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INTRODUCTION

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Ophthalmic surgery is one of the most common surgical procedures requiring anesthesia in developed countries.1 Ophthalmic anesthesia offers insights into some fundamental principles of good anesthetic practice, especially in the conduct of local and regional blocks.

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LOCAL ANESTHESIA IN EYE SURGERY

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Clinical strategies to minimize patient movement during eye surgery are essential. Historically, eye surgeons favored general anesthesia (GA), which usually provided akinesia (through neuromuscular blockade) and low intraocular pressure. However, these conditions are not always achieved under GA. A closed-claims analysis by Gild and coworkers2 found that 30% of eye injury claims associated with anesthesia involved the patient moving during ophthalmic surgery, with most incidents occurring under GA. While perioperative morbidity and mortality rates associated with eye surgery (eg, cataract extraction) are low,3,4 patients having cataract surgery tend to be older and to have significant comorbidities.5,6,7,8,9,10 For this reason, systematic preoperative evaluation should be performed to consider whether a patient is eligible for a GA and surgery.10

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Appropriate anesthetic management contributes to the success or failure of ophthalmic surgery. Quicker patient rehabilitation and fewer complications in this patient population are the main reasons why many ophthalmic surgeons are now choosing local anesthesia (LA) over GA.11,12,13

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Traditionally, the gold standard of eye blocks was retrobulbar anesthesia (RBA), with the surgeon performing the block. However, advances in technology and surgical technique, particularly in cataract surgery, have led to the replacement of the older wide-incision techniques (eg, extra-capsular cataract extraction) with minimally invasive phacoemulsification (PhE) techniques. Consequently, for new generation of cataract surgeons, total akinesia is no longer necessary for PhE.

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Clinical Pearls

  • Twenty-first century innovations and trends have revolutionized eye surgery.

  • Local and regional anesthetic techniques has largely replaced general anesthesia.

  • Understanding functional anatomy and surgical techniques is essential for selection of regional techniques.

  • Sub-Tenon’s block is one of the most common choices for anesthesia as it can generally achieve akinesia with the favorable safety profile.

  • Topical anesthesia, is increasingly becoming most prevalent for cataract surgery.

  • Complications of eye blocks are uncommon but can be life- or sight-threatening, emphasizing the need of adequate training.

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Innovation has also broadened the anesthetic options for eye surgery. As the conventional RBA carries a greater risk of complications, less invasive techniques have increasingly been used, with a substantial diversity in practice styles around the world. For instance, one Australian study from 2002 reported that peribulbar block was the most popular among an international sample of ophthalmic surgeons.14 However, a 2006 survey found that 64% of a sample of UK anesthetists favored the sub-Tenon’s technique,15 and, by 2008, a survey of the British Ophthalmic Anaesthesia Society found that over 87% of anesthesiologist members regularly performed sub-Tenon’s blocks.16 On the other hand, an annual survey ...

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