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| ORIGINAL ARTICLE |
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| Year : 1991 | Volume
: 39
| Issue : 4 | Page : 166-167 |
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A modified technique of anterior peribulbar anaesthesia
Kamal Kishore, Harish C Agarwal, NN Sood, AK Mandal
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
Correspondence Address:
N N Sood
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1810877 
A modified technique of peribulbar anaesthesia consisting of a single injection of anaesthetic solution with a 26G, half inch insulin needle was evaluated in 50 eyes. The operative procedures included extracapsular cataract extraction with intraocular lens implantation in 20 eyes, intracapsular lens extraction in 20 eyes, and trabeculectomy in 10 eyes. Complete anaesthesia was obtained in 45 eyes (90%). No significant complications were observed except for mild to moderate conjunctival chemosis in 40 eyes (80%). The technique is easy to learn, safe, effective and relatively economical.
How to cite this article:
Kishore K, Agarwal HC, Sood N N, Mandal A K. A modified technique of anterior peribulbar anaesthesia. Indian J Ophthalmol 1991;39:166-7 |
| Introduction | |  |
Peribulbar anaesthesia has become popular in recent years because similar degree of analgesia and akinesia as obtained with the retrobulbar block can be achieved using the former method, but without inserting a needle blindly into the intraconal space [1],[2],[3],[4]. Thus, peribulbar anaesthesia is likely to eliminate several complications associated with retrobulbar blocks [5], such as retrobulbar haemorrhage, perforation of the globe, brain-stem anaesthesia, retinal vascular occlusion, contralateral amaurosis and extraocular muscle palsies, grand mal seizures, and cardiopulmonary arrest. Though several modifications in the standard technique of retrobulbar block have been suggested in order to keep the needle away from the optic nerve and its dural sheath [5][6][7], the potential for causing serious complications still exists.
Currently popular techniques of peribulbar anaesthesia require the use of a relatively long needle and large volume of anaesthetic solution, sometimes upto 10 ml [1],[3]. The purpose of this communication is to report a modified technique of peribulbar anaesthesia. It is simple, relatively economical and safe.
| Material and methods | | |
Modified peribulbar anaesthesia was used in 20 eyes having cataract posted for extracapsular cataract extraction with posterior chamber intraocular lens implantation, 20 eyes undergoing intracapsular cataract extraction, and 10 eyes of patients of primary open angle glaucoma posted for trabeculectomy. Anaesthetic solution was prepared by dissolving one ampoule of hyaluronidase (1500 IU), and 0.3 ml of adrenalin in a 30 ml bottle of 2% xylocaine. Three ml of this solution along with 2 ml 0.5% bupivacaine was drawn in a 5 ml syringe, to which a disposable half-inch, 26G insulin needle was attached. The patient was requested to look up to make the orbital septum taut. The needle was inserted in the lower eyelid just above the inferior orbital margin approximately 5mm medial to the lateral canthus. It was advanced backwards and slightly medially parallel to the orbital floor, till the hub indented the skin and lateral part of the lower lid margin showed slight ectropion. Maintaining constant backward pressure with the hub, the solution was slowly deposited in the peripheral space. This was followed by application of a "Super-Pinki" for 30 minutes. No separate injection was given for lid akinesia.
The effect of peribulbar anaesthesia was evaluated after 30 minutes. Lid and globe akinesia, and conjunctival chemosis were assessed according to the scheme shown in the Table. Corneal sensations were tested. Topical anaesthetic drops were not used as a routine.
| Results | | |
Complete lid akinesia, ocular akinesia and ocular analgesia were obtained in 45 (90%) eyes. Three patients required supplemental facial block, and two required retrobulbar block for residual ocular motility. Topical anaesthetic drops were not needed in any patient. Ocular and lid akinesia were maintained throughout the duration of the surgical procedure, which ranged from 30 to 45 minutes. None of the patients complained of pain during the surgical procedure. Mild to moderate conjunctival chemosis (Grade 1 and 2) was observed in 40 eyes (80 %). It did not interfere with the surgical procedure.
| Discussion | | |
Charles Kelman employed peribulbar injection for the first time in cataract surgery on a large scale'. Anaesthesia was achieved by a single injection of the solution with a 1 5/ 8 inch long, 25G needle. No case of retrobulbar haemorrhage or optic nerve damage was encountered in more than 2500 cases [8] . Others have also reported successful results using peribulbar techniques [1],[2],[3],[4]sub .The anaesthetic solution is deposited in the posterior part of the peripheral space in these techniques using a relatively long needle. It is followed by a variable period of ocular compression. The spread of anaesthetic, which may be along the needle track or through the tissue planes is aided by hyaluronidase and ocular compression.
While these methods have been effective, a small risk of ocular perforation and orbital haemorrhage still remains because of the long needles used. We injected the anaesthetic mixture relatively anteriorly using a short needle and allowed the solution to diffuse both anteriorly into the orbicularis, as well as posteriorly into the ciliary ganglion and extraocular muscles during 30 minutes of ocular compression. Shorter period of ocular compression has been tried by others [2], but it was associated with incomplete anaesthesia in 28% of their patients.
No complications as reported with retrobulbar anaesthesia were observed in our study. Pain caused by the prick of a thin 26G needle was well tolerated by our patients, The use of a short (half-inch) needle adds extra safety to the procedure, the needle being too short to enter the muscle cone or damage the extraocular muscles.
Conjunctival chemosis was minimal and confined to the inferotemporal quadrant in the majority. Insertion of needle in the proper direction, maintenance of constant backward pressure with the hub during injection, and ocular compression for 30 minuteswere necessary to minimize chemosis of the conjunctiva. However the conjunctival chemosis, even if moderate, does not in any way cause operative or postoperative problems, as has been observed by other workers as well [1],[2].
An additional benefit of our method is complete sensory anaesthesia of the lids so that the patient does not feel any pain while passing lid sutures. The volume of the anaesthetic solution required is lesser with this technique than that needed for other techniques of peribulbar anaesthesia [l],[3], or combined facial and retrobulbar blocks. This makes the procedure not only more economical, but also safer by reducing the chances of overdose toxicity of the local anaesthetic agent.
The technique of peribulbar anaesthesia described by us is simple, safe, effective and economical, and is presently being used by us for most of our intraocular procedures.
| References | | |
| 1. | Davis DB II, Mandel MR. Posterior peribulbar anaesthesia; an alternative to retrobulbar anaesthesia. Ind J Ophthalmol 1989; 37:59.61.  |
| 2. | Weiss JL, Deichmann CB. A comparison of retrobulbar and periocular anaesthesia for cataract surgery. Arch ophthalmol 1989; 107:96-8. |
| 3. | Bloonbert LB. Administration of periocular anaesthesia. J Cataract Refract Surg 1986; 12:677-9. |
| 4. | Gills JR My method of extracapsular cataract extraction with implantation of a posterior chamber intraocular lens. Ophthalmic surg 1985; 16:38692. |
| 5. | Feibel RM. Current concepts in retrobulbar anaesthesia. Surv Ophthalmol 1985:30:102-10. |
| 6. | Unsold R, Stanley JA, Degroot J. The CT topography of retrobulbar anaesthesia. Graefes Arch Clin Exp Ophthalmol 1981; 217:125-36. |
| 7. | Pautler SE. Grizzard WS. Thompson LN, Wing GL. Blindness from retrobulbar injection into the optic nerve. Ophthalmic Surg 1986; 17:334-7. |
| 8. | Kelman CD. Parachute cataract surgery, in Klein EA (ed). Symposium on Cataract Surgery, Trans New Orleans Acad Ophthalmol. St Louis, Mosby, 1983; pp 159-63. |
[Table - 1]
| This article has been cited by | | 1 |
A comparative study between 25 x 0.70 mm and 20 x 0.55 mm needles for retrobulbar block with a small volume of anesthetic for the treatment of cataracts by phacoemulsification | [Estudo comparativo entre agulhas de 25 x 0,70 mm ou 20 x 0,55 mm para anestesia retrobulbar com baixo volume anestésico em tratamento de catarata por facoemulsificação] |
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| Carneiro, H.M., Teixeira, K.I.S., De Ávila, M.P., Neto, O.A., Hannouche, R.Z., Magacho, L. | | Revista Brasileira de Anestesiologia. 2008; 58(6): 569-581 | | [Pubmed] | | | 2 |
Intraocular pressure control and visual outcome in patients with phacolytic glaucoma managed by extracapsular cataract extraction with or without posterior chamber intraocular lens implantation |
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| Mandal, A.K., Gothwal, V.K. | | Ophthalmic Surgery and Lasers. 1998; 29(11): 880-889 | | [Pubmed] | | | 3 |
An alternate way to manage patients with Morgagnian Cataracts and Phacolytic Glaucoma |
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| Mandal, A.K. | | Indian Journal of Ophthalmology. 1997; 45(1): 53-59 | | [Pubmed] | |
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