Cover Story: Ocular anesthesia trends toward 'fewer needles, no pain'

Various innovations in technology and methods have revolutionized ocular surgery by maximizing outcomes and safety, shortening surgical time and reducing stress on patients.

Patient comfort and immobility are also critical to surgical success and safety, and anesthesia plays a key role. Currently, ophthalmic surgeons use intravenous sedation and topical or infiltration methods such as retrobulbar anesthesia, peribulbar anesthesia and subconjunctival anesthesia to achieve akinesia.

Patients expect less invasive and painless surgery, according to Melissa Toyos, MD, FACS.

“We’re dealing with people with higher levels of expectations. They’re not necessarily willing or used to suffering in any way. They definitely want to be comfortable,” she said. “I think all of the trends are less invasive — fewer needles, no pain.”

In the past, ophthalmic surgeons would perform retrobulbar and peribulbar blocks, in which local anesthetic is injected behind the eye, according to John P. Berdahl, MD. The long-acting anesthetics would prevent the eye from moving and make the surgery painless. “However, nobody really loves having a needle stuck behind their eye,” he said.

Whereas a block might still be preferred for more complex anterior segment surgeries, cataract surgeons generally prefer sedation and intraocular anesthetics for more routine procedures. For retinal procedures, a local anesthetic or block may be preferred. And for ophthalmic procedures in children, general anesthesia is the norm.

Practices and preferences

Retrobulbar block and peribulbar block are generally safe for more complex surgeries, such as cornea transplant and glaucoma procedures, but for cataract surgery it is uncommon, according to Berdahl.

Click here to read the full cover story, published in Ocular Surgery News U.S. Edition, September 25, 2016.