Good anesthetic for good esthetic: Blocks in oculoplasty.

Background: : A good anesthesia not only makes the patient comfortable during surgery, but also has a huge impact on the postoperative recovery. It also makes the operating surgeon carry out each step of the surgery precisely and beautifully. The art of giving a good local anesthesia is to be learnt and practiced not only by anesthetists, but also by the practicing ophthalmologists. Purpose: : This video gives an overview of anatomy in terms of the nerve supply of the orbit, the surface marking, and the techniques of giving regional and nerve blocks. Synopsis: : In this video, we describe the anatomy, the surface marking, the technique of regional anesthesia including peribulbar, retrobulbar, and subtenon blocks and of nerve blocks, specifically of facial, frontal nerve and its branches, infraorbital, nasociliary, infratrochlear, and dorsal nasal nerves, with their application in ocular plastic surgery. Highlights: : This video highlights the essence of providing appropriate and good anesthesia so that the surgeon works in an optimal field with maximum comfort to the patients. Video link https://youtu.be/h8EgTMQAsyE.

Potential Therapeutic Activity of Berberine in Thyroid-Associated Ophthalmopathy: Inhibitory Effects on Tissue Remodeling in Orbital Fibroblasts.

Purpose: Berberine (BBR), an alkaloid produced by a traditional Chinese plant, was recently attributed multiple effects on lipometabolism, inflammation, and fibrosis. Thyroid-associated ophthalmopathy (TAO) is highly associated with these pathologic changes. Thus, we aimed to examine the potential therapeutic effect of BBR in an in vitro model of TAO. Methods: Orbital fibroblasts (OFs) obtained from control donors (n = 6) or patients with TAO (n = 6) were cultured. The CCK-8 assay was conducted for assessing the optimal concentration range. Oil Red O staining, Western blotting, and quantitative RT-PCR (qRT-PCR) were conducted to assess adipogenesis in OFs. RNA sequencing (RNA-seq) was used to screen the key pathways of the antiadipogenic effect mediated by BBR. Along with incremental concentrations of BBR, IL-1ß-induced expression of proinflammatory molecules was determined by ELISA and qRT-PCR. In addition, TGF-ß-induced hyaluronan (HA) production and fibrosis were evaluated by ELISA, qRT-PCR, and Western blotting. Results: TAO-OFs, but not control fibroblasts (CON-OFs), were readily differentiated into adipocytes with the commercial medium. Intracellular lipid accumulation was dose-dependently decreased by BBR, and adipogenic markers were also downregulated. Moreover, the PPARγ and AMPK pathways were screened out by RNA-seq and their downstream effectors were suppressed by BBR. Besides, BBR attenuated IL-1ß-induced expression of proinflammatory molecules in both TAO-OFs and CON-OFs by blocking nuclear factor-κB signaling. BBR's inhibitory effect on TGF-ß-mediated tissue remodeling was also confirmed in OFs. Conclusions: These findings demonstrate BBR has outstanding capabilities of controlling adipogenesis, inflammation, HA production, and fibrosis in OFs, highlighting its potential therapeutic role in TAO management.

Prompt Detection and Management of Globe Perforation due to Retrobulbar Anaesthesia.

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Computed tomography scan measurements of the globe and orbit to assess the risks of traumatic complications from medial peribulbar anaesthesia.

Complications of peribulbar anaesthesia include retrobulbar haemorrhage, globe perforation and brainstem anaesthesia. Therefore, this study took measurements relating the proximity of medial canthus to the optic nerve and also the safe angle between orbit and globe using 200 multiplanar reconstructed computed tomography (CT) images of the orbit. The principal results show that in 1.5% of the sample, the optic nerve is within 20 mm of the medial canthus, with a minimum distance of 15 mm. One% have a safe angle of 10 degrees or less between bone and globe. None of the demographic data, nor axial length were predictive of these results. We have shown that there are a minority of patients with unusual orbital anatomy. This places them at a theoretical higher risk of complications. These cases are not currently predicted by measured data.

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.

Spontaneous retrobulbar hemorrhage in the setting of warfarin therapy and latent scurvy diagnosis.

We present a case of spontaneous nontraumatic retrobulbar hemorrhage associated with anti-coagulation therapy and a new diagnosis of scurvy. A 68-year-old male on chronic anti-coagulation therapy presented with a retrobulbar hemorrhage requiring urgent canthotomy and cantholysis. Despite the absence of a supratherapeutic INR and normal clotting factors, the patient continued to have spontaneous hemorrhages within the orbit and elsewhere. Workup revealed a severe vitamin C deficiency consistent with scurvy. Further investigation of dietary history demonstrated an avoidance of all citrus fruit upon starting warfarin due to misunderstanding in medication counseling on avoidance of grapefruit. With repletion of vitamin C and further medication counseling, the patient had no further episodes of spontaneous hemorrhage.

[Graves' orbitopathy]. / Endokrine Orbitopathie.

BACKGROUND: Graves' orbitopathy (GO) is an autoimmune orbital disease which is mostly associated with Graves' disease and requires good interdisciplinary cooperation. To minimize irreversible damages a stage-adapted anti-inflammatory therapy is of great importance. MATERIAL AND METHODS: Discussion of the latest results of new findings of the pathogenesis, randomized controlled trials on anti-inflammatory treatments for Graves' orbitopathy and novel therapeutic concepts. RESULTS: In all patients with GO achieving euthyroidism, as well as cessation of smoking is very important to avoid prolongated diseases. Mild cases of GO can be treated with selenium supplementation and artificial tears. The moderate-to-severe, active form of GO requires primarily i. v. steroids in combination with orbital irradiation in case of impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening cases even high-dose i. v. steroid treatments are often ineffective and bony orbital decompression is necessary. As latest research data have improved our understanding of the pathophysiology of GO, targeted therapies have been developed for GO. Teprotumumab, an IGF-1 receptor antibody, was shown effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe. Inactive patients, who suffer from disturbing exophthalmos should be also treated with bony decompression before eye muscle or lid surgery. CONCLUSION: The current concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This might be modified in the future, due to the promising effects of targeted therapies.

The Role of Mitochondria-Linked Fatty-Acid Uptake-Driven Adipogenesis in Graves Orbitopathy.

CONTEXT: Depot-specific expansion of orbital adipose tissue (OAT) in Graves orbitopathy (GO; an autoimmune condition producing proptosis, visual impairment and reduced quality of life) is associated with fatty acid (FA)-uptake-driven adipogenesis in preadipocytes/fibroblasts (PFs). OBJECTIVE: This work sought a role for mitochondria in OAT adipogenesis in GO. METHODS: Confluent PFs from healthy OAT (OAT-H), OAT from GO (OAT-GO) and white adipose tissue in culture medium compared with culture medium containing a mixed hormonal cocktail as adipogenic medium (ADM), or culture-medium containing FA-supplementation, oleate:palmitate:linoleate (45:30:25%) with/without different concentration of mitochondrial biosubstrate adenosine 5'-diphosphate/guanosine 5'-diphosphate (ADP/GDP), AICAR (adenosine analogue), or inhibitor oligomycin-A for 17 days. Main outcome measures included oil-red-O staining and foci count of differentiated adipocytes for in vitro adipogenesis, flow cytometry, relative quantitative polymerase chain reaction, MTS-assay/106 cells, total cellular-ATP detection kit, and Seahorse-XFe96-Analyzer for mitochondria and oxidative-phosphorylation (OXPHOS)/glycolysis-ATP production analysis. RESULTS: During early adipogenesis before adipocyte formation (days 0, 4, and7), we observed OAT-specific cellular ATP production via mitochondrial OXPHOS in PFs both from OAT-H and OAT-GO, and substantially disrupted OXPHOS-ATP/glycolysis-ATP production in PFs from OAT-GO, for example, a 40% reduction in OXPHOS-ATP and trend-increased glycolysis-ATP production on days 4 and 7 compared with day 0, which contrasted with the stable levels in OAT-H. FA supplementation in culture-medium triggered adipogenesis in PFs both from OAT-H and OAT-GO, which was substantially enhanced by 1-mM GDP reaching 7% to 18% of ADM adipogenesis. The FA-uptake-driven adipogenesis was diminished by oligomycin-A but unaffected by treatment with ADP or AICAR. Furthermore, we observed a significant positive correlation between FA-uptake-driven adipogenesis by GDP and the ratios of OXPHOS-ATP/glycolysis-ATP through adipogenesis of PFs from OAT-GO. CONCLUSION: Our study confirmed that FA uptake can drive OAT adipogenesis and revealed a fundamental role for mitochondria-OXPHOS in GO development, which provides potential for therapeutic interventions.

A computed tomography-based method for the assessment of canine retrobulbar cone volume for ophthalmic anaesthesia.

OBJECTIVE: To develop a comprehensive formula for calculating the volume of local anaesthetic solution used for retrobulbar anaesthesia in dogs with different skull morphologies. STUDY DESIGN: Retrospective cohort imaging study. ANIMALS: Skull computed tomography (CT) images of 188 dogs of different breeds collected between January 2009 and December 2017. METHODS: Anatomical integrity of the orbit and adjacent structures, presenting complaint, clinical signs and CT findings were verified to exclude ocular abnormalities. The volume of the retrobulbar cone of 376 eyes was calculated using CT scans of the dogs' skulls. Additional data recorded included morphology of the skull, body weight, sex and size of the dogs, all of which were matched for possible association to the retrobulbar cone volume through univariable and multivariable linear regression models. Results of linear regression models were expressed as estimated beta coefficients with the corresponding 95% confidence intervals (95% CIs). RESULTS: Using univariate analysis, the retrobulbar cone volume was positively associated with weight and male sex. In addition, brachycephalic and dolichocephalic dogs showed a larger retrobulbar cone volume than mesocephalic dogs, while sex was no longer significantly associated with the retrobulbar cone volume. In multivariate analysis, when considering all variables in the model, weight emerged as the strongest predictor (beta coefficient: 0.062 mL kg-1, 95% CI: 0.056-0.067 mL kg-1, p < 0.001). CONCLUSIONS: and clinical relevance In the veterinary literature, there is no agreement on the precise volume of local anaesthetic solution that should be used to achieve intraconal retrobulbar anaesthesia in dogs. Here we suggest a formula to calculate the retrobulbar cone volume and, accordingly, the injection volume of local anaesthetic solution for effective retrobulbar anaesthesia.

Anti-inflammatory and Antioxidant Effects of Selenium on Orbital Fibroblasts of Patients With Graves Ophthalmopathy.

PURPOSE: In the present study, the authors investigated the effects of selenium on inflammation, hyaluronan production, and oxidative stress in primary cultured orbital fibroblasts of patients with Graves ophthalmopathy (GO). METHODS: Orbital adipose/connective tissue specimens were obtained during the course of orbital surgery for patients with GO (n = 7) and other noninflammatory problems (n = 5). After incubation with various concentrations of sodium selenite for 48 hours, supernatants from primary cultures were collected. Hyaluronan and cytokine levels were measured using commercially available enzyme-linked immunosorbent assay kits. To determine the effect of selenium on reactive oxygen species (ROS) production stimulated by H2O2 (100 µM) for 30 minutes, the cells were pretreated with various concentrations of sodium selenite for 60 minutes. RESULTS: Interleukin (IL)-6 and tumor necrosis factor-alpha levels were significantly higher in orbital fibroblasts of patients with GO than in orbital fibroblasts of control patients. Hyaluronan production was suppressed by selenium in cultured orbital fibroblasts of patients with GO. Inflammatory cytokines such as IL-1α, IL-8, and tumor necrosis factor-alpha were suppressed by selenium in cultured orbital fibroblasts of patients with GO. IL-1ß and IL-6 were not suppressed by selenium in cultured orbital fibroblasts of patients with GO. Selenium pretreatment reduced intracellular ROS generation stimulated by H2O2 in cultured orbital fibroblasts of patients with GO. CONCLUSIONS: In conclusion, hyaluronan production, inflammatory cytokines, and intracellular ROS generation were suppressed by selenium in cultured orbital fibroblasts of patients with GO. Several inflammatory cytokines may be suppressed by selenium in cultured orbital fibroblasts of patients with GO. This study provide the basis for use of selenium in the treatment of GO.

Resection of an orbital haemangiopericytoma after direct intraoperative injection of 40% N-butyl-2-cyanoacrylate and 60% Lipiodol.

Haemangiopericytoma is a highly vascular tumour, which is a rare soft tissue lesion that may arise anywhere in the body, including the orbit. During its surgical resection, it is too friable for the surgeon to handle and it can bleed severely causing many problems to the surgeon. That is why many surgical approaches have been reported till now, aiming at total excision with minimal blood loss. In this case, total resection of an orbital haemangiopericytoma in a 61-year-old Caucasian woman, using an intraoperative 23G needle injection of 40% n-butyl-2-cyanoacrylate and 60% lipiodol, is presented. The lesion was directly injected under fluoroscopic visualization, after which it became firm enough to be surgically removed without significant bleeding.

Gypenosides Protect Orbital Fibroblasts in Graves Ophthalmopathy via Anti-Inflammation and Anti-Fibrosis Effects.

Purpose: To investigate the effect of Gypenosides (Gyps) on the inflammation and fibrosis in orbital fibroblasts (OFs) in Graves ophthalmopathy (GO). Methods: Bioinformatics analyses were performed to identify the enriched genes and signaling pathways related to Gyps function. For ex vivo experiments, OFs were cultured from orbital connective tissues from patients with GO. OF proliferation was estimated by Cell Counting Kit-8 assay. Effects of Gyps treatment on interleukin (IL)-1ß-induced inflammation and transforming growth factor-ß1 (TGF-ß1)-induced fibrosis were evaluated by real-time quantitative PCR (RT-qPCR), enzyme-linked immunosorbent assay (ELISA), and Western blotting. OFs were treated with IL-1ß or TGF-ß1 in the absence or presence of Gyps pretreatment, and the levels of related mRNA or proteins were evaluated by RT-qPCR or ELISA. Results: Eight inflammation-related target genes and nine fibrosis-related target genes were screened out. These genes were mainly enriched in pathways corresponding to inflammation and fibrosis, respectively. IL-1ß-induced upregulation of inflammatory cytokines, and TGF-ß-induced upregulation of fibrotic mediators in OFs were downregulated by Gyps. Moreover, Gyps reduced the activation of Toll like receptors 4/nuclear factor-κ B signaling and TGF-ß1/SMAD2/SMAD4 signaling in GO OFs. Conclusions: Gyps could protect GO-derived OFs against IL-1ß-induced inflammation and TGF-ß1-induced fibrosis. Thus Gyps might have therapeutic potential on inflammation and fibrosis in GO.

Therapeutic Effect of Guggulsterone in Primary Cultured Orbital Fibroblasts Obtained From Patients with Graves' Orbitopathy.

Purpose: Inflammation, hyaluronan production, and adipogenesis are the main pathological events leading to Graves' orbitopathy (GO). Guggulsterone (GS), a phytosterol found in the resin of the guggul plant, is a well-known treatment for several inflammatory disorders, such as arthritis, obesity, and hyperlipidemia. Here we investigated the effects of GS treatment on GO pathology. Methods: Using primary cultures of orbital fibroblasts from GO patients and non-GO controls, we examined the effects of GS on hyaluronan production and the production of proinflammatory cytokines induced by interleukin (IL)-1ß, using real-time reverse transcription-polymerase chain reaction analysis, western blots, and enzyme-linked immunosorbent assays. Further, adipogenic differentiation was evaluated by quantification of Oil Red O staining and assessment of protein levels of peroxisome proliferator activator gamma (PPARγ), CCAAT-enhancer-binding proteins (C/EBP) α and ß, and sterol regulatory element-binding protein-1 (SREBP-1). Results: Treatment with noncytotoxic concentrations of GS resulted in the dose-dependent inhibition of IL-1ß-induced inflammatory cytokines, including IL-6, IL-8, MCP-1, and COX-2, at both mRNA and protein levels. The hyaluronan level was also significantly suppressed by GS. Moreover, GS significantly decreased the formation of lipid droplets and expression of PPARγ, C/EBP α/ß, and SREBP-1 in a dose-dependent manner. GS pretreatment attenuated the phosphorylation of nuclear factor-kappa B induced by IL-1ß. Conclusions: Our data show significant inhibitory effects of GS on inflammation, production of hyaluronan, and adipogenesis in orbital fibroblasts. To our knowledge, this is the first in vitro preclinical evidence of the therapeutic effect of GS in GO.

Combined retro-peribulbar and subconjunctival anesthesia for evisceration surgery.

PURPOSE: To evaluate the efficacy of retro-peribulbar and subconjunctival anesthesia associated with intravenous sedation in patients undergoing evisceration and orbital implant placement. METHODS: The charts of 217 patients who underwent evisceration with trans-scleral implant placement were reviewed. Midazolam and fentanyl were used for intravenous sedation. For local anesthesia, a combination of lidocaine with epinephrine and bupivacaine was injected into the retrobulbar, upper peribulbar, and subconjunctival areas. The intraoperative pain and need for supplemental anesthetic injection were recorded prospectively. RESULTS: The surgery was performed with local anesthesia in 116 patients (53%) and with general anesthesia in 101 patients (47%). Patients were significantly older in the local anesthesia group than in the general anesthesia group (mean age, 59.9 years vs 45.2 years; P < .05). Supplemental retrobulbar anesthesia was required in 5 patients (4.3%). Transition to general anesthesia was required in 1 patient (0.9%) due to severe anxiety. Orbital hemorrhage developed after retrobulbar injection in 1 patient (0.9%), but did not preclude performing evisceration. CONCLUSIONS: Combined retro-peribulbar and subconjunctival anesthesia with intravenous sedation can provide safe and effective intraoperative analgesia for evisceration surgery with trans-scleral implant placement.

A prospective comparison of the efficacy of 0.5% bupivacaine vs 0.75% ropivacaine in peribulbar anesthesia for vitreoretinal surgery.

Purpose: To date, there is no information on the comparison of the effect of 0.5% bupivacaine with 0.75% ropivacaine solution for vitreoretinal surgery. The aim of the study was to: compare the efficacy of 0.5% bupivacaine with 0.75% ropivacaine in peribulbar anesthesia for vitreoretinal surgery. This was a prospective randomized double-blinded observational study in a hospital setting. Sixty patients planned for vitreoretinal surgery were randomized into two groups based on the peribulbar injection administered either with 0.5% bupivacaine or 0.75% ropivacaine solution, as Group B (n = 30) and Group R (n = 30), respectively. Time of onset of analgesia, akinesia, and the need for supplemental anesthesia were noted. Student's t-test or Mann-Whitney U test were used for comparing continuous variables and Chi-square or a Fischer exact test were used as appropriate for comparing two proportions. Results: The patients in Group R showed an earlier onset of both, analgesia (1.97 min vs. 2.10 min, P = 0.002) and akinesia (2.77 min vs. 4.20 min, P < 0.001) compared with the patients in Group B. The efficacy of the block attained was Grade 5 (adequate anesthesia and akinesia without supplementation) in about 97% of the patients in Group R while only 90% in Group B. However, the differences between the groups for the efficacy of the block were not statistically significant (P = 0.301) neither for Grades 5 nor for Grade 4 and 3 (P = 1.00 for both). The onset of postoperative pain was similar for both groups (P = 1.00). Conclusion: We concluded that 0.75% ropivacaine is a better choice of local anesthetic solution for patients undergoing primary vitreoretinal surgery compared with 0.5% bupivacaine.

Efficacy and Safety of a Novel Blunt Cannula Trans-Sub-Tenon's Retrobulbar Block for Vitreoretinal Surgery.

PURPOSE: To evaluate a novel trans-sub-Tenon's retrobulbar block (TSTRB) compared to sub-Tenon's block (STB) and peribulbar block (PBB) anesthesia for vitreoretinal surgery. METHODS: This study was a prospective evaluation of cases undergoing TSTRB, STB, or PBB. The Kallio scale and Brahma scales were used to score hemorrhage and extraocular motility, respectively. Pain was documented on a visual analog score graded (1-10) at induction, intraoperatively, and postoperatively, any confounding variables were noted. RESULTS: Seventy eyes have been used in this analysis, of which TSTRB was used in 37% (n = 26), PBB in 34% (n = 24), and STB in 29% (n = 20). Postoperative analgesia was required by 10% (n = 2) of STB and 8% (n = 2) of PBB; none of the TSTRB cases required analgesia (P = 0.003). The mean volume required with each technique was as follows: TSTRB, 4.8 ml; STB, 5.3 ml; and PBB, 10.4 ml (P = 0.030). The volume of anesthesia was correlated with the level of proptosis and even more important affected the ease of surgery most (P = 0.005). Akinesia was greatest with TSTRB > PBB > STB (P = 0.040). There were no complications such as brainstem anesthesia, globe perforation, or retrobulbar hemorrhage. CONCLUSION: Intentionally extending a STB into the retrobulbar space, via a TSTRB fenestration utilizes a familiar skill set. TSTRB produced the best levels of reduced kinesia during surgery and increased duration of postoperative analgesia. The technique uses a small-volume anesthesia.

Orbital supratrochlear fistula secondary to anaesthetic block in cataract surgery. / Fístula orbitaria supratroclear secundaria a la realización de un bloqueo para anestesia en una cirugía de catarata.

A case is described of a woman with history of right peribulbar nerve block prior to cataract surgery that, within a few days, presented with a trochlear intraorbital arteriovenous fistula. This was resolved without sequelae after three months by performing intermittent homolateral carotid massages. This is the first case of supratrochlear intraorbital arteriovenous fistula. There are only 8 cases reported of traumatic intraorbital arteriovenous fistula, and only one was with post-peribulbar anaesthesia.