Evaluation of Anxiolysis and Pain Associated with Combined Peri- and Retrobulbar Eye Block for Cataract Surgery

doi:10.1016/S0952-8180(98)00008-7

Journal of Clinical Anesthesia

Volume 10, Issue 3, May 1998, Pages 204-210

https://doi.org/10.1016/S0952-8180(98)00008-7 Get rights and content

Abstract

Study Objectives: To evaluate five different preoperative anxiolytic regimens in cataract surgery performed under regional anesthesia; to quantify the pain associated with combined peri- and retrobulbar injection (PRBI) of local anesthetic drugs; and to describe a technique of painless eye block.

Design: Randomized, double blind, placebo-controlled study.

Setting: Private clinic.

Patients: 376 ASA I and II patients presenting for cataract surgery.

Interventions: Patients were extensively briefed by the nursing staff on the various procedures. Of the 376 study patients, 136 preferred to have no anxiolytic drug. The remaining 240 patients were randomly allocated to one of six groups to receive either 3 mg of bromazepam, 6 mg of bromazepam, 0.5 mg of alprazolam, 1 mg of alprazolam, 5 mg of diazepam, or a placebo on a double-blind protocol. All patients received a standard combined peri- and retrobulbar eye block (PRBB) before surgery.

Measurements and Main Results: Anxiety at various stages of the procedure and PRBB were measured on visual analog scale (0–10). PRBB pain was compared with pain of intravenous (IV) cannula placement. On admission, anxiety of the 136 patients who preferred no anxiolytic premedication was significantly less than that of the 240 patients assigned to one of the six treatment groups (p <0.05). There was no difference between the six treatment groups in reported anxiety before surgery (p >0.05) except for Group 1 (3 mg bromazepam), where anxiety increased before and during PRBB administration (p <0.05). In all six treatment groups, anxiety decreased significantly 30 minutes after medication was administered (p <0.05). For the total group, 61.18% of patients reported more or equal pain associated with the placement of the 20-gauge IV cannula than by the PRBB. Of the patients who received medication, 94% stated that, should they require another eye operation, they would like the same anxiolytic treatment. No patient requested general anesthesia for their next operation or to be rendered unconscious for PRBB.

Conclusions: 1. There was interpersonal variation in the level of preoperative anxiety. 2. In patients who were anxious, the anxiolytic drugs and placebo decreased anxiety although the level of anxiety did not differ between the anxiolytic drugs or between placebo and the anxiolytic drugs. The only difference was in Group 1 patients (3 mg promazepam), who reported slightly increased anxiety before and during PRBB administration (p <0.05). 3. Placement of the PRBB is less painful than the insertion of a 20 g IV cannula.

Introduction

There is disagreement about the need for sedative or anxiolytic drugs to be given before peribulbar or retrobulbar injection of local anesthetic drugs in patients undergoing cataract surgery.[1] In some centers, it is customary to administer sedative doses of various intravenous (IV) anesthetic drugs before retrobulbar injection.[2] However, this practice has been criticized, particularly when used in elderly patients.[3] Campbell et al.[4] suggested a close correlation between pain and anxiety. Because retrobulbar injection with a 21-gauge or 23-gauge Atkinson needle is painful and uncomfortable,[2] sedation with short-acting IV anesthetic drugs before retrobulbar injection has been advocated.[2]

The goals of this study were (1) to evaluate the value of premedication with different anxiolytic drugs in reducing anxiety in patients undergoing cataract surgery with local anesthesia and (2) to quantify the pain associated with PRBB by comparing it with the relatively familiar pain associated with the placement of an IV cannula. A technique of painless PRBB is described, and the rationale for this technique is discussed.

Section snippets

Materials and Methods

The protocol was approved by the Medi-Clinic Hospital Institutional Ethical Committee. All patients provided written informed consent.

A total of 376 adult ASA I and II patients presenting for cataract surgery with regional anesthesia were studied. On admission to the hospital, patients were extensively briefed by the nursing staff on the various procedures and asked if they required an anxiolytic drug; 240 patients (63.8%) requested anxiolytic therapy. These patients were then randomly

Results

The mean age of the study patients was 67.2 ± 12.5 years. There was no difference in the ages of the treatment groups (p >0.05). None of the patients were excluded from the study due to amnesia that could possibly have been caused by the benzodiazepine drugs, and oculocardiac reflex was not triggered in any of the patients. VAS values for anxiety at different stages of the procedure are summarized in Table 1.

In the six treatment groups (including the placebo group), anxiety decreased

Discussion

Anxiety and pain are subjective experiences and, as such, they are difficult to measure. By making use of the patient’s own perception, graded on a VAS, we could obtain anxiety and pain measurements to address the questions posed in this study. The VAS is a well accepted method of quantifying subjective perceptions for study purposes.12, 13, 14, 15 A further consideration in the design of the study was the fact that benzodiazepines might have had an anterograde amnesic effect on some of the

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Cited by (17)

Cataract in the Adult Eye Preferred Practice Pattern®
2017, Ophthalmology
Eye surgery in the elderly
2003, Best Practice and Research: Clinical Anaesthesiology
Elderly patients represent the majority of the surgical population scheduled for ophthalmological surgery. Eye surgery is usually minimally invasive, enabling most of the procedures to be performed as day-case surgery despite the high co-morbidity of these patients. This, however, requires a specific perioperative anaesthetic strategy.
In this chapter we address features of perioperative care in the geriatric population undergoing eye surgery, from pre-medication and pre-operative testing, to choice and performance of anaesthesia, and finally to post-anaesthesia care.
A comparison of propofol and remifentanil for sedation and limitation of movement during periretrobulbar block
2001, Journal of Clinical Anesthesia
Study Objectives: To compare clinical conditions in patients sedated with propofol or remifentanil during combined peri-bulbar and retrobulbar block (PRBB) for cataract surgery.
Design: Prospective, randomized, double-blind study.
Setting: Private clinic.
Patients: 106 ASA physical status I and II patients scheduled for cataract surgery.
Interventions: Patients were randomized to receive either 0.5 mg/kg propofol (Group P) or 0.3 μmg/kg remifentanil (Group R) as an intravenous (IV) bolus 1 minute prior to PRBB. At the same time, patients in both groups also received 0.5 to 1 mg midazolam IV. Movement of the hands, arms, head, and eyes were counted during each stage of the procedure by an observer who was blinded to the sedation used. Heart rate (HR), blood pressure (BP), respiratory rate (RR), expiratory CO₂ (PECO₂), and hemoglobin oxygen saturation (SaO₂) were recorded every minute for 10 minutes after the PRBB. Anesthetic complications, recall, and the pain experienced with the block and surgery were compared between the two groups. Means and variance of the results were compared with one-way analysis of variance and Fisher’s exact test.
Measurements and Main Results: Movements of the hands, arms, and head were significantly greater in Group P during all stages of the block. Almost no movements were recorded in the remifentanil group. Immediately after the PRBB (1 to 6 min), HRs were higher in Group P (73 ± 11 bpm vs. 67 ± 10 bpm; p = 0.0075), whereas the RRs were slower in Group R for the period 1 to 5 minutes after the PRBB (16 ± 5 breaths/min vs .14 ± 4 breaths/min; p = 0.0206). At these times, the mean PECO₂ was higher in Group R (36 ± 7 mmHgvs. 32 ± 9 mmHg; p = 0.0125). Nineteen patients in the propofol group sneezed during the medial peribulbar injection compared with none in the remifentanil group. Anesthetic and surgical complications were unremarkable and similar for the two groups.
Conclusions: Respiratory depression with remifentanil was mild and not clinically significant. Remifentanil sedation for this application was superior to sedation with propofol.
The methodologic quality of clinical trials on regional anesthesia for cataract surgery
2001, Ophthalmology
To assess the methodologic quality of published randomized trials of regional anesthesia management strategies for cataract surgery.
Literature review and analysis.
We performed a systematic search of the literature to identify all articles pertaining to regional anesthesia for cataract surgery on adults. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two investigators experienced in methodologic research who independently reviewed all relevant articles using a quality abstraction form.
Study quality in each of five domains: representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation.
Eighty-two randomized clinical trials were identified with a mean overall quality score of 44%. The mean domain scores ranged from 37% for representativeness to 58% for outcomes and follow-up. Forty percent or fewer studies received the maximum score for reporting the setting, the population, and the start and end dates; describing the inclusion and exclusion criteria; adequately randomizing subjects; and adequately masking individuals participating in the study. Key outcomes were often inadequately reported, including the distribution of patient-reported pain scores and the mean surgical time.
Greater attention to methodologic quality and detailed reporting of study results will improve the ability of readers to interpret the results of clinical trials assessing regional anesthesia for cataract surgery.
Topical anesthesia versus retrobulbar block for cataract surgery: The patients' perspective
2000, Journal of Clinical Anesthesia
Study Objectives: To compare patients’ perception of topical anesthesia (TA) with combined peribulbar and retrobulbar block (PRBB) for cataract surgery.
Design: Prospective, randomized, controlled, cross-over observational study.
Setting: Private clinic.
Patients: 98 ASA physical status I and II patients presenting for bilateral cataract surgery 1 week apart.
Interventions: Patients were prospectively randomized to receive either TA for surgery to one eye, followed by PRBB for surgery to the other eye 1 week later, or to receive PRBB first, followed by TA for the second operation the following week. Surgery, PRBB, and TA were standard for all cases. Interviews were conducted the day following surgery by an unbiased observer unaware of the technique used. Surgical pain was estimated on a visual analog scale of 0 to 10, and the surgeon judged the difficulty of surgery based on patient compliance and cooperation on a scale of 0 to 5. Means and variance of results were compared with analysis of variance.
Measurements and Main Results: Mean age was 71.45 ± 9.76 years (mean ± SD). Seventy patients (71.43%) preferred PRBB while 10 patients (10.20%) preferred TA (p = 0.0001). Eighteen patients (18.37%) reported no difference between the two techniques. Ninety-six patients (97.96%) were not aware of the PRBB being injected. Duration of surgery was similar for TA (11.92 ± 3.43 min) and PRBB (10.78 ± 3.00 min; p = 0.06). Surgery was more difficult during TA (p = 0.0004). Pain was worse during TA (p = 0.0001). Surgical and anaesthetic complications were unremarkable for both techniques.
Conclusions: Patients who experienced both TA and PRBB preferred PRBB.
Injectable versus topical anesthesia for cataract surgery: Patient perceptions of pain and side effects
2000, Ophthalmology
To compare patient reports of intraoperative pain and postoperative side effects by different anesthesia strategies for cataract surgery.
Prospective cohort study.
Men and women 50 years of age and older undergoing 19,250 cataract surgeries at nine centers in the United States and Canada from June 1995 through June 1997.
Topical anesthesia or anesthesia with injection, with or without sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl).
Patient ratings of intraoperative pain, satisfaction with pain management, and early postoperative side effects (drowsiness, nausea, vomiting, or a combination thereof).
Twenty-six percent of surgeries were performed using topical anesthesia alone, and the remainder were performed with peribulbar, retrobulbar, or facial nerve block, or a combination thereof. Local anesthesia by injection with sedatives and diphenhydramine resulted in the lowest reporting of any intraoperative pain (1.3%), with postoperative drowsiness (9.6%) and nausea, vomiting, or both (1.5%) comparable with those administered topical anesthesia alone. Among those receiving topical anesthesia, use of sedatives and opioids reduced reports of any pain during surgery by 56% (95% confidence interval [CI], 34%, 70%), but increased nausea and vomiting (odds ratio, 2.27; 95% CI, 1.26, 4.09) compared with those administered topical anesthesia alone, after adjusting for age, gender, race, American Society of Anesthesiologists risk class, self-reported health status, and duration of surgery. Among those receiving local injections, use of opioids reduced reports of any pain among those receiving sedatives by 37% (95% CI, 15%, 54%), but did not increase postoperative side effects. The use of diphenhydramine among those receiving sedatives decreased reports of any pain by 59% (95% CI, 33%, 75%) and also reduced drowsiness and nausea and vomiting by 57% (95% CI, 48%, 65%) and by 60% (95% CI, 36%, 75%), respectively. Use of hypnotics with sedatives was associated with increased reports of any pain during surgery and increased nausea and vomiting after surgery.
Patient reports of any pain during cataract surgery (5%) and postoperative side effects (16% drowsiness and 4% nausea and vomiting) were low, but varied by anesthesia strategy. Patient perceptions of pain and side effects can be helpful in guiding the appropriate choice of anesthesia strategy.

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¹: Senior Consultant, Department of Anesthesiology, University of Stellenbosch

²: Ophthalmologist

³: Registered Nurse, Medi-Clinic Hospital

View full text

Original ContributionsEvaluation of Anxiolysis and Pain Associated with Combined Peri- and Retrobulbar Eye Block for Cataract Surgery

Abstract

Introduction

Section snippets

Materials and Methods

Results

Discussion

AORN J

AORN J

Br J Anaesth

Limiting movement during retrobulbar block [Letter]

Anesth Analg

Comparison of methohexital and alfentanil on movement during placement of retrobulbar nerve block

Anesth Analg

Intravenous sedation for ocular surgery under local anaesthesia

Br J Ophthalmol

Visual analogue measurement of pain

Ulster Med J

Stressful pre-operative preparation proceduresThe routine removal of dentures during pre-operative preparation contributes to pre-operative distress

Anaesthesia

Original Contributions
Evaluation of Anxiolysis and Pain Associated with Combined Peri- and Retrobulbar Eye Block for Cataract Surgery