USE OF ANESTHETICS PROCEDURES

Introduction

IN

OPHTHALAMIC

Ophthalmic surgery is one of the most frequent surgical procedures requiring anesthesia in developed countries. Perioperative morbidity and mortality rates associated with eye (eg, cataract) surgery are low. Nevertheless, because patients with cataracts tend to be older and to have serious comorbidities, systematic preoperative evaluation should be performed to consider a patient eligible for surgery. Anesthetic management may contribute to the success or failure of ophthalmic surgery. Clinical strategies to ensure patient immobility are essential, as blindness is the outcome in many cases of eye injury. Most problems occurred during general anesthesia. Quicker patient rehabilitation and fewer complications are the main reasons why many ophthalmic surgeons are choosing local (LA) over general anesthesia. In the past, regional anesthesia on the eye typically consisted of retrobulbar anesthesia (RBA), with the surgeon performing the block. Widespread use of the phacoemulsification technique, however, has changed the anesthesia requirements for this technique total akinesia and lowered intraocular pressure are no longer necessary. Consequently, conventional RBA is used less frequently today, particularly since it carries a greater risk for complications than do the emerging techniques. The newer techniques do not provide akinesia of the globe paralleling that of the retrobulbar block; however, they are useful for anterior segment surgery, especially cataract surgery. Accurate knowledge of anatomy and of various anesthetic techniques are necessary to determine the appropriate block for specific clinical situations. This chapter will review the relevant anatomy of the eye, classic (retro and peribulbar) needle block techniques, emerging anesthesia techniques, and choice of LAs and adjuvant agents.

Anatomy
The cavity of the orbit has a truncated pyramid shape, with a posterior apex, and a base corresponding to the anterior aperture. The orbit contains mainly adipose tissue, and the globe is suspended in the anterior part. The four rectusmuscles of the eye insert anteriorly near the equator of the globe. Posteriorly, insert at the apex on the tendineus anulus communis of Zinn, through which the optic nerve

enters the orbit. The four rectus muscles delineate the retrobulbar cone, which is not sealed by any intermuscular membrane.1417 Sensory innervation is supplied by the ophthalmic nerve (first branch of the trigeminal nerve [V]), which passes through the muscular cone. The trochlear nerve (IV) provides motor control to the superior obliquemuscles, the abducens nerve (VI) to the lateral rectus muscle, and the oculomotor nerve (III) to all other extraocular muscles. All but the trochlear nerve pass through the muscular conus. Injection of LA solution inside the cone will provide anesthesia and akinesia of the globe and the extraocularmuscles. Only the motor nerve to the orbicularis muscle of the eyelids has an extraorbital course, coming from the superior branch of the facial nerve (VII). Many major structures are located within the muscular conus and are, therefore, at risk of needle and injection injury. These include the optic nerve with its meningeal coverings; blood vessels of the orbit; and the autonomic, sensory, and motor innervation of the globe. However, the extraconal space is only a virtual space, because the rectus muscles are in contact with the bone walls of the orbit. The scleral portion of the globe is surrounded by Tenons capsule, a fibroelastic layer stretching from the corneal limbus anteriorly to the optic nerve posteriorly. Its proper anatomic name is the facial sheath of the eyeball. It delimits a potential space named the episcleral space (sub-Tenons space). This is only a virtual space that expands when fluid is injected into it.

Retrobulbar Anesthesia
Historically, RBA has been the gold standard for anesthesia of the eye and orbit. This technique generally consists of injecting a small volume of LA solution (35 mL) inside the muscular cone . A facial nerve block is occasionally required to prevent blinking. Because of its extraconal motor control, the superior oblique muscle may frequently remain functional, precluding total akinesia of the globe. The main hazard of RBA is risk of injury to the globe or to one of the anatomic structures in the muscular cone. Near the apex, these structures are packed in a very small space and are fixed by the tendon of Zinn, which prevents them from moving away from a needle.

Retrobulbar Versus Peribulbar Blocks

Retrobulbar block has been traditionally assumed to be more effective than PBA. However, when a sufficient volume of LA is injected, both blocks have similar success rates. There is a sound anatomic explanation for this: the absence of an inter

muscular membrane to separate extra- from intraconal compartments results in a similar space for the spread of local anesthetic. Therefore, if the effectiveness is similar, one would prefer to use the technique with less risk of complications. Because the retrobulbar block theoretically carries a higher risk of complications (optic nerve injury, brainstem anesthesia, retrobulbar hemorrhage), peribulbar block is deemed preferable to retrobulbar block.

Major Complications of Eye Blocks

The primary cause of serious complications is needle misplacement. Although some anatomic features may increase the risk of complications, the main risk factor is inadequate knowledge and limited experience on the part of the physician. However, it should be noted that complications such as retrobulbar hemorrhage may occur with even the most experienced practitioners. Presenting signs, symptoms, and mechanism of common complications are summarized in Tables 1 and 2). Table 1: Signs, Symptoms and Mechanism Retrobulbar Anesthesia Complications Signs & Symptoms Ocular Perforation of Ocular pain, intraocular globe hemorrhage, restlessness of Complications of Mechanism

Direct trauma: Myopic eye, posterior staphyloma, repeated injections Retrobulbar Subconjunctival or eyelid Direct trauma hemorrhage ecchymosis, increasing (artery or vein) proptosis pain, and/or, increased intraocular pressure Optic nerve Visual loss, optic disc Direct injury to damage pallor nerve or blood vessels, vascular occlusion Systemic Intraarterial Cardiopulmonary arrest, Retrograde flow injection convulsions to internal carotid and access to midbrain

Optic nerve Agitation, or sheath mydriasis injection dizziness, contralateral ophthalmoplegia, respiratory depression or cardiac arrest Oculocardiac Bradycardia, other Trigeminal nerve reflex arrhythmias, asystole (afferent, arc) to floor of fourth ventricle with efferent arc via vagus nerve

structures ptosis, Subdural dysphagia, subarachnoid confusion, injection

Table 2: Other, Minor Complications Complication Comment Chemosis Usually of minimal concern; (subconjunctival disappears with pressure edema) Venous hemorrhage Usually mild and while unsightly, it is easily controlled Arterial hemorrhage Can be dramatic, causing proptosis, extensive subconjunctival and lid hematoma, and a dramatic increase in intraocular pressure. It often necessitates postponement of surgery Globe perforation Probably more likely in long myopic eyes. A long eye has thinner sclera and may have an irregular outline (staphylomata). The needle should be inserted tangentially to the globe, should move in freely in the orbital globe, and should move freely in the orbital fat without rotating the globe Damage to the optic A result from direct trauma, injection nerve into nerve sheath, or the ischemic consequences of the pressure on

Decreased acuity Myotoxicity

injection visual Resolves with resolution of the block May follow the use of high concentrations of LA (eg, 4% lidocaine) or direct injection into a muscle and may result in muscle palsy Include potential for subarachnoid injection during retrobulbar block as a cause of respiratory arrest These complications can result from systemic LA toxicity, injection of LA into the optic nerve sheath, or retrograde arterial flow

Systemic complications

Grand mal seizures, loss of consciousness, and respiratory depression or cardiac arrest Pulmonary edema Rare, the mechanism poorly understood Reaction to Often inappropriately refferred to as epinephrine Epinephrine toxicity In patients with hypertension, angina, or arrhythmias, the amount of epinephrine injected with the LA should be reduced Oculocardiac reflex, See text for presentation and vasovagal reaction management Allergic reaction to Extremely rare with amide-type local LA anesthetics

Central nervous system complications of eye blocks may occur following a needle block by two different mechanisms: 1. An unintentional intraarterial injection may reverse the blood flow in the ophthalmic artery up to the anterior cerebral or the internal carotid artery so that an injected volume as small as 4 mL may produce seizures. Symptomatic treatment by maintaining patent airway; providing oxygenation; and abolishing seizure activity with small doses of benzodiazepam, propofol, or barbiturates, is usually adequate and results in a rapid recovery without sequelae. 2. An unintentional injection under the dura mater sheath of the optic nerve or directly through the optic foramenmay result in subarachnoid spread of the

LA.This causes partial or total brainstem anesthesia. Depending on the dose and volume of LA spreading toward the brainstem, a bilateral block; cranial nerve palsy with sympathetic activation, confusion, and restlessness; or total spinal anesthesia with tetra paresis, arterial hypotension, bradycardia, and eventually respiratory arrest can occur. Symptomatic treatment (oxygen, vasopressors, and, if required, tracheal intubation and ventilation) should permit complete recovery after the spinal block wears off (a few hours). Unintentional globe perforation and rupture is the most devastating complication of eye blocks. Injury to an extraocular muscle may cause diplopia and ptosis. Several mechanisms can be involved, including direct injury by the needle resulting in intramuscular hematoma, high pressure because of injection into the muscle sheath, or myotoxicity of the LA. The injury may progress in three steps: first, the muscle is paralyzed; second, it seems to recover; and third, a retractile scar develops
Direct optic nerve trauma by the needle is rare but causes blindness. Computed tomography imaging usually shows optic nerve enlargement caused by intraneural hematoma. Overall, there is a 13% chance of complications, often necessitating postponement of the planned surgery. Since some complications may be life-threatening if patients are not immediately resuscitated, it is recommended that an anesthesiologist be present and monitor the patient perioperatively.

Topical Anesthesia
Instillation of LA eye drops provides corneal anesthesia, thus allowing cataract surgery by phacoemulsification . It is quick and simple to perform and avoids the potential hazards of needle techniques. The technique is used in up to 50% of the cataract surgeries performed worldwide.1 Some surgeons prefer topical anesthesia for routine phacoemulsification in more than 90% of their cases; however, its effectiveness is limited. The lack of akinesia and intraocular pressure control, associated with its short duration, may make surgery hazardous. Therefore, use of topical anesthesia should be limited to uncomplicated procedures performed by experienced surgeons in cooperative patients. Whenever phacoemulsification is not possible, total akinesia is still required and topical anesthesia is questionable. Intraoperative comfort is more constantly obtained under retrobulbar or subTenons than under topical anesthesia. Topical anesthesia appears to be no more effective than no anesthesia in selected cases for an experienced surgeon. Intracameral injection of LA has been proposed to enhance analgesia. It consists of injecting small LA amounts (0.1 mL) in the anterior chamber at the beginning of, or during, surgery. Intracameral anesthetic needs to be preservative-free. Some concerns have been expressed about the toxicity effects of LA on corneal endothelium, which is unable to regenerate. The safety of intracameral injection seems acceptable in this regard but its analgesic benefit when compared with simple topical anesthesia has not been established. The insertion of sponges soaked in LA into the conjunctival fornices has been proposed. The use of lidocaine jelly instead of eye

drops seems to enhance the quality of analgesia of the anterior segment and is becoming very popular for improving the patients comfort under topical anesthesia.

Perilimbar (subconjuctival) Anesthesia

Subconjunctival injection of LA may provide analgesia of the anterior segment without akinesia. This technique is not popular.

Episcleral (sub-tenon's) blocks

Common Principle Episcleral (sub-Tenons) anesthesia, sometimes also called parabulbar anesthesia, places the injection into the episcleral space. This allows the LA to spread circularly around the scleral portion of the globe, ensuring high-quality analgesia of the whole globe with relatively low injected volumes (usually 35 mL). In addition, use of a larger volume (up to 811 mL) causes the LA to spread to the extraocular muscle sheaths, ensuring effective and reproducible akinesia. Needle Technique The needle is introduced into the fornix between the semilunaris fold of the conjunctiva and the globe, tangentially to the globe. After it has encroached the conjunctiva, the needle is slightly shifted medially and advanced strictly posteriorly, therefore attracting the globe and directing the gaze medially. After a small loss of resistance (click) is perceived, the globe comes back to its primary gaze position. This serves as a depth marker, thus indicating injection depth at 10 to 15 mm. The volume injected may be up to 10 mL, depending on the patients anatomy. Using a large volume with this technique (611 mL) results in good globe and eye lid akinesia that is more reproducible than classic peribulbar anesthesia. This technique is associated with a low risk of complications and it is simple to learn and use Surgical Approach This technique was first proposed as a supplement to (or rescue block) RBA. After topical anesthesia, the bulbar conjunctiva is grasped with a small forceps in the inferior and nasal, superior and nasal, or superior and temporal quadrant, 510 mm from the limbus. Small scissors are used to open a small opening into the conjunctiva

and Tenons capsule to gain access to the episcleral space. A blunt cannula is then inserted into the episcleral space to allow the injection. This technique is typically used with injection of low volumes of LA (35 mL). It provides good globe analgesia but only partial akinesia of the globe and lids. The injection causes only a minor increase in intraocular pressure, so that preoperative compression of the globe is typically unnecessary. In a similar way, episcleral injection of a small volume of LA may be used on an open globe; it is the technique of choice as an intraoperative supplemental injection when anesthetic technique appears insufficient during surgery. Increasing the injected volume (e.g., 11 mL) results in a good akinesia, allowing surgery of the posterior segment. The main advantage of this technique is its safety as it avoids blind introduction of the needle into the orbit.

Use of Eye Block For Postoperative Analgesia

All available LAs have been used for eye block, either alone or as a mixture of two different agents. The LAs used most often are lidocaine, bupivacaine, ropivacaine, mepivacaine, or a combination of two of these. The choice of LAs should be based on the pharmacologic properties and availability of the drugs, mainly depending on the requirement for a quick onset (lidocaine, mepivacaine), prolonged effect or postoperative residual block for analgesia (ropivacaine, bupivacaine), or akinesia (higher concentration). Because the amount of LA injected is usually small (311 mL), systemic toxicity is not a major concern. Hyaluronidase is an enzyme that has been proposed to hasten the onset and increase the success rate of regional anesthesia for the eye Clonidine enhances intra- and postoperative analgesia when added to the LA. At a dose of 1 mcg/kg, it does not increase the incidence of systemic adverse events such as hypotension or excessive sedation. Moreover, it may help to prevent intraoperative arterial hypertension and lower intraocular pressure. Epinephrine is sometimes used to increase the duration of eye block. However, the availability of long-acting LAs has decreased its value. Fear of vasospasm and subsequent retinal ischemia is probably not justified because the LA mixture does not spread inside the globe where retinal arteries are located.

Perioperative Management
Eye surgery (e.g., cataract surgery) carries a low risk of perioperative morbidity and mortality. Eye block is associated with lower perioperative morbidity than is general

anesthesia used for ophthalmic surgery, provided that heavy sedation is avoided. Intraoperative monitoring should include basic monitoring (ie, electrocardiogram, pulse oximetry, and automated noninvasive blood pressure measurement). An intravascular access is required. Older patients undergoing eye surgery frequently have coexisting diseases such as diabetes mellitus, hypertension, coronary artery disease, or cardiac insufficiency. A preoperative assessment should be routinely done to ensure that coexisting medical conditions are reasonably well controlled.