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Peribulbar Block Without Sedation
LETTERS
of all instruments before their intraocular use may help reduce the occurrence of this phenomenon. JAY M. STEWART, MD DAVID A. HOLLANDER, MD San Francisco, California, USA
References 1. Wadood AC, Dhillon B. Unidentified foreign objects in the wound after clear corneal tunnel phacoemulsification. J Cataract Surg 2002; 23:2238–2239
access than the traditional two-thirds/one-third entry location. If executed carefully using the above steps, this technique without sedation offers several key advantages. The patient can instantaneously report atypical pain associated with an errant block. Akinesia and anesthesia can be assessed immediately in the conscious patient, who also remains more alert and cooperative during the surgery. Furthermore, the risks of systemic sedation are eliminated and the patient can safety leave the recovery area in a more expeditious fashion.
Peribulbar Block Without Sedation
JASON S. DILLY, MD Detroit, Michigan, USA
I
use the modified inferolateral approach to peribulbar anesthesia described in the article by Hamilton.1 He brings up the important point that heavy intravenous sedation can render the patient less capable of reporting atypical pain experienced during injection. This atypical pain can be associated with the serious complication of globe penetration during administration of the block.2,3 I routinely place peribulbar blocks without the use of systemic sedation with minimal discomfort to the patient and would like to point out several small but key maneuvers that minimize patient discomfort when injecting without sedation. Initially, the patient is placed in a comfortable supine position. He or she is instructed to keep his or her head still and the eyes open, looking straight ahead, with a target on the ceiling if possible. After it is cleaned, the skin at the entry side is given a vigorous digital massage to hyperstimulate the area. The surgeon then distracts the patient with simple questions and conversation as the block is accomplished. A 11⁄4-inch 27-gauge sharp needle is inserted transcutaneously at the inferotemporal orbit, palpating the bony rim and guiding the needle toward the apex along an imaginary line just above the inferior orbital fissure. The anesthetic agent (50/50 lidocaine and bupivacaine 0.75%) is injected slowly to cause minimal “squeeze” and discomfort to the patient. If severe or atypical pain is encountered during the injection, the block should be aborted and the eye evaluated for potential trauma. After the injection, direct manual pressure is applied to the eye for several seconds to discourage hemorrhage and help disperse the anesthetic agent. I agree with Dr. Hamilton that the inferotemporal approach to the block offers more physical space between the globe and the orbital wall and therefore provides safer 2046
References 1. Hamilton RC. Ocular penetration/perforation after peribulbar anesthesia [letter]. J Cataract Refract Surg 2003; 29:423–424 2. Brar GS, Ram J, Dogra MR, et al. Ocular explosion after peribulbar anesthesia. J Cataract Refract Surg 2002; 28:556–561 3. Wadood AC, Dhillon B, Singh J. Inadvertent ocular perforation and intravitreal injectin of an anesthetic agent during retrobulbar injection. J Cataract Refract Surg 2002; 28:562–565
Conjunctival Ballooning During Scleral Tunnel Phacoemulsification
W
e would like to comment on the letter by Ismail and coauthors1 and the subsequent comments2,3 as well as the letter by Saleh4 and share our experience. As reported in these letters, conjunctival ballooning occurs even with apparently clear corneal incisions, especially when a bevel-up keratome is used. We routinely perform phacoemulsification through a superior scleral tunnel and have noted that conjunctival ballooning is a frequent problem. In 852 procedures performed by 2 experienced surgeons (N.G.Z, N.G.) over the past 12 months (January 2001 to January 2002), ballooning was encountered in 64 eyes (7.5%). The etiopathogenesis of this condition was probably related to the combination of disinsertion of the conjunctiva from the limbus, which is necessary to fashion the scleral tunnel, and possible small leakage from the incision. This leads to accumulation of irrigating solution under the
J CATARACT REFRACT SURG—VOL 29, NOVEMBER 2003
of all instruments before their intraocular use may help reduce the occurrence of this phenomenon. JAY M. STEWART, MD DAVID A. HOLLANDER, MD San Francisco, California, USA
References 1. Wadood AC, Dhillon B. Unidentified foreign objects in the wound after clear corneal tunnel phacoemulsification. J Cataract Surg 2002; 23:2238–2239
access than the traditional two-thirds/one-third entry location. If executed carefully using the above steps, this technique without sedation offers several key advantages. The patient can instantaneously report atypical pain associated with an errant block. Akinesia and anesthesia can be assessed immediately in the conscious patient, who also remains more alert and cooperative during the surgery. Furthermore, the risks of systemic sedation are eliminated and the patient can safety leave the recovery area in a more expeditious fashion.
Peribulbar Block Without Sedation
JASON S. DILLY, MD Detroit, Michigan, USA
I
use the modified inferolateral approach to peribulbar anesthesia described in the article by Hamilton.1 He brings up the important point that heavy intravenous sedation can render the patient less capable of reporting atypical pain experienced during injection. This atypical pain can be associated with the serious complication of globe penetration during administration of the block.2,3 I routinely place peribulbar blocks without the use of systemic sedation with minimal discomfort to the patient and would like to point out several small but key maneuvers that minimize patient discomfort when injecting without sedation. Initially, the patient is placed in a comfortable supine position. He or she is instructed to keep his or her head still and the eyes open, looking straight ahead, with a target on the ceiling if possible. After it is cleaned, the skin at the entry side is given a vigorous digital massage to hyperstimulate the area. The surgeon then distracts the patient with simple questions and conversation as the block is accomplished. A 11⁄4-inch 27-gauge sharp needle is inserted transcutaneously at the inferotemporal orbit, palpating the bony rim and guiding the needle toward the apex along an imaginary line just above the inferior orbital fissure. The anesthetic agent (50/50 lidocaine and bupivacaine 0.75%) is injected slowly to cause minimal “squeeze” and discomfort to the patient. If severe or atypical pain is encountered during the injection, the block should be aborted and the eye evaluated for potential trauma. After the injection, direct manual pressure is applied to the eye for several seconds to discourage hemorrhage and help disperse the anesthetic agent. I agree with Dr. Hamilton that the inferotemporal approach to the block offers more physical space between the globe and the orbital wall and therefore provides safer 2046
References 1. Hamilton RC. Ocular penetration/perforation after peribulbar anesthesia [letter]. J Cataract Refract Surg 2003; 29:423–424 2. Brar GS, Ram J, Dogra MR, et al. Ocular explosion after peribulbar anesthesia. J Cataract Refract Surg 2002; 28:556–561 3. Wadood AC, Dhillon B, Singh J. Inadvertent ocular perforation and intravitreal injectin of an anesthetic agent during retrobulbar injection. J Cataract Refract Surg 2002; 28:562–565
Conjunctival Ballooning During Scleral Tunnel Phacoemulsification
W
e would like to comment on the letter by Ismail and coauthors1 and the subsequent comments2,3 as well as the letter by Saleh4 and share our experience. As reported in these letters, conjunctival ballooning occurs even with apparently clear corneal incisions, especially when a bevel-up keratome is used. We routinely perform phacoemulsification through a superior scleral tunnel and have noted that conjunctival ballooning is a frequent problem. In 852 procedures performed by 2 experienced surgeons (N.G.Z, N.G.) over the past 12 months (January 2001 to January 2002), ballooning was encountered in 64 eyes (7.5%). The etiopathogenesis of this condition was probably related to the combination of disinsertion of the conjunctiva from the limbus, which is necessary to fashion the scleral tunnel, and possible small leakage from the incision. This leads to accumulation of irrigating solution under the
J CATARACT REFRACT SURG—VOL 29, NOVEMBER 2003