Ultrasound navigation during retrobulbar blockade in children with retinoblastoma and enucleation of the eyeball

BACKGROUND: The retrobulbar block in children is used to enucleate analgesia in the intra- and postoperative period and prevent oculocardiac reflex (OCD), postoperative nausea, and vomiting. However, when the block is performed blindly, it results in serious complications. AIM: This study aimed to evaluate the efficacy and safety of a retrobulbar block performed under ultrasound guidance compared with a retrobulbar block performed blindly during enucleation of the eyeball in children with retinoblastoma. MATERIALS AND METHODS: A prospective randomized controlled trial was performed. The study included 40 patients who met the inclusion criteria. The patients were divided into two groups: 20 patients who underwent ultrasound-guided retrobulbar blockade (RBВ + ultrasound) and 20 patients who underwent blindly retrobulbar blockade (RBВ). RESULTS: There was an insignificant decrease in intraoperative opioid requirements in the RBB + ultrasound group, where the average dose of fentanyl was 41.4 g/kg, and in the RBB group, 4.70.8 g/kg (p 0.05). The time before the administration of the first dose of analgesic in the postoperative period was 4.70.8 h in the RBB group and 11.73.3 h in the RBB + ultrasound group (p 0.05). VAS and CHIPPS scores obtained 6 h after the end of surgery in the RBB + ultrasound and RBB groups were 1.8 (1.2; 2) and 2.5 (3.8; 4.5) points (p 0.05), respectively. CONCLUSION: There was no statistically significant difference between the time of the retrobulbar blockade under ultrasound guidance and the retrobulbar regional block performed blindly. Retrobulbar blockade performed under ultrasound guidance provides a decrease in intraoperative opioid requirements, stable intraoperative hemodynamics, and longer postoperative analgesia.

A Case of Brainstem Anesthesia after Retrobulbar Block for Globe Rupture Repair

Purpose. To present a rare case of brainstem anesthesia from retrobulbar block and discuss evidence-based methods for reducing the incidence of this complication. Case. A 72-year-old female, was given a retrobulbar block of 5 mL of bupivacaine 0.5% for postoperative pain management, after a globe rupture repair under general anesthesia. Prior to injection, the patient was breathing spontaneously via the anesthesia machine circuit and had not received any additional narcotics/muscle relaxants for 2.5 hr (with full recovery of neuromuscular blocking agent after anesthetic reversal). Over 7 min, however, there was a steady increase in ETCO2 and the patient became apneic, consistent with brainstem anesthesia. She remained intubated and was transported to the postanesthesia care unit for prolonged monitoring, with eventual extubation. Discussion. Brainstem anesthesia is an important complication to recognize as it can lead to apnea and death. The judicious use of anesthetic volume, shorter needle tips, and mixed formulations can help reduce the chance of brainstem anesthesia. Observation of the contralateral eye 5–10 minutes after injection for pupillary dilation, and prior to surgical draping, can help identify early CNS involvement.

Efficacy and safety of retrobulbar blockade of 0.5% ropivacaine during eyeball enucleation surgery in children with retinoblastoma

Introduction. Retinoblastoma (RB) is a malignant tumor of the embryonic nerve retina. Purpose. To determine the effectiveness of retrobulbar blockade (RbB) with ropivacaine 0.5% for intra- and postoperative analgesia, as well as for the prevention of oculocardial reflex (OCR), postoperative nausea and vomiting (PONV) during enucleation. Material and methods. A prospective, randomized, controlled clinical trial was performed. Eighty patients aged 0 to 10 years were included, who were randomly assigned to the RbB group (retrobulbar blockade with ropivacaine 0.5% with general anesthesia) N = 40 and the GA control group (general anesthesia) N = 40. Results. There were no complications in the RbB group caused by the methodology. In the intraoperative period, the average dose of fentanyl in the RbB group was 4.7 ± 0.7 μg / kg, which is significantly lower than in the OA group of 10.1 ± 1.9 μg / kg (P <0.05). OCR in the RbB group was observed in 5% of cases versus 100% in the GA group (P = 0.002). The average VAS score was 1.8 vs. 3.7 60 minutes after surgery (P <0.001). For the first time 12 hours after surgery, PONV was not observed in the RBB group, and in the control group it was observed in 45% of patients. Conclusions. The study revealed that intraoperative retrobulbar blockade with 0.5% ropivacaine solution in children with RB is effective and safe. Provides stable intraoperative hemodynamics and reduces the need for opioids. Promotes the prevention of OCD and PONV, as well as the improvement of postoperative analgesia during the operation of enucleation of the eyeball in pediatric. Key words: ropivacaine, retrobulbar block, oculocardial reflex, pain, retinoblastoma, enucleation, pediatric patients.

Complications of classic double injection technique of peribulbar anaesthesia given in supine position before cataract surgery

Background: Peribulbar anaesthesia has almost totally replaced general anaesthesia and retrobulbar block for ocular procedures especially in adults. Peribulbar block involves injections above and below the orbit, with local anesthetic deposited within the orbit but does not enter the muscle cone. Relatively safe but it is still associated with complications which are detailed in this study. Aims and Objective: To study the complications of classic double injection technique of peribulbar anaesthesia given in supine position before cataract surgery and to find the percentage of patients achieving complete block with 7ml of anaesthetic solution given by peribulbar route. Materials and Methods: This prospective observational study was conducted on 500 patients who were admitted for undergoing cataract extraction surgery in the Department of Ophthalmology in GMC Jammu for a period of 8 months from December 2018 to July 2019. Results: It was observed that 103 patients out of 500 (20.6%) developed one or more of complications. Chemosis was the most common complication which occurred in 87 (17.4%) patients followed by subcunjunctival haemorrhage observed in 19 (3.8%) patients. Lid ecchymosis occurred in 16 (2.4%) patients. Retrobulbar haemorrhage occurred in 11 (2.2%) patients. 2 (0.4%) patients developed severe lid edema. In 2 (0.4%) patients wrong eye was given block. 1 (0.2%) patient developed CRAO. Complete akinesia was obtained in 415 (83%) patients with 7ml of block. Rest required supplementary injections. 14 (2.8%) patients did not attain full akinesia after 12ml of block. Conclusion: Peribulbar block is a relatively safe procedure for obtaining ocular analgesia and akinesia, but is still associated with complications ranging from minor lid edema and chemosis to grave events like RBH to CRAO.

Squamous cell carcinoma of an eyelid in a horse: A case report

The aim of this report is to describe a clinical case of squamous cell carcinoma in an 18-year-old horse. This tumor is one of the most common superficial oncological problems in these animals. A lesion in the lateral corner of the eye was already observed about 10 years earlier, but due to the lack of significant growth or alarming symptoms, no diagnostics or treatment was implemented. A year before surgery, an episode of acute inflammation in the eye and a slight enlargement of the nodule occurred. Initially, an autoimmune origin of the lesion was assumed, but anti-inflammatory and bactericidal treatment did not lead to a significant improvement. As a result of sampling for histopathological examination, the tumor doubled its volume, so, given the inefficacy of the subsequent anti-inflammatory and antibiotic therapy, the horse was sent to the clinic. A convex, painful lesion partially covering the cornea was found on arrival. In view of the rapid growth of the tumor and its infiltration of surrounding tissues, a decision was made to carry out transpalpebral enucleation. The procedure was performed under general anesthesia and with an additional retrobulbar block. Because of significant tissue tensions and the risk of hematoma, an intermittent horizontal mattress suture was used. The area was secured with a compression dressing. The horse returned to sport, and no recurrence of the tumor was observed up to 7 months after surgery. Histopathological examination confirmed squamous cell metaplasia forming keratin pearls, characteristic of squamous cell carcinoma.

Dexmedetomidine as an adjuvant to local anesthetics in ophthalmic surgery

Vitreoretinal surgery aims to restore the structural relationships of the posterior segment of the eye, with the possibility of partial or complete restoration of visual functions, and imposes certain requirements to the anesthetic support of operations. These are injuries, operations length, age, and concomitant pathology of organs and systems of patients. In this regard, there is a recent tendency to use different pharmacological groups as adjuvants to local anesthetics to enhance or prolong their analgesic effect. Purpose to evaluate the effectiveness of dexmedetomidine as an adjuvant in retrobulbar blockades. Materials and methods. Retrobulbar block bupivacaine with dexmedetomidine at a dose of 0.25 mg/kg was performe in the 1st group (n = 22), retrobulbar block was performed with a mixture of bupivacaine in the 2nd group (n = 22). Changes in hemodynamics at the stages of surgery were evaluated. To assess the oxidative status, the evaluation of the redox coefficient (FORT/FORD) was conducted before and after the surgery. The level of comfort of the operation by the surgeon and the patient. Assessment of pain was performed by a VRS in the points. Results. In patients of the 1st group the decrease in SAD was more pronounced and persisted throughout the entire period of surgical treatment. 54.5% of patients of group 1 and 18% of group 2 had no pain 8 hours after the surgery. 82% of patients of group 2 reported moderate pain that required medication (p 0,05). In patients of group 1, it increased from 0.45 0.5 to 0.62 0.2 (p 0,005) by 37% of the initial value, in patients of group 2, it was shown to decrease by 5% (p 0,05). In group 1, the comfort of the operation was estimated by ophthalmic surgeons as satisfactory in 77.3%, and in group 2 in 54.5% (p 0,05). Conclusion. The use of dexmedetomidine as an adjuvant of local anesthetics in ophthalmic surgery provides the necessary analgesia, hemodynamic profile of the patient, antioxidant effect and affects the quality of the surgeons work, which affects the duration of operations.

Effect of pterygopalatine blockade on perioperative stress and inflammatory outcomes following paediatric cataract surgery

BackgroundGeneral anesthesia is required to perform pediatric cataract surgery. To reduce severity of surgical intervention and postoperative complications, regional techniques have been concomitantly used. The traditional regional ophthalmic techniques are retrobulbar, peribulbar and sub-Tenon blocks, which present some technical difficulties and associated complication risks. The pterygopalatine blockade has been exempt of many of these concerns as it is performed out of the orbit. The purpose of this study was to compare the analgesic and anti-inflammatory effects of the pterygopalatine blockade with retrobulbar block in children undergoing elective congenital cataract surgery.MethodsAfter approval of ethics committee and informed consents, patients were enrolled to the study to have either ultrasound-guided pterygopalatine block (group P) or retrobulbar block (group R), with 2 mL lidocaine 2% and 1 mL ropivacaine 0.5%. Hemodynamic monitoring was recorded throughout the perioperative period. Cortisol level and oxidation–reduction status were assessed before and after surgery. Pain and inflammatory response (Tyndall effect, corneal syndrome and edema) were assessed on the first postoperative day.ResultsComparative analysis demonstrated a decrease in cortisol of 123.24% (p˂0.05) and an increase in the redox coefficient of 37.7% (p˂0.05) in group P. Pain intensity was significantly higher in group R until the 16th postoperative hour. The corneal syndrome in patients in group P and group R was noted by 7.6% and in 32.1%, respectively (p˂0.05).ConclusionThe use of the pterygopalatine blockade as a component of anesthesia in pediatric cataract surgery allows reduction of the severity of surgical stress during surgical intervention, providing intraoperative hemodynamic stability and prolonged analgesia.