A comparative study of clinical outcome following topical versus peribulbar anesthesia in phacoemulsification surgery

The objective of our study was to evaluate and compare clinical outcomes, patients and surgeon’s satisfaction following topical versus peribulbar anesthesia in phacoemulsification surgery. A hospital based Randomized Prospective interventional Comparative Study done between November 2017 to May 2019. A total of 200 patients included in the study, ocular examination, biometry were done. Patients were randomly distributed into group1 TA (topical anesthesia) and group 2 PA (Peribulbar anesthesia), they underwent phacoemulsification with intraocular lens implantation, postoperative visual outcome and inflammation on day1 and after 1 week, VAS (Visual Analogue scale) pain scale used to analyse patients comfort and pain postoperatively. The Statistical analysis was performed by STATA 11.2 (College Station TX USA). In our study 200 participated, it was found in PA group, 60.47 ± 11.86 yrs and in TA group 59.01 ± 11.29yrs as mean age, majority were male. PA group had few complications during anesthesia and in both groups majority had no intraoperative complications. Log Mar visual acuity postoperative day 1, PA group was 0.65±0.40 and in TA was 0.49±0.32, post operative visual recovery was better in TA group patients and had less pain and more comfortable than PA. Surgeon had difficulty more with TA group patients. It was found, postoperative visual recovery was faster and better in patients with topical group with less postoperative inflammation and complications. Topical anesthesia being a non invasive procedure can be considered better than peribulbar when compared in terms of patients comfort and postoperative recovery.

Visual outcomes and intraoperative complications of small incision cataract surgery performed by junior residents in GMC

To evaluate in intraoperative complications of MSICS performed by Junior Residents and to compare the incidences of major complications in the first six months of training versus last six months of training.It is a retrospective type of study. From March 2018 to February 2019 a total of 293 manual SICS were conducted by the Junior Residents in Department of Ophthalmology. Each of the patients underwent a detailed ophthalmological examination preoperatively and underwent MSICS under peribulbar anesthesia. Consents for surgeries were obtained from each patient.Following intraoperative complications were noted: tunnel related complications, capsulorrhexis related complications, Iridodialysis, posterior capsular rent, zonular dialysis, vitreous leak, surgical aphakia, Descemet membrane detachment, placement of ACIOL, Nucleus drop and IOL drop. The patient’s immediate postoperative vision was also noted. SPSS version 15.0.Tunnel related complications were found in 13.98% patients either as scleral button holing or premature entry. Posterior capsular rents and bag disinsertion were found in total of 11.94% patients owing to which 3.07% were left aphakic. 63.13% patients had visual acuity better than 6/12 by snellens chart on first postoperative day. Performance of adequate anterior capsulotomy, minimal handling of the cornea and avoidance of posterior capsular rent are some of the challenges faced by the residents while learning MSICS. Stepwise supervised training can help a resident doctor master these steps while keeping the complications at acceptably low levels. Stepwise supervised training of residents performing MSICS can minimize complications

Modified capsulorhexis for fluid-filled mature cataracts

Background: The aim of this study was to develop a modified capsulorhexis technique featuring a new maneuver for the removal of subcortical fluid in fluid-filled mature cataracts to avoid high intralenticular pressure. Methods: This prospective interventional study included 33 eyes with mature cataracts and evidence of subcapsular fluid spaces by slit lamp examination. For each patient, 20% mannitol was administered intravenously according to the bodyweight 1 h preoperatively. Under peribulbar anesthesia, a 2.2-mm main incision was made, and the anterior chamber was filled with a dispersive ophthalmic viscosurgical device. Using a bent-tip cystotome, a 2-mm curved incision was made in the center of the anterior capsule, which released subcortical fluid and was drained through compression of the posterior lip of the main incision using a spatula. Then, fine gentle milking in all quadrants around the puncture on the anterior lens capsule from the periphery toward the site of puncture using the blunt-edged spatula further assists drainage of subcortical fluid and breaks fine septa inside the lens to remove fluid from intralenticular fluid pocket collections. Results: The study included 15 (45.5%) men and 18 (54.5%) women with a mean ± standard deviation (SD) of age of 63.2 ± 5.33 and 64.4 ± 6.21 years, respectively. The modified capsulorhexis technique was performed for 33 intumescent cataracts. Capsulorhexis was completed in all cases; capsulorhexis was easy in 31 (94%) eyes and difficult in 2 (6%) eyes. In the two difficult cases, radial extension occurred in one eye, and it was retrieved using the Little technique; the other case with radial tear was completed successfully using a retinal micro scissor from the other edge of the capsulorhexis until reaching an oval, continuous capsulorhexis. Conclusions: This modified capsulorhexis technique with compression on the posterior lip of the main incision and capsule milking allowed for a safe, continuous curvilinear capsulorhexis. Further comparative studies are necessary to confirm our preliminary results. How to cite this article: Ghoneim EM. Modified capsulorhexis for fluid-filled mature cataracts. Med Hypothesis Discov Innov Ophthalmol. 2021 Summer; 10(2): 17-24. https://doi.org/10.51329/mehdioptometry1422

Comparative study between medial canthus episcleral block versus peribulbar block in intracapsular cataract surgery

Background Ophthalmic regional anesthesia is now the most common anesthetic technique used for eye surgeries. There are various modes of needle-based ophthalmic anesthesia which are retrobulbar, peribulbar, and episcleral. The sub-Tenon episcleral anesthesia technique became a potential alternative to the retrobulbar and peribulbar anesthesia in most of the anterior and posterior segment eye surgeries; this is due to its better safety profile and tolerability than the other blocks. The aim of this study was to compare between medial episcleral block and peribulbar block in intracapsular cataract surgery as regards anesthesia and akinesia of the eye, the need of supplementation of local anesthetic, and finally the safety profile of each block. This was a prospective, comparative, randomized, double-blinded clinical study. It was carried out on 60 patients that were scheduled for intracapsular cataract surgery in ophthalmic surgery unit. The patients were randomly allocated into two equal groups; group A received medial canthus episcleral block technique and group B received peribulbar block technique. Results Results of this prospective, comparative, randomized, double-blinded study showed no statistical difference between the two groups as regards demographic and vital data. As regards Akinesia score, the ESA group had better akinesia score at 1, 5, and 10 min and at the end of surgery than PBA group (P value, 0.001). No patient in the ESA group received supplemental injection via inferotemporal peribulbar block technique, while 66.7% of PBA group was in need of supplementation. Regarding time to onset of acceptable akinesia score; ESA group had a faster onset with high statistical significance (P value, 0.001). Numeric pain scale was better in ESA group than PBA group with high statistical significance. There were chemosis after injection in two of the ESA group (6.6%). On the other hand, slight pricking pain at the end pf surgery developed in two cases in the PBA group. Conclusion Medial canthal episcleral technique proved to be superior in motor akinesia score, time to onset of acceptable akinesia score, and numeric pain scale in comparison to peribulbar anesthesia with high statistical significance between the two groups. Both techniques proved to be safe with no incidence of major complications.

Unexpected amaurosis occurring after peribulbar anesthesia: Exploring the causes in two cases

Peribulbar anesthesia (PB) is known to be safer than retrobulbar (RB) anesthesia. To our knowledge, no amaurosis has been described after PB. We report here the cases of two patients who underwent PB before membrane peeling. The injections were administered with a 25-gauge, 22-mm bevel disposable needle. The anesthetic used was ropivacaine 1% with a volume of 8 ml and 75 µg of clonidine as an adjuvant (7.5 µg/ml). Given that complete akinesia was not achieved, a second injection of 2 ml was administered in the supero-medial injection site. Thirty minutes after the PB, the first patient experienced amaurosis with no light perception (LP). The ophthalmic examination was normal. Visual acuity recovered after 1 day. Regarding the second patient, the loss of VA was observed 20 min after the PB. IOP was 20 mmHg. The anterior segment and fundus exam were normal. Rubin found the PB technique to be as effective and safer than RB injection, as the needles are not supposed to enter the RB space and Davis and Mandel found no amaurosis after PB. PB is administered via the extraconal injection of an anesthetic agent. These amaurosis might be explained by the fact that some anesthetic may have penetrated the RB space. In cases where two PB injections are administered, the anatomy is expected to change due to the volume effect of the first injection. The second injection is higher risk as it is administered closer to the optic nerve.