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   Table of Contents      
Year : 2002  |  Volume : 50  |  Issue : 4  |  Page : 313-316

Peribulbar anaesthesia for penetrating keratoplasty. A case series

Dept. of Ophthalmology, Clear Vision Eye Center, Bombay, India

Correspondence Address:
V Agrawal
Dept. of Ophthalmology, Clear Vision Eye Center, Bombay
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Source of Support: None, Conflict of Interest: None

PMID: 12532497

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Purpose: To prospectively analyse the efficacy and safety of peribulbar anaesthesia for penetrating keratoplasty through a noncomparative, consecutive series.
Methods: One hundred twenty-four (91.1%) of 136 patients undergoing penetrating keratoplasty (PK) from January 1997 to December 2001, were administered peribulbar anaesthesia. The anaesthetic mixture consisted 5ml of lignocaine, bupivacaine, and hyaluronidase (to avoid evaluation bias) in the peribulbar space. A repeat injection of 3 ml was used if the primary injection was inadequate. Digital ocular compression was done for 10-15 minutes after the first injection. Each patient was analysed for degree of akinesia, subjective patient comfort, analgesia, subjective surgeon comfort, and types of surgical conditions.
Results: The age ranged from 19 to 86 years. Forty-nine of 124 patients (39.5%) received PK only and remaining 75 patients (60.5%) received additional procedures. A single injection was sufficient to achieve adequate akinesia (grade II and III) in 114 (92%) patients and 120 (97%) of patients were satisfied (graded pain as ≤ grade II). During surgery, 6 (5%) phakic eyes developed episodes of positive intraocular pressure and 5 eyes (4%) developed chemosis. There were no other local or systemic adverse events. The surgeon level comfort was (grade II or more) 98% (122 of 124).
Conclusion: One-point, low volume, peribulbar anaesthesia for penetrating keratoplasty is safe and efficacions.

Keywords: Penetrating keratoplasty, peribulbar anaesthesia

How to cite this article:
Agrawal V, Tharoor M. Peribulbar anaesthesia for penetrating keratoplasty. A case series. Indian J Ophthalmol 2002;50:313-6

How to cite this URL:
Agrawal V, Tharoor M. Peribulbar anaesthesia for penetrating keratoplasty. A case series. Indian J Ophthalmol [serial online] 2002 [cited 2020 Aug 15];50:313-6. Available from: http://www.ijo.in/text.asp?2002/50/4/313/14760


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Peribulbar anaesthesia has been accepted as a modality of regional anaesthesia for various ocular surgical procedures since 1986.[1] In penetrating keratoplasty (PK), however, there is still hesitation in using this method because of a fear of the "open sky" situation.[2] Also, isolated incidents of suprachoroidal haemorrhage have been reported in cases where retrobulbar[3],[4] or peribulbar anaesthesia has been used.[5] Our literature search showed very few reports of PK done under peribulbar or topical anaesthesia[6][7][8][9][10] In these studies a large volume anaesthetic bolus (5 to 18 ml) with a two-point, multistage mode of injection was used.

Our prospective study was designed to assess the safety and efficacy of one-point low-volume peribulbar anaesthesia for penetrating keratoplasty.

  Materials and Methods Top

One hundred and thirty-six consecutive cases were studied prospectively from January 1997 through December 2000. Eyes undergoing combined procedures were also included. A single surgeon performed all the surgeries. Four surgeries were performed under general anaesthesia as the patients were young (2-7 years); these cases were excluded from further analysis. Eight patients needed a tectonic or therapeutic keratoplasty and were excluded, as the surgical conditions were very different from those undergoing elective procedures. All coexisting systemic conditions were well controlled, and patients were cleared for surgery under peribulbar anaesthesia at the preoperative anaesthesia evaluation. Informed consent was obtained from all patients.

All patients received single-point anaesthesia injected at the junction of the lateral one-third and medial two-thirds of the infra-orbital rim, using a 24 g disposable 35mm needle directed vertically downward. The injection consisted of a 60:40 mixture of 2% lignocaine (Lidocaine) and 0.5% bupivacaine (Sensorcaine) with 10 IU/ml of hyaluronidase. 5 ml was injected at the first instance. To reduce the intraocular pressure (IOP) ocular compression was applied by digital massage for 10 to 15 minutes. The patients were evaluated for motor akinesia 10 minutes after ocular compression. Motor akinesia was graded 0-2; zero if there was free movement; one if there was partial movement; and 2 if there was no movement. This was done for each of the four recti, levator superioris, and orbicularis oculi muscles. The maximum score was 12, indicating total akinesia. Any eye with a score of less than 8 received a repeat 3ml injection of the same anaesthestic mixture. No intraocular local supplementation was used in any patient.

At the end of the surgery an attendant, masked to the surgical procedure, asked the patient to grade their surgical experience on a numeric scale of 10, where 0 represented no pain and 10 represented unbearable pain. At the one-week postoperative visit they were asked to respond to a questionnaire inquiring the surgical experience. This included a repeat question about the pain, and whether they would recommend the same procedure to others or go through it again themselves.

The other observed parameters included surgical indication, conditions during surgery, duration of surgery, associated complications, and need for supplemental anaesthesia during surgery.

  Results Top

The patients studied included 82 males and 42 females ranging in age from 19 to 86 years (mean 66.7 17.3).

Four patients judged too anxious by the anaesthesiologist received intravenous sedation (Propofol 1mg/kg/hour). Five of 11 patients who complained of claustrophobia due to the surgical drapes were sedated; other 6 patients settled down on repeat explanation of the procedure. Thus a total of 9 (7.2%) patients in this study needed intravenous sedation. Preoperative diagnosis had no bearing on the anaesthesia protocol. An anaesthesiologist was present throughout the procedure as per standard practice. Vital parameters were monitored at all times during the surgery and these included pulse oximetry, cardiac monitoring and blood pressure assessment throughout the procedure.

In all cases the IOP was digitally normal to low before commencement of surgery. Accurate measurement of IOP was not feasible due irregular corneal surface. The surgery lasted for 55 (6) minutes (range 30-75 minutes). The indications for surgery are listed in [Table - 1] and the procedures detailed in [Table - 2].

Global akinesia was complete in 103 (83.6%) eyes 15 minutes after injection. Another 11 (8.9%) patients were deemed to have adequate akinesia (partial movement in 2 quadrants) for safe surgery. Ten (8%) patients a needed 3ml supplemental injection of peribulbar anaesthesia. Thus this regimen allowed all the patients to undergo surgery. Complete akinesia lasted through the procedure in 78 (62.9%) patients. Akinesia less than optimum but adequate through the procedure (small eye movements during surgery) was noted in the remaining eyes. The orbicularis oculi muscle activity was noted in 27 (21.7%) eyes after removal of the speculum at the end of surgery. However, this did not affect the surgical procedure. In all these eyes the surgical time was more than 60 minutes.

The pain score recorded by the patients immediately after the surgery was 0 (no pain) in 70 (56.4%) patients, 1-3 (some pain) in 50 (40.32%), 4-6 (moderate pain) in 3 (2.4%), and above 6 (severe pain) in one (0.08%) patient. Thus 96.7% of patients (including those reporting a pain score of 3 or less) had satisfactory pain control. At the one-week postoperative visit the pain scores recorded by the patients as part of routine questionnaire differed significantly (p<0.05, student t-test) for the second group. The reported incidence was no pain in 114 (91.9%), some pain, in 10 (8.06%) and moderate pain in one patient. The pain scores and surgeon comfort levels were compared between various groups depending on the type of surgical procedure ([Table - 2]). No statistical significance was seen though a trend towards higher pain scores was observed in patients undergoing simultaneous multiple procedures. This could be due to the small number of patients within each group.

Eleven patients undergoing multiple procedures during keratoplasty had positive vitreous pressure intra-operatively. This caused difficulty in anterior capsulotomy in the phakic patients, but there was no incidence of vitreous loss in these eyes. In one case of planned anterior vitrectomy, the surgeon also reported a positive vitreous pressure. These events had no effect on the final outcome. There was no incidence of suprachoroidal haemorrhage or scleral collapse.

Conjunctival extravasation of anaesthetic agent leading to significant chemosis was noticed in 5 (4%) patients but was always mild to moderate and did not interfere with surgery or trephination. There were no other local or systemic complications in any of the patients.

  Discussion Top

Use of peribulbar anaesthesia has increased steadily since its first description.[1] This is due to a better safety profile with the same efficacy as the retrobulbar anaesthesia.[11] In penetrating keratoplasty; however, general anaesthesia is still in use by a significant number of surgeons. In the United Kingdom, 93% of surgeons prefer general anaesthesia,[2] and in some other countries up to 78% of cases are performed under general anaesthesia.[3] Other corneal surgeons have reported a routine use of retrobulbar anaesthesia supplemented with intravenous sedation for their series of patients. [7,8] Yavitz et al[9] have performed penetrating keratoplasty under topical anaesthesia with an O'Brien block in 90 patients. In the only other study on peribulbar anaesthesia for penetrating keratoplasty Muraine et al[10] used peribulbar anaesthesia in 73% of patients. In the present study we were able to use peribulbar anaesthesia for all patients over 18 years of age without exception. This may reflect in part a cultural variation or the felt demand of the patient. The surgical protocol did not influence the nature of anaesthesia in our group. In fact 70.5% of our patients had a combined procedure.

The amount of anaesthesia required by us was the same as in our past study for cataract surgery.[11] The anaesthestic mixture volume was 5-8 ml, and 8% patients needed the 3 ml supplemental injection after the initial 5 ml injection. Unlike Muraine et al[10] we saw no tensing of the eyelids; neither did we need to do a multistage injection. This method thus reduces the risk of the rare but significant complication of optic neuropathy reported with peribulbar anaesthesia.[5] This is probably because the vertically downward single penetration of the 35 mm needle minimises the risk of direct damage to the optic nerve by inadvertent retrobulbar penetration. The low volume used in peribulbar anaesthesia also helps avoid the risk of activating the oculo-cardiac reflex and vasovagal syncope. These reflexes are related to the tension exerted on the adnexal structures and the stretch receptor activation due to the small intraconal and orbital space available for injection.[11] In spite of the low volume of initial injection, the reinjection rate was low at 8%. We were also able to achieve total akinesia in over 83% of our cases before commencing the surgery. Orbicularis ocularis activity was seen in 21% of our patients at the end of surgery, much higher than the 11% reported by Muraine and co-authors.[10] This could be attributed to the lower volume of the anaesthesia. An alternative explanation may be that the single point injection in the lower orbit resulted in inadequate spread to all muscle fibres. However, this did not affect either patient or surgeon comfort. We feel higher volumes of anaesthestic drug are not needed. It may be pertinent to caution that the surgeon's experience may have contributed to the relative lack of difficulty. Surgeons in the early part of the learning curve should be cautious about the type of associated procedure needed before considering this method.

The commonest fear that precludes the use of peribulbar anaesthesia in most cases relates to expulsive haemorrhage. The incidence in cases of keratoplasty is higher than other surgeries.[12] It is reported after both local and general anaesthesia,[3] and the relative risk of anaesthesia type is not studied. In retrobulbar anaesthesia, the increased episcleral pressure is thought to cause congestion in the venous system and predispose the eye to expulsive haemorrhage. It is thus recommended that low volume peribulbar anaesthesia be used with a large latency.[12] It is also believed that keratoplasty performed under peribulbar anaesthesia with a long time compression has a very low risk of an expulsive haemorrhage.[10]

We previously reported a 12.7% incidence of chemosis with the same technique of injection for cataract surgery.[11] Currently the incidence has reduced to 4%. This is due to the increased duration of ocular compression, from earlier 5-7 minutes to current 10-15 minutes. This is important with the use of limbal suction trephine systems like the BarronTM suction trephine system. Additionally, insertion and suturing of a Flierenga ring is difficult with excessive chemosis. We did not face any problems in the attachment of the trephines or the actual trephination.

Despite achieving low IOP preoperatively we experienced positive IOP in some patients. This could be due the pressure exerted by the eyelid speculum or the open chamber status of the eye while attempting the capsulorhexis. The open chamber status does not allow a good control of the iris-lens diaphragm and the anterior shift could be a significant factor. While this pressure, was not significant in any of the aphakic eyes, it was difficult to perform anterior capsulorhexis in eyes scheduled for combined cataract surgery. In 6 patients we could not complete the capsulorhexis due to radial tears. We now recommend a closed chamber rhexis in all cases wherever visualisation permits. Alternatively one can scrape the loose epithelium; this allows good visualisation of the cataract in most cases of corneal oedema. After shifting to this technique we have not had such problems with capsulorhexis.

In conclusion our study suggests that single 5ml injection of peribulbar anaesthesia along with ocular compression of moderate duration is a safe modality for keratoplasty in adults.

  References Top

Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to retro bulbar anesthesia. J Cataract Refract Surg 1986;12:182-84.  Back to cited text no. 1
Burdon MA, McDonnell P. A survey of corneal graft practice in the United Kingdom. Eye 1995;9:6-12.  Back to cited text no. 2
Price FW Jr, Whitson WE, Ahad KA, Tavakkoli H. Suprachoroidal hemorrhage in penetrating keratoplasty. Ophthalmic Surg 1994;25:521-25.  Back to cited text no. 3
Gloor BM, Kalman A. Choroidal effusion and expulsive hemorrhage in penetrating interventions - lessons from 26 patients. Klin Monatsbl Augenhelikd 1993;202:224-37.  Back to cited text no. 4
Davis DB, Mandel MR. Efficacy and complication rate of 16,224 consecutive peribulbar blocks. A prospective multicenter study. J Cataract Refract Surg 1994; 20:327-37.  Back to cited text no. 5
Wang HS. Peribulbar anesthesia for ophthalmic procedures. J Cataract Refract Surg 1988;14:441-43.  Back to cited text no. 6
Aquavella JV. Outpatient corneal surgery. Int Ophthalmol Clin 1988;28:184-47.  Back to cited text no. 7
Collie DM. Outpatient penetrating keratoplasty. Aust NZ J Ophthalmol 1989;17:73-77.  Back to cited text no. 8
Yavitz E. Topical and intracameral anesthesia in corneal transplant (letter). J Cataract Refract Surg 1997;23:1435.  Back to cited text no. 9
Muraine M, Calenda E, Watt L, Proust N, Cardon A, Euphrete L, et al. Peribulbar anesthesia during keratoplasty: A prospective study of 100 cases. Br J Ophthalmol 1999;83:104-09.  Back to cited text no. 10
Agrawal V, Athanikar NS. Single injection, low volume periocular anesthesia in 1000 cases. J Cataract Refract Surg 1994;20:61-63.  Back to cited text no. 11
Ingraham HJ, Donnenfeld ED, Perry HD. Massive suprachoroidal hemorrhage in penetrating keratoplasty. Am J Ophthalmol 1989;108:670-75.  Back to cited text no. 12


  [Table - 1], [Table - 2]


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