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Immediate visual capability after cataract surgery: Topical versus retrobulbar anesthesia
Immediate visual capability after cataract surgery: Topical versus retrobulbar anesthesia Per Julius Nielsen, M.D.
ABSTRACT This study evaluated vision immediately after surgery in 56 consecutive patients (31 who had topical anesthesia and 25 who had retrobulbar anesthesia) for cataract extraction by phacoemulsification and intraocular lens implantation. An unbiased, trained nurse measured uncorrected and best corrected visual acuities one hour, one day, and one week after surgery. One hour after surgery, patients in the topical anesthesia group had significantly better visual acuity than those in the retrobulbar anesthesia group. One day and one week after surgery there was no difference between the groups in visual acuity. In the topical anesthesia patients, there were no complications. In the retrobulbar anesthesia patients, ptosis occurred in 19 patients at one hour, in 4 patients at one day, and in 1 patient after one week; diplopia occurred in 13 patients at one hour. Key Words: phacoemulsification, retrobulbar anesthesia, small incision,
sutureless incision, topical anesthesia, visual acuity
Advances in cataract surgery have made the goal of emmetropia more attainable because of more accurate intraocular lens (IOL) power calculation and improved control of surgically induced astigmatism. Another advance, small incision cataract surgery using topical anesthesia, minimizes surgical trauma, allowing most patients to achieve good visual results immediately after surgery .1 In this study, visual performance after retrobulbar anesthesia and after topical anesthesia was compared. Postoperative complications and complaints were also evaluated.
SUBJECTS AND METHODS In this prospective study, 56 consecutive patients scheduled for cataract extraction by phacoemulsification through a self-sealing, 3.5 mm incision (either clear corneal or corneoscleral tunnel) and implantation of a foldable silicone IOL were divided into two groups based on type of anesthesia: retrobulbar (n = 25) or topical (n = 31). In the retrobulbar group, the anesthetic comprised a mixture of 2 ml of bupivacaine hydrochloride (Marcaine®) 5 mg/ml, and 2 ml of lidocaine hydrochloride 20 mg/ml with hyaluronidase (Permease®) 750 I.U.
The topical anesthesia group received three doses of three drops of lidocaine hydrochloride 40 mg/ml beginning 15 minutes before surgery. When needed, propoful (Diprivan®) 10 mg/ml in separate doses of 1 ml was given intravenously during surgery for sedation. Using a Humphrey automatic refractor (model570), an unbiased, trained nurse measured uncorrected and best corrected Snellen visual acuities one hour, one day, and one week after surgery. Postoperative complaints and complications (i.e., ptosis, diplopia, bleeding, pain) were also recorded. Data were statistically analyzed by paired and unpaired two-tailed t-tests. A P-value of less than 0.05 was considered significant.
RESULTS One hour after surgery, there was a significant difference in mean visual acuity between groups (Table 1; Figure 1). In the retrobulbar anesthesia group, uncorrected and best corrected visual acuity improved significantly from one hour to one day after surgery (P < .0001 ). From one day to one week postoperatively, best cor-
Reprint requests to Per Julius Nielsen, M.D., Department of Ophthalmology, Rigshospitalet DK-2100, Copenhagen, Denmark. 302
J CATARACT REFRACT SURG-VOL 21, MAY 1995
rected visual acuity improved significantly (P = .001) but uncorrected visual acuity did not (P = .28). In the topical anesthesia group, uncorrected and best corrected visual acuity improved significantly from one hour to one day after surgery (P = .002 and P = .0002, respectively). From one day to one week postoperatively, best corrected visual acuity improved significantly (P = .01) but uncorrected visual acuity did not (P = .12). There were no postoperative complications or complaints in the topical anesthesia group through one week. In the retrobulbar anesthesia group at one hour after surgery, 19 patients had ptosis, 13 diplopia, 3 bleeding, and 2 pain. At one day postoperatively, 4 had ptosis and 2 bleeding. At one week, 1 had ptosis.
sealing incisions that close immediately after instruments are removed from the eye has made cataract surgery safer and faster, with less intraocular manipulation, and therefore less dependent on total, anesthetic-induced akinesia, thus encouraging the use of topical anesthesia. Topical anesthesia carries its own risks that must be considered when choosing type of anesthesia. 6 •7 Those risks should be weighed against the benefits of visual recovery immediately after surgery. In this study, the uncorrected and best corrected visual acuities one hour after surgery were significantly better in the topical anesthesia group than in the retrobulbar anesthesia group. After that time, there were no significant differences between groups. Best uncorrected visual acuity was established on the first postoperative day in both groups, with no significant improvement between day one and week one. However, best corrected visual acuity continued to improve significantly during the first postoperative week. These findings indicate that in small incision surgery with both types of anesthesia, best uncorrected visual acuity is established on the first postoperative day and best corrected visual acuity during the first week after surgery. With topical anesthesia, the eye may be left unpatched because of the lack of ptosis and diplopia, symptoms present in some eyes in the retrobulbar anesthesia group after surgery. Although patient satisfaction may be difficult to evaluate, subjectively it was high because of the rapid visual rehabilitation and perhaps in part from the "verbal anesthesia" the surgeon provides during the procedure. In several cases, topical anesthesia may be a better choice than other forms of anesthesia (e.g., bleeding or ptosis after a previous retrobulbar block, after trauma, patients on anticoagulants). Patients with chronic open-angle glaucoma, especially those with normal tension glaucoma, are candidates for topical anesthesia as the retrobulbar block may affect an already compromised blood flow to the optic nerve head. Topical anesthesia should be used only by surgeons already comfortable with and proficient in phacoemulsification and small incision cataract surgery. It may not be the best choice for extracapsular cataract extraction because of the large wound required for nucleus expression. Future studies should further evaluate topical anesthesia compared with retrobulbar anesthesia from a patient's perspective, especially in regard to intraoperative pain and anxiety.
DISCUSSION
REFERENCES
Table 1. Mean visual acuity after small incision cataract surgery.
Time Uncorrected 1 hour 1 day 1 week Corrected 1 hour 1 day 1 week
Anesthesia Retrobulbar Topical
P-value
0.17 :t 0.17 0.54 :t 0.27 0.63 :t 0.30
0.37 :t 0.17 0.62 :t 0.30 0.72 :t 0.24
<.0001 .30 .19
0.24 :t 0.20 0.76 :t 0.24 1.00 :t 0.23
0.54 :t 0.22 0.80 :t 0.28 0.97 :t 0.24
<.0001 .57 .58
D
0,9
Retrobulbar
~
0,8
Topical
0,7 0,6
~
h=hourl
0,5
d =day
0,4 0,3
I
w=weeki
......
0,2 0,1 0 11 h 1 d 1 w
1h 1d 1w\
Fig. 1. (Nielsen) Mean uncorrected and best corrected visual acuities one hour, one day, and one week after surgery.
General anesthesia is still preferred for cataract surgery by some European surgeons because of the pos_sible serious c~mgVcations of retrobulbar and penbulbar anesthesia. - The advent of small, self-
1. Fine IH, Fichman RA, Grabow HB, eds. Clear-Corneal
Cataract Surgery and Topical Anesthesia. Thorofare, NJ, Slack, 1993 2. Percival SPB, Setty SS. Cost effectiveness of anaesthe-
J CATARACf REFRACf SURG-VOL 21, MAY 1995
303
sia and hospitalization. Eur J Implant Refract Surg 1992; 4:75-78 3. Edge KR, Nicoll JMV. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. Anesth Analg 1993; 76:1019-1022 4. Loots JH, Koorts AS, Venter JA. Peribulbar anesthesia; a prospective statistical analysis of the efficacy and predictability of bupivacaine and a lignocaine/bupivacaine mixture. J Cataract Refract Surg 1993; 19:72-76
304
5. Feibel RM, Custer PL, Gordon MO. Postcataract ptosis; a randomized, double-masked comparison of peribulbar and retrobulbar anesthesia. Ophthalmology 1993; 100: 660-665 6. Thornton SP. Anesthesia for cataract surgery and its complications. Curr Opin Ophthalmol 1993; 4:29-32 7. Lindstrom RL. Cataract surgery and lens implantation; editorial overview. Curr Opin Ophthalmol 1993; 4:1-2
J CATARACT REFRACT SURG-VOL 21, MAY 1995
ABSTRACT This study evaluated vision immediately after surgery in 56 consecutive patients (31 who had topical anesthesia and 25 who had retrobulbar anesthesia) for cataract extraction by phacoemulsification and intraocular lens implantation. An unbiased, trained nurse measured uncorrected and best corrected visual acuities one hour, one day, and one week after surgery. One hour after surgery, patients in the topical anesthesia group had significantly better visual acuity than those in the retrobulbar anesthesia group. One day and one week after surgery there was no difference between the groups in visual acuity. In the topical anesthesia patients, there were no complications. In the retrobulbar anesthesia patients, ptosis occurred in 19 patients at one hour, in 4 patients at one day, and in 1 patient after one week; diplopia occurred in 13 patients at one hour. Key Words: phacoemulsification, retrobulbar anesthesia, small incision,
sutureless incision, topical anesthesia, visual acuity
Advances in cataract surgery have made the goal of emmetropia more attainable because of more accurate intraocular lens (IOL) power calculation and improved control of surgically induced astigmatism. Another advance, small incision cataract surgery using topical anesthesia, minimizes surgical trauma, allowing most patients to achieve good visual results immediately after surgery .1 In this study, visual performance after retrobulbar anesthesia and after topical anesthesia was compared. Postoperative complications and complaints were also evaluated.
SUBJECTS AND METHODS In this prospective study, 56 consecutive patients scheduled for cataract extraction by phacoemulsification through a self-sealing, 3.5 mm incision (either clear corneal or corneoscleral tunnel) and implantation of a foldable silicone IOL were divided into two groups based on type of anesthesia: retrobulbar (n = 25) or topical (n = 31). In the retrobulbar group, the anesthetic comprised a mixture of 2 ml of bupivacaine hydrochloride (Marcaine®) 5 mg/ml, and 2 ml of lidocaine hydrochloride 20 mg/ml with hyaluronidase (Permease®) 750 I.U.
The topical anesthesia group received three doses of three drops of lidocaine hydrochloride 40 mg/ml beginning 15 minutes before surgery. When needed, propoful (Diprivan®) 10 mg/ml in separate doses of 1 ml was given intravenously during surgery for sedation. Using a Humphrey automatic refractor (model570), an unbiased, trained nurse measured uncorrected and best corrected Snellen visual acuities one hour, one day, and one week after surgery. Postoperative complaints and complications (i.e., ptosis, diplopia, bleeding, pain) were also recorded. Data were statistically analyzed by paired and unpaired two-tailed t-tests. A P-value of less than 0.05 was considered significant.
RESULTS One hour after surgery, there was a significant difference in mean visual acuity between groups (Table 1; Figure 1). In the retrobulbar anesthesia group, uncorrected and best corrected visual acuity improved significantly from one hour to one day after surgery (P < .0001 ). From one day to one week postoperatively, best cor-
Reprint requests to Per Julius Nielsen, M.D., Department of Ophthalmology, Rigshospitalet DK-2100, Copenhagen, Denmark. 302
J CATARACT REFRACT SURG-VOL 21, MAY 1995
rected visual acuity improved significantly (P = .001) but uncorrected visual acuity did not (P = .28). In the topical anesthesia group, uncorrected and best corrected visual acuity improved significantly from one hour to one day after surgery (P = .002 and P = .0002, respectively). From one day to one week postoperatively, best corrected visual acuity improved significantly (P = .01) but uncorrected visual acuity did not (P = .12). There were no postoperative complications or complaints in the topical anesthesia group through one week. In the retrobulbar anesthesia group at one hour after surgery, 19 patients had ptosis, 13 diplopia, 3 bleeding, and 2 pain. At one day postoperatively, 4 had ptosis and 2 bleeding. At one week, 1 had ptosis.
sealing incisions that close immediately after instruments are removed from the eye has made cataract surgery safer and faster, with less intraocular manipulation, and therefore less dependent on total, anesthetic-induced akinesia, thus encouraging the use of topical anesthesia. Topical anesthesia carries its own risks that must be considered when choosing type of anesthesia. 6 •7 Those risks should be weighed against the benefits of visual recovery immediately after surgery. In this study, the uncorrected and best corrected visual acuities one hour after surgery were significantly better in the topical anesthesia group than in the retrobulbar anesthesia group. After that time, there were no significant differences between groups. Best uncorrected visual acuity was established on the first postoperative day in both groups, with no significant improvement between day one and week one. However, best corrected visual acuity continued to improve significantly during the first postoperative week. These findings indicate that in small incision surgery with both types of anesthesia, best uncorrected visual acuity is established on the first postoperative day and best corrected visual acuity during the first week after surgery. With topical anesthesia, the eye may be left unpatched because of the lack of ptosis and diplopia, symptoms present in some eyes in the retrobulbar anesthesia group after surgery. Although patient satisfaction may be difficult to evaluate, subjectively it was high because of the rapid visual rehabilitation and perhaps in part from the "verbal anesthesia" the surgeon provides during the procedure. In several cases, topical anesthesia may be a better choice than other forms of anesthesia (e.g., bleeding or ptosis after a previous retrobulbar block, after trauma, patients on anticoagulants). Patients with chronic open-angle glaucoma, especially those with normal tension glaucoma, are candidates for topical anesthesia as the retrobulbar block may affect an already compromised blood flow to the optic nerve head. Topical anesthesia should be used only by surgeons already comfortable with and proficient in phacoemulsification and small incision cataract surgery. It may not be the best choice for extracapsular cataract extraction because of the large wound required for nucleus expression. Future studies should further evaluate topical anesthesia compared with retrobulbar anesthesia from a patient's perspective, especially in regard to intraoperative pain and anxiety.
DISCUSSION
REFERENCES
Table 1. Mean visual acuity after small incision cataract surgery.
Time Uncorrected 1 hour 1 day 1 week Corrected 1 hour 1 day 1 week
Anesthesia Retrobulbar Topical
P-value
0.17 :t 0.17 0.54 :t 0.27 0.63 :t 0.30
0.37 :t 0.17 0.62 :t 0.30 0.72 :t 0.24
<.0001 .30 .19
0.24 :t 0.20 0.76 :t 0.24 1.00 :t 0.23
0.54 :t 0.22 0.80 :t 0.28 0.97 :t 0.24
<.0001 .57 .58
D
0,9
Retrobulbar
~
0,8
Topical
0,7 0,6
~
h=hourl
0,5
d =day
0,4 0,3
I
w=weeki
......
0,2 0,1 0 11 h 1 d 1 w
1h 1d 1w\
Fig. 1. (Nielsen) Mean uncorrected and best corrected visual acuities one hour, one day, and one week after surgery.
General anesthesia is still preferred for cataract surgery by some European surgeons because of the pos_sible serious c~mgVcations of retrobulbar and penbulbar anesthesia. - The advent of small, self-
1. Fine IH, Fichman RA, Grabow HB, eds. Clear-Corneal
Cataract Surgery and Topical Anesthesia. Thorofare, NJ, Slack, 1993 2. Percival SPB, Setty SS. Cost effectiveness of anaesthe-
J CATARACf REFRACf SURG-VOL 21, MAY 1995
303
sia and hospitalization. Eur J Implant Refract Surg 1992; 4:75-78 3. Edge KR, Nicoll JMV. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. Anesth Analg 1993; 76:1019-1022 4. Loots JH, Koorts AS, Venter JA. Peribulbar anesthesia; a prospective statistical analysis of the efficacy and predictability of bupivacaine and a lignocaine/bupivacaine mixture. J Cataract Refract Surg 1993; 19:72-76
304
5. Feibel RM, Custer PL, Gordon MO. Postcataract ptosis; a randomized, double-masked comparison of peribulbar and retrobulbar anesthesia. Ophthalmology 1993; 100: 660-665 6. Thornton SP. Anesthesia for cataract surgery and its complications. Curr Opin Ophthalmol 1993; 4:29-32 7. Lindstrom RL. Cataract surgery and lens implantation; editorial overview. Curr Opin Ophthalmol 1993; 4:1-2
J CATARACT REFRACT SURG-VOL 21, MAY 1995