Background: To compare the efficacy of topicalanaesthesia with peribulbar anaesthesia inphacoemulsification.Method: This comparative analytical study wasconducted in the Department of Ophthalmology, FaujiFoundation Hospital, Rawalpindi, from February 2006 toJanuary 2007. A total of 200 patients who underwentphacoemulsification with intraocular lens (IOL)implantation were included in this study. Patients wererandomly assigned to peribulbar group (group 1, n=100)who received 4-5 ml of local anaesthetic (equal quantitiesof 2% xylocaine and 0.5% bupivacaine) in peribulbarregion and topical group (group 2, n=100) using 0.5%proparacaine in conjunctival sac every 5 minutes for halfan hour before surgery. Patients refusing informedconsent, having communication problem and nystagmuswere excluded from the study. All surgeries wereperformed by the same surgeon.Results: The difference between two groups regardinganalgesia was found to be statistically insignificant.Periocular group provided significant akinesia.Conclusion: Topical anaesthesia is an effectivealternative to peribulbar anaesthesia forphacoemulsification reducing the risks associated withperibulbar injection

Badar- ud-din Athar Naeem , Abrar Raja, Rabia Bashir , Shahzad Iftikhar , Khawaja Naeem Akhtar , Rasheed Hussain Jaffri , Mustafa Kamal Akbar , Badar- ud-din Athar Naeem , Abrar Raja, Rabia Bashir , Shahzad Iftikhar , Khawaja Naeem Akhtar , Rasheed Hussain Jaffri , Mustafa Kamal Akbar

Background: To compare the efficacy of topicalanaesthesia with peribulbar anaesthesia inphacoemulsification.
Methods: This comparative analytical study wasconducted in the Department of Ophthalmology, FaujiFoundation Hospital, Rawalpindi, from February 2006 toJanuary 2007. A total of 200 patients who underwentphacoemulsification with intraocular lens (IOL)implantation were included in this study. Patients wererandomly assigned to peribulbar group (group 1, n=100)who received 4-5 ml of local anaesthetic (equal quantitiesof 2% xylocaine and 0.5% bupivacaine) in peribulbarregion and topical group (group 2, n=100) using 0.5%proparacaine in conjunctival sac every 5 minutes for halfan hour before surgery. Patients refusing informedconsent, having communication problem and nystagmuswere excluded from the study. All surgeries wereperformed by the same surgeon.
Results: The difference between two groups regardinganalgesia was found to be statistically insignificant.Periocular group provided significant akinesia.
Conclusion: Topical anaesthesia is an effectivealternative to peribulbar anaesthesia forphacoemulsification reducing the risks associated withperibulbar injection

Journal of Rawalpindi Medical College

Journal of Rawalpindi Medical College (JRMC); 2007;11(2):  79 Comparison  of  Peribulbar  Vs  Topical Anaesthesia  for  Phacoemulsification   Badar- ud-din Athar Naeem , Abrar Raja, Rabia Bashir , Shahzad Iftikhar , Khawaja Naeem Akhtar , Rasheed Hussain Jaffri , Mustafa Kamal Akbar  Department  of Ophthalmology ,Foundation University Medical College , Rawalpindi.   Abstract  Background: To compare the efficacy of topical anaesthesia with peribulbar anaesthesia in phacoemulsification.   Method: This comparative analytical study was conducted in the Department of Ophthalmology, Fauji Foundation Hospital, Rawalpindi, from February 2006 to January 2007. A total of 200 patients who underwent phacoemulsification with intraocular lens (IOL) implantation were included in this study.  Patients were randomly assigned to peribulbar group (group 1, n=100) who received 4-5 ml of local anaesthetic (equal quantities of 2% xylocaine and 0.5% bupivacaine) in peribulbar region and topical group (group 2, n=100) using 0.5% proparacaine in conjunctival sac every 5 minutes for half an hour before surgery. Patients refusing informed consent, having communication problem and nystagmus were excluded from the study. All surgeries were performed by the same surgeon.   Results: The difference between two groups regarding analgesia was found to be statistically insignificant. Periocular group provided significant akinesia.   Conclusion: Topical anaesthesia is an effective alternative to peribulbar anaesthesia for phacoemulsification reducing the risks associated with peribulbar injection.  Key Words: Phacoemulsification, anaesthesia, analgesia, akinesia.  Introduction      Retrobulbar block remained popular for ages. But each time with a needle introduced into the orbit there is definite risk of complications1. Since 1986, peribulbar anaesthesia has replaced retrobulbar as a safe and effective method of block2. However injection related complications such as orbital bleeding, ocular perforation, optic nerve trauma, intra vascular injection of anaesthetic agent and extra ocular muscle dysfunction have been reported3. Although these blocks provide excellent anaesthesia but risk of vision threatening and even life threatening complications is always there4. These complications can be avoided by using topical anaesthesia5.  Topical anaesthesia is not new. In 1984, Knapp described the use of cocaine eye drops6. Advances in the techniques of phacoemulsification, self sealing incisions and foldable IOLs renewed interest in topical anaesthesia. Fichman reported the use of topical anaesthesia for the first time for modern cataract extraction in 1927. Since then the use of this technique has increased tremendously. Our goal was to study the difference between peribulbar and topical anaesthesia for cataract surgery.      Patients and Methods   A total of 200 patients were included in this study. They were conveniently assigned to either the peribulbar group (group 1, n=100) or topical group (group 2, n=100). The patients in group 1 received 4-5 ml of local anaesthetic (equal quantities of 2% xylocaine and 0.5% bupivacaine) into the peribulbar space with 1 inch 25 gauge needle. In group 2, 0.5% proparacaine eye drops were instilled every 5 minutes half an hour before surgery. No sedation was given. All of the patients under went phacoemulsification with IOL implantation. A four point verbal pain scale was used for analgesia. Patients were asked to grade the pain during different stages of surgery. Akinesia  Correspondence: Dr. B.A. Naeem Associate Professor (Eye) Foundation University Medical College, Rawalpindi Journal of Rawalpindi Medical College (JRMC); 2007;11(2):  80 was also assessed on four point scale as depicted:                                      Inclusion Criteria  Patients with senile cataract  Exclusion Criteria  Patients refusing informed consent  Patients with communication difficulty  Patients suffering from dementia  Patients with nystagmus  Patients unable to understand pain scale  Patients with hazy cornea All surgeries were done by same surgeon to avoid inter-observer bias. Convenient sampling of patients was done in order to avoid bias in selection. The data was analyzed by SPSS version 10. Standard errors and standard deviation for all variables were calculated, where necessary. Data of anaesthesia and akinesia was compared between two groups using chi square test.   Table 1: Descriptive Statistics for Group 1 (Peribulbar) and Group 2 (Topical)  (n=200) Means and Standard Deviation  Group 1 Group 2  Min Max Mean SD Min Max Mean SD Age 40 86 62.32 12.67 42 87 62.08 13.48 Akinesia 0 3 0.69 0.84 0 3 2.21 0.70 Analgesia 0 3 0.56 0.64 0 3 0.78 0.85  Results  The descriptive data for akinesia and analgesia for all subjects is given in Table 1. The relationship of akinesia with peribulbar and  topical anaesthesia is given in Table 2 whereas relationship of analgesia between two groups is shown in Table 3. In Group 1, there were 26 % males and 74% females while Group 2 comprised 21% males and 79%females. Table 2: Relationship of Akinesia between Group 1 (Peribulbar) and Group 2 (Topical) Anaesthesia (n=200) Akinesia Values  Group 1 Group 2 Cumula-tive No Movement (0) 51 2 53 Slight Movement (1) 34 14 48 Moderate Movement (2) 14 47 61 Full Movement (3) 1 37 38 Total 100 100 200 Chi Square Value = 1432.63        p < 0.005  Table 3: Relationship of Analgesia between Group 1 (Peribulbar) and Group 2 (Topical) Anaesthesia (n=200) Analgesia Values  Group 1 Group 2 Cumulative No Pain (0) 52 46 98 Slight Pain (1) 40 45 85 Moderate Pain (2) 6 5 11 Severe Pain (3) 2 4 6 Total 100 100 200 Chi Square Value = 3.484       p = 0.323  In group 1, 51% of patients had no movements whereas only 2% patients had no movements in group 2. 34 % patients with periocular anaesthesia exhibited slight movements whereas 14% patients of topical anaesthesia had slight movements. 14% patients had moderate and only 1% had full movements in periocular group. 47% of patients in topical group showed moderate movements and 37% exhibited full movements. Mean value for akinesia in group 1 was 0.69 with SD 0.84, and the mean for akinesia in group 2 was 2.21 with SD 0.78. The chi-square value came out to be 1432.63 with p value of less than 0.005 which is statistically significant.   52% of patients in group 1 and 46% in group 2 did not feel any pain. Mild pain was felt by 40% patients in group 1 and 45% of group 2. 6% patients of periocular and 5% patients of topical anaesthesia  3Journal of Rawalpindi Medical College (JRMC); 2007;11(2):  81 group had moderate pain. Severe pain was felt by only 2% patients of group 1 and 4% of group 2. Mean for analgesia in periocular group was 0.56 with SD 0.64, whereas mean value for analgesia in topical group was 0.78 with SD 0.85. The chi-square value was 3.484 with p value of 0.323 which is statistically insignificant.  Discussion  Complications of retrobulbar and peribulbar anaesthesia are numerous. Ptosis, conjunctival or eyelid bruising, orbital hemorrhage, globe perforation, optic nerve damage, CRVO, CRAO, brain stem anaesthesia and even death have been reported 8-12. Topical anaesthesia eliminates these risks and has several other benefits like:   The return of vision is more rapid.   It is less costly.  Patients can have surgery without discontinuation of systemic anticoagulants or aspirin.  There is more patient satisfaction13. The main disadvantage of topical anaesthesia is lack of akinesia which can make surgery technically difficult. But with good patient selection, proper counseling and patient cooperation this problem can be avoided. During capsulorrhexis, the patient should be asked to particularly keep the eyes still. However during phacoemulsification and irrigation and aspiration, the instruments placed in the main tunnel and side port incisions immobilize the eye. It is best to slightly lower the bottle height while inserting the phaco tip because this can cause less stretch on zonules due to posterior lens migration. This might cause pain as ciliary body is not anesthetized.  The surgeon should avoid touching iris, especially during IOL implantation. This can be achieved by having widely dilated pupil. As patients with topical anaesthesia are more sensitive to IOP elevation after surgery, we recommend careful and complete viscoelastic removal.  Pain killers and acetazolamide tablet after surgery would minimise pain and maintain IOP. Up till now we have mostly been able to achieve these goals with good patient satisfaction.   The key to successful cataract surgery  with topical anaesthesia is surgeon-patient communication. Patients with hearing or language problems or dementia are poor candidates.  In our study there was no statistically significant difference in pain between the two groups. No significant difference in duration of surgery was noted. The ocular movements were quite marked in topical group and the difference was statistically significant, but mobility , is not a problem for experienced surgeons especially if the patients are also cooperative.  Our study confirms the results of Agarwal , who has evaluated topical anaesthesia and found it a technique of choice in small incision cataract surgery14. Similarly, Saunder and Jonas did not find significant difference between two techniques in terms of subjective pain experienced by 140 patients15. They recommended more frequent use of topical anesthesia. Similar equality between two techniques has been observed by many other investigators16,17.   Jacobi PC and Dietleim have gone a step ahead in evaluating the efficacy and usefulness of topical anaesthesia in complicated cataract surgery18. They recommend the use of topical anaesthesia  even in coexisting ophthalmic diseases like  glaucoma, uveitis and patients with previous intraocular surgeries. Topical anaesthesia is  justified as a means of improving safety without causing discomfort to the patients even in complicated cases. Roman and Auckin have demonstrated that overall, 62.2% patients preferred topical over peribulbar anaesthesia, citing lack of periocular injection as a reason18. Similar superiority of topical anaesthesia over peribulbar anaesthesia has been demonstrated in many other studies19.  Our results are contrary to the findings of Lindely, who found that patients experience more pain with topical anaesthesia as compared to peribulbar anaesthesia20. Many authors report the same findings21.   For a trained surgeon, complications of topical anaesthesia are neither more frequent nor more difficult to manage. If topical anaesthesia proves to be inadequate in any case, the self sealing incision allows safe intra operative conversion to peribulbar or subtenon anesthesia.   In our study supplemental paraocular anaesthesia was required in four cases of topical anaesthesia group.   Conclusion  Topical anaesthesia is an effective and reliable method for phacoemulsification. It has many benefits over retrobulbar and peribulbar anaesthesia and a high level of patient satisfaction. The  technical difficulty as a result of eye mobility is  not a problem for the surgeons experienced  Journal of Rawalpindi Medical College (JRMC); 2007;11(2):  82 in this technique. As trend of less invasive  cataract surgery is rapidly growing, topical anaesthesia should replace the other methods of anaesthesia in most cases.  References  1. Davis BD, Mandel MV. Efficacy and complication rate of 16224 consecutive peribublar blocks. A prospective multicentric study. J Cataract Refract Surg 1994; 20:327-37. 2. Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986; 12:182-84 3. Hamilton RC, Grizzard WS. Complications in : Gills JP, Hustead RF, Sanders DR, Eds, Ophthalmic Anesthesia. Thotofare, NJ, Slack Inc, 1993; 187-202. 4. Fichman RA, Hoffman J. Anaesthesia for cataract surgery and its complications. Curr Opin Ophthalmol 1994:5 (1); 21-27. 5. Kershner RM. Topical anaesthesia for small incision  self sealing cataract surgery: A prospective evaluation  of 100 patients. J cataract Refract Surg 1993; 19: 290-92.  6. Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol (old series) 1884; 13: 402-48. 7. Fichman RA. Topical eye drops replace injection for anesthesia. Ocular Surgery 1992; 3: 20-21.  8. Alpar JJ. Acquired ptosis following cataract and glaucoma surgery. Glaucoma 1982; 4: 66-68. 9. Pwstjarvi T, Purhonen S. Permanent blindness following retrobulbar hemorrhage after peribulbar anaesthesia for cataract surgery. Opthalmic Surg 1992; 23: 450-52. 10. Duker JS, Belmont JB, Benson WE Inadvertent globe perforation during retrobulbar and peribulbar anesthesia; patient characteristics, surgical management and visual outcome. Ophthalmology 1991; 98: 519-26. 11. Klein ML, Jampol LM and Condon PL. Central artery occlusion without retrobulbar hemorrhage after retrobulbar anesthesia. AMJ Ophthalmol 1982; 93: 573-77. 12. Javitt JC, Addigo R and Friedberg HL. Brainstem anaesthesia after retrobulbar block. Ophthalmology 1987; 94: 718-23. 13. Roman S, Auclin F and Ullern M. Topical versus peribulbar anaesthesia in cataract surgery. J Cataract Refract  Surg 1996; 22: 1121-44.  14. Agarwal S, Agarwal A, Agarwal A, Indumathy TR and  Agarwal S. No injection, no stitch, no pad cataract surgery technique. Pak J Ophthalmol 1998; 14: 22-27. 15. Sauder G and Jonoas JB. Topical versus peribulbar anaesthesia for cataract surgery. Acta Ophthalmologica Scandinavica 2003; 81(6): 596. 16. Randleman JB, Srivastava SK and Aqrom MM. Phacoemulsification with topical anaesthesia performed by resident surgeons. J Cataract Refract Surg 2004;30:149-54. 17. Johnston RL, Whitefield LA, Giralt J, Harrun S, Akerele T, Bryan SJ,et al.Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification.J Cataract Refract Surg 1998;  24: 407-10. 18. Jacobi PC, Dieltein TS and Jacobi FK. A comparative study of topical versus retrobulbar anaesthesia in complicated cataract surgery. Arch Ophthalmol 2000; 118: 1037-43. 19. Maclean H, Burton T and Murray A. Patient comfort during cataract surgery with modified topical and peribulbar anesthesia. J Cataract refract Surg 1997; 23: 277-83. 20. Lindley-Jones MF. Topical anaesthesia for phacoemulsification surgery. Clinical Experiment Ophthalmol 2000; 28: 287-89. 21. Virtanem P and Buha T. Pain in scleral pocket incision cataract surgery using topical and peribulbar anesthesia. J Cataract Refact Surg 1998; 24: 1609-13.  

Comparison of Peribulbar Vs Topical Anaesthesia for Phacoemulsification

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Journal of Rawalpindi Medical College