple of years and these are particularly worthy of attention. The United Kingdom Royal Colleges of Anaesthetists and Ophthalmologists have produced joint guidance on the peri-operative management of patients undergoing eye surgery under local anaesthesia [1 .]. This reects a consensus among an expert group of clinicians, but the strength of the evidence behind the advice is stated when possible. Many patients are anxious before cataract surgery. A pilot study to quantify this anxiety during different stages (pre-assessment clinic, operation day and postoperative clinic) [2] showed that the average patient was not unduly anxious. The statistical notion of the `average' patient is less useful in clinical practice than data to help us identify and manage those who are most affected, and we hope that future research will address these needs. Most of these patients are elderly, and local anaesthesia is offered partly to avoid postoperative cognitive dysfunction. However, Kubitz and colleagues [3] used two different general-anaesthetic techniques, and found only a minor decit 2 h after cataract surgery and no persisting impairment after 24 h. Unfortunately assessments were not made at intermediate times. Another general-anaesthestic study [4] reported that clonidine premedication reduced intraocular pressure (IOP). However, that was a non-randomized study (which would tend to overestimate the drug's effect) and the authors' practice of endotracheal intubation for these patients will lead to higher potential increases in IOP than the laryngeal mask airway, which is now quite widely used in ophthalmic anaesthesia. A prospective cohort study of
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Patient management and safety

2002 Lippincott Williams & Wilkins.

Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK Correspondence to Andrew Smith, Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster, UK Tel: +44 01524 583517; fax: +44 01524 583519; e-mail: andrew.smith@l.bay-tr.nwest.nhs.uk Current Opinion in Anaesthesiology 2002, 15:615620 Abbreviations IOP POBF PONV intraocular pressure pulsatile ocular blood flow postoperative nausea and vomiting

# 2002 Lippincott Williams & Wilkins 0952-7907

DOI: 10.1097/01.aco.0000043962.13957.ac

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19 250 cataract operations under topical or injection anaesthesia examined the incidence of adverse intraoperative medical events [5 . .]. The use of intravenous sedatives signicantly increased the risk of an adverse event, and this was highest (4.04%) when a combination of hypnotics, sedatives and opioids was used. The cardiovascular system was the most commonly affected, manifesting with arrhythmia and hypertension [5 . .]. Patients' perceptions of pain and side effects were also elicited as part of the study and were reported separately [6]. Overall, 5% of patients reported some degree of pain, 16% were drowsy postoperatively, and 4% experienced nausea and vomiting. The balance of side effects varies with the use of different sedative and opioid agents, and readers are recommended to read the paper for themselves to elucidate the relationship. Phacoemulsication for cataract surgery appears to require more limited anaesthesia than traditional extracapsular extraction, and is increasingly performed under topical anaesthesia. This appears to be generally safe and effective. However, care should be taken when interpreting the published literature. Although we take `topical anaesthesia' to mean simply the instillation of local-anaesthetic drops, some surgeons supplement this with intracameral injections, and many centres sedate the patient either before or after local anaesthetic is administered. A prospective observational Swedish study of 890 cataract operations [7 .] found that eye pain was experienced during surgery in less than 2% of patients (although the degree of pain was not quantied). Only 15% of patients were sedated (usually by oral diazepam) [7 .]. Furthermore, most patients who had had surgery on one eye preferred topical anaesthesia for the second. Further data came from a study assessing pain during different stages of phacoemulsication cataract surgery under topical anaesthesia [8]. Pain scores were averaged using the mean rather than the median, as would be more usual, but were generally low (overall 1.46). The highest pain was reported during the phacoemulsication stage, but this was not signicantly worse than the pain caused by the administration of topical anaesthetic agent. In our experience, when a subconjunctival injection of antibiotic and steroid is used at the end of the procedure, this can occasionally be painful, but this was not scored. Topical anaesthesia has been compared with needle blocks as part of a large systematic review [9 . .], and does not seem to provide such good pain relief during surgery as peribulbar or retrobulbar blocks. In a three-armed subsequent study, Kallio and colleagues [10] compared topical (that is, drops plus intracameral injection) with topical and propofol sedation with retrobulbar/peribulbar

block. The addition of propofol did not improve the surgical conditions. In addition, all patients were given intravenous fentanyl 0.81 mg/kg 5 min before surgery. The overall technique is thus considerably more complex than drops alone, and one wonders how much the adjuncts affect the success. Other reports showed that `pure' topical anaesthesia has also been used successfully in patients with co-existing glaucoma [11], and for posterior vitrectomy with apparently adequate results [12].

Topical anaesthesia

The debate over which block is best continues. One aspect to the controversy is the concern over safety, particularly with regard to the serious complications of optic nerve damage, brainstem anaesthesia, globe perforation and retrobulbar haemorrhage. Complications have been carefully reviewed by Hamilton [13]. In a large systematic review of the effectiveness of regional anaesthesia for cataract surgery [9 . .], there was good evidence that retrobulbar and peribulbar blocks produce equivalent analgesia and akinesia, retrobulbar blocks provide better analgesia than topical anaesthesia, and topical anaesthesia with intracameral lidocaine provides better analgesia than without. There was only poor evidence to support increased effectiveness from the addition of hyaluronidase and also for buffering local anaesthetic for use in needle blocks. Further data on peribulbar blocks came from an English study of 1000 consecutive blocks [14 . .]. Akinesia together with very low operative pain scores were present in 79% of patients and no major complications were seen. The authors described their `painless' injection technique and this is worth reading. Both peribulbar and retrobulbar blocks appear to be effective, but a fundamental question is how do anaesthetists know which block they are actually performing? A recent editorial [15 .] described how when anaesthetists rst moved from retrobulbar to peribulbar blocks, onset times were long and many blocks were inadequate or even failed. With experience, peribulbar blocks seemed to work more quickly, were of better quality and more successful. Thind and Rubin [15 .] speculated that anaesthetists had reverted to performing retrobulbar blocks, albeit with shorter needles and maybe other slight modications. However, the notion that retrobulbar and peribulbar blocks are distinct from each other rests on the assumption that there is an intermuscular membrane separating the two spaces. A cadaver study by Ripart et al. [16 . .] denied that such an anatomical barrier existed. Are the two blocks really one, differing only in where the needle tip is placed? We have long suspected this. Certainly, the sign of upper lid lag or ptosis as an endpoint for injection during block insertion has been associated with blocks

Local-anaesthestic blocks: peribulbar or retrobulbar?

What's new in ophthalmic anaesthesia? Venkatesan and Smith 617

described as both peribulbar [17] and retrobulbar [18]. This dual nding would also lend support to this emerging hypothesis. Ripart and colleagues [16 . .] recommended that peribulbar should replace retrobulbar anaesthesia on the grounds, often stated previously, that complications are more likely if needles are placed nearer the apex of the orbit. So we conclude this section with two comments. First, readers should be aware that a given block can be performed in many different ways, and that it is not always possible from published descriptions to tell exactly what is happening. Second, proper training and experience are probably more important in ensuring safety and quality than whether the chosen block is nominally peribulbar or retrobulbar.

conjuntiva and no postoperative diplopia or other ocular motility problems were reported. Frow et al. [17], in a prospective study that assessed total upper eyelid drop as a new endpoint marker to singleinjection peribulbar block without ocular compression, achieved satisfactory akinesia in 90% and satisfactory operating conditions in 98% of patients with a minimal increase in IOP 10 min after injection. The authors also found a negative correlation between the volume of local anaesthetic injected and an increase in IOP, which has not been reported previously. They suggested that ocular compression, with its attendant risks, can be avoided and effective peribulbar anaesthesia can still be achieved if total upper eyelid drop is used as an endpoint for injection. The rapid onset of ptosis, indicating accurate intraconal placement during retrobulbar anaesthetic injection, has also been reported [18]. A modication of orbicularis oculi plus retrobulbar block via a single entry point has been described [29], with no major complications. The potential advantage of this approach is that it is a single injection, although it can sometimes be painful.

Drugs, balloons and catheters

A number of studies have compared different combinations of local anaesthetic with and without hyaluronidase for peribulbar block [1921], and broadly support the view that satisfactory results can be obtained with most regimens. The last two of the studies [20,21] used articaine, a drug little used in current practice. Clonidine at a dose of 1 mg/kg with 2% lidocaine signicantly prolonged the duration of anaesthesia and analgesia with limited side effects [22]. In a randomized study [23], peribulbar morphine was added to lignocaine in pterygium surgery, and produced effective postoperative pain relief compared with lignocaine alone with minimal opioid side effects. That small study (20 patients) is promising but the technique needs further validation. Is ocular compression needed after peribulbar block? One study found no signicant difference in block efcacy with the use of Honan's balloon [24 .]. Even though IOP was lower in patients with compression, it did not increase signicantly without compression. One randomized study [25] found that ropivacaine led to lower IOP than bupivacaine when used in peribulbar block. The authors attributed this nding to vasoconstriction with ropivacaine. The successful insertion of indwelling catheters into both intraconal and extraconal spaces has been described in cadavers and also in patients undergoing vitreoretinal surgery [26,27]. In all patients with a retrobulbar catheter, adequate anaesthesia was achieved and maintained with the continuous infusion of local anaesthetic. No major complications or macroscopic injury to the catheter were reported. The catheter did not interfere with the surgeon's access, suggesting that continuous retrobulbar anaesthesia is an alternative to general anaesthesia for prolonged ophthalmic surgery. It has also been used successfully for titratable postoperative analgesia after painful cyclodestructive and retinal destructive surgery [28]. No swelling of the eyelids or

A number of studies have used a simple non-invasive method of estimating pulsatile ocular blood ow (POBF) during needle blocks. Watkins et al. [30 .] in a randomized study found no signicant increase in IOP after peribulbar and retrobulbar injections, but found that POBF signicantly decreased 1 min after injection, and tended to remain low after 10 min. Does this mean that POBF can fall even without an increase in IOP? The authors speculated about the possible mechanisms to explain their ndings. Similar ndings were noted in another study after retrobulbar injection [31 .], leading the authors to recommend POBF monitoring in patients having retrobulbar injection, orbital compression or digital manipulation of the globe. Furthermore, POBF decreases as the axial length increases [32], suggesting that long eyes may be more at risk of ischaemia during block placement than normal eyes. The systematic review cited above [9 . .] found that subTenon's anaesthesia was at least as good as retrobulbar/ peribulbar anaesthesia. A subsequent randomized double-blinded study [33] suggested that sub-Tenon's block provided a quicker onset of anaesthesia, better akinesia and a lower rate of incomplete blockade requiring reinjection than peribulbar anaesthesia. A signicant reduction in IOP after sub-Tenon's block has been reported [34]. The authors concluded that sub-Tenon's block should be the technique of choice if an increase in IOP is undesirable (such as in individuals with

Pulsatile ocular blood flow and ophthalmic regional anaesthesia

Sub-Tenon's block

618 Ambulatory anaesthesia

glaucoma), although no such patients were actually included in their study. Sub-Tenon's block has been successfully performed through a Greenbaum cannula [35], a standard 22 gauge intravenous cannula [36], and also by a nurse practitioner [37 .] safely and effectively. As one might expect with a relatively new technique, some complications of sub-Tenon's block are now being reported. Rectus muscle trauma [38], globe perforation [39], and orbital cellulitis [40] have been described. However, these seem to be rare. An editorial by Smerdon [41 .] conceded that needle blocks are safe in expert hands, but suggested that sub-Tenon's block and topical anaesthesia should be promoted as they are intrinsically safer. Hamilton [13] suggested that when the patient is at risk of the particular complications of needle blocks, then sub-Tenon's (or topical) anaesthesia might be preferable, and this is surely the reason why ophthalmic anaesthetists should be skilled in as many techniques as possible. Controversy continues about the management of patients taking anticoagulant and anti-platelet drugs. A survey of oculoplastic specialists in one region of the United Kingdom revealed considerable uncertainty about the safest course of action in these patients, with approximately half of the respondents stating that they would consider altering warfarin therapy but not aspirin [42]. Konstantatos [43 . .] performed a qualitative review of the literature on anticoagulation and cataract surgery. An interesting nding is that patients on anticoagulants appear to be at higher risk of bleeding whether the drugs are stopped preoperatively or not. There is also evidence for rebound hypercoagulability if anticoagulants are stopped, which would predispose to a higher risk of stroke. It is clearly necessary to strike a balance between the various risks. Konstantatos [43 . .] suggested the following: continue warfarin preoperatively and conrm that INR (international normalised ratio) is therapeutic; discuss with the patient the risks and benets of continuing or stopping the anticoagulant; consider an alternative technique with a lower incidence of retrobulbar haemorrhage, such as topical anaesthesia or subTenon's block if it is acceptable to both the patient and the surgeon; if peribulbar/retrobulbar block is chosen, use a smaller, ner needle in the inferotemporal quadrant with surgeon standing by to decompress the eye if retrobulbar haemorrhage develops. In the national survey of local anaesthesia for ocular surgery in the United Kingdom, the incidence of reported severe retrobulbar haemorrhage (with associated proptosis) was 7.3 per 10 000 after retrobulbar

injection and was 4.2 per 10 000 after peribulbar injection [44]. Less severe retrobulbar haemorrhage occurs 10 times more frequently. In a large prospective study including at-risk patients on warfarin (5.5%), acetylsalicylic acid (35%), and other non-steroidal antiinammatory drugs (19%) [45], no retrobulbar haemorrhage was reported even though the incidence of minor haemorrhage was 4%. Taken together with the earlier review, this suggests that it may be preferable to continue anticoagulant therapy in the perioperative period.

Paediatric ophthalmic anaesthesia

Warfarin and anti-platelet agents

Examination under anaesthesia in the young child is a commonly performed procedure. In a randomized study [46], propofol total intravenous anaesthesia (with supplemental oxygen through a nasal cannula) was compared with inhalational anaesthesia using halothane for paediatric non-invasive day-case ophthalmic diagnostic procedures. The propofol technique appeared to provide a feasible option in these spontaneously breathing children, and provided more complete access to the eye. Squint surgery is possibly the most common procedure performed, and is often associated with postoperative nausea and vomiting (PONV). A recent study compared sevourane with halothane [47]. The authors suggested that sevourane may be more suitable because of a signicantly lower incidence of oculocardiac reex and dysrhythmias and also less airway irritability and ventilatory disturbance. A number of studies have examined the effect of antiemetic drugs. High-dose ondansetron (0.2 mg/kg) markedly decreased postoperative vomiting when compared with standard doses, without an increase in side effects [48]. Ramosetron was more effective than granisetron between 24 and 48 h postoperatively but had no advantage in the rst 24 h [49]. This is considerably longer than the drug's half-life but may be explained by ramosetron's greater afnity for the 5hydroxytryptamine 3 receptor. The combination of dexamethasone and low-dose ondansetron seemed to be signicantly more effective than dexamethasone alone [50]. Careful reading of the paper reveals that retching was not considered an emetic event in the study and so the lowest incidence of postoperative vomiting (5%) in the combined group may be an underestimate of troublesome symptoms in everyday practice. In a separate study [51], dexamethasone 1 mg/kg (up to a maximum of 25 mg) was found to be more effective than ondansetron 0.1 mg/kg (up to a maximum of 4 mg), and the authors concluded that because dexamethasone is 22 times cheaper, it may be a cost-effective alternative to ondansetron in these children.

What's new in ophthalmic anaesthesia? Venkatesan and Smith 619

There have been two descriptions of local blocks for postoperative analgesia after general anaesthesia. Peribulbar block appears to be a safe and useful analgesic technique, with signicantly lower postoperative analgesic requirements, lower PONV and a lower incidence of oculocardiac reex [52 .]. Sub-Tenon's block has also been used in squint surgery [53 .]. Vitreoretinal surgery generally lasts longer than cataract surgery and has traditionally been performed under general anaesthesia. However, Newsom et al. [54 .] used local anaesthesia for 1221 vitreoretinal procedures and found it to be generally suitable, with nearly 90% of patients being pain free. Most of the remaining patients seemed to experience only non-painful sensations [54 .]. Fekrat et al. [55], in a survey of pain after vitreoretinal surgery, found that approximately half of these patients, particularly those undergoing longer procedures, requested pain relief within 5 h postoperatively, and approximately a quarter of them required narcotics for analgesia. The title suggests that the paper looked at patients' postoperative experiences, but in fact enquiry was restricted to a small number of symptoms. The ndings of Kristin et al. [56] are therefore relevant. Vitrectomies were performed under general anaesthesia, peribulbar block or both. The blocks were administered either before or after surgery. Preoperative blocks were reportedly more effective than postoperative blocks, but even if there is a pre-emptive effect in this setting, it probably makes little difference in practical terms because it is more convenient to perform the block at the time of induction. Finally, Morley et al. [57] compared anaesthetistadministered midazolam with patient-controlled propofol sedation in vitreoretinal surgery. There was no evidence of a difference in a number of outcome measures, although the authors identied a trend in patients preferring propofol. As there is no report of a statistical power calculation one wonders if the sample size was too small to be certain about this nding.

we may see further evaluation of the patient's perspective.

Papers of particular interest, published within the annual period of review, have been highlighted as: . of special interest .. of outstanding interest 1
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References and recommended reading

Posterior segment surgery

Local Anaesthesia for Intraocular Surgery. London: Royal College of Anaesthetists and Royal College of Ophthalmologists, 2001. Available at www.rcoa.ac.uk An authoritative guideline on the perioperative management of these patients. 2 3 Foggitt PS. Anxiety in cataract surgery: pilot study. J Cataract Refract Surg 2001; 27:16511655. Kubitz J, Epple J, Bach A, et al. Psychomotor recovery in very old patients after total intravenous or balanced anaesthesia for cataract surgery. Br J Anaesth 2001; 86:203208. Pacella E, Abdolrahimzadeh B, Brauneis S, et al. Efficacy of preoperative systemic clonidine for intraocular pressure reduction on ophthalmic surgery. Ann Ophthalmol 2001; 33:116118.

Katz J, Feldman MA, Bass EB, et al. Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery. Ophthalmology 2001; 108:17211726. A substantial, well conducted survey of adverse medical events and their relationship to adjunctive systemic drugs. 5
..

6 7
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Katz J, Feldman MA, Bass EB, et al. Injectable versus topical anesthesia for cataract surgery. Ophthalmology 2000; 107:20542060.

Monestam E, Kuusik M, Wachtmeister L. Topical anaesthesia for cataract surgery: a population-based perspective. J Cataract Refract Surg 2001; 27:445451. A large survey of phacoemulsification under topical anaesthesia. 8 O'Brien PD, Fulcher T, Wallace D, Power W. Patient pain during different stages of phacoemulsification using topical anesthesia. J Cataract Refract Surg 2001; 27:880883.

Friedman DS, Bass EB, Lumboski LH, et al. Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery. Ophthalmology 2001; 108:519529. A large, well conducted systematic review, listing the strength of evidence for the relative effectiveness of different local anaesthetic techniques. 9
..

10 Kallio H, Uusitalo RJ, Maunuksela E-L. Topical anesthesia with or without propofol sedation versus retrobulbar/peribulbar anesthesia for cataract extraction. Prospective randomised trial. J Cataract Refract Surg 2001; 27:13721379. 11 Jacobi PC, Dietlein TS, Jacobi FK. Cataract surgery under topical anesthesia in patients with co-existing glaucoma. J Cataract Refract Surg 2001; 27:12071213. 12 Yepez J, de Yepez JC, Arevalo JF. Topical anesthesia in posterior vitrectomy. Retina 2000; 20:4145. 13 Hamilton RC. A discourse on the complications of retrobulbar and peribulbar blockade. Can J Ophthalmol 2000; 35:363372. 14 Budd J, Hardwick M, Barber K, Prosser J. A single-centre study of 1000 . . consecutive peribulbar blocks. Eye 2001; 15:464468. A large observational study showing the successful use of peribulbar block. 15 Thind GS, Rubin AP. Local anaesthesia for eye surgery no room for . complacency. Br J Anaesth 2001; 86:473476. An interesting editorial tracing the development of current controversies in this area. 16 Ripart J, Lefrant J-Y, de La Coussaye JE, et al. Peribulbar versus retrobulbar . . anesthesia for ophthalmic surgery. An anatomical comparison for extraconal and intraconal injections. Anesthesiology 2001; 94:5662. A cadaver study suggesting that the anatomical distinction between peribulbar and retrobulbar block is artificial. 17 Frow MW, Miranda-Carabello JI, Akhtar TM, Hugkulstone CE. Single injection peribulbar anaesthesia. Total upper eyelid drop as an end-point marker. Anaesthesia 2000; 55:750756. 18 Morgan JP, Clearkin LG. Rapid onset of ptosis indicates accurate intraconal placement during retrobulbar anaesthetic injection. Br J Ophthalmol 2001; 85:363365.

Conclusion

Recent years have seen a wider range of ophthalmic operations performed under topical anaesthesia. Our understanding of peribulbar and retrobulbar blocks has advanced, and sub-Tenon's local anaesthesia has gained in popularity. Many people take anticoagulants and aspirin for medical conditions. The balance of evidence suggests that anticoagulation should be continued around the time of surgery as long as the effect of the drug is within the therapeutic range. There can be no substitute for sound training and clinical experience in maintaining quality and safety in ophthalmic anaesthesia, as in any other branch of our profession. In the future

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19 van den Berg AA, Montoya-Pelaez LF. Comparison of lignocaine 2% with adrenaline, bupivacaine 0.5% with or without hyaluronidase and a mixture of bupivacaine, lignocaine and hyaluronidase for peribulbar block analgesia. Acta Anaesthesiol Scand 2001; 45:961966. 20 Allman KG, Barker LL, Werrett GC, et al. Comparison of articaine and bupivacaine/lidocaine for peribulbar anaesthesia by inferotemporal injection. Br J Anaesth 2002; 88:676678. 21 Allman KG, McFadyen JG, Armstrong J, et al. Comparison of articaine and bupivacaine/lidocaine for single medial canthus peribulbar anaesthesia. Br J Anaesth 2001; 87:584587. 22 Madan R, Bharti N, Shende D, et al. A dose response study of clonidine with local anesthetic mixture for peribulbar block: a comparison of three doses. Anesth Analg 2001; 93:15931597. 23 Wishaw K, Billington D, O'Brien D, Davies P. The use of orbital morphine for postoperative analgesia in pterygium surgery. Anaesth Intens Care 2000; 28:4345. 24 Ling R, Beigi B, Quinn A, Jacob J. Effect of Honan balloon compression on . peribulbar anesthesia adequacy in cataract surgery. J Cataract Refract Surg 2002; 28:113117. An interesting paper questioning the necessity of using ocular pressure as part of the peribulbar block. 25 Nociti JR, Serzedo PSM, Zuccolotto EB, et al. Intraocular pressure and ropivacaine in peribulbar block: a comparative study with bupivacaine. Acta Anaesthesiol Scand 2001; 45:600602. 26 Laszlo CJ, Gombos K, Vimlati L, et al. A catheter technique in ophthalmic regional anaesthesia. Cadaver experiments. Acta Anaesthesiol Scand 2000; 44:450452. 27 Gombos K, Laszlo CJ, Hatvani I, et al. A catheter technique in ophthalmic regional anaesthesia. Clinical investigations. Acta Anaesthesiol Scand 2000; 44:453456. 28 Jager M, Hemmerling T, Jonas JB. Retrobulbar catheter technique for postoperative titratable analgesia after glaucoma surgery. J Glaucoma 2002; 11:2629. 29 Recep OF, Abdik O, Hasiripi H, et al. Combined ocular anesthesia via a single entry. J Cataract Refract Surg 2001; 27:17291731. 30 Watkins R, Beigi B, Yates M, et al. Intraocular pressure and pulsatile ocular . blood flow after retrobulbar and peribulbar anaesthesia. Br J Ophthalmol 2001; 85:796798. See Ref 31 . below. 31 Coupland SG, Deschenes MC, Hamilton RC. Impairment of ocular blood flow . during regional orbital anesthesia. Can J Ophthalmol 2001; 36:140144. Two papers addressing the same issue of changes in POBF with the injection of local anaesthetic. 32 Mori F, Konno S, Hikichi T, et al. Factors affecting pulsatile ocular blood flow in normal subjects. Br J Ophthalmol 2001; 85:529530. 33 Ripart J, Lefrant J-Y, Vivien B, et al. Ophthalmic regional anesthesia: medial canthus episcleral (sub-Tenon) anesthesia is more efficient than peribulbar anesthesia. Anesthesiology 2000; 92:12781285. 34 Alwitry A, Koshy Z, Browning AC, et al. The effect of sub-Tenon's anaesthesia on intraocular pressure. Eye 2001; 15:733735. 35 Kumar CM, Dodds C. Evaluation of the Greenbaum sub-Tenon's block. Br J Anaesth 2001; 87:631633. 36 Amin S, Minihan M, Lesnik-Oberstein S, Carr C. A new technique for delivering sub-Tenon's anaesthesia in ophthalmic surgery. Br J Ophthalmol 2002; 86:119120. 37 Waterman H, Mayer S, Lavin MJ, et al. An evaluation of the administration of sub. Tenon local anaesthesia by a nurse practitioner. Br J Ophthalmol 2002; 86:524 526. This paper evaluates sub-Tenon's blocks as given by a specially trained nurse, and contributes to the debate in the United Kingdom about flexibility in professional roles in the operating theatre. 38 Jaycock PD, Mather CM, Ferris JD, Kirkpatrick JNP. Rectus muscle trauma complicating sub-Tenon's local anaesthesia. Eye 2001; 15:583586. 39 Frieman BJ, Friedberg MA. Globe perforation associated with sub-Tenon's anesthesia. Am J Ophthalmol 2001; 131:520521. 40 Redmill B, Sandy C, Rose GE. Orbital cellulitis following corneal gluing under sub-Tenon's local anesthesia. Eye 2001; 15:554556. 41 Smerdon D. Needle local anaesthesia for cataract surgery: a chip off the old . block? Eye 2001; 15:439440. An editorial comment on the paper by Budd and colleagues [14 . .]. 42 Parkin B, Manners R. Aspirin and warfarin therapy in oculoplastic surgery. Br J Ophthalmol 2000; 84:14261427. 43 Konstantatos A. Anticoagulation and cataract surgery: a review of the current . . literature. Anaesth Intens Care 2001; 29:1118. A qualitative review of the evidence on the management of anticoagulated patients. 44 Eke T, Thompson JR. The national survey of local anaesthesia for ocular surgery. II: Safety profiles of local anaesthesia techniques. Eye 1999; 13:196204. 45 Kallio H, Paloheimo M, Maunuksela EL. Haemorrhage and risk factors associated with retrobulbar/peribulbar block: a prospective study in 1383 patients. Br J Anaesth 2000; 85:708711. 46 Madan R, Kapoor I, Balachander S, et al. Propofol as a sole agent for paediatric day care diagnostic ophthalmic procedures: comparison with halothane anaesthesia. Paediatr Anaesth 2001; 11:671677. 47 Allison CE, De Lange JJ, Koole FD, et al. A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anaesthesia for strabismus surgery in children. Anesth Analg 2000; 90:306310. 48 Bowhay AR, May HA, Rudnicka AR, Booker PD. A randomised controlled trial of the antiemetic effect of three doses of ondansetron after strabismus surgery in children. Paediatr Anaesth 2001; 11:215221. 49 Fujii Y, Tanaka H, Ito M. Ramosetron compared with granisetron for the prevention of vomiting following strabismus surgery in children. Br J Ophthalmol 2001; 85:670672. 50 Splinter WM. Prevention of vomiting after strabismus surgery in children: dexamethasone alone versus dexamethasone plus low-dose ondansetron. Paediatr Anaesth 2001; 11:591595. 51 Subramaniam B, Madan R, Sadhasivam S, et al. Dexamethasone is a costeffective alternative to ondansetron in preventing PONV after paediatric strabismus repair. Br J Anaesth 2001; 86:8489. 52 Deb K, Subramaniam R, Dehran M, et al. Safety and efficacy of peribulbar block . as adjunct to general anaesthesia for paediatric ophthalmic surgery. Paediatr Anaesth 2001; 11:161167. 53 Parulekar MV, Berg S, Elston JS. Adjunctive peribulbar anaesthesia for . paediatric ophthalmic surgery: are the risks justified? Paediatr Anaesth 2002; 12:8589. An article describing adjunctive blocks in children and a letter in response. 54 Newsom RSB, Wainwright AC, Canning CR. Local anaesthesia for 1221 . vitreoretinal procedures. Br J Ophthalmol 2001; 85:225227. A large prospective survey monitoring the change to local anaesthesia for this group of patients. 55 Fekrat S, Elsing SH, Raja SC, et al. Eye pain after vitreoretinal surgery. Retina 2001; 21:627632. 56 Kristin N, Schonfeld CL, Bechmann M, et al. Vitreoretinal surgery: preemptive analgesia. Br J Ophthalmol 2001; 85:13281331. 57 Morley HR, Karagianis A, Schultz DJ, et al. Sedation for vitreoretinal surgery: a comparison of anaesthetist-administered midazolam and patient-controlled sedation with propofol. Anaesth Intens Care 2000; 28:3742.