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Topical plus intracameral anesthesia for a triple procedure (penetrating keratoplasty, phacoemulsification and lens implantation)
TIPS AND CHIPS
Topical plus intracameral anesthesia for a triple procedure (penetrating keratoplasty, phacoemulsification and lens implantation)
C
ombined topical plus intracameral anesthesia is becoming more widely used for phacoemulsification with intraocular lens (IOL) implantation. 1 Topical anesthesia eliminates the risk of retrobulbar hemorrhage and does not increase the retrobulbar pressure. 2 This is especially important in patients who are receiving systemic anticoagulant therapy and those who are simultaneously undergoing penetrating keratoplasty (PKP). To our knowledge there is only one report in the literature describing the use of topical plus intracameral anesthesia for a triple procedure (PKP, phacoemulsification and IOL implantation) with an open-sky technique.2 We propose a different surgical approach to performing a triple procedure, in a patient with Fuchs' corneal dystrophy and a cataract who was receiving warfarin therapy. CASE REPORT
A 69-year-old myopic woman presented with a 1year history of painless decrease of vision in both eyes secondary to corneal edema and cataracts. She had a past history of atrial fibrillation, for which she was being treated with 2.5 mg/d of warfarin. She had a 5year history of hypertension. Her past ocular history included the removal of a basal cell carcinoma from the right eyelid and removal of the right tear duct 10 months earlier. In addition to warfarin, her systemic medications included metoprolol tartrate, hydrochlorothiazide, potassium chloride, pravastatin sodium, prednisone, lorazepam and nitroglycerine.
Correspondence to: Dr. Allan R. S1omovic, Toronto Western Hospital, EC7-0l1, 399 Bathurst St., Toronto ON MST 2S8; fax (416) 603-5114
Can J Ophthalmol 2000;35:331-3
Ophthalmic examination showed a best corrected visual acuity of 20/200 in both eyes. Pupillary examination was normal. The intraocular pressure was 16 mm Hg in the right eye and 14 mm Hg in the left. Slit-lamp examination revealed marked corneal endothelial guttae bilaterally. Her left eye had significant stromal edema with moderate microcystic epithelial edema. There were advanced nuclear sclerotic and central posterior subcapsular cataracts bilaterally. A diagnosis of bilateral Fuchs' corneal dystrophy and cataracts was made. Since the left corneal edema was more advanced, it was decided to perform a left triple procedure. Preoperative laboratory investigations showed an international normalized ratio of 1.9 (normally 0.8 to 1.2). Given the increased risk of bleeding intraoperatively, it was decided to perform the operation using topical plus intracameral anesthesia, and the appropriate informed consent was obtained. The patient received two drops of 0.5% tetracaine, administered topically, 15 minutes before surgery and another two drops immediately before surgery. Systemic sedation consisted of 2 mg of midazolam, given intravenously. The operative procedure was as follows. A lid speculum was inserted, and partialthickness trephination to a depth of 0.4 mm was performed with a Hannah trephine with a 7.75-mm blade. Care was taken not to enter the anterior chamber. Next, clear corneal temporal phacoemulsification with a 3.0-mm wound was performed. Then 0.3 mL of 1% lidocaine was injected into the anterior chamber. Standard "divide-and-conquer" phacoemulsification was performed with the Series 20000 Legacy machine (Alcon Canada Inc., Mississauga, Ont.). An AcrySof foldable posterior chamber IOL (Alcon Canada Inc.) was implanted into the capsular bag. Then 1 mL of acetylcholine chloride was injected into the anterior chamber to achieve pupillary miosis. The acetylcholine caused the patient to experience moderate ocular discomfort, which was only partially alleviated by intracameral injection of an additional 0.2 mL of 1% lidocaine. The cataract wound was closed with two interrupted 10-0 nylon sutures. The anterior chamber was filled with a viscoelastic agent (sodium chondroitin sulfate-sodium hyaluronate [Viscoat]) (Alcon Canada Inc.). The donor button was prepared with an 8-mm Hannah trephine. The corneal button was excised with scissors, and the
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Tips & Chips
donor tissue was placed into the recipient site and sewn into place with a combination of eight interrupted 10-0 nylon sutures and a running 16-bite 10-0 nylon suture. Then 0.5 mL of cefazolin sodium was injected subconjunctivally. The eye was not patched, and the patient was instructed to start topical treatment with antibiotics and steroids that same day. At 1 week postoperatively the patient was comfortable. The uncorrected visual acuity in her left eye was 20/400 (20/200 with pinhole disc). The intraocular pressure was 10 mm Hg. The graft was clear, and there was no epithelial defect. There was minimal reaction in the anterior chamber and no evidence of bleeding complications. The lens was well positioned in the capsular bag, and there was a good red reflex. At 3 months the postoperative course was uneventful. COMMENTS
For patients receiving anticoagulant therapy who must undergo surgery, the risk of systemic thromboembolism associated with stopping the therapy must be weighed against the risk of intraoperative or postoperative bleeding if anticoagulant therapy is continued throughout the perioperative period. 3 The most common complication from retrobulbar injection is retrobulbar hemorrhage. Another option would be to admit the patient to hospital to receive systemic heparinization for the perioperative period. Gainey and colleagues4 reported six perioperative hemorrhagic events (e.g., hyphema or subconjunctival hemorrhage) in 50 patients treated with warfarin who underwent ocular surgery, compared with no such events in a control group of 50 patients who did not receive anticoagulant therapy. McMahan5 observed more eyelid ecchymoses and subconjunctival hemorrhages in 28 patients receiving warfarin therapy than in control patients not receiving such therapy; no sight-threatening complications occurred in the warfarin group. As a result of these and other studies showing a relatively low risk of a sight-threatening hemorrhage (e.g., retrobulbar hemorrhage), the lifethreatening risks associated with cessation of anticoagulant therapy are felt to outweigh the surgical risks.4-7 In 1997 Yavitz2 reported using topical plus intracameral anesthesia for PKP with open-sky extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation. We believe that closed-chamber phacoemulsification performed before PKP has ad-
332
CAN J OPHTHALMOL-VOL. 35, NO.6, 2000
vantages over the open-sky approach. Rao and Padmanabhan8 highlighted these advantages, stating that closed-chamber phacoemulsification before PKP can minimize the risk of complications stemming from increased posterior pressure during open-sky ECCE. Such complications include peripheral extension of a capsular tear and collapse of the capsular fornix, which make irrigation and aspiration of lens cortex and "in the bag" implantation of the posterior chamber IOL more difficult. 8 However, unlike our patient, the two patients described by Rao and Padmanabhan had peribulbar anesthesia, and the authors used a scleral tuimel incision to perform phacoemulsification. We chose closed-chamber phacoemulsification for our patient because her cornea was clear enough to perform the operation safely. This technique is not suitable for opaque corneas. Since we chose not to give our patient a retrobulbar injection, we felt it would be safer to perform closed-chamber phacoemulsification rather than expose the eye to the possible risks described in the previous paragraph. Another advantage of closedchamber phacoemulsification is better control of the eye position with the help of the intraocular instruments. A Fleringa ring helps stabilize the eye during the surgery but may also add discomfort to the eye anesthesized with only topically plus intracamerally administered lidocaine. Although closed-chamber phacoemulsification adds to the length of the operation, it is fairly comfortable for the patient, and the anesthesia provided works well for the manipulations involved with such a procedure. It is important to secure the clear corneal phacoemulsification incision well at the end of the cataract portion of the operation, before excising the corneal button. We closed the wound with two interrupted 10-0 nylon sutures. In our experience the additional astigmatism caused by these sutures is negligible and can be managed by removing the sutures a few weeks postoperatively. Not all patients are candidates for topical plus intracameral anesthesia for a triple procedure. Certainly, having an anesthetist who is willing to cooperate and is able to be flexible with the sedation level is very helpful. In our case there was no need for more than midazolam, but another option would be the adjunctive use of alfentanil hydrochloride, which Y avitz2 routinely employed. We elected not to use regional anesthesia (facial nerve block), but this would be a safe adjunct in a patient receiving anticoagulant therapy. We could probably have spared our patient some discomfort by injecting additional lidocaine intracamerally before injecting the acetylcholine. Other factors that should be considered
Tips & Chips
preoperatively to assess a patient's suitability for topical plus intracameral anesthesia include the patient's ability to communicate and cooperate with the surgeon's directives and the patient's preoperative performance during tonometry and A-scan ultrasonography.9 The standard of care for triple procedures remains retrobulbar anesthesia combined with seventh cranial nerve akinesia. However, there are certain circumstances in which consideration of alternative methods of anesthesia may be helpful. As in our case, if there is a justifiable reason to avoid retrobulbar injection, such as warfarin therapy, topical anesthesia may be considered. We believe that in carefully selected patients, topical plus intracameral anesthesia is an effective and safe alternative to retrobulbar anesthesia.
Dwight Silvera, BSc Second-year medical student McMaster University Hamilton, Ont. Adi Michaeli-Cohen, MD Allan R. Slomovic, MA, MD, FRCSC Department of Ophthalmology Toronto Western Hospital and University of Toronto Toronto, Ont.
REFERENCES
1. Learning DV. Practice styles and preferences of ASCRS members - 1998 survey. J Cataract Refract Surg 1999; 25:851-9. 2. Yavitz EQ. Topical and intracameral anesthesia for corneal transplants [letter]. J Cataract Refract Surg 1997;23:1435. 3. Carter K, Miller KM. Phacoemulsification and lens implantation in patients treated with aspirin or warfarin. J Cataract Refract Surg 1998;24:1361-4. 4. Gainey SP, Robertson DM, Fay W, Ilstrup D. Ocular surgery on patients receiving long-term warfarin therapy. Am J Ophthalmo/1989;108:142-6. 5. McMahan LB. Anticoagulants and cataract surgery. J Cataract Refract Surg 1988;14:569-71. 6. Attitudes regarding the concomitant use of anti-coagulants with elective cataract surgery. J Cataract Refract Surg 1992;18:531-5. 7. Robinson GA, Nylander A. Warfarin and cataract extraction. Br J Ophthalmo/1989;73:702-3. 8. Rao SK, Padmanabhan P. Combined phacoemulsification and penetrating keratoplasty. Ophthalmic Surg Lasers 1999; 30:488-91. 9. Fraser SG, Siriwadena D, Jamieson H, Girault J, Bryan SJ. Indicators of patient suitability for topical anesthesia. J Cataract Refract Surg 1997;23:781-3. Key words: topical anesthesia, corneal transplantation, warfarin, cataract extraction
CAN J OPHTHALMOL-VOL. 35, NO.6, 2000
333
Topical plus intracameral anesthesia for a triple procedure (penetrating keratoplasty, phacoemulsification and lens implantation)
C
ombined topical plus intracameral anesthesia is becoming more widely used for phacoemulsification with intraocular lens (IOL) implantation. 1 Topical anesthesia eliminates the risk of retrobulbar hemorrhage and does not increase the retrobulbar pressure. 2 This is especially important in patients who are receiving systemic anticoagulant therapy and those who are simultaneously undergoing penetrating keratoplasty (PKP). To our knowledge there is only one report in the literature describing the use of topical plus intracameral anesthesia for a triple procedure (PKP, phacoemulsification and IOL implantation) with an open-sky technique.2 We propose a different surgical approach to performing a triple procedure, in a patient with Fuchs' corneal dystrophy and a cataract who was receiving warfarin therapy. CASE REPORT
A 69-year-old myopic woman presented with a 1year history of painless decrease of vision in both eyes secondary to corneal edema and cataracts. She had a past history of atrial fibrillation, for which she was being treated with 2.5 mg/d of warfarin. She had a 5year history of hypertension. Her past ocular history included the removal of a basal cell carcinoma from the right eyelid and removal of the right tear duct 10 months earlier. In addition to warfarin, her systemic medications included metoprolol tartrate, hydrochlorothiazide, potassium chloride, pravastatin sodium, prednisone, lorazepam and nitroglycerine.
Correspondence to: Dr. Allan R. S1omovic, Toronto Western Hospital, EC7-0l1, 399 Bathurst St., Toronto ON MST 2S8; fax (416) 603-5114
Can J Ophthalmol 2000;35:331-3
Ophthalmic examination showed a best corrected visual acuity of 20/200 in both eyes. Pupillary examination was normal. The intraocular pressure was 16 mm Hg in the right eye and 14 mm Hg in the left. Slit-lamp examination revealed marked corneal endothelial guttae bilaterally. Her left eye had significant stromal edema with moderate microcystic epithelial edema. There were advanced nuclear sclerotic and central posterior subcapsular cataracts bilaterally. A diagnosis of bilateral Fuchs' corneal dystrophy and cataracts was made. Since the left corneal edema was more advanced, it was decided to perform a left triple procedure. Preoperative laboratory investigations showed an international normalized ratio of 1.9 (normally 0.8 to 1.2). Given the increased risk of bleeding intraoperatively, it was decided to perform the operation using topical plus intracameral anesthesia, and the appropriate informed consent was obtained. The patient received two drops of 0.5% tetracaine, administered topically, 15 minutes before surgery and another two drops immediately before surgery. Systemic sedation consisted of 2 mg of midazolam, given intravenously. The operative procedure was as follows. A lid speculum was inserted, and partialthickness trephination to a depth of 0.4 mm was performed with a Hannah trephine with a 7.75-mm blade. Care was taken not to enter the anterior chamber. Next, clear corneal temporal phacoemulsification with a 3.0-mm wound was performed. Then 0.3 mL of 1% lidocaine was injected into the anterior chamber. Standard "divide-and-conquer" phacoemulsification was performed with the Series 20000 Legacy machine (Alcon Canada Inc., Mississauga, Ont.). An AcrySof foldable posterior chamber IOL (Alcon Canada Inc.) was implanted into the capsular bag. Then 1 mL of acetylcholine chloride was injected into the anterior chamber to achieve pupillary miosis. The acetylcholine caused the patient to experience moderate ocular discomfort, which was only partially alleviated by intracameral injection of an additional 0.2 mL of 1% lidocaine. The cataract wound was closed with two interrupted 10-0 nylon sutures. The anterior chamber was filled with a viscoelastic agent (sodium chondroitin sulfate-sodium hyaluronate [Viscoat]) (Alcon Canada Inc.). The donor button was prepared with an 8-mm Hannah trephine. The corneal button was excised with scissors, and the
CAN J OPHTHALMOL-VOL. 35, NO.6, 2000
331
Tips & Chips
donor tissue was placed into the recipient site and sewn into place with a combination of eight interrupted 10-0 nylon sutures and a running 16-bite 10-0 nylon suture. Then 0.5 mL of cefazolin sodium was injected subconjunctivally. The eye was not patched, and the patient was instructed to start topical treatment with antibiotics and steroids that same day. At 1 week postoperatively the patient was comfortable. The uncorrected visual acuity in her left eye was 20/400 (20/200 with pinhole disc). The intraocular pressure was 10 mm Hg. The graft was clear, and there was no epithelial defect. There was minimal reaction in the anterior chamber and no evidence of bleeding complications. The lens was well positioned in the capsular bag, and there was a good red reflex. At 3 months the postoperative course was uneventful. COMMENTS
For patients receiving anticoagulant therapy who must undergo surgery, the risk of systemic thromboembolism associated with stopping the therapy must be weighed against the risk of intraoperative or postoperative bleeding if anticoagulant therapy is continued throughout the perioperative period. 3 The most common complication from retrobulbar injection is retrobulbar hemorrhage. Another option would be to admit the patient to hospital to receive systemic heparinization for the perioperative period. Gainey and colleagues4 reported six perioperative hemorrhagic events (e.g., hyphema or subconjunctival hemorrhage) in 50 patients treated with warfarin who underwent ocular surgery, compared with no such events in a control group of 50 patients who did not receive anticoagulant therapy. McMahan5 observed more eyelid ecchymoses and subconjunctival hemorrhages in 28 patients receiving warfarin therapy than in control patients not receiving such therapy; no sight-threatening complications occurred in the warfarin group. As a result of these and other studies showing a relatively low risk of a sight-threatening hemorrhage (e.g., retrobulbar hemorrhage), the lifethreatening risks associated with cessation of anticoagulant therapy are felt to outweigh the surgical risks.4-7 In 1997 Yavitz2 reported using topical plus intracameral anesthesia for PKP with open-sky extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation. We believe that closed-chamber phacoemulsification performed before PKP has ad-
332
CAN J OPHTHALMOL-VOL. 35, NO.6, 2000
vantages over the open-sky approach. Rao and Padmanabhan8 highlighted these advantages, stating that closed-chamber phacoemulsification before PKP can minimize the risk of complications stemming from increased posterior pressure during open-sky ECCE. Such complications include peripheral extension of a capsular tear and collapse of the capsular fornix, which make irrigation and aspiration of lens cortex and "in the bag" implantation of the posterior chamber IOL more difficult. 8 However, unlike our patient, the two patients described by Rao and Padmanabhan had peribulbar anesthesia, and the authors used a scleral tuimel incision to perform phacoemulsification. We chose closed-chamber phacoemulsification for our patient because her cornea was clear enough to perform the operation safely. This technique is not suitable for opaque corneas. Since we chose not to give our patient a retrobulbar injection, we felt it would be safer to perform closed-chamber phacoemulsification rather than expose the eye to the possible risks described in the previous paragraph. Another advantage of closedchamber phacoemulsification is better control of the eye position with the help of the intraocular instruments. A Fleringa ring helps stabilize the eye during the surgery but may also add discomfort to the eye anesthesized with only topically plus intracamerally administered lidocaine. Although closed-chamber phacoemulsification adds to the length of the operation, it is fairly comfortable for the patient, and the anesthesia provided works well for the manipulations involved with such a procedure. It is important to secure the clear corneal phacoemulsification incision well at the end of the cataract portion of the operation, before excising the corneal button. We closed the wound with two interrupted 10-0 nylon sutures. In our experience the additional astigmatism caused by these sutures is negligible and can be managed by removing the sutures a few weeks postoperatively. Not all patients are candidates for topical plus intracameral anesthesia for a triple procedure. Certainly, having an anesthetist who is willing to cooperate and is able to be flexible with the sedation level is very helpful. In our case there was no need for more than midazolam, but another option would be the adjunctive use of alfentanil hydrochloride, which Y avitz2 routinely employed. We elected not to use regional anesthesia (facial nerve block), but this would be a safe adjunct in a patient receiving anticoagulant therapy. We could probably have spared our patient some discomfort by injecting additional lidocaine intracamerally before injecting the acetylcholine. Other factors that should be considered
Tips & Chips
preoperatively to assess a patient's suitability for topical plus intracameral anesthesia include the patient's ability to communicate and cooperate with the surgeon's directives and the patient's preoperative performance during tonometry and A-scan ultrasonography.9 The standard of care for triple procedures remains retrobulbar anesthesia combined with seventh cranial nerve akinesia. However, there are certain circumstances in which consideration of alternative methods of anesthesia may be helpful. As in our case, if there is a justifiable reason to avoid retrobulbar injection, such as warfarin therapy, topical anesthesia may be considered. We believe that in carefully selected patients, topical plus intracameral anesthesia is an effective and safe alternative to retrobulbar anesthesia.
Dwight Silvera, BSc Second-year medical student McMaster University Hamilton, Ont. Adi Michaeli-Cohen, MD Allan R. Slomovic, MA, MD, FRCSC Department of Ophthalmology Toronto Western Hospital and University of Toronto Toronto, Ont.
REFERENCES
1. Learning DV. Practice styles and preferences of ASCRS members - 1998 survey. J Cataract Refract Surg 1999; 25:851-9. 2. Yavitz EQ. Topical and intracameral anesthesia for corneal transplants [letter]. J Cataract Refract Surg 1997;23:1435. 3. Carter K, Miller KM. Phacoemulsification and lens implantation in patients treated with aspirin or warfarin. J Cataract Refract Surg 1998;24:1361-4. 4. Gainey SP, Robertson DM, Fay W, Ilstrup D. Ocular surgery on patients receiving long-term warfarin therapy. Am J Ophthalmo/1989;108:142-6. 5. McMahan LB. Anticoagulants and cataract surgery. J Cataract Refract Surg 1988;14:569-71. 6. Attitudes regarding the concomitant use of anti-coagulants with elective cataract surgery. J Cataract Refract Surg 1992;18:531-5. 7. Robinson GA, Nylander A. Warfarin and cataract extraction. Br J Ophthalmo/1989;73:702-3. 8. Rao SK, Padmanabhan P. Combined phacoemulsification and penetrating keratoplasty. Ophthalmic Surg Lasers 1999; 30:488-91. 9. Fraser SG, Siriwadena D, Jamieson H, Girault J, Bryan SJ. Indicators of patient suitability for topical anesthesia. J Cataract Refract Surg 1997;23:781-3. Key words: topical anesthesia, corneal transplantation, warfarin, cataract extraction
CAN J OPHTHALMOL-VOL. 35, NO.6, 2000
333