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Surgical Modifications Required for Planned Extracapsular Cataract Extraction under Topical Anaesthesia with Van Lint Block
Surgical Modifications Required for Planned Extracapsular Cataract Extraction under Topical Anaesthesia with Van Lint Block M. N. ABDEL-KHALEK and R. F. REFAAT Pilgrim Hospital, Boston, Lincolnshire, UK
M. N. Abdel-Khalek and R. F. Refaat. Surgical Modification Required for Planned Extracapsular Cataract Extraction under Topical Anaesthesia with Van Lint Block. Eur. J. Implant Ref. Surg., 1995; 7: 338-341. OBJECTIVE: To assess the intensity of pain after applying some modifications in the surgical steps undertaken during the course of planned extracapsular cataract extraction under topical anaesthesia with Van Lint block. STUDY DESIGN AND PATIENTS: This is a prospective study of 20 patients divided into 2 groups. Fifteen patients had previous extracapsular cataract extraction in 1 eye under retrobulbar anaesthesia (group 1). Those were chosen to compare the difference in their perception of pain under retrobulbar anaesthesia vs topical anaesthesia using these surgical modifications. Group 2 was initially made of 15 patients who had no previous ocular surgery and had no preference for the type of anaesthesia. They were chosen to outline their response to topical anaesthesia. This would have made the total of 30 patients, however, it was felt that the first 10 patients of this group did not have the benefit of all the surgical modifications and their responses would distort the results. Therefore, only the responses of the last 5 who benefited from the modifications were included. SETTING: The Eye Department, Pilgrim Hospital, Boston, Lincolnshire, UK. MAIN OUTCOME MEASURES: Single dose of 0.5 ml preservative free Xylocaine 4% drops in the conjunctival sac with the lids maintained open for up to 1 min immediately preoperatively gives complete anaesthesia of the cornea and conjunctiva. A 'clear corneal incision', a wide 'can-opener capsulotomy', and 'equatorial flush' are surgical modifications required to abolish any feeling of pain in planned extracapsular cataract extraction under topical anaesthesia. RESULTS: The severity of the pain was graded from 0-4. Eight patients had no pain, 5 patients had grade 1 and 7 patients had grade 2 pain. No patients graded 3 or 4. CONCLUSIONS: Xylocaine 4% preservative-free drops produce complete corneal anaesthesia and decrease the palpebral reflex when applied immediately before the start of surgery for 30-60 s while the lids are held apart - allowing complete immersion of the ocular surface under a layer of drops. Corneal section and wide capsulotomy are surgical steps that prevented pain during nucleus delivery. Equatorial flush speeds aspiration/irrigation. Pain was caused during suturing the posterior lip of the incision involving the conjunctiva if the surgery took longer than expected. Keywords: Retrobulbar anaesthesia; Topical anaesthesia; Extracapsular cataract extraction; Xylocaine 4% drops; Equatorial flush.
INTRODUCTION
We used the term topical anaesthesia to define noninvasive anaesthesia of the eye or its coverings during planned extracapsular cataract extraction 0955-3681/95/060338 + 04 $12.00/0
(ECCE). This was achieved by instillation of preservative-free Xylocaine 4% drops. No other form of anaesthetic agent was injected in the immediate vicinity of the globe through the retrobulbar, peribulbar or subconjunctival route. Two millilitres of a © 1995 W.B. Saunders Company Limited
339
Surgical Modifications for Planned ECCE under Topical Anaesthesia
zygomatic nerve block - 'Van Lint' - with Xylocaine 2%, was injected deep along the upper and lower orbital rims and along the superior edge of the zygomatic arch. This relieved any spasm of the orbicularis muscle. This article studies the effectiveness of surgical modifications required to make planned ECCE a safe and comfortable procedure under topical anaesthesia with Van Lint block.
METHODS
A prospective study of 30 patients was set up. They were divided into 2 groups. The first group consisted of 15 patients who had undergone previous ECCE in one eye under retrobulbar anaesthesia. These patients were chosen to compare their perception of pain under retrobulbar anaesthesia us. topical anaesthesia with Van Lint block. The second group was made of 15 patients who had no previous eye surgery and had no preference for the type of anaesthesia to be used during surgery. This group was intentionally chosen to find out their initial response to topical anaesthesia with Van Lint block. Preoperative 0.5 ml preservative free Xylocaine 4% drops were used to anaesthetize the eye. The fornices and ocular surface were immersed as the lids were kept open by an assistant for up to 1 min. This allowed maximum saturation of the nerve endings of the cornea and conjunctiva. No injection was used for fixating the superior rectus muscle. Zygomatic nerve block with Xylocaine 2% was used to reduce the orbicularis spasm. Each patient was asked to grade the severity of the pain from 0-4 during every step of the operation.
RESULTS
We reported the response to these modifications on the final 20 patients, 15 in group 1 and 5 in group 2, where the pain was graded 0-4. The first 10 patients in group 2 were excluded as their grading of the pain distorted the results, as all surgical modifications to minimize the pain were not used on them. No patients graded above 2. Eight patients had no pain. Five patients had grade 1 and 7 patients had grade 2. The 0 grade being no feeling, grade 1 when the patient was aware of the various steps of the operation. Grade 2 was when the patient felt discomfort during those steps. Grade 3 was for tolerable pain and grade 4 being intolerable pain. Eur J Implant Ref Surg, Vol 7, December 1995
DISCUSSION
Although rare, the literature records numerous complications of retrobulbar anaesthesia. Some of these complications are vision-as well as life-threatening. They ranged from retrobulbar haemorrhage, being the most common, to central nervous system complications, including ipsi- and contra-lateral amaurosis, cranial nerve palsy, acute confusion, respiratory arrest and seizures [1-13J. Ocular complications included globe perforation, central retinal artery and/or vein occlusion [14-16J, postoperative shivering [17J and ptosis [18J. This has led to the advent of peribulbar [19, 20J and subconjunctival [21-23J anaesthesia. A large number of papers comparing the three methods have been published [24, 25]. The agent used in these types of anaesthesia are also discussed [26J. Only one case report [27J describes the use of topical anaesthesia for planned ECCE as we defined above, i.e. using non-invasive anaesthesia by using drops only. The nearest to complete topical anaesthesia in ECCE has been coined the non retro bulbar NR method and advocated the use of a couple of drops of Amethocaine 1% and an injection of 1 ml of Xylocaine 2% superiorly, 7 mm from the limbus [28J. Surgeons in the UK, Canada and USA (pers. comm., [29]), advocated the use of drops supplemented with subconjunctival agents to anaesthetize the eye in phakoemulsification. In some centres topical anaesthesia with drops only for phakoemulsification has been used for more than 3 years in the USA. Xylocaine 4% drops seemed the agent of their choice when instilled at 1 min intervals about 5-10 minutes preoperatively. In our experience, on two occasions a phacoemulsification incision had to be widened and the procedure had to be finished as an ECCE. On another occasion, an automated anterior vitrectomy had to be carried out. We noted that the three patients did not complain of pain. Planned ECCE is still performed by the majority of surgeons in the UK, Europe and indeed the world. To avert the known complications of general or invasive local anaesthesia we decided to assess topical anaesthesia with Van Lint block in planned ECCE which is still performed on a fair percentage of patients in our department (60%). Despite phacoemulsification under topical anaesthesia becoming the procedure of choice in extracting cataracts and more surgeons in the developed world are taking it up, ECCE will remain the procedure most-performed throughout the world population simply for financial reasons. The strength of the palpebral reflex was assessed by the ease of the insertion of a Barraquer's one-
340
piece wire speculum. If this was found difficult to insert, a zygomatic block using Xylocaine 2% (Van Lint's) was given, this abolished all orbicularis contraction. Later it was decided to use this nerve block as a routine step since it was deemed safer to abolish any orbicularis tone while the eye was open. We realize that some superficial sensory block could occur by diffusion using the Van Lint block. We found that 0.5 ml of Xylocaine 4% instilled once as one dose while the lids are held open by an assistant for about 1 min causes full saturation of the nerve endings of the cornea and conjunctiva and decreased the palpebral reflex for the whole surgical procedure. A corneollimbal incision from 10 o'clock to 2 o'clock was made with a diamond knife in a 2 step fashion, a perpendicular incision in the superficial half of the cornea, then a deep slanting incision towards the pupil to enter the anterior chamber. No pain was felt at this stage. A letter-box capsulotomy or a wide capsulorhexis (7 mm) was performed on alternative patients. Nucleus delivery induced pain initially in letter-box capsulotomy. However, this was relieved if a capsular tear extended laterally. The pain was not relieved in capsulorhexis cases as no capsule tear occurred. This can be explained because during nucleus delivery through small capsular openings, pull on the ciliary body due to stretching of the zonule induces pain. This was confirmed also when 'in-the-bag' insertion of the 13.00 mm implant took place. The pain was more noticeable if the stretch mark appeared in the posterior capsule. It is recognized that can-opener capsulotomy can lead to tearing of the capsule with centration problems if capsule fibrosis and haptic splaying occur in some cases. We did not encounter such tearing and this method of performing the capsulotomy was adopted for this study. The conclusion that a wide 'can-opener' capsulotomy or a wide capsulorhexis would allow easy delivery of the nucleus and was an important step to avoid pain and also prevented the possibility of lateral tearing of the anterior capsule. Hydrodissection was found to increase the volume of the capsular bag and led to pain by the same mechanism described above and was avoided. An extra step helped to speed up the time taken for aspiration-irrigation and replaced hydrodissection. This consisted of flushing the equatorial area of the lens bag with balanced salt solution through a curved 26 gauge lacrimal needle. This broke the equatorial attachments of the lens fibres allowing easy and fast aspiration of the lens cortex. We named this step the 'equatorial flush'. The use of a 12-mm overall diameter implant seems to fit in the bag without causing the posterior
M. N. Abdel-Khalek and R. F. Refaat
capsule stretch lines usually seen when an IOL of a larger size is inserted in the bag. The other time when pain occurred was during suturing the corneo-limbal incision. This was noticeable when the needle pierced the posterior lip of the wound (sclera and conjunctiva) between the 11 o'clock and 1 o'clock positions, especially if the procedure took longer than expected (15-20 min). This could be relieved by applying a drop of preservative-free Xylocaine 4% while the wound was in apposition, left for a few seconds, then washed with balanced salt solution. As we are aware of some reports that some topical agents may affect the endothelium if instilled directly in an open eye, in the very few cases when patients felt pain during suturing we applied a soaked cotton tip swab to the scleral side of the incision for a few seconds. This allowed the procedure to be completed safely. The criteria for choosing these patients was that they should have good hearing and be quite responsive. They were advised to mention the degree of pain during the procedure. An objective assessment was also made by a regular anaesthetic nurse who held the patient's hand. She could tell from previous experience of the way patients were squeezing her hand as to the severity of their pain.
CONCLUSION
Xylocaine 4% drops soaking the conjunctival sac and fornices for up to 1 min with Van Lint block immediately prior to towelling the patient is a more effective way of producing anaesthesia than repeated instillation for prolonged periods preoperatively which can lead to some epithelial clouding. Xylocaine 4% drops instilled in this fashion give complete corneal anaesthesia and almost complete conjunctival anaesthesia. For this reason a larger corneal incision is preferable. Xylocaine 4% drops also reduces the palpebral reflex by abolishing corneal sensation and allows good eye exposure during surgery. This is enhanced by Van Lint zygomatic nerve block. A 'wide capsulotomy', a 'small overall diameter implant' and 'equatorial flush' are surgical modifications that allow painless completion of extracapsular cataract implant under topical anaesthesia with Van Lint block. It must be stressed that the surgeon's speed of completion of the procedure (while the eye is under the effect of anaesthesia) is a requirement for the successful painless completion of the operation. We found that the action of the Xylocaine 4% drops Eur J Implant Ref Surg, Vol 7, December 1995
Surgical Modifications for Planned ECCE under Topical Anaesthesia
provided a feeling-free period of 15-20 min, which in our hands appears to be sufficient to complete a complication-free ECCE.
ACKNOWLEDGEMENTS We would like to convey our gratitude to Miss Angela Broughton for her secretarial support.
REFERENCES 1 KR Edge, J Martin, V Nicoll. Retrobulbar haemorrhage after 12,500 retrobulbar blocks. Anesth. Analg., 1993; 76: 1019-22. 2 D Brent, H Singh. The effect of retrobulbar anaesthesia on visual acuity in planned extracapsular cataract extraction. Ophthalmic Surgery 1991: 22: 392-395. 3 T Puustjarvi, S Purhonen. Permanent blindness following retrobulbar hemorrhage after peribulbar anesthesia for cataract surgery. Ophthalmic Surgery 1992; 23: 450-453. 4 R Rodgers, J Orellana. Cranial nerve palsy following retrobulbar anaesthesia. Br. J. Ophthalmol., 1988; 72: 78. 5 SJ Talks, NHV Chong, JM Gibson, IR Francis. Visual acuity and pupillary reactions after peribulbar anaesthesia. Br. J. Ophthalmol., 1994; 78: 41-43. 6 NC Kaushik. Orbital haemorrhage following retrobulbar i~ection. Ind. J. Ophthal., 1988; 36: 128-130. 7 J Martin, V Nicholl, P Acharya Arun, K Ahlen, S Baguneid, RK Edge. Central nervous system complications after 6000 retrobulbar blocks. Anesth. Analg., 1987; 66: 1298-1302. 8 SM Cohen, FJ Sousa, NE Kelly, RT Wendel. Respiratory arrest and new retinal hemorrhages after retrobulbar anaesthesia. Am. J. Ophthalmol., 1992; 113: 209-210. 9 RM Rosenblatt, DR May, K Barsoumian. Cardiopulmonary arrest after retrobulbar block. Am. J. Ophthalmol., 1980; 90: 425-426. 10 LG Brookshire, KY Gleitsmann, EC Schenk. Life-threatening complication of retrobulbar block. Ophthalmology, 1986; 93: 1476-1478. 11 AS Mayer, RE O'Conner. Respiratory arrest after local aesthesia for outpatient cataract surgery: a dramatic but transient complication. Annals of Emergency Medicine, 1993; 1357: 149-151.
Eur J Implant Ref Surg, Vol 7, December 1995
341
12 P Ruusuvaara, K Setala, A Tarkkanen. Respiratory arrest after retrobulbar block. Acta Ophthalmol., 1988; 66: 223-225. 13 HP Beltranena, MJ Vega, JJ Garcia, G Blankenship. Complications of retrobulbar marcaine injection. J. Clin. Neuro Ophthalmol., 1982; 2: 159-161. 14 HC Seward, AM Mount. Scleral perforations during peribulbar anaesthesia. Eye, 1993; 7: 766-767. 15 RN Ginsburg, JS Duker. Globe perforation associated with retrobulbar and peribulbar anaesthesia. Seminars in Ophthalmology, 1993; 8: 87-95. 16 WF Mieler, SR Bennett, LW Platt, SB Koenig. Localised retinal detachment with combined central retinal artery and vein occlusion after retrobulbar anesthesia. Retina, 1990; 10: 278-283. 17 DS Lee, NJ Kwon. Shivering following retrobulbar·bloek. Can. J. Anaesth., 1988; 35: 294--296. 18 RM Feibel, PL Custer, MO Gordon. Postcataract ptosis. A randomized, double-masked comparison of peribulbar and retrobulbar anesthesia. Ophthalmology, 1993; 100. 19 A Apel, R Woodward. Single-injection peribulbar local anaesthesia-a study of fifty consecutive cases. Australian, New Zealand J. Ophthalmol., 1991; 19: 149-153. 20 S Ahmad, A Ahmad, HT Benzon. Clinical experience with the peribulbar block for ophthalmologic surgery. Regional Anesthesia, 1993; 18: 184--188. 21 JD Stevens. A new local anaesthesia technique for cataract extraction by one quadrant sub-Tenon's infiltration. Br. J. Ophthalmol., 1992; 76: 670-674. 22 RM Redmond, NL Dallas. Extracapsular cataract extraction under local anaesthesia without retrobulbar injection. Br. J. Ophthalmol., 1990; 74: 203-204. 23 WC Petersen, M Yanoff. Subco~unctival anaesthesia: an alternative to retrobulbar and peribulbar techniques. Ophthalmic Surgery, 1991: 22: 199-201. 24 JC Whitsett, HD Baleat, B McClure. Comparison of onei~ection-site peribulbar anaesthesia and retrobulbar anaesthesia. J. Cataract Refract. Surg., 1990; 16: 243-245. . 25 L Bauchiero, G Aimino, K Timofejeff. Peribulbar and retrobulbar anaesthesia: a comparison of the two methods. New trends in Ophthalmology, 1991; 6: 337-341. 26 J Lawton-Smith. Retrobulbar bupivacaine can cause respiratory arrest. Annals of Ophthalmology, 1982; 155: 1005-1006. 27 JD Shuler. Topical anaesthesia in a patient with a history of retrobulbar haemorrhage. Arch. Ophthalmol. 1993; 111: 733. 28 R Smith. Cataract extraction without retrobulbar anaesthetic injection. Br. J. Ophthalmol., 1990; 74: 205-207. 29 HJ Shammas. Cataract surgery without retrobulbar or peribulbar anaesthesia. J. Cataract Refract. Surg., 1993; 19: 116.
M. N. Abdel-Khalek and R. F. Refaat. Surgical Modification Required for Planned Extracapsular Cataract Extraction under Topical Anaesthesia with Van Lint Block. Eur. J. Implant Ref. Surg., 1995; 7: 338-341. OBJECTIVE: To assess the intensity of pain after applying some modifications in the surgical steps undertaken during the course of planned extracapsular cataract extraction under topical anaesthesia with Van Lint block. STUDY DESIGN AND PATIENTS: This is a prospective study of 20 patients divided into 2 groups. Fifteen patients had previous extracapsular cataract extraction in 1 eye under retrobulbar anaesthesia (group 1). Those were chosen to compare the difference in their perception of pain under retrobulbar anaesthesia vs topical anaesthesia using these surgical modifications. Group 2 was initially made of 15 patients who had no previous ocular surgery and had no preference for the type of anaesthesia. They were chosen to outline their response to topical anaesthesia. This would have made the total of 30 patients, however, it was felt that the first 10 patients of this group did not have the benefit of all the surgical modifications and their responses would distort the results. Therefore, only the responses of the last 5 who benefited from the modifications were included. SETTING: The Eye Department, Pilgrim Hospital, Boston, Lincolnshire, UK. MAIN OUTCOME MEASURES: Single dose of 0.5 ml preservative free Xylocaine 4% drops in the conjunctival sac with the lids maintained open for up to 1 min immediately preoperatively gives complete anaesthesia of the cornea and conjunctiva. A 'clear corneal incision', a wide 'can-opener capsulotomy', and 'equatorial flush' are surgical modifications required to abolish any feeling of pain in planned extracapsular cataract extraction under topical anaesthesia. RESULTS: The severity of the pain was graded from 0-4. Eight patients had no pain, 5 patients had grade 1 and 7 patients had grade 2 pain. No patients graded 3 or 4. CONCLUSIONS: Xylocaine 4% preservative-free drops produce complete corneal anaesthesia and decrease the palpebral reflex when applied immediately before the start of surgery for 30-60 s while the lids are held apart - allowing complete immersion of the ocular surface under a layer of drops. Corneal section and wide capsulotomy are surgical steps that prevented pain during nucleus delivery. Equatorial flush speeds aspiration/irrigation. Pain was caused during suturing the posterior lip of the incision involving the conjunctiva if the surgery took longer than expected. Keywords: Retrobulbar anaesthesia; Topical anaesthesia; Extracapsular cataract extraction; Xylocaine 4% drops; Equatorial flush.
INTRODUCTION
We used the term topical anaesthesia to define noninvasive anaesthesia of the eye or its coverings during planned extracapsular cataract extraction 0955-3681/95/060338 + 04 $12.00/0
(ECCE). This was achieved by instillation of preservative-free Xylocaine 4% drops. No other form of anaesthetic agent was injected in the immediate vicinity of the globe through the retrobulbar, peribulbar or subconjunctival route. Two millilitres of a © 1995 W.B. Saunders Company Limited
339
Surgical Modifications for Planned ECCE under Topical Anaesthesia
zygomatic nerve block - 'Van Lint' - with Xylocaine 2%, was injected deep along the upper and lower orbital rims and along the superior edge of the zygomatic arch. This relieved any spasm of the orbicularis muscle. This article studies the effectiveness of surgical modifications required to make planned ECCE a safe and comfortable procedure under topical anaesthesia with Van Lint block.
METHODS
A prospective study of 30 patients was set up. They were divided into 2 groups. The first group consisted of 15 patients who had undergone previous ECCE in one eye under retrobulbar anaesthesia. These patients were chosen to compare their perception of pain under retrobulbar anaesthesia us. topical anaesthesia with Van Lint block. The second group was made of 15 patients who had no previous eye surgery and had no preference for the type of anaesthesia to be used during surgery. This group was intentionally chosen to find out their initial response to topical anaesthesia with Van Lint block. Preoperative 0.5 ml preservative free Xylocaine 4% drops were used to anaesthetize the eye. The fornices and ocular surface were immersed as the lids were kept open by an assistant for up to 1 min. This allowed maximum saturation of the nerve endings of the cornea and conjunctiva. No injection was used for fixating the superior rectus muscle. Zygomatic nerve block with Xylocaine 2% was used to reduce the orbicularis spasm. Each patient was asked to grade the severity of the pain from 0-4 during every step of the operation.
RESULTS
We reported the response to these modifications on the final 20 patients, 15 in group 1 and 5 in group 2, where the pain was graded 0-4. The first 10 patients in group 2 were excluded as their grading of the pain distorted the results, as all surgical modifications to minimize the pain were not used on them. No patients graded above 2. Eight patients had no pain. Five patients had grade 1 and 7 patients had grade 2. The 0 grade being no feeling, grade 1 when the patient was aware of the various steps of the operation. Grade 2 was when the patient felt discomfort during those steps. Grade 3 was for tolerable pain and grade 4 being intolerable pain. Eur J Implant Ref Surg, Vol 7, December 1995
DISCUSSION
Although rare, the literature records numerous complications of retrobulbar anaesthesia. Some of these complications are vision-as well as life-threatening. They ranged from retrobulbar haemorrhage, being the most common, to central nervous system complications, including ipsi- and contra-lateral amaurosis, cranial nerve palsy, acute confusion, respiratory arrest and seizures [1-13J. Ocular complications included globe perforation, central retinal artery and/or vein occlusion [14-16J, postoperative shivering [17J and ptosis [18J. This has led to the advent of peribulbar [19, 20J and subconjunctival [21-23J anaesthesia. A large number of papers comparing the three methods have been published [24, 25]. The agent used in these types of anaesthesia are also discussed [26J. Only one case report [27J describes the use of topical anaesthesia for planned ECCE as we defined above, i.e. using non-invasive anaesthesia by using drops only. The nearest to complete topical anaesthesia in ECCE has been coined the non retro bulbar NR method and advocated the use of a couple of drops of Amethocaine 1% and an injection of 1 ml of Xylocaine 2% superiorly, 7 mm from the limbus [28J. Surgeons in the UK, Canada and USA (pers. comm., [29]), advocated the use of drops supplemented with subconjunctival agents to anaesthetize the eye in phakoemulsification. In some centres topical anaesthesia with drops only for phakoemulsification has been used for more than 3 years in the USA. Xylocaine 4% drops seemed the agent of their choice when instilled at 1 min intervals about 5-10 minutes preoperatively. In our experience, on two occasions a phacoemulsification incision had to be widened and the procedure had to be finished as an ECCE. On another occasion, an automated anterior vitrectomy had to be carried out. We noted that the three patients did not complain of pain. Planned ECCE is still performed by the majority of surgeons in the UK, Europe and indeed the world. To avert the known complications of general or invasive local anaesthesia we decided to assess topical anaesthesia with Van Lint block in planned ECCE which is still performed on a fair percentage of patients in our department (60%). Despite phacoemulsification under topical anaesthesia becoming the procedure of choice in extracting cataracts and more surgeons in the developed world are taking it up, ECCE will remain the procedure most-performed throughout the world population simply for financial reasons. The strength of the palpebral reflex was assessed by the ease of the insertion of a Barraquer's one-
340
piece wire speculum. If this was found difficult to insert, a zygomatic block using Xylocaine 2% (Van Lint's) was given, this abolished all orbicularis contraction. Later it was decided to use this nerve block as a routine step since it was deemed safer to abolish any orbicularis tone while the eye was open. We realize that some superficial sensory block could occur by diffusion using the Van Lint block. We found that 0.5 ml of Xylocaine 4% instilled once as one dose while the lids are held open by an assistant for about 1 min causes full saturation of the nerve endings of the cornea and conjunctiva and decreased the palpebral reflex for the whole surgical procedure. A corneollimbal incision from 10 o'clock to 2 o'clock was made with a diamond knife in a 2 step fashion, a perpendicular incision in the superficial half of the cornea, then a deep slanting incision towards the pupil to enter the anterior chamber. No pain was felt at this stage. A letter-box capsulotomy or a wide capsulorhexis (7 mm) was performed on alternative patients. Nucleus delivery induced pain initially in letter-box capsulotomy. However, this was relieved if a capsular tear extended laterally. The pain was not relieved in capsulorhexis cases as no capsule tear occurred. This can be explained because during nucleus delivery through small capsular openings, pull on the ciliary body due to stretching of the zonule induces pain. This was confirmed also when 'in-the-bag' insertion of the 13.00 mm implant took place. The pain was more noticeable if the stretch mark appeared in the posterior capsule. It is recognized that can-opener capsulotomy can lead to tearing of the capsule with centration problems if capsule fibrosis and haptic splaying occur in some cases. We did not encounter such tearing and this method of performing the capsulotomy was adopted for this study. The conclusion that a wide 'can-opener' capsulotomy or a wide capsulorhexis would allow easy delivery of the nucleus and was an important step to avoid pain and also prevented the possibility of lateral tearing of the anterior capsule. Hydrodissection was found to increase the volume of the capsular bag and led to pain by the same mechanism described above and was avoided. An extra step helped to speed up the time taken for aspiration-irrigation and replaced hydrodissection. This consisted of flushing the equatorial area of the lens bag with balanced salt solution through a curved 26 gauge lacrimal needle. This broke the equatorial attachments of the lens fibres allowing easy and fast aspiration of the lens cortex. We named this step the 'equatorial flush'. The use of a 12-mm overall diameter implant seems to fit in the bag without causing the posterior
M. N. Abdel-Khalek and R. F. Refaat
capsule stretch lines usually seen when an IOL of a larger size is inserted in the bag. The other time when pain occurred was during suturing the corneo-limbal incision. This was noticeable when the needle pierced the posterior lip of the wound (sclera and conjunctiva) between the 11 o'clock and 1 o'clock positions, especially if the procedure took longer than expected (15-20 min). This could be relieved by applying a drop of preservative-free Xylocaine 4% while the wound was in apposition, left for a few seconds, then washed with balanced salt solution. As we are aware of some reports that some topical agents may affect the endothelium if instilled directly in an open eye, in the very few cases when patients felt pain during suturing we applied a soaked cotton tip swab to the scleral side of the incision for a few seconds. This allowed the procedure to be completed safely. The criteria for choosing these patients was that they should have good hearing and be quite responsive. They were advised to mention the degree of pain during the procedure. An objective assessment was also made by a regular anaesthetic nurse who held the patient's hand. She could tell from previous experience of the way patients were squeezing her hand as to the severity of their pain.
CONCLUSION
Xylocaine 4% drops soaking the conjunctival sac and fornices for up to 1 min with Van Lint block immediately prior to towelling the patient is a more effective way of producing anaesthesia than repeated instillation for prolonged periods preoperatively which can lead to some epithelial clouding. Xylocaine 4% drops instilled in this fashion give complete corneal anaesthesia and almost complete conjunctival anaesthesia. For this reason a larger corneal incision is preferable. Xylocaine 4% drops also reduces the palpebral reflex by abolishing corneal sensation and allows good eye exposure during surgery. This is enhanced by Van Lint zygomatic nerve block. A 'wide capsulotomy', a 'small overall diameter implant' and 'equatorial flush' are surgical modifications that allow painless completion of extracapsular cataract implant under topical anaesthesia with Van Lint block. It must be stressed that the surgeon's speed of completion of the procedure (while the eye is under the effect of anaesthesia) is a requirement for the successful painless completion of the operation. We found that the action of the Xylocaine 4% drops Eur J Implant Ref Surg, Vol 7, December 1995
Surgical Modifications for Planned ECCE under Topical Anaesthesia
provided a feeling-free period of 15-20 min, which in our hands appears to be sufficient to complete a complication-free ECCE.
ACKNOWLEDGEMENTS We would like to convey our gratitude to Miss Angela Broughton for her secretarial support.
REFERENCES 1 KR Edge, J Martin, V Nicoll. Retrobulbar haemorrhage after 12,500 retrobulbar blocks. Anesth. Analg., 1993; 76: 1019-22. 2 D Brent, H Singh. The effect of retrobulbar anaesthesia on visual acuity in planned extracapsular cataract extraction. Ophthalmic Surgery 1991: 22: 392-395. 3 T Puustjarvi, S Purhonen. Permanent blindness following retrobulbar hemorrhage after peribulbar anesthesia for cataract surgery. Ophthalmic Surgery 1992; 23: 450-453. 4 R Rodgers, J Orellana. Cranial nerve palsy following retrobulbar anaesthesia. Br. J. Ophthalmol., 1988; 72: 78. 5 SJ Talks, NHV Chong, JM Gibson, IR Francis. Visual acuity and pupillary reactions after peribulbar anaesthesia. Br. J. Ophthalmol., 1994; 78: 41-43. 6 NC Kaushik. Orbital haemorrhage following retrobulbar i~ection. Ind. J. Ophthal., 1988; 36: 128-130. 7 J Martin, V Nicholl, P Acharya Arun, K Ahlen, S Baguneid, RK Edge. Central nervous system complications after 6000 retrobulbar blocks. Anesth. Analg., 1987; 66: 1298-1302. 8 SM Cohen, FJ Sousa, NE Kelly, RT Wendel. Respiratory arrest and new retinal hemorrhages after retrobulbar anaesthesia. Am. J. Ophthalmol., 1992; 113: 209-210. 9 RM Rosenblatt, DR May, K Barsoumian. Cardiopulmonary arrest after retrobulbar block. Am. J. Ophthalmol., 1980; 90: 425-426. 10 LG Brookshire, KY Gleitsmann, EC Schenk. Life-threatening complication of retrobulbar block. Ophthalmology, 1986; 93: 1476-1478. 11 AS Mayer, RE O'Conner. Respiratory arrest after local aesthesia for outpatient cataract surgery: a dramatic but transient complication. Annals of Emergency Medicine, 1993; 1357: 149-151.
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