Haemorrhagic complications following cataract and vitreoretinal surgery with sub-Tenon's block in patients receiving non-vitamin K oral anticoagulant agents: A prospective audit.

There is a lack of data to support either continuation or interruption of non-vitamin K oral anticoagulants for cataract and vitreoretinal surgery. A prospective audit was undertaken of 291 patients undergoing cataract surgery or vitreoretinal surgery, predominantly under sub-Tenon's block, while continuing these agents. The median time from last non-vitamin K oral anticoagulant dose to the insertion of sub-Tenon's block was five hours. No patient required emergency reversal of anticoagulation. There were no sight-threatening complications in the immediate perioperative period, although two vitreoretinal patients (3.8%) had a moderate haemorrhagic complication on day five, and two cataract patients (0.8%) had a minor haemorrhagic complication on days one and 14 postoperatively. Despite continuing their non-vitamin K oral anticoagulants, three (1%) cataract patients had a moderate thromboembolic complication within the 30-day postoperative period. The risk of haemorrhagic complications associated with continuation of anticoagulation with non-vitamin K oral anticoagulants for cataract and vitreoretinal surgery is low, and this audit supports the continuation of non-vitamin K oral anticoagulants for our patients having cataract and vitreoretinal surgery.

Comparison of topical and retrobulbar anesthesia in terms of pain experience during silicone oil extraction.

PURPOSE: To compare the use of topical anesthesia and retrobulbar anesthesia during silicone oil removal with a mixed pars plana technique, through evaluating the pain experience of patients. METHODS: We selected patients according to their behavior during previous vitreoretinal surgery and ophthalmologic examinations and divided them into two anesthesia groups: topical (n=36) and retrobulbar (n=33). We used a mixed technique for the passive removal of silicone oil in both groups. During each step of the surgery, the patients' pain experience and the surgeon's comfort were scored according to a pain scale. RESULTS: The pain experienced during the application of the anesthesia was significantly greater in the retrobulbar group (p<0.001). The topical group experienced greater pain during trocar insertion (p<0.001). There was no significant difference between the groups regarding the overall pain experience or complications. CONCLUSIONS: The pain experience of the selected patients during silicone oil removal was comparable between the topical and the retrobulbar anesthesia. Topical anesthesia with the mixed pars plana technique is an effective and safe alternative option for silicone oil removal surgery.

Comparison of topical and retrobulbar anesthesia in terms of pain experience during silicone oil extraction / Comparação da sensação de dor durante a extração de óleo de silicone sob anestesia tópica e retrobulbar

ABSTRACT Purpose: To compare the use of topical anesthesia and retrobulbar anesthesia during silicone oil removal with a mixed pars plana technique, through evaluating the pain experience of patients. Methods: We selected patients according to their behavior during previous vitreoretinal surgery and ophthalmologic examinations and divided them into two anesthesia groups: topical (n=36) and retrobulbar (n=33). We used a mixed technique for the passive removal of silicone oil in both groups. During each step of the surgery, the patients' pain experience and the surgeon's comfort were scored according to a pain scale. Results: The pain experienced during the application of the anesthesia was significantly greater in the retrobulbar group (p<0.001). The topical group experienced greater pain during trocar insertion (p<0.001). There was no significant difference between the groups regarding the overall pain experience or complications. Conclusions: The pain experience of the selected patients during silicone oil removal was comparable between the topical and the retrobulbar anesthesia. Topical anesthesia with the mixed pars plana technique is an effective and safe alternative option for silicone oil removal surgery.

RESUMO Objetivo: Comparar a sensação de dor de pacientes durante a remoção do óleo de silicone sob anestesia tópica e retrobulbar, usando uma técnica via pars plana combinada. Métodos: Os pacientes foram selecionados, de acordo com suas atitudes durante cirurgia vitreorretiniana prévia e exames oftalmológicos, e divididos em dois grupos: anestesia tópica e retrobulbar. Para a remoção passiva do óleo de silicone, utilizou-se uma técnica combinada em ambos os grupos. A sensação de dor dos pacientes e o conforto do cirurgião foram classificados através de uma escala de dor durante cada etapa da cirurgia. Resultados: Os grupos anestesia tópica e retrobulbar incluíram 36 e 33 pacientes, respectivamente. A sensação de dor durante a aplicação da anestesia foi significativamente maior no grupo retrobulbar (p<0,001). O grupo anestesia tópica sentiu mais dor durante a inserção do trocarte (p<0,001). Não houve diferença significativa entre os grupos em relação à sensação geral de dor e a complicações. Conclusões: A sensação de dor é comparável entre a anestesia tópica e a retrobulbar durante a remoção de óleo de silicone. A combinação de anestesia tópica e uma técnica via pars plana é uma opção alternativa eficaz e segura para a cirurgia de remoção de óleo de silicone.

CONTRALATERAL ANESTHESIA IN TWO PATIENTS AFTER RETROBULBAR BLOCK.

PURPOSE: To report a case series of two patients with contralateral anesthesia after retrobulbar block. METHODS: Retrospective review of two cases and review of the literature. RESULTS: Two patients of one practitioner received contralateral anesthesia after retrobulbar block for posterior segment surgery. Patient 1 suffered from transient contralateral akinesia, whereas Patient 2 experienced transient contralateral amaurosis. CONCLUSION: Posterior spread of anesthetics is a rare but potentially serious complication of retrobulbar anesthesia caused by spread of anesthetics along the optic nerve sheath. Modification of injection technique can decrease the risk of this complication.

Retrobulbar Block in Pediatric Vitreoretinal Surgery Eliminates the Need for Intraoperative Fentanyl and Postoperative Analgesia: A Randomized Controlled Study.

BACKGROUND AND OBJECTIVES: Pediatric ophthalmologic surgery is traditionally accomplished by general anesthesia with opioids, but respiratory depression remains a major concern. Our study compared the efficacy of retrobulbar block with systemic fentanyl on pain, hemodynamic, and stress response in pediatric vitreoretinal surgery. METHODS: A prospective double-blind, randomized controlled study was performed comparing retrobulbar block with intravenously administered fentanyl in 28 children aged 1 to 6 years undergoing vitreoretinal surgery. After general anesthesia was induced, retrobulbar block with 0.5% ropivacaine was accomplished in group RB (general anesthesia plus retrobulbar block) (n = 13), and normal saline was injected into retrobulbar space in group F (general anesthesia alone) (n = 15). Fentanyl 0.5 µg/kg was administered when signs of inadequate anesthesia were observed. RESULTS: Respiratory depression (defined as a persistent respiratory rate <10 breaths/min or persistent oxygen desaturation <92%) was observed in 5 of 15 patients in group F after laryngeal mask airway was removed in the operating room, compared with none in group RB. All children in group F consumed intraoperative fentanyl rescue (average intraoperative fentanyl consumption, 1.3 ± 0.3 µg/kg) compared with none in group RB. Pain scores assessed with Faces, Legs, Activity, Cry and Consolability were significantly lower in group RB than in group F (1 [0, 3.5] vs 5 [3, 7], P = 0.003) immediately after laryngeal mask airway removal. Heart rate in group RB was significantly lower than that in group F before anesthesia induction, at the beginning and end of surgery, respectively. Mean blood pressure in group RB was significantly lower than that in group F at the beginning of surgery. Postoperative tumor necrosis factor α concentration in group RB was significantly lower than that in group F. CONCLUSIONS: Retrobulbar block is safe and effective as an alternative to systemic fentanyl and could provide better pain management, hemodynamic suppression, and stress response suppression in pediatric vitreoretinal surgery.

The Effect of Low-Dose Dexmedetomidine as an Adjuvant to Levobupivacaine in Patients Undergoing Vitreoretinal Surgery Under Sub-Tenon's Block Anesthesia.

BACKGROUND: This study evaluated the motor and sensory block durations and the postoperative analgesic effects of adding dexmedetomidine to levobupivacaine for sub-Tenon's block anesthesia in patients undergoing vitreoretinal surgery. Motor and sensory block durations were considered as a primary end point. METHODS: Sixty ASA physical status I to III patients subjected to vitreoretinal surgery under sub-Tenon's block anesthesia were randomly divided equally into 2 groups, depending on the local anesthesia solution used, to receive 4 mL of 0.75% levobupivacaine plus 15 IU hyaluronidase diluted with 1 mL normal saline (group L) or 4 mL of 0.75% levobupivacaine plus 15 IU hyaluronidase and 20 µg dexmedetomidine diluted with 1 mL normal saline (group LD). The total volume of the local anesthesia solution used was 5 mL. Motor block and sensory block durations were evaluated until the return of normal motor and sensory functions. The sedation level was assessed during the surgery period and 24 hours postoperatively, together with the degree of postoperative pain. The total diclofenac consumption (milligrams) and the number of patients (%) who required tramadol were recorded. The sleep quality of the first postoperative night was assessed using the Consensus Sleep Diary. RESULTS: Dexmedetomidine provided significantly longer motor block duration (371.90 ± 48.10 vs 264.13 ± 41.48 minutes, P = 0.001) and significantly longer sensory block duration (499.10 ± 51.76 vs 344.33 ± 45.46 minutes, P = 0.001) compared with levobupivacaine alone. Furthermore, the patients in the dexmedetomidine group achieved significantly (P < 0.0001) greater levels of sedation during the surgery period and for 12 hours postoperatively together with significantly (P < 0.0001) lower values of verbal numeric rating scale of pain between the periods from 4 to 12 hours postoperatively compared with the patients in the levobupivacaine group. There was significantly (P = 0.001) less diclofenac consumed (mg) in the dexmedetomidine group. The patients in the dexmedetomidine group reported significantly higher rates of good sleep quality on the first postoperative night (70%) compared with those in the levobupivacaine group (30%; P < 0.0001). CONCLUSIONS: For patients undergoing vitreoretinal surgery, adding 20 µg of dexmedetomidine to levobupivacaine for sub-Tenon's block anesthesia in vitreoretinal surgery extended the motor and sensory block durations and provided more effective postoperative analgesia with improvement in the sleep quality in the first postoperative night compared with levobupivacaine alone.

Understanding people's experience of vitreo-retinal day surgery: a Gadamerian-guided study.

AIM: This paper is a report of a study that aimed to understand the individual's experience of day surgery for repair of vitreo-retinal pathology. BACKGROUND: Day surgery evolved as a global phenomenon in response to tensions existing between community demand for health-care services and fiscal limitations. Since then vitreo-retinal surgery has been routinely performed as day surgery. Whilst studies have reported on patients' experience's following inpatient surgery, there has been limited investigation of vitreo-retinal day surgery from the patient's perspective. METHODS: In-depth unstructured interviews with 18 people were conducted between July 2006 and December 2007. Data analysis using philosophical hermeneutic techniques enabled a co-constructed understanding, where, the 'conditions of understanding' as described by Gadamer were established. FINDINGS: Guided by a Gadamerian approach to analysis, four constitutive themes were identified: 'the physical Self', 'the psychological Self', 'the historically located Self' and 'the Self located in the community'. Within each theme the participant's positive and negative experiences were understood in the context of human need, and gaps in nursing care became illuminated. These experiences included: pain, nausea, problematic self-care and psychological angst. CONCLUSION: Insights into the experience of vitreo-retinal day surgery, gained from this study can be used to inform nurses planning care for people with vitreo-retinal pathology. Nursing care must address broader patient needs that span multiple human domains, particularly when vision has been threatened by complex pathology.