title: Combined topical and intracameral anesthesia in penetrating keratoplasty.
abstract: BACKGROUND
  The standard of care for penetrating keratoplasty (PKP) is either retrobulbar or peribulbar anesthesia combined with seventh cranial nerve akinesia or general anesthesia. These methods are known to be associated with rare but potentially serious adverse ocular and systemic events.
  
  
  OBJECTIVE
  To determine the safety and efficacy of combined topical and intracameral anesthesia in addition to intravenous sedation for repeat penetrating keratoplasty (PKP).
  
  
  METHODS
  Tertiary-care university hospital.
  
  
  METHODS
  In this prospective study, combined topical tetracaine 0.5% and 0.2 cc intracameral 1% lidocaine along with i.v. sedation with midazolam and fentanyl were used for patients undergoing repeat PKP in 15 eyes of 15 selected patients. The indication for surgery was failed corneal graft. Verbal pain scale (VPS, 0-3) was recorded preoperatively, intraoperatively at 3 time-points (after trephination, after placing 8 interrupted sutures, and after placing the running suture), and postoperatively (1 hour postoperatively, overnight pain, and 1 day postoperatively). Patient and surgeon satisfaction were assessed postoperatively using a scale (1-5). After surgery patients were asked for their preferences comparing the current use of topical anesthesia compared with retrobulbar anesthesia used for their initial PKP.
  
  
  RESULTS
  The mean intraoperative VPS score was 0.51 +/- 0.32 (range 0-1.33), and the mean postoperative VPS score was 0.47 +/- 0.50 (range 0-1.67). There were no serious intraoperative or postoperative complications. All patients reported high mean satisfaction score of 4.67 +/- 0.49 (range 4-5). The mean satisfaction score reported by the surgeon was 4.47 +/- 0.63 (range 3-5). All patients but 1 (93.3%) preferred combined topical over retrobulbar anesthesia, which they had in their previous surgery.
  
  
  CONCLUSIONS
  We found combined topical and intracameral anesthesia to be safe and effective in our selected group of patients undergoing repeat PKP, and it may provide a satisfactory alternative anesthetic modality for patients in whom general, retrobulbar, or peribulbar anesthesia may be contraindicated.
authors.affiliation: Department of Ophthalmology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Fani
authors.initials: F
authors.lastname: Segev
authors.forename: Aristotle N
authors.initials: AN
authors.lastname: Voineskos
authors.forename: Gladwin
authors.initials: G
authors.lastname: Hui
authors.forename: Michael S H
authors.initials: MS
authors.lastname: Law
authors.forename: Robert
authors.initials: R
authors.lastname: Paul
authors.forename: Frances
authors.initials: F
authors.lastname: Chung
authors.forename: Allan R
authors.initials: AR
authors.lastname: Slomovic
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000771:Anesthesia, Intravenous / Q000379:methods; D000772:Anesthesia, Local / Q000379:methods*; D019162:Anesthetics, Combined / Q000008:administration & dosage*; D000867:Anterior Chamber / Q000187:drug effects*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D015948:Keratoplasty, Penetrating; D008012:Lidocaine / Q000008:administration & dosage; D008297:Male; D008874:Midazolam / Q000008:administration & dosage; D008875:Middle Aged; D009915:Orbit / Q000187:drug effects*; D010147:Pain Measurement; D011446:Prospective Studies; D012086:Reoperation; D012449:Safety; D013748:Tetracaine / Q000008:administration & dosage
chemical_list: D019162:Anesthetics, Combined; D006993:Hypnotics and Sedatives; D013748:Tetracaine; D008012:Lidocaine; D008874:Midazolam; D005283:Fentanyl