Original article contributed

Namrata Bhuta, MD, Sujata Sanjay Chahande

by:
All contributors: Brad H. Feldman, M.D. and Namrata Bhuta, MD
Assigned editor:
Assigned status Up to Date by Namrata Bhuta, MD on May 31,
Review:
2015.

Introduction [edit source]

Ophthalmic surgery has been performed under a wide range of anaesthetic techniques . The
type of anaesthesia for each ophthalmic surgery depends on a large number of factors like
patient co-operation , the nature of the surgery and surgeon’s preference. Over the years ,
ocular anaesthesia has evolved tremendously , with topical anaesthesia (which was first used in
1884) making a comeback in the last few years. In this article we are going to review the various
types of anaesthesia used during ophthalmic surgeries, their techniques and their possible
complications.

Background [edit source]

Carl Koller first used cocaine as a topical anaesthetic for eye surgery in 1884. Later that year,
retrobulbar anaesthesia was introduced with Cocaine by Knapp. The year 1904 turned out to be
a landmark year for ocular anaesthesia with the development of procaine for retrobulbar
anaesthesia. It was Einborn who synthesized procaine and led to its worldwide acceptance in
retrobulbar anaesthesia. Peribulbar anaesthesia was discovered late in the 1980s by Dr David
and Mandal. The more recent drift is again towards topical anaesthesia, which has steadily
increased with the advent of modern phacoemulsification cataract extraction.

Objectives [edit source]

1. Akinesia of the globe and lids

2. Anaesthesia of the globe, lids and adnexa
3. Adequate postoperative analgesia
FIG 1. Anatomy of the Orbit showing the intraconal compartment of the eye.

Clinical anatomy [edit source]

Extraocular muscles [edit source]

The origin of recti muscles from the Annulus of Zinn and their attachment to the globe forms a
cone around the globe. The intraconal components include the optic nerve , ophthalmic artery
and vein , 3rd ,6th and nasociliary nerves and ciliary ganglion . Blocking the motor components
causes akinesia , blocking the sensory nerves causes anaesthesia . The retrobulbar anaesthesia
is injected in this intraconal compartment. Peribulbar anaesthesia is injected in the extraconal
compartment and hence is considered safer since it avoids potential damage to the intraconal
structures.

Nerve supply [edit source]

In order to understand various types of anaesthesia used in ophthalmic surgery, it is important to

understand the nerve supply of the eye and its adnexa.

Motor supply [edit source]

The occulomotor nerve supplies all the extraocular muscless (except the superior oblique and
and the lateral rectus muscle) and levator palpebrae superiors . The trochlear nerve supplies the
superior oblique whereas the abducens nerve supplies the lateral rectus muscle. The trochlear
nerve lies outside the muscle cone and hence is not usually blocked .

Sensory supply [edit source]

The trigeminal nerve is divided into the ophthalmic branch (further divided into nasociliary,
lacrimal, and frontal branches) . The nasociliary branch supplies the cornea, perilimbal
conjunctiva and the superonasal quadrant of bulbar conjunctiva. The rest of the conjunctiva is
supplied by the lacrimal, infraorbital, and frontal nerve.
FIG 2. Akinesia of the right eye in all directions after instillation of Retro/Peribulbar Block as
compared with the left eye .

Classification of anaesthetic
technique [edit source]

Techniques of anaesthesia [edit source]

Local anaesthesia[edit source]

Infiltration anaesthesia[edit source]

It is indicated for procedures involving more than superficial manipulations of the eye and its
adnexa.
It is contraindicated in uncooperative patients and in presence of an infected field .

Retrobulbar anaesthesia[edit source]

In this technique the anaesthetic solution is injected into the intraconal compartment of the eye.

Method: After preparation of the skin, a 23G needle with 3-5 ml of anaesthetic solution is
introduced intradermally at inferior temporal margin of the orbit, at the junction of lateral 2/3rd
and medial 1/3 rd of orbital margin. The needle is then directed superiorly and medially to enter
the tenon’s capsule between the lateral and inferior rectus muscles. Once the needle has
reached the retroorbital space , the syringe is aspirated to ensure that no blood vessel has been
entered and the anaesthetic is injected. Immediately following this injection superpinky ((a
pressure device) is placed on the eye for 10-15 minutes . Intermittent pressure with superpinky
should be given to prevent occlusion of vessels..

Complications:
Advantages and disadvantages of retrobulbar

anaesthesia

Peribulbar anaesthesia[edit source]

In this procedure, the anaesthetic is injected into the extraconal compartment of the eye. Thus ,
most of the complications associated with retrobulbar anaesthesia are avoided.

Hence, it is a much safer, equally efficient and less painful anaesthesia.

Technique: This technique involves giving two injections of long acting anaesthetic at least 20
minutes before the surgery. The first injection is given inferiorly with a 23 g needle at the junction
of outer one third and inner two third of the lower orbital rim(5cc). The second injection is given
superonasally beneath the superior orbital notch(3cc). Immediately following this injection
superpinky is placed on the eye for 10-15 minutes. Intermittent pressure with superpinky should
be given to prevent occlusion of vessels.
Subconjunctival anaesthesia[edit source]

Can be utilized in almost every operation on the eyeball. However it should not be used in the
presence of infection.

In this technique, a sharp 26 G needle mounted on a syringe is introduced subconjunctivally and

the anaesthetic solution is injected beneath the bulbar conjunctiva at variable distance from
limbus.

Subtenon infiltration anaesthesia:[edit source]

The tenon’s capsule is the anterior extension of the visceral layer of the Dura. It fuses with the
conjunctiva about 2-3 mm away from the limbus.

Thus 2-3 mm beyond the limbus region the subtenon's space is continuous with the retrobulbar
space. Anaesthetic injected in this space reaches the retrobulbar space. This the mechanism of
action of subtenon's block.

In this technique, forceps are used to elevate the conjunctiva and tenon’s capsule and the
needle is directed posteriorly and anaesthetic is injected in the subtenon’s space between the
tenon’s capsule and sclera in the equatorial region of the superotemporal quadrant of the
eyeball. This results in blocking of the ciliary nerves.

Intracameral anaesthesia:[edit source]

 Intracameral anaesthesia is instilled by injecting non preserved 1% lignocaine (lidocaine) in the
anterior chamber through paracentesis or side port incision. It anaesthetises the iris and the
ciliary body and hence reduces pain and IOP fluctuations during small procedures like IOL
redialling. The drug must be washed after 15-30 seconds by irrigation through viscoelastics or
basal salt solution as it may reach the retina and cause gradual decrease in vision.

Nerve blocks [edit source]

Facial nerve blocks [edit source]

To prevent the squeezing action of eyelids during cataract extraction, temporary paralysis of the
orbicularis oculi muscle is affected by blocking the facial nerve, by one of the following methods
of Facial block:

1. Van Lint's block

 In this method, only the terminal branches of facial nerve are blocked, thus avoiding total facial
paralysis. A 23 g needle with anaesthetic solution is placed subcutaneously posterior to the
intersection of horizontal line along the most inferior margin of the orbit and a vertical line along
the most lateral margin of the orbit. The anaesthetic solution is then injected superiorly and
inferiorly in a V shaped pattern.
2. O' Brien's block
 It is also known as facial nerve trunk block. The block is done at the level of the neck of the
mandible near the condyloidprocess just anterior to the tragus of the ear. This offers more
complete akinesia .
3. Atkinson's block
 This was introduced to overcome the disadvantage of Van Lint and O’Brien’s block. Van
Lint causes ballooning and distortion of the lids and ocular adnexa while that of O’Brien
produces postoperative pain at site of anaesthesia . The superior branch of the facial nerve is
blocked by injecting the anaesthetic solution at the inferior margin of zygomatic bone
subcutaneously with a 23g needle .Firm pressure is then applied to produce a more rapid and
complete block.
4. Nadbath block
 In Nadbath block, the facial nerve is blocked at the stylomastoid foramen. It involves blocking of
the facial nerve as it emerges from the stylomastoid foramen and before it enters the parotid
gland. The patient is likely to experience pain.
5. Spaeth block:
 Injection is given proximal to classic approach of O’Brien over the mandibular condyle, thus
catching the facial nerve before it divides.

Blocking of other nerves [edit source]

 Infratrochlear nerve block

 The infratrochlear nerve supplies branches to the skin, conjunctiva, and eyelids near the medial
canthus. Its nerves run to the caruncle, lacrimal sac and nose. It has to be blocked in all lacrimal
apparatus operation.

About 1 ml of anaesthetic is injected against the bony orbital wall just below the trochlea in the
superomedial angle of the orbit.

 Supraorbital nerve block

The supraorbital notch or the foramen is located by palpation and 1ml of anaesthetic solution is
injected into the supraorbital notch or the foramen.

 Lacrimal nerve block

1 ml of anaesthetic solution is injected just above the zygomaticofrontal suture above the
tubercle of the zygomatic bone.

 Infraorbital and zygomatic nerve

The needle is introduced through the skin below the middle third of the lower lid 1 cm below the
orbital rim and 1ml of anaesthetic solution injected.

Topical anaesthesia [edit source]

In the last few years the shift in anaesthesia in ophthalmic surgery has been towards topical
anaesthesia. Cataract surgeries have now become sutureless with the advent of
phacoemulsification and rapid visual rehabilitation is expected. Topical agents like 0.5 %
proparacaine are used to anaesthetise the nerves. All the complications associated with orbital
injections can be avoided. It is the ideal choice for same day surgery, where patients can be
immediately discharged post operatively. However, the anaesthesia is limited to conjunctiva,
cornea and anterior sclera. The iris and ciliary body are not anesthetized. Reliance on patient
cooperation along with epithelial toxicity is a key disadvantage in the use of topical anaesthesia.

General anaesthesia [edit source]

Indications for g.a. in ophthalmic surgery[edit source]

 Extensive operation in which local anesthesia is impractical

 Operations on patients who may prove uncooperative during local anesthesia
 Children
 Psychosis or poor comprehension
 Deaf
 Operation on infected fields where local anesthesia is contraindicated

Whereas general anaesthesia gives complete control over the patient and avoids the
 complications of an orbital injection, there is increased nausea, vomiting , cardiovascular and
pulmonary stress.

Most G.A drugs reduce IOP except ketorolac and succinylcholine .

Build up of gases like carbon dioxide intraocularly during G.A. may cause expulsion
of intraocular contents. Gases used during vitrectomy and retinal detachment may interact with
nitrous oxide used for G.A

Anaesthetic solutions [edit source]

Local anaesthestics are combined with various other drugs like adrenaline and hyaluronidase in
order to enhance their effects or supplement their actions.

 Lignocaine (lidocaine) 2% - 4% : Fast onset of action and effects last for an hour.
 Bupivacaine 0.5% - 0.75% : slow onset of action but lasts for 3-4hrs
 Hyaluronidase (7.5 units/ml) helps facilitate spread of anaesthetic through tissues by increasing
permeability of fibrous septa . It improves the speed of onset and quality of nerve block.
 Adrenaline (1:1,00,000) helps in slower absorption of anaesthetic and longer action of
anaesthetic. It also reduces the incidence of haemorrhages and of intraoperative vitreous bulging
. However, adrenaline in very high doses causes toxic effects to macula and also central retinal
artery spasm..
 Small amount of 8.4 % sodium bicarbonate is added to raise the pH of the commercially
available solution (because with increased pH, the amount of drug present in base form is
increased which promotes more effective nerve block , less burning and also shortens onset
time).

Each anaesthetic technique comes with its unique set of advantages and disadvantages . The
decision for the type of anaesthesia should be made after taking into consideration all these
factors including the duration of anaesthesia, patient cooperation, type of surgery and surgeon's
preference.

References [edit source]

1. Comparison of different techniques of Anaesthesia by Dr. Sujata Chahande and Dr. Ashok Patel,
1998; Bombay University;1-53
2. VV Jaichandran; Ophthalmic regional anaesthesia;Indian Journal of Anaesthesia 2013 Jan-
Feb ;57(1):7-13
3. Hansen EA ,Mein CE, Mazzoli R. Ocular anaesthesia for cataract surgery : A direct subTenon's
approach . Ophthalmic Surg. 1990;21:696-9
4. Wolff.E.Philadelphia and London : WB Saunders ; 1996. Anatomy of the Eye and Orbit ;p31
5. Kumar CM, Dowd TC.Complications of ophthalmic regional blocks: Their treatment and
Prevention.Ophthalmologica;2006;220:73-82
6. Preoperative preparation and anaesthesia :Manual of Small Incision Cataract Surgery by
K.P.S.Malik, Ruchi Goel;2003 :5-9