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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 111  |  Issue : 3  |  Page : 108-115

Evaluation of small-volume (3 ml) ophthalmic anaesthesia for both subtenon anaesthesia using blunt-tipped curved needle and single medial canthal injection with sharp needle for phacoemulsification surgery


1 Department of Ophthalmology, Research Institute of Ophthalmology, Giza, Egypt
2 Department of Anaesthesia, Research Institute of Ophthalmology, Giza, Egypt

Date of Submission16-May-2018
Date of Acceptance10-Jul-2018
Date of Web Publication22-Nov-2018

Correspondence Address:
Dr. Tamer A Refai
Department of Ophthalmology, Research Institute of Ophthalmology, Giza, 12211
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_29_18

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  Abstract 


Introduction Medial canthus injection as well as subtenon anaesthesia has been used in anterior segment surgery. In this research, we compared the effectiveness and safety of small volume (3 ml) for either technique.
Patients and methods Forty eyes of 40 patients undergoing phacoemulsification surgery at the Research Institute of Ophthalmology, Giza, Egypt, were divided into two groups: group A (20 eyes) included eyes of patients who received subtenon injection with blunt-tipped curved needle and group B (20 eyes) included eyes of patients who received single injection at medial canthus with sharp needle. Following either injection, the akinesia score and surgeon and patient satisfaction scores were reported as well as any related complications. The studied data were subjected to statistical analysis and results emphasized.
Results In our study, the akinesia score had a mean value of 6±2.43 for subtenon group and 3.25±2.61 for the single injection medial canthus group, with a highly significant difference (P<0.01). A total of 17 (85%) patients were satisfied from anaesthesia in group A versus 12 (60%) patients in group B, with a highly significant difference (P<0.001). Moreover, 12 (60%) cases needed facial supplementation in group A versus zero (0%) cases in group B, with a highly significant difference (P<0.01). There was no statistically significant difference among both groups regarding surgeon satisfaction as well as rate of complications related to anaesthesia injection (P>0.05).
Conclusion For phacoemulsification, subtenon anaesthesia using small volume of 3 ml was more effective regarding better akinesia score compared with a similar volume of medial canthus injection, with lower rate of supplemental injection as well as better patient and comparable surgeon satisfaction. The main disadvantage was a higher rate of pain to injection as well as more need for facial supplementation.

Keywords: akinesia score, blunt, final total anaesthetic volume, sharp, tipped needle subtenon injection, tipped single medial canthus injection


How to cite this article:
Refai TA, Khattab RS. Evaluation of small-volume (3 ml) ophthalmic anaesthesia for both subtenon anaesthesia using blunt-tipped curved needle and single medial canthal injection with sharp needle for phacoemulsification surgery. J Egypt Ophthalmol Soc 2018;111:108-15

How to cite this URL:
Refai TA, Khattab RS. Evaluation of small-volume (3 ml) ophthalmic anaesthesia for both subtenon anaesthesia using blunt-tipped curved needle and single medial canthal injection with sharp needle for phacoemulsification surgery. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2018 Dec 11];111:108-15. Available from: http://www.jeos.eg.net/text.asp?2018/111/3/108/245981




  Introduction Top


Cataract is related to aging and its extraction is considered the most commonly performed ocular surgery all over the world. Phacoemulsification with or without the use of phacolaser had largely replaced the classic extracapsular cataract extraction, being faster, more controllable, resulting in less postoperative astigmatism, being more precise in-the-bag intraocular lens implantation, with much faster visual recovery and with less need for full ocular akinesia [1],[2],[3]. General anaesthesia, which was frequently used in performing cataract extraction in the previous century, had been largely replaced by retrobulbar injection of local anaesthetic mixtures in the past 30 years with reasonable degree of ocular safety and thus avoiding exposing the ophthalmic patients to the hazards of general anaesthesia [4],[5]. However, complications related to retrobulbar anaesthesia, like retrobulbar haemorrhage, raised vitreous pressure, the remote risk of globe perforation and injection through the optic nerve, had led to the evolution of peribulbar anaesthesia trying to decrease these complication [6].

Peribulbar anaesthesia, in spite of being associated with decreased incidence of perforation, did not abolish it as well as being associated with decreased incidence of full akinesia [7],[8]. Medial canthus single injection (≤6 ml of local anaesthetic mixture) through the conjunctiva was used by some anaesthesiologists trying to decrease the incidence of peribulbar complications [1]. The popularity of phacoemulsification and phacolaser (which does not necessitate full akinesia) for cataract extraction had led to the evolution of anaesthetic techniques like topical anaesthesia as well as subtenon anaesthesia using blunt-tipped needle for injection, which in spite of being associated with less complications may not provide complete akinesia [9],[10].


  Aim Top


The aim of this study was to compare the effectiveness of small volume (3 ml) for both subtenon injection using blunt-tipped curved cannula as well as single injection medial canthus regarding akinesia, patient as well as surgeon satisfaction and possible complications, hoping to provide the patient with the most ideal anaesthetic technique.


  Patients and methods Top


Forty eyes of 40 patients undergoing phacoemulsification surgery at the Research Institute of Ophthalmology, Giza, Egypt, between 2015 and 2017 were included in the study. There were 19 eyes of 19 male patients and 21 eyes of 21 female patients. These forty patients with ASA status I, II and III were divided into two groups: group A (20 patients) who received subtenon injection with blunt-tipped curved needle given by ophthalmology consultant and group B (20 patients) who received single injection at medial canthus with sharp 25-mm needle length given by the anaesthesia consultant. Approval of the ethical committee was obtained as well as a written informed consent. Exclusion criteria included patients below 25 years of age, single-eyed patients, patients with mental disorders, patients under anticoagulant treatment or anticonvulsants treatment as well as patients with previous ocular surgery. All patients were admitted to the operating theatre, intravenous cannula inserted (for sedation if needed), noninvasive blood pressure monitored, heart rate measured, ECG performed and peripheral oxygen saturation measured. After instilling benoxite hydrochloride (0.4%) eye drops into conjunctival sac, 3 ml of anaesthetic mixture of equal amounts of 2% lidocaine (to which hyaluronidase 15 IU/ml was added) and 0.5% bupivacaine was used in either techniques. For subtenon injection (group A), after opening the eye by wire speculum, the patient was asked to look up and out. The conjunctiva and tenon’s capsule were held by a toothed forceps, opened and dissected by Westcott scissors, then a blunt-tipped curved subtenon cannula with an opening near the end (connected to a 3 ml syringe containing the anaesthetic mixture) was inserted around the globe in the subtenon space and the anaesthetic mixture injected taking care to avoid subconjunctival escape that might decrease the effectiveness of the anaesthetic technique. For the single injection medial canthus group, a 22-G sharp-tipped needle (25 mm needle length) was inserted in contact with the conjunctiva between the eyeball and the semilunaris fold with the bevel directed towards the globe. The needle was advanced in anteroposterior direction, and then by the thumb and index fingers, digital pressure was applied around the needle hub during injection (Ripart et al. 2005) [13]. After negative aspiration, 3-ml local anaesthetic solution was slowly injected. Following either technique, ocular massage performed by the corresponding consultant was applied by the hand palm for 5 min (in cycles of 25 s compression followed by 5 s release to avoid central retinal artery occlusion) to allow for better diffusion of the anaesthetic solution and avoiding occurrence of retrobulbar haemorrhage. Five minutes following either injection technique, the akinesia score was reported as well as any related complications. Akinesia was evaluated and scored in each of the four quadrants, where 2=total akinesia, 1=incomplete akinesia and 0=normal movement, giving a maximal score of 8 for the four muscles. In the event of inadequate akinesia, supplementary anaesthetic solution was injected into the involved site using the same needle length and additional assessment was performed 5 min later. Surgeon as well as patient satisfaction was questioned immediately after surgery.

Statistical analysis

The studied data were subjected to statistical analysis to obtain mean and SD values of studied values. Comparison tests such as Student t-test as well as χ2-test were performed as needed and results emphasized.


  Results Top


General findings

The age ranged from 43 to 73 (mean 60.35±8.22) years in group A and from 47 to 95 (mean 62.5±12.18) years in group B, with t-test showing nonsignificant difference (>0.05). The body weight (kg) ranged from 70 to 110 kg (mean 92.75±11.18 kg) for group A and 70–100 kg (mean 86.92±9.25 kg) for group B, with t-test showing a significant difference (<0.05). The ASA (I/II/III) was 8/12/0 (40%/60%/0%), respectively, for group A and 4/13/3 (20%/65%/15%), respectively, for group B, with χ2-test showing a nonsignificant difference (>0.05). The male : female ratio was 11 : 9 (55%/45%) for group A and 8 : 12 (40% : 60%) for group B, with χ2-test showing a nonsignificant difference (>0.05) ([Table 1]).
Table 1 Demographic data

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The axial length in mm had a mean value of 24.33±8.22 (range: 20.5–30.5) for subtenon group and 23.07±1.51(range: 20.5–29.99) for single injection medial canthus group, with t-test showing a nonsignificant difference (t-test=0.26, P>0.05) ([Table 2]). The akinesia score (graded from 0 to 8,with higher values denoting better akinesia) had a mean value of 6±2.43 (range: 0–8) for subtenon group and 3.25±2.61 (range: 0–8) for the single injection medial canthus group (denting better akinesia with the subtenon injection), with t-test showing a highly significant difference (t-test=3.50, P<0.01) ([Table 2] and Chart 1)

.
Table 2 Comparison between subtenon anaesthesia group and single injection medial canthus group for various studied criteria

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Successful block (i.e. no need for supplementation) was achieved in 19 (95%) eyes in group A and in three (15%) cases in group B, with χ2-test showing a highly significant difference (<0.001, χ2=23.7) ([Table 3] and Chart 2)

.
Table 3 The number and percentage of cases that need supplementation in both groups and comparison by χ2-test

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The final anaesthetic volume injected in ml had a mean value of 3.0±0.55 (range: 2–5) for subtenon group and a much higher mean value of 7.55±3.12 (range: 3–13) for the single injection medial canthus group, with t-test showing a highly significant difference (t-test=6.35, P<0.01) ([Table 2] and Chart 3)

.

A total of 17 (85%) cases were satisfied from anaesthesia in group A versus 12 (60%) cases in group B, with χ2-test showing a highly significant difference (<0.001, χ2=15.9) ([Table 4] and Chart 4)

.
Table 4 The number and percentage of patients satisfied with anaesthesia in both groups and comparison by χ2-test

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Surgeon satisfaction was achieved in 19 (95%) cases in group A and in three (15%) cases in group B, with χ2-test showing a highly significant difference (<0.001, χ2=23.7) ([Table 5] and Chart 5)

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Table 5 The number and percentage of cases with surgeon satisfaction from anaesthesia in both groups and comparison by χ2-test

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Moreover, 10 (50%) cases had pain related to anaesthesia injection in group A versus two (10%) cases in group B, with χ2-test showing a highly significant difference (<0.001, χ2=11.25) ([Table 6] and Chart 6)

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Table 6 The number and percentage of patients who experienced pain related to anaesthesia injection in both groups and comparison by χ2-test

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In addition, five (25%) cases had complications related to anaesthesia injection (chemosis and subconjunctival haemorrhage) in group A versus four (20%) cases in group B, with χ2-test showing a nonsignificant difference (>0.05, χ2=0.06) ([Table 7] and Chart 7)

.
Table 7 Showing number and percentage of patients who suffered from complications related to anaesthesia injection in both groups and comparison by χ2-test

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Additionally, 12 (60%) cases needed facial supplementation in group A versus zero (0%) cases in group B, with χ2-test showing a highly significant difference (<0.001, χ2=18.05) ([Table 8] and Chart 8)

.
Table 8 Showing number and percentage of cases that needed facial supplementation in both groups and comparison by χ2-test

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  Discussion Top


Regional anaesthesia is still considered the standard anaesthesia for phacoemulsification in many countries. Two promising techniques for regional anaesthesia are the subtenon injection [11] anaesthesia using a blunt cannula as well as medial canthal injection using sharp needle [12]. In either technique, the anaesthetic injectate is supposed to reach the subtenon space affecting the ciliary nerves as they emerge from the globe (resulting in analgesia) as well as being guided by the tenon capsule to reach the recti muscle sheaths (resulting in akinesia) as well as the orbicularis muscle (thus preventing blinking during surgery) [13].

In our study, the akinesia score showed a higher mean value of 6±2.43 for subtenon group compared with 3.25±2.61 for the single injection medial canthus group (denting better akinesia with the subtenon injection). Successful block (i.e. no need for supplementation) was better achieved in group A [i.e. 19 (95%) eyes] compared with group B [i.e. three (15%) cases]. The final anaesthetic volume injected in ml had a mean value of 3.0±0.55 (range: 2–5) for subtenon group A and a much higher mean value of 7.55±3.12 (range: 3–13) for the single injection medial canthus group B, with a highly significant difference. Patient satisfaction was better achieved in group A [17 (85%) eyes] compared with group B [12 (60%) eyes]. However, surgeon satisfaction was almost similarly achieved in group A [14 (70%) eyes] compared with group B [13 (65%) cases]. The main disadvantage of subtenon injection was related to a higher rate of pain to injection (50% in group A compared with 10% in group B) as well as the more need for facial supplementation (60% compared with 0% in group B). A nonsignificant difference was found regarding complications related to anaesthesia injection (mainly chemosis and subconjunctival haemorrhage) among both groups.

Previous studies regarding subtenon injection:

El-Sherbeny et al. [14] studied 20 eyes with subtenon anaesthesia assisted by hyaluronidase in anterior segment surgery (6 ml volume), and akinesia more than 4/8 was achieved in 100% of eyes which was comparable to values achieved in our study, and pain to injection in 5% of eyes, which was lower than the rate found in our study, in which sedation was not used as routine. Parker et al. [15] studied 80 eyes with subtenon injection (1 ml of 2% lignocaine with 1 : 10 000 adrenaline) for manual small incision cataract surgery and revealed that 77.5% of subtenon group experienced no pain during administration of anaesthesia. Only 18.7% of cases showed akinesia score of 4/8 equivalent to successful block in our study (this percentage was much lower than in our study probably related to lower anaesthetic volume in addition to lack of use of hyaluronidase, which is supposed to help better diffusion of anaesthesia). Moreover, 58% of eyes showed subconjunctival haemorrhage and 29% showed chemosis, which is considered comparable to the results obtained with our study.

Previous studies regarding medial canthus injection

Samir and Galab [16] studied 80 patients undergoing phacoemulsification under single injection at the medial canthus (6 ml ophthalmic mixture with hyaluronidase), and approximately three-quarters of the patients developed adequate akinesia in 10 min. Remaining 25% received second injection with the same technique but with less volume after which the percent of patients with adequate akinesia rose to 91% which was higher than the values obtained in our study, probably related to higher volume injected than in our study. Adequate analgesia developed in almost all patients, and only in one patient, intravenous analgesia was necessary to complete the operation. All operations were completed uneventfully. No perforations or penetrations were recorded, and no other major complications were encountered. Approximately 97% of the surgeons and 96% of the patients found the operative conditions satisfactory [16], and again these values are higher than the values obtained in our study in which we used lower injectate volume.Ripart et al. [17] studied 151 consecutive patients with single injection medial canthus scheduled for elective short-duration ophthalmic procedures. The injected volume of local anaesthetic solution was 8.6±1.7 ml. Additional reinjections were necessary in 14 (9.2%) cases which was lower than the rate found in our study probably related to higher injectate volume than in our study. The subjective surgical score was 4.8±0.6, which agreed with our study. There were no complications, including injury to the globe, optic nerve, or retina or orbital hematoma [17], which is comparable to our study.

Thus, according to our study, we recommend using either low-volume (3 ml) subtenon anaesthesia better with sedation or a higher volume (7.5 ml) single injection medial canthus supplemented with hyaluronidase in either technique to achieve reasonable safe comparable analgesia and akinesia for phacoemulsification surgery.





For phacoemulsification, subtenon anaesthesia using small-volume dose of 3 ml was more effective regarding better akinesia score compared with a similar volume of medial canthus injection with lower rate of supplemental injection as well as better patient and comparable surgeon satisfaction. The main disadvantage was a higher rate of pain to injection as well as more need for facial supplementation.

Financial support and sponsorship

Nil.Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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13.
El-Sherbeny M, Kallil R, El-Gazzar H, Alrabiey M, Hamed M. Compartive study between sub-tenon’s, conventional peribulbar block and low volume single injection medial canthus block for anterior segment surgery. Ain Shams J Anesthesiol 2011; 4:15–23.  Back to cited text no. 13
    
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Parker T, Gogate P, Deshpande M, Adenwala A, Maske A, Verappa K. Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery. Indian J Ophthalmol 2005 53:225–259.  Back to cited text no. 14
    
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Samir A, Gabal A. Percaruncular single injection peribulbar anaesthesia in patients with axial myopia for phacoemulsification. Saudi J Ophthalmol 2012; 26:87–90.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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