Evaluation of efficacy of peribulbar block with the combination of 2% lidocaine and 0.5% bupivacaine in comparison with 2% lidocaine and 0.75% ropivacaine in cataract surgery.

Introduction: Cataract surgery is performed under peribulbar or retrobulbar block. Majority of the patients posted for cataract have some form of medical diseases like diabetes, hypertension, angina, ischaemic heart disease etc. Lidocaine and bupivacaine are the most commonly used local anesthetic for the block procedure. Here we compare the efficacy of peribulbar block in cataract surgery using the combination of 1:1 mixture of 2% lidocaine with 0.5% bupivacaine and 1:1 mixture of 2% lidocaine with 0.75% ropivacaine. Materials and Methods: It is a prospective, randomized, double blinded study including 60 patients were devided into two groups of 30 each, Group-R received 8 ml of 1:1 mixture of 4 ml of 2% lidocaine, 4 ml of 0.75% ropivacaine and 15 IU/ml of hyaluronidase and group-B received 8 ml of 1:1 mixture of 4 ml of 2% lidocaine, 4 ml of 0. 5% bubivacaineand 15 IU/ml of hyaluronidase. Peribulbar block was performed as per Bloomberg's modification of the Davis and Mandel technique where 5 ml of local anesthetic was injected in the infero temporal region and 3 ml of drug was injected in the superi nasal area. Patients were assessed for sensory block, eyelid and occular movements at an interval of 2 minutes. Systolic, diastolic and mean arterial pressures, heart rate, oxygen saturation, ECG were monitored non invasively at 1,3,5,8,10,15 and then every 10 minutes till the end of the surgery. Observation and Discussion: Mean time for the onset of sensory blockade was 2.70 ± 6.5 minutes in Group B and 2.63 ± 0.57 minutes in group R with P-value 0.671, showing no significant difference in the onset of sensory blockade. Onset of motor blockade was 6.53 ± 1.81 minutes in group B, and 7.57 ± 1.46 minutes in the group R, the P-value being 0.018 was statistically significant. Regarding the duration of analgesia, our study showed mean time for analgesia lasted for 295 ± 54.63 minutes in group B and 414.67 ± 99.47 in group R with P value 0.001 showing statistically significant prolongation of duration of analgesia with group R. We observed a significant increase of mean IOP in bupivacaine group from 13.333 ± 1.582 mm Hg to 21.966 ± 2.697 mm Hg, whereas in ropivacaine group it increased from 12.766 ± 1.222 mm Hg to 13.0 ± 1.341 mm Hg after peribulbar anaesthesia.

Role of hyaluronidase as an adjuvant in local anesthesia for cataract surgery.

Cataract surgery ranks among the commonest procedures performed worldwide. Approximately 51% of blindness worldwide is related to cataracts, affecting about 65.2 million people worldwide and more so in developing countries. Over the years, there has been a significant evolution in the surgical techniques of cataract extraction. The advancement in phacoemulsification machines, phaco-tips, and the availability of ophthalmic viscoelastic devices have played a substantial role in cataract surgery such that they are faster and more controlled than before. Similarly, anesthetic techniques in cataract surgery have advanced significantly from retrobulbar, peribulbar, and sub-Tenon's blocks to topical anesthesia. Though topical anesthesia eliminates the possible complications of injectable anesthesia, it is not suitable for use in uncooperative, anxious patients, pediatric age groups, and patients with cognitive disabilities. Hyaluronidase is an enzyme that breaks down hyaluronic acid in the retrobulbar tissue, facilitating uniform diffusion of the anesthetic drug and hastening the onset of anesthesia and akinesia. Hyaluronidase has been used in the last 80 years successfully as an adjuvant in retrobulbar, peribulbar, and sub-Tenon's blocks. Initially, the hyaluronidase enzyme was animal-derived and of bovine and ovine sources. Recombinant human-derived hyaluronidase, which has lesser allergic reactions, impurities, and toxicity, is now available. There is conflicting evidence regarding the efficacy of hyaluronidase as an adjuvant in retrobulbar and peribulbar blocks. This article summarizes a brief review of the literature on the role of hyaluronidase as an adjuvant in local anesthetic blocks in ophthalmic surgeries.

A prospective, randomized, triple-blind comparative study of ropivacaine-dexmedetomidine versus ropivacaine alone in peribulbar blocks.

Background and Aims: Bupivacaine and lidocaine mixtures are the commonly used local anesthetic drugs for the peribulbar blocks. Because of its safe anesthetic profile, ropivacaine is being investigated as an alternative agent. Several centers have evaluated the effect of the addition of an adjuvant like dexmedetomidine (DMT) to ropivacaine in enhancing the block characteristics. We proposed to evaluate the effect of the addition of DMT to ropivacaine versus a control group not having DMT as adjuvant. Material and Methods: A prospective, randomized comparative study was conducted on a total of 80 patients attending our hospital for cataract surgeries. Patients were allocated into four groups of 20 each (n = 20) and peribulbar blocks were given 6 mL of 0.75% ropivacaine in group R and 6 mL of 0.75% ropivacaine plus 10 µg, 15 µg, and 20 µg DMT, respectively, in groups RD1, RD2, and RD3. Results: When DMT was used as an adjunct to ropivacaine, there was a prolongation of the duration of the sensory block. Conclusion: In peribulbar blocks, 6 mL of ropivacaine 0.75% produces satisfactory block characteristics, and the addition of 10 µg, 15 µg, or 20 µg of DMT as an adjuvant to ropivacaine 0.75% had the effect of significantly prolonging the duration of the sensory block, which is directly proportional to the dose of DMT employed. However, 20 µg of DMT added as an adjuvant to ropivacaine 0.75% appears to be the optimal dose, as this anesthetic drug mixture provides maximum prolongation of the sensory block besides providing satisfactory operating conditions, acceptable sedation levels, and stable hemodynamic parameters.

Ketamine versus midazolam as an adjuvant to peribulbar block using a single inferonasal injection in patients undergoing vitreoretinal surgery: A randomized controlled trial.

INTRODUCTION AND OBJECTIVES: This study aimed to assess the safety and efficacy of midazolam and ketamine as adjuvants to the peribulbar block in vitreoretinal surgeries. PATIENTS AND METHODS: This randomized controlled trial included 93 adult patients undergoing vitreoretinal surgeries performed with peribulbar anaesthesia. Patients were randomly allocated to 3 groups (31 participants each): control (standard anaesthetic mixture), midazolam (standard mixture + midazolam), and ketamine (standard mixture + ketamine). The primary outcomes were onset of globe akinesia and duration of analgesia. Secondary outcomes were duration of motor blockade, onset of corneal anaesthesia and lid akinesia, and changes in vital data (blood pressure, oxygen saturation, and pulse rate). RESULTS: The ketamine group vs. the control and midazolam groups showed the most rapid onset of lid and globe akinesia (p < 0.001) and corneal anaesthesia (0.7 ± 0.2 vs. 1.5 ± 0.5 and 1.2 ± 0.4, respectively; p < 0.001) and the longest duration of both analgesia (3.7 ± 0.6 vs. 2.3 ± 0.4 and 3.1 ± 0.6, respectively; p < 0.001) and akinesia (3.8 ± 0.5 vs. 3.0 ± 0.4, and 3.7 ± 0.5, respectively; p < 0.001). The midazolam group showed better outcomes than controls, but the drug was less effective than ketamine. There were no significant differences in vital data among groups (p > 0.05). CONCLUSIONS: Ketamine is an effective adjuvant for peribulbar blockade. It enhances both motor and sensory blockade by hastening onset and prolonging duration. These effects are desirable in lengthier ophthalmic procedures such as vitreoretinal surgeries. The effects of ketamine were superior to those of midazolam.

Effect of adding dexmedetomidine to 0.75% ropivacaine in peribulbar block for vitreoretinal surgery.

Background and Aims: Peribulbar anesthesia is suitable for vitreoretinal (VR) surgery. Dexmedetomidine has been used in peribulbar block (PBB) to improve akinesia and analgesia. We aimed to study the efficacy of adding dexmedetomidine to 0.75% Ropivacaine in PBB for VR surgery. The primary outcome was the requirement of block supplementation and secondary outcome was post-operative analgesic requirement. Material and Methods: 100 adult patients undergoing VR surgery were included in this prospective randomized double-blinded controlled study. The composition of the drug used for PBB in the 3 groups was Group R (8 ml of 0.75% Ropivacaine +0.5 ml normal saline (NS)), Group D25 (8 ml of 0.75% Ropivacaine +25µg Dexmedetomidine) and Group D50 (8 ml of 0.75% Ropivacaine +50 µg Dexmedetomidine). Results: The groups were comparable in terms of patient demographics. The requirement for block supplementation was 16.7% in Group R (5/30), 12.5% in Group D25 (4/32) and 8.8% in group D50 (3/34) (P = 0.64). The mean time to first request for post-operative analgesia was432 ± 362 min in Group R, 572 ± 339 min in Group D25 and 614 ± 394 min for Group D50 (P = 0.26). There was significant difference in the heart rate (P = 0.047), mean arterial pressure (P = 0.012) at 30 min and sedation (RASS) score at 15, 30, 60 (P < 0.001) and 120 (P = 0.019) min between the D50 and group R. Patients undergoing buckling procedures had significantly shorter time to request for analgesia (P = 0.003). Conclusion: Addition of dexmedetomidine does not offer advantage over 0.75% Ropivacaine in PBB for vitrectomy. Its benefit in more painful procedures like scleral buckle needs further validation.

A comparison of sub-tenon block with peribulbar block in small-incision cataract surgery.

Purpose: To compare the efficacy and safety of sub-tenon block to peribulbar block with respect to analgesia, akinesia, and complications. Methods: It is an observational study conducted at a government hospital in Karnataka. Seventy patients who came to the ophthalmology OPD for small-incision cataract surgery (SICS) under local anesthesia were included in the study. The participants were divided into two groups of 35 as per the surgeon. The pain was evaluated at the time of administration of the block, during the surgery, and during the postoperative period of 4 h. Akinesia was noted in both the groups and the time of onset of akinesia was noted. Any complications associated with the block such as chemosis or subconjunctival hemorrhage were also noted. Statistical analysis was done using PSS version 25.0, where P < 0.05 was considered significant. Results: The baseline pain score was higher in the peribulbar group (1.57). The onset of akinesia was faster in sub-tenons (90.34 s). Complete akinesia was achieved in 82.9% of patients after peribulbar block. There was no significant difference in complications in both groups. Conclusion: Sub-tenons block is an effective and safer technique of ocular anesthesia for SICS. It can be considered as an alternative to the conventional peribulbar block for SICS.

Clinical Presentation and Management of Eyes with Globe Perforation during Peribulbar and Retrobulbar Anesthesia: A Retrospective Case Series.

PURPOSE: To evaluate the clinical presentation, management, and outcome of eyes with an inadvertent globe perforation during peribulbar or retrobulbar block. METHODS: This retrospective study evaluated the eyes which had an accidental globe perforation during local ocular anesthesia from 2012 to 2020. The patients were divided into three groups: group 1, Clear media with no rhegmatogenous retinal detachment (RRD); group 2, significant vitreous hemorrhage (VH) precluding the retinal view without RRD; and group 3, RRD with/without VH. RESULTS: Twenty-five patients were included in the study. The mean axial length (AL) was 24.7 ± 2.7 mm (range, 20.9-31.2 mm). The most common presenting feature was VH (n = 14). The treatment included retinal laser barrage (n = 7) and vitrectomy (n = 17). Retinal breaks were identified in all the eyes (total breaks = 37). The mean presenting best-corrected visual acuity in groups 1, 2, and 3 were logarithm of the minimum angle of resolution 0.79 ± 0.73, 1.82 ± 0.78, and 2.13 ± 0.59 respectively. All the treated patients had an attached retina at the last follow-up. The mean final best-corrected visual acuity for each group was logarithm of the minimum angle of resolution 0.59 ± 0.79, 0.48 ± 0.26, and 1.25 ± 0.64, respectively (p = 0.006). The development of RRD was associated with a larger AL (p = 0.015); while the development of significant VH associated with the superior location of the perforation (p = 0.015), late recognition of the perforation (p = 0.004), and multiple perforations (p = 0.015). CONCLUSIONS: Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer AL, superior, and multiple perforations are at higher risk of developing complications like RRD and VH. Complications like RRD, macular injury, and vascular occlusion are risk factors for poor prognosis.

Unexpected amaurosis occurring after peribulbar anesthesia: Exploring the causes in two cases.

Peribulbar anesthesia (PB) is known to be safer than retrobulbar (RB) anesthesia. To our knowledge, no amaurosis has been described after PB. We report here the cases of two patients who underwent PB before membrane peeling. The injections were administered with a 25-gauge, 22-mm bevel disposable needle. The anesthetic used was ropivacaine 1% with a volume of 8 ml and 75 µg of clonidine as an adjuvant (7.5 µg/ml). Given that complete akinesia was not achieved, a second injection of 2 ml was administered in the supero-medial injection site. Thirty minutes after the PB, the first patient experienced amaurosis with no light perception (LP). The ophthalmic examination was normal. Visual acuity recovered after 1 day. Regarding the second patient, the loss of VA was observed 20 min after the PB. IOP was 20 mmHg. The anterior segment and fundus exam were normal. Rubin found the PB technique to be as effective and safer than RB injection, as the needles are not supposed to enter the RB space and Davis and Mandel found no amaurosis after PB. PB is administered via the extraconal injection of an anesthetic agent. These amaurosis might be explained by the fact that some anesthetic may have penetrated the RB space. In cases where two PB injections are administered, the anatomy is expected to change due to the volume effect of the first injection. The second injection is higher risk as it is administered closer to the optic nerve.

Comparison of peribulbar block and subtenon infiltration in pediatric enucleation for retinoblastoma.

Purpose: Enucleation performed in children with retinoblastoma is associated with severe postoperative pain. The use of opioids for the pain is associated with numerous complications which demand careful monitoring. Subtenon infiltration and peribulbar block are useful in ameliorating pain perioperatively following various ophthalmic surgeries which are yet to be evaluated in enucleation. Therefore, we designed this study to compare the effects of peribulbar block and subtenon infiltration on postoperative pain with opioids in pediatric enucleation surgeries. Methods: 60 children of American Society of Anesthesiologists grade I and II, age ranging from 6 months to 6 years with retinoblastoma undergoing enucleation surgery were included in the study. Group A (n = 20): received peribulbar block (peribulbar group); Group B (n = 20): received subtenon local infiltration (subtenon group); and Group C (n = 20): no block was given. Results: The postoperative fentanyl consumption was lowest with Group B compared to Group A and Group C (P value 0.001). However, the total fentanyl consumption was comparable between groups A and B, while it was significantly higher in the control group. The mean pain score face, legs, activity, cry, consolability (FLACC) scale and mean time to discharge from post anesthesia care unit were lowest in Group B followed by Group A, while Group C had the highest. There was no statistically significant difference among the 3 groups with regards to side effects. Conclusion: Subtenon infiltration showed significantly better outcomes when compared to peribulbar block and intravenous opioids alone without any untoward adverse effects.

Preventive Analgesia, Hemodynamic Stability, and Pain in Vitreoretinal Surgery.

Background and Objectives: Although vitreoretinal surgery (VRS) is most commonly performed under regional anaesthesia (RA), in patients who might be unable to cooperate during prolonged procedures, general anaesthesia (GA) with intraprocedural use of opioid analgesics (OA) might be worth considering. It seems that the surgical pleth index (SPI) can be used to optimise the intraprocedural titration of OA, which improves haemodynamic stability. Preventive analgesia (PA) is combined with GA to minimise intraprocedural OA administration. Materials and Methods: We evaluated the benefit of PA combined with GA using SPI-guided fentanyl (FNT) administration on the incidences of PIPP (postprocedural intolerable pain perception) and haemodynamic instability in patients undergoing VRS (p < 0.05). We randomly assigned 176 patients undergoing VRS to receive GA with SPI-guided FNT administration alone (GA group) or with preventive topical 2% proparacaine (topical anaesthesia (TA) group), a preprocedural peribulbar block (PBB) using 0.5% bupivacaine with 2% lidocaine (PBB group), or a preprocedural intravenous infusion of 1.0 g of metamizole (M group) or 1.0 g of paracetamol (P group). Results: Preventive PBB reduced the intraprocedural FNT requirement without influencing periprocedural outcomes (p < 0.05). Intraprocedural SPI-guided FNT administration during GA resulted in PIPP in 13.5% of patients undergoing VRS and blunted the periprocedural effects of preventive intravenous and regional analgesia with respect to PIPP and haemodynamic instability. Conclusions: SPI-guided FNT administration during GA eliminated the benefits of preventive analgesia in the PBB, TA, M, and P groups following VRS.

Effect of dexmedetomidine on intraocular pressure as an additive in peribulbar block during glaucoma surgery.

Purpose: The purpose of this study is to assess the effect of dexmedetomidine on intraocular pressure (IOP) as an additive in peribulbar injections in glaucoma surgeries. Methods: A prospective, randomized, double-blind, parallel assignment interventional study was conducted for patients undergoing glaucoma surgeries at a tertiary eye care hospital in North India. Patients were randomized to two groups, Dexmed group and Placebo group. In the Dexmed group, dexmedetomidine (0.4 µg/kg body weight) was given as an additive along with peribulbar block. The primary outcome was change in IOP pre- and postperibulbar injections (IOP before the block, and after 5 and 15 min of the block). Secondary outcome measures were onset of block, adverse effects (bradycardia, hypotension, respiratory depression, and level 4 sedation), and surgeon satisfaction. Results: A total of 104 patients were randomized, 52 each in the Dexmed group and Placebo group. The percentage decrease in IOP was significantly more in the Dexmed group than in the Placebo group both at 5 and 15 min' post block (P < 0.05). At 5 min, the mean percent decrease in IOP in Dexmed group was -10.48, whereas it was 2.85 in the Placebo group. At 15 min, the mean percent decrease in IOP was -22.59 and -9.42 in the Dexmed and Placebo group, respectively. There was no significant difference between the two groups in the onset of block and adverse effects. Surgeon satisfaction was significantly greater in the Dexmed group than the Placebo group (P < 0.05). Conclusion: Dexmedetomidine lowers IOP significantly in patients undergoing glaucoma surgeries with safe hemodynamic changes and sedative effect.

Ophthalmic artery resistance index after peribulbar block in the presence of epinephrine.

PURPOSE: There are controversies regarding ophthalmic artery (OA) flow after peribulbar block in the presence of epinephrine. Therefore, we aimed to evaluate OA flow via echo-Doppler before and after peribulbar block with lidocaine in the presence or absence of epinephrine. METHODS: Fifty-six patients who had an American Society of Anesthesiologists (ASA) classification of I, II or III and were eligible for cataract phacoemulsification surgery were selected. Patients with other eye diseases were excluded. Patients were divided into two groups: group 1-peribulbar block with lidocaine and 1/200,000 epinephrine; group 2-peribulbar block with lidocaine in the absence of epinephrine. The resistance index (RI), peak systolic velocity (PSV), end diastolic velocity (EDV) of the OA were evaluated using echo-Doppler before and 10 min after the peribulbar block. RESULTS: No differences between groups were observed in the RI before the peribulbar block as well regarding the presence of hypertension and the age or gender of the patient. After the peribulbar block, we observed a decrease in the RI in group 1 (p = 0.038, Cohen's d = 0.336) and no difference in the RI in group 2 (p = 0.109, Cohen's d = 0.172). When comparing group 1 and group 2, we observed a decrease in the RI in group 1 (p = 0.028, Cohen's d = 0,583). There was no difference between groups regarding the PSV and EDV after the peribulbar block. CONCLUSIONS: A decrease in RI was observed in the OA after peribulbar block with a vasoconstrictor, an effect that could be a benefit in some ocular surgeries.

Dexmedetomidine as an Additive to Local Anesthesia for Decreasing Intraocular Pressure in Glaucoma Surgery: A Randomized Trial.

BACKGROUND: Nowadays, the peribulbar block is used as a tool in glaucoma surgery. As a side effect, it increases intraocular pressure that raises the need for adjuvant medication to overcome this problem in the diseased eye. Dexmedetomidine has proven to decrease intraocular pressure (IOP) in the non-glaucomatous eye. OBJECTIVES: In a triple-blinded randomized study, dexmedetomidine as an adjuvant to the peribulbar block was used to decrease IOP in the diseased eye. METHODS: We randomized 98 eyes to three groups, including D50 (35 eyes) with dexmedetomidine 50 µg, D25 (33 eyes) with dexmedetomidine 25 µg, or control group (C) (30 eyes) with the plain peribulbar block. The study was randomized triple-blinded, aiming at testing the effect of dexmedetomidine on IOP after block injection. RESULTS: The pre-injection IOP was 27.71 ± 2.52, 27.25 ± 3.53, and 26.2 ± 3.57 mmHg in groups D50, D25, and C, respectively, then increased to 29.71 ± 1.69, 30.25 ± 2.36 and 29.4 ± 3.756 in groups D50, D25 and C, respectively, with P >0.05. The pressure decreased after the surgery to 10.86 ± 1.478 in group D50, 10.75 ± 1.63 in group D25, and 10.6 ± 1.589 in group C, with no statistical differences (P > 0.05) between the groups. CONCLUSIONS: Dexmedetomidine did not decrease IOP in the glaucomatous eye.

Evaluation of the effect and safety of dexmedetomidine as an additive to local anesthesia in peribulbar block for vitreoretinal surgery.

Purpose: We conducted a prospective, randomized study to evaluate the efficacy of dexmedetomidine as an additive to peribulbar block for vitreoretinal surgery in terms of onset time of block, hemodynamic stability profile, patient comfort, and surgeon satisfaction. Methods: One hundred patients of American Society of Anesthesiologists grade 1 and 2 scheduled for vitreoretinal surgery were randomly assigned into two groups: control group (n = 50) received lignocaine bupivacaine block, and Dex group (n = 50) received lignocaine bupivacaine plus 20 µg dexmedetomidine peribulbar block. Information regarding time for onset of block, hemodynamic data, visual analog scale for pain, sedation levels, total duration of surgery, and surgeon satisfaction levels were collected. Results: All the demographic characteristics including age, gender, American Society of Anesthesiologists grade, onset of anesthesia, and duration of surgery were comparable in both groups. At the baseline, there was no statistically significant difference in heart rate, mean arterial pressure, diastolic blood pressure, and respiratory rate between the two groups, with a difference noted in systolic blood pressure at the baseline. There was significant difference noted in the systolic blood pressure and mean arterial pressure at different time intervals with a decreasing trend as time progressed. The mean sedation score was significantly higher in the Dex group than that in the control group. The surgeon satisfaction was higher in the Dex group than that in the control group. Conclusion: Dexmedetomidine is a useful and safe drug in combination with lignocaine bupivacaine in peribulbar for vitreoretinal surgery as it maintains hemodynamic stability and provides sedation, which enables full cooperation and potentially better operating conditions.

Comparative Study between the Efficacy of Fentanyl, Antihistamines, and Dexmedetomidine in Suppressing Photic Sneeze Reflex during Peribulbar Block.

BACKGROUND: The photic sneeze reflex (autosomal dominant) is a condition that causes sneezing in response to numerous stimuli, such as looking at bright lights or periocular (surrounding the eyeball) injection. Unexpected or sudden sneezing during injection can be a dangerous side effect in periocular injection, in which abrupt head movement may cause globe injury. AIMS: We intended to evaluate the efficacy of adding fentanyl, dexmedetomidine, and antihistamines on the incidence of the sneeze reflex associated with propofol sedation during periocular local anesthesia injections. SETTINGS AND DESIGN: Our study was a randomized, prospective, double-blinded and controlled clinical study. PATIENTS AND METHODS: This study was conducted in Ain Shams and Fayoum university hospitals at the ophthalmic surgery department. After obtaining approval from our universities ethical committee and written informed valid consents from the patients, 90 patients were included in this study. The study population included patients of both sex, ASA grade 1 and 2, in the age ranging from 18-65 years. Patients were scheduled for cataract extraction surgeries and received peribulbar block. Then patients were randomly divided into three groups (30 patients each) using a computer- generated table of random numbers. Patients were preoxygenated with supplemental oxygen by nasal cannula, all 90 patients received intravenous propofol 1mg.kg- 1 bolus for sedation and were randomized to receive adjunctive drug 2 to 4 minutes prior to propofol injection: 30 patients received intravenous fentanyl 1 µmg.kg-1 (Group F), 30 patients received dexmedetomidine 1µmg.kg-1 (Group D), and 30 patients received antihistamine (pheniramine 22.75 mg) (Group H). The same local anesthetic admixture, consisting of 5 mL 2% lidocaine with 90 IU hyaluronidase, combined with 5 mL 0.5% plain bupivacaine in a 10-mL syringe at room temperature was administered to all patients using peribulbar block technique. A masked observer (surgeon or anesthesia assistant) recorded whether the patient had a sneezing event. Continuous cardiorespiratory monitoring was performed intraoperatively. Intraoperative and postoperative medication side effects were recorded including bradycardia (HR <55 beats/min), hypotension (MAP <50 mmHg sustained for >10 min), oxygen desaturation (SpO2<90%), nausea, vomiting and prolonged sedation using Ramsay Sedation Score (RSS). STATISTICAL ANALYSIS USED: Student's t-test and Chi-square test were used for analysis. RESULTS: The demographic data of the three study groups revealed non-significant differences between the three study groups as regards age, sex distribution, and the duration of surgery. No patient was excluded after inclusion to the study. All patients were able to complete the entire study and their data were included in the final analysis. Five events of sneezing had occurred in 90 patients. Two in (D) group and three in (H) group with is no statistically significant difference between the three groups as regard sneezing. Bradycardia, hypotension and sedation had occurred significantly in group (D) compared to group (F) and group (D). No patient suffered from nausea, vomiting or oxygen desaturation in all studied groups. No statistically significant difference as regards patient satisfaction between the three studied groups. CONCLUSION: Fentanyl, dexmedetomidine and antihistamines with propofol sedation suppress photic sneeze reflex during peribulbar block.

Ropivacaine plus lidocaine versus bupivacaine plus lidocaine for peribulbar block in cataract surgery: A prospective, randomized, double-blind, single-center, comparative clinical study.

BACKGROUND AND AIMS: Cataract surgery in ophthalmology is usually done under peribulbar block with a mixture of 0.5% bupivacaine and 2% lidocaine. Several case reports of fatalities associated with bupivacaine has necessitated a search for alternative safe agents. The aim of this study was to compare peribulbar block characteristics using a mixture of 0.5% bupivacaine and 2% lidocaine with a mixture of 0.5% ropivacaine and 2% lidocaine. MATERIAL AND METHODS: Eighty patients were allocated to two random groups of 40 each. Patients of groups BL and RL were given 4 ml of 0.5% bupivacaine and 4 ml of 0.5% ropivacaine each in a mixture with 4 ml of 2% lidocaine and 100 IU of hyaluronidase respectively. Block characteristics, hemodynamic variables, adverse drug interactions and other complications were recorded. RESULTS: Demographic characteristics were comparable in both the groups. Duration of onset of the block and the side effect profile was comparable in both the groups but the total duration of the block and the time for first rescue analgesia was found to be longer in group BL than in group RL. CONCLUSIONS: Ropivacaine 0.5% and lidocaine 2% as a 1:1 mixture in a volume of 8 ml with 100 IU of hyaluronidase is as effective as a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% in a volume of 8 ml with 100 IU of hyaluronidase with regards to onset and total duration of the block and side effects and hemodynamic changes.

Dexamethasone Compared to Dexmedetomidine as an Adjuvant to Local Anesthetic Mixture in Peribulbar Block for Vitreoretinal Surgery. A Prospective Randomized Study.

BACKGROUND: Dexamethasone or dexmedetomidine may improve the quality of peribulbar block. AIM: The aim of this study is to compare the effects of adding either dexamethasone or dexmedetomidine to peribulbar block on the efficacy, intraocular pressure (IOP), time to first analgesic request, total analgesic requirement, and side effects in patients undergoing vitreoretinal surgery. DESIGN: This was a clinical prospective randomized study. PATIENTS AND METHODS: One hundred and fifty adult patients scheduled for vitreoretinal surgery with peribulbar block were randomized into three groups (50 patients each). Group I received 3.5 ml of 0.5% bupivacaine and 3.5 ml of 2% lidocaine + 1 ml normal Saline. 4 mg dexamethasone and 25 µg dexmedetomidine in 1 ml were added to the local anesthetic mixture in Groups II and III respectively. Onset and duration of sensory and motor blocks, adequate time to start surgery, IOP, time to first request of rescue analgesia, total analgesic consumption, and side effects were recorded. The statistical software SPSS 16 was utilized for statistical analysis. RESULTS: Dexamethasone and dexmedetomidine groups showed significantly prolonged duration of corneal anesthesia (234.07 ± 1.37 and 233.54.1.97 min respectively), prolonged lid and globe akinesia (194.27 ± 1.63 and 194.73 ± 2.35 min respectively) with prolonged time to first request of analgesia and less consumption of rescue analgesia as compared to control group (P < 0.05) with non significant differences between both groups (P > 0.05). The onset of corneal anesthesia as well as lid and globe akinesia were enhanced in dexmedetomidine group compared to the other two groups (P < 0.05). In addition, the measurement of IOP was significantly less in the dexmedetomidine group after 10 min. All the patients were hemodynamically stable with no side effects observed. CONCLUSION: The addition of dexamethasone and dexmedetomidine to local anesthetic mixture in peribulbar block for vitreoretinal surgeries provided safe and effective block with prolonged duration and decreased requirements of postoperative analgesia with better quality for dexmedetomidine group regarding the fast onset of the block and reduced IOP.

Effect of Addition of Fentanyl and Clonidine to Local Anesthetic Solution in Peribulbar Block.

OBJECTIVE: To compare the effect of addition of fentanyl and clonidine as adjuvants to bupivacaine and lignocaine in peribulbar block. METHODS: The study was conducted on 105 adult patients of either sex, of ASA grade I and II undergoing ophthalmic surgeries. Patients were randomly divided into 3 groups of 35 each. All the patients were given peribulbuar block with 5ml lignocaine 2% +3 ml bupivacaine 0.5% +1 ml hyaluronidase (250 IU). In addition to this 1 ml normal saline was added to Group S, 25 µg fentanyl to Group F and 25 µg clonidine to Group C. Onset and duration of globe and lid akinesia, duration of sensory blockage and analgesia, hemodynamic parameters, number of rescue analgesic and visual analogue score were recorded. RESULTS: The mean time of onset of globe and lid akinesia was significantly faster in group F and group C compared to group S, mean duration of globe and lid akinesia was longer in Group F (207.71 + 13.54 and 143.14 + 7.86 min) and group C (213.52 + 14.52 and 162.06 + 17.1 min) compared to group S (117.78 + 10.42 and 87.64 + 9.76 min). The mean duration of analgesia was significantly longer in group F (217.71 + 12.67) and C (258.82 + 14.50 min) as compared to group S (131.39 + 9.63 min). CONCLUSION: Addition of fentanyl or clonidine as adjuvant to local anaesthetic in peribulbar block provides faster onset and prolonged analgesia compared to local anaesthetic alone.

Effect of the addition of rocuronium to 2% lignocaine in peribulbar block for cataract surgery.

BACKGROUND AND AIMS: Peribulbar anesthesia is associated with delayed orbital akinesia compared with retrobulbar anesthesia. To test the hypothesis that rocuronium added to a mixture of local anesthetics (LAs) could improve speed of onset of akinesia in peribulbar block (PB), we designed this study. This study examined the effects of adding rocuronium 5 mg to 2% lignocaine with adrenaline to note orbital and eyelid akinesia in patients undergoing cataract surgery. MATERIAL AND METHODS: In a prospective, randomized, double-blind study, 100 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 6 ml lidocaine 2% with adrenaline and hyaluronidase 50 IU/ml (Group I), a mixture of rocuronium 0.5 ml (5 mg), 6 ml lidocaine 2% with adrenaline and hyaluronidase 50 IU/ml (Group II). Orbital akinesia was assessed on a 0-8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean ± standard deviation. RESULTS: Rocuronium group demonstrated significantly better akinesia scores than control group at 2 min intervals post-PB (significant P value obtained). No significant complications were recorded. Rocuronium added to a mixture of LA improved the quality of akinesia in PB and reduced the need for supplementary injections. CONCLUSION: The addition of rocuronium 5 mg to a mixture of lidocaine 2% with adrenaline and hyaluronidase 50 IU/ml shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.

Effect of addition of magnesium to local anesthetics for peribulbar block: A prospective randomized double-blind study.

BACKGROUND: Magnesium sulphate has been used along with local anesthetics in different regional blocks and found to be effective in decreasing the time of onset of the block and increasing the duration of the block. OBJECTIVE: To evaluate the effect of addition of magnesium sulfate to standard local anesthetics mixture on the time for onset of the globe and lid akinesia for peribulbar block in ophthalmic surgeries. MATERIALS AND METHODS: Sixty patients with American Society of Anesthesiologists status I to III undergoing ophthalmic surgery under peribulbar block were included in this study. Patients were randomized into two groups. Both the groups received 4.5 ml of 2% lidocaine, 4.5 ml of 0.5% bupivacaine with150 IU hyaluronidase. Group NS received normal saline 1 ml in the peribulbar block and Group MS, magnesium sulfate 50 mg in 1 ml normal saline. The onset of akinesia, satisfactory block and complications were observed by an independent observer. RESULTS: Demographic data was statistically similar. In the Group NS at 3, 5, 10 and 15 min after the block, complete akinesia was seen in 0, 2, 11 and 28 patients respectively. In the Group MS, at 3, 5, 10 and 15 min after the block, complete akinesia was seen in 13, 23, 27 and 28 patients respectively. Patients received magnesium sulfate showed the statistically significant rapid onset of lid and globe akinesia than the control group till 10 min (P < 0.000). None of the patients needed a supplementary block and had complications during the surgery. CONCLUSION: Addition of 50 mg of magnesium sulfate to the lidocaine-bupivacaine mixture for peribulbar block decreases the onset of akinesia without any obvious side effect.