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    Anesthesia For Cataract Surgery: Recent Trends: Editorial Commentary

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    Anesthesia For Cataract Surgery: Recent Trends: Editorial Commentary

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    Jurnal terpercaya

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    39 views2 pages

    Anesthesia For Cataract Surgery: Recent Trends: Editorial Commentary

    Uploaded by

    Neva Arsita
    Jurnal terpercaya

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    [Downloaded free from http://www.ojoonline.org on Friday, May 08, 2015, IP: 114.125.50.

    3]

    Editorial Commentary

    Anesthesia for cataract surgery: Recent trends


    Rikin Shah
    Department of Ophthalmology, Al Nahdha Hospital, Ruwi, Oman

    The world has witnessed a significant evolution in surgical


    technique of cataract extraction in last few decades. After Ridley
    introduced the intraocular lens, the challenge was to reduce the
    size of incision. It was fulfilled by Kelman with the introduction
    of phacoemulsification and by Mazzocco with the introduction of
    foldable intraocular lens. Of course advances in phaco machines,
    phacotips, ophthalmic viscosurgical devices (OVD), etc. also have
    played a major role to reach todays faster, more controlled, and
    less traumatic cataract surgery.
    As incisional size of cataract extraction has reduced, anesthesia
    techniques have also advanced significantly. General anesthesia
    was introduced in mid-19th century. Koller and Knapp can be
    considered the pioneers of local anesthesia for cataract surgery.
    Koller introduced topical cocaine in 1884 while Knapp introduced
    retrobulbar anesthesia in 1884. In the beginning of 19th century,
    orbicularis block was introduced by Van Lint, OBeriens,
    and Alkinson. In last 25 years, local anesthesia techniques
    have progressed from posterior peribulbar to no anesthesia
    techniques.
    Peribulbar and retrobulbar techniques are associated with a risk
    for complications such as globe perforation, damage to optic nerve,
    retrobulbar hemorrhage, and ocular muscle injury. Rarely, they
    can be life-threatening. Introduction of the sub-Tenons anesthesia
    technique reduced the risk of complications of peribulbar/
    retrobulbar anesthesia but the technique is still associated with
    a possibility of all the complications of peribulbar/retrobulbar
    techniques. Evolving surgical techniques have reduced the need
    for akinesia. In 1992, Fichman reintroduced topical anesthesia for
    cataract surgery. Topical anesthesia is used to block the afferent
    nerves of the corneal and the conjunctiva (long and short ciliary
    nerves, nasociliary, and lacrimal nerves). This technique eliminates
    the possible complications of injectable anesthesia. However, it
    does not eliminate pain sensitivity of the iris, the zonule, and the
    ciliary body. In 1992, Gills introduced intracameral technique of
    anesthesia with preservative free 1% lidocaine. In 1999, KochAssia introduced use of Xylocaine jelly for surface anesthesia.
    Today different agents are available in market for topical

    anesthesia like Procaine (1%/2%/10%), Proparacaine (0.5%),


    Oxybuprocaine (0.4%), Tetracaine (0.5%/1%), Bupivacaine
    (0.25%/0.5%), Etidocaine (1%), Lidocaine (0.5%/1%), Prilocaine
    (4%), and Ropicacaine (0.2%/1%). All these agents have different
    time of onset and duration of anesthesia. Topical and intracameral
    techniques are not absolutely safe as epithelial and endothelial
    toxicities are reported with them.
    In 1998, Amar Agarwal introduced the technique of no
    anesthesia for cataract extraction. In this technique, no topical
    or intracameral drugs are used. Although without any side effects,
    the stress for the surgeon is increased. A question that arises is
    - cornea is supplied by a dense plexus of sensory nerves. Then
    how it is possible to do cataract surgery without any anesthesia?
    Possible explanations are: peripheral and superior cornea is less
    sensitive than central cornea, dark-brown eyed Indians, Chinese,
    and blacks have a corneal sensitivity that is four times less
    than blue-eyed Caucasians, people in developing countries like
    India are more exposed to ultraviolet rays which may result in a
    significant loss of corneal sensitivity. Due to increased stress on
    surgeon, the no anesthesia technique has not gained popularity
    in the western world.
    In 1999, GutierrezCarmona modified no anesthesia technique
    and introduced cryoanalgesia for cataract surgery. In this
    technique, all solutions to be used during surgery are cooled to
    4 C except povidone drops. Before surgery, an eye mask of cold
    gel is placed over the eye for 10 min. During the surgery, the eye
    is irrigated with cold balanced salt solution (BSS). All OVD used
    during surgery are cooled to 4 C. Although showed to be a safe
    technique for clear cornea phacoemulsification with acceptable
    level of pain, it is not suitable for all cataracts and all patients.
    Is there any role for general anesthesia in modern cataract
    surgery? Of course yesfor pediatric cataracts and for some
    adult patients (i.e., mental retardation). The concept of providing
    different pharmacological agents for balanced anesthesia, i.e., for
    analgesia, muscle relaxant, abolishment of all reflexes including
    somatic reflexes, and somnolence has removed the use of very

    Copyright: 2010 Shah R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
    permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
    DOI: 10.4103/0974-620X.71881

    www.ojoonline.org

    Correspondence:
    Dr. Rikin Shah, Department of Ophthalmology, Al Nahdha Hospital, Post Box No: 937, Ruwi 112, Oman. E-mail: [email protected]

    107

    Oman Journal of Ophthalmology, Vol. 3, No. 3, 2010

    [Downloaded free from http://www.ojoonline.org on Friday, May 08, 2015, IP: 114.125.50.3]

    Shah: Anesthesia for cataract surgery


    potent, toxic, and long-acting agents. The drugs used include:
    Opioids ( receptor agonist): Fentanyl, Remifentanil, Alfentanil,
    Benzodiazepine (sedative/hypnotic): Midazolam, anesthetic
    gases: Isoflurane, Sevoflurane, and intravenous anesthetic agent
    Propofol (which in low dose can be used as sedative with topical
    anesthesia).
    The million dollar question is: which anesthesia to select for
    cataract surgery? Only two persons can decide thisthe patient,
    who is undergoing cataract surgery and the ophthalmic surgeon,
    who is going to operate. For the same patient, different surgeons
    may select different techniques of anesthesia. The skill and
    experience of surgeon, co-operation of patient, type of cataract,
    associated ocular co-morbidity like corneal opacity, pupillary
    dilatation, etc. are important factors while deciding upon the type
    of anesthesia.

    Oman Journal of Ophthalmology, Vol. 3, No. 3, 2010

    Studies have showed different trends in different countries.


    A national postal survey was conducted in 2008 in the United
    Kingdom for choice of local anesthetic techniques. Sub-Tenons
    anesthesia was the local anesthetic technique of choice (47%
    compared to topical 33%, peribulbar 16%, retrobulbar 2%, and
    others 2%). Of sub-Tenon blocks, 28% were given by surgeons and
    47% by the anesthetist. A similar survey done in Singapore in 2004
    showed 92% cataract extraction were done by phacoemulsification
    technique. For phacoemulsification technique, the anesthetic
    technique of choice was peribulbar anesthesia (43%). A survey
    of members of the American Society of Cataract and Refractive
    Surgeons (ASCRS) in 2000 revealed an increase in the use of
    topical anesthesia among surgeons. In Oman, over the last few
    years, anesthesia for cataract surgery has shifted from general to
    local anesthesia.

    108

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