Comparative Assessment of Pain in Sequential Cataract Surgery with Topical Phacoemulsification - A Prospective Observational Study from a Tertiary Care Hospital in Uttar Pradesh

BACKGROUND With the advancement in anaesthetic measures, a safe and effective alternative to peribulbar and retrobulbar anaesthesia for phacoemulsification is provided by topical anaesthesia.1 (Fichman, 1996). Studies highlighting varied pain experiences have been published with some reporting higher pain in second eye surgery,2,3 (Ursea et al. 2011; Tan et al. 2011) while others did not.4,5 (Bardocci, 2011; HariKovacs, 2012). So, we conducted this study to assess and compare pain experienced by patients subjectively as well as objectively in first and subsequent eye following topical phacoemulsification cataract surgery. METHODS A prospective observational clinical study was done for a duration of two years at Institute of Ophthalmology, Jawaharlal Nehru Medical College, AMU Aligarh. Study groups consisted of patients having bilateral cataract, to be operated in both eyes undergoing topical phacoemulsification and placement of an intraocular lens within one-year interval. Subjective as well as objective assessment of postoperative pain was done in the recovery room. RESULTS A total of 60 patients were included in the study with 51 (85 %) patients having higher pain score for second eye surgery as compared to first eye surgery, which was also significant while comparing their mean pain score (0.73  0.86 vs 2.17  0.91). Systolic and diastolic blood pressure as well as mean arterial pressure (MAP) were higher in first eye surgery as compared to second eye surgery. CONCLUSIONS In our comparative study, we observed higher pain in second eye surgery. As this subjective assessment of higher pain was not supplemented by objective assessment, we concluded that it may be due to more apprehension and uneasiness because of previous surgery. Patients going for second eye surgery should be prior consulted as well as managed properly. KEYWORDS Cataract, Pain, Topical Phacoemulsification

Outcome of Conventional Trabeculectomy in Terms of Intraocular Pressure and Visual Acuity in Primary Open Angle Glaucoma

Purpose: To determine the outcomes of conventional trabeculectomy in terms of decrease in Intra Ocular Pressure (IOP) and improvement in visual acuity in patients of primary open glaucoma, coming to a tertiary care hospital. Study Design: Retrospective case series. Place and Duration of Study: Ophthalmology department of a tertiary care hospital from January 2017 to December 2018. Methods: Patients undergoing trabeculectomy for Primary open angle glaucoma were included. Patients with repeated trabeculectomy, failed argon laser trabeculoplasty, advance cataract, corneal opacities and absolute glaucoma were excluded. All the trabeculectomies were done under retrobulbar anaesthesia after taking all aseptic measures. Primary outcome measures were preoperative and postoperative visual acuity, intraocular pressure, number of antiglaucoma medications and failed or successful trabeculectomy. Results: Total 52 patients underwent trabeculectomy. There were 36 (69.2%) males and 16 (30.8%) females. Mean age was 56.73 years ± 10.9 SD. Mean preoperative IOP was 30.96 ± 6.71 mm Hg, post operatively IOP at 1 year it was 15.6 ± 4.2 mm Hg. P value was <.000. Mean number of antiglaucoma medications was 3.03 and 1.19, pre and post-operatively respectively (p value <.000). Improvement in visual acuity after trabeculectomy was seen in 32 (61.5%) patients. Complete Surgical success was seen in 28 (53.8%) and qualified success in 21 (40.4%) patients. Failed trabeculectomy was seen in 3 (5.8%) patients. Conclusion: Conventional trabeculectomy is effective in lowering IOP in primary open angle glaucoma patients. It maintains IOP within normal range with and without anti-glaucoma medications at 1 year follow-up. Trabeculectomy significantly reduces number of anti-glaucoma medications. Key Words: Intraocular pressure, Primary open angle glaucoma, Trabeculectomy.

Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events

Background Vitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra- and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy (PPV) under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients with an interruption in this therapy before surgery. Methods Ninety-six patients will be randomly assigned to either the control group, in whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group in whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated. Discussion This trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy. Trial registration Clinical Trials Register EudraCT, 2018–000753-45. Registered on 11 November 2018.

Transient choroidal detachment after ultrasonic circular cyclocoagulation

Two patients with refractory glaucoma followed in our ophthalmology department registered progression on left eyes (OS) despite best practice. Best corrected visual acuity (BCVA) was 9/10 and 8/10 and intraocular pressure (IOP) was above 20 mm Hg while under maximal hypotensive therapy. The procedure was performed under retrobulbar anaesthesia with second-generation EyeOp1probes. In follow-up, OS were hypotonic with registered IOP ≤5 mm Hg and revealed a 3/10 BCVA. The funduscopy showed one temporal and superior and another nasal and temporal choroidal detachments. The patients started oral steroids and interrupted all ocular hypotensive medication. After therapy, patients returned with normal rising OS IOPs and with totally reapplied choroids, accompanied by normalised BCVA. These two cases are proof of the possibility of transient choroidal detachment after a ultrasonic circular cyclocoagulation. While a very rare major vision-threatening complication, every ophthalmologist should remind it when sudden BCVA reductions occur after this procedure.

Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events

Abstract Background Vitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients who interrupt this therapy before surgery. Methods Ninety six patients will be randomly assigned to either the control group, to whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group to whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed-up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated. Discusion This trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy.

Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events

Background Vitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients who interrupt this therapy before surgery. Methods Ninety six patients will be randomly assigned to either the control group, to whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group to whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed-up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated. Discusion This trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy.

Brainstem anaesthesia after retrobulbar block

Regional anaesthesia techniques in ophthalmology are usually utilized for day case surgery. During various procedures, profound akinesia of the eye and anaesthesia of the surgical site are required, both of which are achieved with retrobulbar block. Due to the anatomy of the eye, life-threatening complications are possible. An 82-year-old female with secondary post-herpetic uveitic glaucoma of the right eye presented at the Department of Ophthalmology for an elective trans-scleral laser cyclophotocoagulation. She was given a retrobulbar block to the right eye with 2 mL of 0.5% levobupivacaine and 2 mL of 2% lidocaine. The procedure was technically performed without any issues. 2-3 minutes after the injection she became lethargic and 5 minutes later she lost consciousness and developed severe hypotension with bradycardia and respiratory arrest. She was successfully intubated and resuscitated, using mechanical ventilation, vasoactive medications, fluid therapy and intravenous lipid emulsion. There are three mechanisms for local anaesthetic (LA) to reach the central nervous system after a retrobulbar block: systemic absorption of LA, direct intra-arterial injection and retrograde flow into the cerebral circulation, and injecting LA into the subdural space via puncturing the dural optic nerve sheath, the latter being most common. The clinical picture of our patient was very consistent with subdural anaesthesia after exposure of the pons, midbrain and cranial nerves to LA, i.e. brainstem anaesthesia. Following appropriate life support measures taken in our case, there was a successful outcome. To minimize the chance for brainstem anaesthesia after retrobulbar block, we recommend low volume with low concentration of LA and block performance by an experienced ophthalmologist or anaesthesiologist with proper technique. Patients receiving retrobulbar anaesthesia should be carefully monitored at least 20 minutes after the block. Life support equipment should be available before performing retrobulbar block.