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BLOG: In defense of needles
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If we were to describe an ideal anesthetic agent for eye surgery, it would be one that works for virtually every patient, carries few local risks, provides deep anesthesia and akinesia, and has no unwanted systemic effects. Furthermore, a truly effective anesthetic would require only sparse and brief sedation for the patient and would immobilize the eye from unwanted movements. That sounds an awful lot like a peribulbar block.
While I perform 90% of my procedures under topical anesthetic, peribulbar anesthesia for routine cataract surgery has great value in certain patients. First, among those who are particularly nervous or have a tendency to squeeze their eyelids during pressure measurements or when drops are administered, it’s difficult to keep them comfortable during surgery without significant, sustained sedation. With a peribulbar block, this is just not necessary; we give an upfront dose of sedation to give the block, and patients remain comfortable throughout the procedure. Patients with limited eyelid exposure also benefit from peribulbar anesthetic, in which the extra fluid in the orbit brings the eye a bit forward. Coupled with a Honan balloon, peribulbar anesthesia yields this exposure without causing vitreous pressure.
Pupils that are marginally dilated gain about 1 mm in size when a peribulbar anesthetic is administered. Sometimes this is the deciding factor to use a peribulbar in my OR — we are nudged toward a peribulbar in patients with poor dilation.
How safe is peribulbar anesthesia? In about 50,000 cataract surgeries that my anesthesiologist has provided peribulbar anesthetics, his rate of noticeable eyelid bruising is about 1%, and we have never encountered a globe perforation or other significant, long-lasting side effect. Rather, we believe that many of those patients we treat with peribulbar fare much better than they would have with topical anesthetic. Similar results might be achieved with sub-Tenon’s injections, retrobulbar placement of anesthetic or other routes of administration.
I gladly embrace new methods of sedating patients and approaches that allow safe topical anesthesia in more patients, but it’s unlikely that I will entirely give up my tried-and-true peribulbar injection for appropriate candidates. As we’re taking the drapes off at the end of the case, it’s the peribulbar patients who most commonly ask, “When are we going to start the surgery?”