A comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery.
OBJECTIVE
To evaluate and compare levels of patient discomfort and perioperative complications during phacoemulsification and implantation of a foldable intraocular lens under topical lidocaine hydrochloride and retrobulbar anesthesia in patients with cataract who also had exfoliation syndrome, uveitis, posterior synechia, phacodonesis, or previous intraocular surgery.


METHODS
A prospective, randomized, controlled trial was carried out at 2 institutions.


METHODS
A total of 476 eyes of 476 patients with various well-established risk factors fulfilled the inclusion criteria. In 238 eyes, phacoemulsification was performed under retrobulbar anesthesia, while the other 238 eyes received topical anesthesia.


METHODS
All patients underwent temporal clear corneal phacoemulsification and implantation of a foldable intraocular lens. Patients under retrobulbar anesthesia received a single injection (3. 5-5.5 mL) of a combination of 0.75% bupivacaine hydrochloride, 2% lidocaine, and hyaluronidase into the retrobulbar space. Patients in the topical anesthesia group received a minimum of 5 doses (approximately 40 microL per dose) of 2% topical lidocaine. No intracameral injection of any anesthetic was given.


METHODS
The number of complications and adverse events. The intraoperative conditions were judged by the surgeon (P.C.J. or F.K. J.), and a 10-point visual analog scale was used immediately after surgery to assess each patient's overall severity of intraoperative pain.


RESULTS
The overall intraoperative complication rate was 1.9% for capsular tear, 3.8% for zonular tear, 1.5% for vitreous loss, and 1.0% for iris prolapse. Apart from the incidence of vitreous loss, which was significantly (P =.041) lower in the topical anesthesia group, no statistically significant differences in intraoperative and early postoperative complications were found between the groups. A supplemental posterior sub-Tenon space injection was required in 1.3% of the topical anesthesia group and in 0.8% of the retrobulbar anesthesia group. Chemosis (2.5%), subconjunctival hemorrhage (1.7%), and periorbital hematoma (0.8%) were seen only in the retrobulbar anesthesia group. The mean + SE pain scores estimated by the patients were 0.84 + 1.30 in the topical anesthesia group and 0.73 + 1.50 in the retrobulbar anesthesia group (P =.41). Patient preference for topical anesthesia (91%) appeared to be significantly (P =.01) higher than for retrobulbar anesthesia (62%). The surgeons found anesthesia-related intraoperative difficulty to be slightly lower in the retrobulbar anesthesia group (8%) than in the topical anesthesia group (14%).


CONCLUSIONS
Surgery-related complications and patient discomfort were similar for the 2 methods of anesthesia. Topical anesthesia is justified as a means of improving safety without causing discomfort to the patient even in complicated cases of cataract surgery. Arch Ophthalmol. 2000;118:1037-1043
Department of Ophthalmology, University of Cologne, Joseph-Stelzmannstrasse 9, 50931 Cologne, Germany. Phillip.Jacobi@uni-koeln.de.
P C
PC
Jacobi
T S
TS
Dietlein
F K
FK
Jacobi
D000287:Administration, Topical; D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D002045:Bupivacaine / Q000008:administration & dosage; D005260:Female; D006801:Humans; D006821:Hyaluronoglucosaminidase / Q000008:administration & dosage; D007431:Intraoperative Complications; D019654:Lens Implantation, Intraocular / Q000009:adverse effects*; D008012:Lidocaine / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D009915:Orbit; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control; D017060:Patient Satisfaction; D018918:Phacoemulsification / Q000009:adverse effects*; D011183:Postoperative Complications; D011446:Prospective Studies
D000779:Anesthetics, Local; D008012:Lidocaine; D006821:Hyaluronoglucosaminidase; D002045:Bupivacaine