Deep topical anesthesia with ropivacaine-soaked sponge for phacoemulsification.

PURPOSE: To assess safety and efficacy of deep topical anesthesia with ropivacaine-soaked sponge compared with topical anesthesia with oxybuprocaine in patients undergoing phacoemulsification. METHODS: This was a retrospective study where records of patients operated for cataract were evaluated. Patients using a visual analogue scale scored pain during surgery, and the surgeon on a questionnaire recorded ease of operation. Medical records were evaluated for patients who received topical anesthesia with multiple administrations of oxybuprocaine 0.4% or those who received deep topical anesthesia with a polyvinyl acetal sponge impregnated with ropivacaine 0.75% and positioned under the eyelid 30 min before surgery. RESULTS: A total of one hundred patient records, equally divided in patients receiving deep topical anesthesia or topical anesthesia, were included. The visual analogue scale scores among the groups were statistically significant for a lower pain score in patients who received deep topical anesthesia with ropivacaine-soaked sponges (p = 0.0069). The average surgeon score was significantly higher for the deep topical anesthesia group indicating favorable ease of surgery (p = 0.0341). Six patients had major complications during surgery. No additional anesthesia was necessary to manage the complications in four patients in the deep anesthesia group, whereas propofol was used for the induction and maintenance of anesthesia in two patients in the topical anesthesia group. CONCLUSIONS: Deep topical anesthesia with ropivacaine-soaked sponges performed as well as topical oxybuprocaine regarding safety and efficacy. It provided a lower patient pain score, favorable surgeon satisfaction, and long-lasting anesthesia.

Progesterone Application to the Rat Forehead Produces Corneal Antinociception.

Purpose: Ocular pain and discomfort are the most defining symptoms of dry eye disease. We determined the ability of topical progesterone to affect corneal sensitivity and brainstem processing of nociceptive inputs. Methods: Progesterone or vehicle gel was applied to the shaved forehead in male Sprague Dawley rats. As a site control, gel also was applied to the cheek on the side contralateral to corneal stimulation. Corneal mechanical thresholds were determined using the Cochet-Bonnet esthesiometer in intact and lacrimal gland excision-induced dry eye animals. Eye wipe behaviors in response to hypertonic saline and capsaicin were examined, and corneal mustard oil-induced c-Fos immunohistochemistry was quantified in the brainstem spinal trigeminal nucleus. Results: Progesterone gel application to the forehead, but not the contralateral cheek, increased corneal mechanical thresholds in intact and lacrimal gland excision animals beginning <30 minutes after treatment. Subcutaneous injection of the local anesthetic bupivacaine into the forehead region before application of progesterone prevented the increase in corneal mechanical thresholds. Furthermore, progesterone decreased capsaicin-evoked eye wipe behavior in intact animals and hypertonic saline evoked eye wipe behavior in dry eye animals. The number of Fos-positive neurons located in the caudal region of the spinal trigeminal nucleus after corneal mustard oil application was reduced in progesterone-treated animals. Conclusions: Results from this study indicate that progesterone, when applied to the forehead, produces analgesia as indicated by increased corneal mechanical thresholds and decreased nociceptive responses to hypertonic saline and capsaicin.

Peribulbar anesthesia in sclero-retinal surgery: two quadrants vs single injection.

PURPOSE: To evaluate the advantage of peribulbar anesthesia in two quadrants (infero-temporal and upper nasal) vs single injection technique (infero-temporal) for scleral rhegmatogenous retinal detachment surgery (RRD). PATIENTS AND METHODS: 57 patients, aged between 33 and 75 years (57.01 ± 8.68), waiting for retinal detachment surgery, were randomized in two groups: a group S (29 patients), with single quadrant injection technique and a group C (28 patients) with two quadrants injection. Patients in Group S were injected in two quadrants with a 10 ml mixture containing Mepivacaine 2% 5 ml and Ropivacaine 0.75% 5 ml, with hyaluronidase 10 IU/ ml. Patients in group C were injected with the same anesthetic mixture in one quadrant. Number of additional injection, during surgery, in two groups, were reported. Pain was tested with VAS (Verbal Analogue Scale 0-10) after regional block, when muscles were insulated, during scleral buckling positioning, when conjunctive was closed and 6, 12, 24 hours after surgery. RESULTS: The need for a second peribulbar injection of anesthetic occurred in 9 patients of group C (32.14%); further injection was necessary in 1 patient (3.57%) of group S during scleral buckling (VAS = 7), statistically significant (p <0.05). Postoperative VAS 6 - 12 - 24 hours after surgery was not significant. CONCLUSIONS: The peribulbar anesthesia may be proposed in scleral surgery of retinal detachment; the injection in two quadrants secured solid and satisfactory anesthesia, increasing the outcome of retinal surgery in loco-regional anesthesia.

Comparison of Lidocaine Gel-Assisted Transconjunctival and Transcutaneous Local Anesthesia for Outpatient Eyelid Surgery.

PURPOSE: Determine whether transconjunctival local anesthesia using 2% lidocaine gel decreases pain perception in comparison with transcutaneous anesthesia in patients undergoing outpatient eyelid surgery. METHODS: This is a randomized controlled clinical trial. This study approved by an institutional review board and adhered to the Declaration of Helsinki and the Health Insurance Portability and Accountability Act. A total of 120 patients undergoing bilateral upper or lower eyelid surgery were enlisted. Topical 2% lidocaine gel was administered to the palpebral conjunctiva for 1 minute, followed by a local transconjunctival injection. Local anesthetic was administered to the contralateral eyelid by a transcutaneous approach without use of topical anesthetic. Both injections were 1 ml of 1% lidocaine with epinephrine 1:100,000 on a 30-gauge needle. After each injection, patients rated the pain on a 0-to-10 visual analog scale. Patients were also asked for preference between the 2 sides. RESULTS: The mean pain scores were 2.33 (standard deviation 0.98) for the transconjunctival side and 3.42 (standard deviation 0.88) for the transcutaneous side. The reduction in pain scores for lidocaine gel-treated sides was statistically significant (p < 0.001) when controlling for side of intervention, upper versus lower eyelid procedures, sex of participants, and type of procedure. In addition, 85% of participants found the transconjunctival injection to be less painful than the transcutaneous (p < 0.001). CONCLUSIONS: Transconjunctival local anesthesia in conjunction with topical anesthesia with 2% lidocaine gel provides a clinically and statistically significant decrease in perceived pain when compared with transcutaneous anesthesia in patients undergoing outpatient eyelid surgery.

Pregabalin and gabapentin for post-photorefractive keratectomy pain: a randomized controlled trial.

PURPOSE: To evaluate the efficacy of pregabalin and gabapentin for reducing post-photorefractive keratectomy (PRK) pain. METHODS: In this randomized clinical trial, 150 subjects undergoing PRK were allocated into 3 groups. In addition to the routine regimen, pregabalin 75 mg, gabapentin 300 mg, and placebo were administered 3 times daily for 3 days, in groups 1, 2, and 3, respectively. Subjects could take acetaminophen-codeine 300/10 mg tablets every 4 hours as needed. Patients completed a pain assessment survey (visual analogue scale ranging from 0 = no pain to 10 = most severe pain) 7 times in the first 3 days following PRK and also recorded the number of consumed acetaminophen-codeine tablets. RESULTS: Age, sex, refractive error, ablation depth, and mitomycin-C (MMC) application were similar in the 3 study groups (all p values>0.05). Overall pain scores in the placebo group were 0.9 and 1 unit higher than the pregabalin (p=0.029) and gabapentin (p=0.023) groups, respectively. Severe pain (score >7) was more frequent in the placebo group on the morning of the first postoperative day (p=0.043). The difference in the number of consumed acetaminophen-codeine tablets was statistically borderline (p=0.061) and less in the pregabalin (7.9 ± 5.2) and gabapentin (9.0 ± 4.1) groups in comparison to the placebo group (10.3 ± 5.6). CONCLUSIONS: Pregabalin and gabapentin seem to be helpful in alleviating post-PRK pain when combined with other measures. Depending on availability, either compound can be used as an adjuvant for pain control in this setting.

Preemptive analgesia with ropivacaine for pars plana vitrectomy: randomized controlled trial on efficacy and required dose.

BACKGROUND: The rationale of preemptive analgesia in ocular surgery is avoiding central sensitization because of nociceptive stimuli. The applicability in clinical practice has been argued because evidence for a relevant effect is missing. The present study attempts to demonstrate a clinically relevant pain reduction by preemptive peribulbar ropivacaine injection. METHODS: Sixty patients scheduled for vitrectomy under general anesthesia between March and June 2007 were randomly assigned to receive 0.75% ropivacaine with 75 IU of hyaluronidase as peribulbar injection of 1, 3, or 5 mL before or 5 mL after surgery. Control subjects were 30 patients without any additional analgesic treatment. Groups were compared regarding procedure duration, consumed amount of analgesics during and after surgery, and pain 1, 3, and 24 hours postoperatively. RESULTS: Postoperative pain was most marked in control subjects and in the group that received the injection after surgery. Before surgery, the dose of 5 mL of ropivacaine was most effective (postoperative pain median = 0), whereas patients who had received 1 mL or 3 mL reported some pain. CONCLUSION: The study highlights the benefit of the concept of preemptive analgesia in general: the peribulbar injection of 5 mL of 0.75% ropivacaine before surgery provides a substantial benefit in terms of analgesic demand and postoperative discomfort.

Topical anesthesia versus regional anesthesia for cataract surgery: a meta-analysis of randomized controlled trials.

PURPOSE: To examine possible differences in the clinical outcomes of topical anesthesia (TA) and regional anesthesia including retrobulbar anesthesia (RBA) and peribulbar anesthesia (PBA) in phacoemulsification. DESIGN: Systematic review and meta-analysis. PARTICIPANTS: Patients from previously published randomized controlled trials (RCTs) of phacoemulsification under TA and RBA/PBA reporting clinical outcomes. METHODS: A comprehensive literature search was performed according to the Cochrane Collaboration method to identify RCTs that compare TA and RBA/PBA in phacoemulsification. MAIN OUTCOME MEASURES: Primary outcome parameters investigated were pain score during and after surgery, intraoperative difficulties and inadvertent ocular movement, intraoperative necessity to administer additional anesthesia, and patient preference. Secondary outcome parameters investigated were postoperative visual acuity, anesthesia-related complications, intraoperative complications, and severe local or systemic complications. RESULTS: Fifteen studies were identified and analyzed to compare TA (1084 eyes) with RBA/PBA (1121 eyes) in phacoemulsification. Data synthesis showed that intraoperative and postoperative pain perception was significantly higher in the TA group (P < 0.05). The TA group showed more frequent inadvertent ocular movement (P < 0.05) and a greater intraoperative need for supplementary anesthesia (P = 0.03). There was no statistically significant difference between the 2 groups in intraoperative difficulties as assessed by the surgeons (P > 0.05). Patients significantly preferred TA (P < 0.00001). The RBA/PBA group had more frequent anesthesia-related complications, such as chemosis, periorbital hematoma, and subconjunctival hemorrhage (P < 0.05). There was no statistically significant difference in surgery-related complications (P > 0.05). CONCLUSIONS: Compared with RBA/PBA, TA does not provide the same excellent pain relief in cataract surgery; however, it achieves similar surgical outcomes. Topical anesthesia reduces injection-related complications and alleviates patients' fear of injection. The choice of TA is not suitable for patients with a higher initial blood pressure or greater pain perception.

Randomized comparative clinical study of cryoanalgesia versus topical anesthesia in clear corneal phacoemulsification.

PURPOSE: To compare intraoperative pain scores and objective stress signs during clear corneal phacoemulsification under cryoanalgesia and topical anesthesia. SETTING: Hospital Ramón y Cajal, Madrid, and Hospital Universitario Nuestra Sra. de la Candelaria, Tenerife, Canary Islands, Spain. METHODS: Eighty-two patients were randomized to have phacoemulsification under cryoanalgesia or topical anesthesia. Uncooperative patients and those with shallow anterior chamber and small pupils were excluded. In case of breakthrough pain during the surgery, a supplemental anesthesia protocol was established. Each patient was asked to grade the severity of pain on a 4-point scale (verbal description score; 0=none, 1=little, 2=some, or 3=much). Immediately after surgery, the general discomfort and pain were evaluated. Surgeon stress was evaluated during surgery. A comparison of the 2 groups was performed using a statistical analysis of variance. RESULTS: Supplemental anesthesia was required in 1 patient in each group. A total of 95.23% of patients would repeat the same technique under cryoanalgesia versus 97.5% under topical anesthesia. Similar pain levels and surgical stress scores were noted in both groups. CONCLUSIONS: Cryoanalgesia clear corneal phacoemulsification was safe with an acceptable level of pain. It induced a physiological stress response to that of topical anesthesia (blood pressure and heart rate). Cryoanalgesia was preferred over topical anesthesia by some patients. It is a suitable technique for anesthetic allergy cases.