Regional Anesthesia as an Adjunct to Eyelid Surgery

Elizabeth Giuliano, DVM, MS Diplomate, ACVO

Local Anesthesia
Produce desensitization and analgesia of local tissues May be used as an adjunct to intravenous and inhalation anesthesia My personal uses in ophthalmic surgery:
Enucleation Eyelid surgery Canthoplasty, entropion/ectropion, wedge resection, laceration repair Especially helpful in entropion repairs where anatomic component is minimal but spastic component great Post-operative cataract patient IOP checks where canthotomy was performed Lidocaine + Bupivicaine

Local Anesthesia - Drugs

Chemical Group:
Amide (lidocaine, mepivicaine, bupivicaine)
Reversible depression of nerve conduction by blocking sodium channels Prevents rapid influx of sodium ions into nerve axon and production of action potential local muscle paralysis and analgesia Metabolized by the liver

Esters (procaine, cocaine, chloroprocaine, tetracaine)

Metabolized by enzyme called p-aminobenzoic acid Caution in patients with reduced cholinesterase activity (newborn, pregnant)

Local Anesthesia - Toxicity

Toxicity:
CNS
Most common in areas with large blood vessels (i.e. epidurals) CNS toxicity (e.g. seizures) usually occur before cardiovascular toxicity Tx: diazepam for seizures & oxygen/supportive measures until drugs metabolized

Cardiovascular arrhythmias, vasodilation, hypotension, cardiac arrest Wound healing delayed with large volumes

Local Anesthesia - Toxicity

Do not exceed toxic dose
Lidocaine (Abbott Laboratories, other sources also available)
Rapid onset (2 minutes) Short duration of action (20 minutes 2 hours)
Can be prolonged by addition of epinephrine at 1:200,000 or 1:400,000

Toxic IV dose: 10-20 mg/kg ( I use 5 mg/kg ) Bupivicaine (Marcaine, Abbott Laboratories)
Slow onset (3-6 minutes) Long duration of action (4-6 hours)
Can be prolonged by addition of epinephrine at 1:200,000 or 1:400,000

Toxic dose: 2-3 mg/kg ( I use 1.5 mg/kg )

How much? Examples:

Weight vs Dose
Lidocaine
(5 mg/kg) * 2%=20 mg/ml

5 kg
25 mg 1.25 ml 7.5 mg 1.5 ml 1 ml

10 kg
50 mg 2.5 ml 15 mg 3 ml 2 ml

30 kg
150 mg 7.5 ml 45 mg 9 ml 6 ml

Bupivicaine
(1.5 mg/kg) * 0.5%=5mg/ml 0.75%=7.5 mg/ml

Enucleation Surgery
Retrobulbar block (JAVMA paper) Regional eyelid infusion & splash block

Local Anesthesia Retrobulbar Block

Development of a retrobulbar injection technique for ocular surgery and analgesia in dogs. Accola PJ, Bentley E, Smith LJ, et al. J Am Vet Med Assoc. 2006 Jul 15;229(2):220-5. OBJECTIVE: To develop and compare 3 techniques for retrobulbar injection of local anesthetic agents for ocular surgery and analgesia in dogs. DESIGN: Prospective study. ANIMALS: 17 dogs (including 9 cadavers).

Local Anesthesia Retrobulbar Block

Development of a retrobulbar injection technique for ocular surgery and analgesia in dogs. Accola PJ, Bentley E, Smith LJ, et al. J Am Vet Med Assoc. 2006 Jul 15;229(2):220-5.

PROCEDURES: Inferior-temporal palpebral (ITP), perimandibular, and combined superior-inferior peribulbar injection techniques were compared by assessing the distribution of latex after injection into the orbits of 5 canine cadavers;

Development of a retrobulbar injection technique for ocular surgery and analgesia in dogs. Accola PJ, Bentley E, Smith LJ, et al. J Am Vet Med Assoc. 2006 Jul 15;229(2):220-5.

PROCEDURES: magnetic resonance imaging (MRI) evaluation of the distribution of contrast agent after injection in the retrobulbar space of 4 canine cadavers; & assessment of the efficacy and MRI evaluation of the anatomic distribution of injections of a lidocaine contrast agent mixture in 4 anesthetized, nonrecovery dogs.

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Development of a retrobulbar injection technique for ocular surgery and analgesia in dogs. Accola PJ, Bentley E, Smith LJ, et al. J Am Vet Med Assoc. 2006 Jul 15;229(2):220-5.

PROCEDURES: By use of the preferred technique (ITP), the ocular effects of lidocaine anesthesia were evaluated in 4 dogs; during a 2-week period after treatment, dogs underwent ophthalmic examination, Schirmer tear testing (STT), intraocular pressure (IOP) measurement, and CochetBonnet esthesiometry.

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Development of a retrobulbar injection technique for ocular surgery surgery and analgesia in dogs. Accola PJ, Bentley E, Smith LJ, et al. J Am Vet Med Assoc. 2006 Jul 15;229(2):22015;229(2):220-5.

RESULTS: Of the 3 techniques, the ITP technique was the preferred method for because it was efficacious (pupil dilation and central rotation of the globe achieved in all eyes), easiest to perform, and provided thorough coverage of the intraconal retrobulbar space without complication. During the 2-week follow-up period, the ITP injection did not significantly affect STT, IOP, or Cochet-Bonnet esthesiometry values in dogs.

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Development of a retrobulbar injection technique for ocular surgery surgery and analgesia in dogs. Accola PJ, Bentley E, Smith LJ, et al. J Am Vet Med Assoc. 2006 Jul 15;229(2):22015;229(2):220-5.

CONCLUSIONS AND CLINICAL RELEVANCE: In dogs, retrobulbar administration of anesthetic agents via the ITP technique is a potential alternative to systemic administration of neuromuscular blocking agents for ophthalmic surgery and provides the additional benefit of local ocular analgesia. *** TF Evans, PD da Costa. Medial Peribulbar (MPB) Nerve Block for Corneal and Intraocular Surgery in the Dog. ACVO 37th Annual Conference, 2006, Proceedings pg 1

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Enucleation Surgery
Retrobulbar block (JAVMA paper) Regional eyelid infusion & splash block

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Enucleation Surgery

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Annabella, 2 y.o. Shar Pei with entropion OU

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Annabella, 2 y.o. Shar pei with entropion OU, intra-op

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Annabella, 2 y.o. Shar pei with entropion OU, intra-op

Small gauge needle: 25 or 27

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5 hours post-op
Repaired via an upper and lower Hotz-Celsus, arrow-head modification and lateral canthal tendonotomy OU

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5 hours post-op
Useful space occupying effect for spastic component Important to keep ocular surface well lubricated

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