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Year : 2005  |  Volume : 53  |  Issue : 4  |  Page : 255-259

Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery

H.V. Desai Eye Hospital, Pune, India

Correspondence Address:
Parikshit Gogate
H. V. Desai Eye Hospital, 93 Tarawade Vasti Mohammadwadi, Hadapsar, Pune – 411 028
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.18907

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Purpose: To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual small incision cataract surgery using a randomised control clinical trial.
One hundred and sixty-eight patients were randomised to subtenon and peribulbar groups with preset criteria after informed consent. All surgeries were performed by four surgeons. Pain during administration of anaesthesia, during surgery and 4 h after surgery was graded on a visual analogue pain scale and compared for both the techniques. Sub-conjuntival haemorrhage, chemosis, akinesia after administration of anaesthesia and positive pressure during surgery were also compared. Patients were followed up for 6 weeks postoperatively.
About 146/168 (86.9%) patients completed the six-week follow-up. Thirty-one out of 88 (35.2%) patients of peribulbar group and 62/80(77.5%) of subtenon group experienced no pain during administration of anaesthesia. There was no significant difference in pain during and 4 h after surgery. Subtenon group had slightly more sub-conjunctival haemorrhage. About 57 (64.8%) patients of the peribulbar group had absolute akinesia during surgery as compared to none (0%) in sub-tenon group. There was no difference in intraoperative and postoperative complications and final visual acuity.
Sub-tenon anaesthesia is safe and as effective as peribulbar anaesthesia and is more comfortable to the patient at the time of administration.

Keywords: manual small incision cataract surgery; peribulbar anaesthesia; sub-tenon anaesthesia

How to cite this article:
Parkar T, Gogate P, Deshpande M, Adenwala A, Maske A, Verappa K. Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery. Indian J Ophthalmol 2005;53:255-9

How to cite this URL:
Parkar T, Gogate P, Deshpande M, Adenwala A, Maske A, Verappa K. Comparison of subtenon anaesthesia with peribulbar anaesthesia for manual small incision cataract surgery. Indian J Ophthalmol [serial online] 2005 [cited 2023 Feb 2];53:255-9. Available from: https://www.ijo.in/text.asp?2005/53/4/255/18907

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Peribulbar anaesthesia for cataract surgery was the most popular technique in the previous decade,[1] but it is not completely free from complications.[2] Retrobulbar anaesthesia, which was used for almost a century, was associated with a number of potentially sight-threatening complications.[3] Alternative anaesthesia procedures have been developed to reduce the risk of injuring intraorbital structures, [4],[5],[6]

Advances in cataract surgery including the use of a smaller, self-sealing incision have shortened the duration of surgery[7] resulting in the use of shorter acting anaesthetic agents with less invasive methods of administration.

Sub-tenon anaesthesia[4],[6],[8] involves transconjunctival infiltration of local anaesthetic agent directly to the subtenons space, after instillation of local anaesthetic drop in the conjunctiva which takes away the pain from, the needle prick. This technique has been used for conventional extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens implantation (PCIOL)[8] and phacoemulsification.[8],[9] Manual small incision cataract surgery (MSICS) has become popular in developing countries like India as it gives better uncorrected vision as compared to ECCE,[10] and at an affordable cost.[7] A comparison of subtenon anaesthesia with the more popular peribulbar anaesthesia for MSICS could not be found by us in the literature. The study aimed to compare the two methods of anaesthesia in MSICS with respect to pain, akinesia, intraocular pressure control, surgeon comfort and complications, using a randomised control clinical trial.

  Materials and Methods Top

All the patients admitted for cataract surgery, were asked to participate in the trial. The first 168, who agreed to informed consent, were randomised to either subtenon or peribulbar technique.

The exclusion criteria were:

1.Age < 30 or > 90 years,

2.sensitivity to Xylocaine,

3.history of convulsion, epilepsy,

4.inability to give informed consent,

5.people who preferred phacoemulcification or conventional extracapsular surgery,

6.previous intraocular injury, inflammation or surgery,

7.pupil <5 mm in diameter,

8.inability to understand the visual analogue pain scale.

They were operated upon by four surgeons of reasonably good experience (minimal experience of 3 years and 1000 surgeries with the surgical technique, and 100 surgeries with subtenon anaesthesia).

Assuming 90% power and 5% level of significance and assuming that there would be no pain in 40% and 60% of cases by either technique (difference of proportions), each arm should have a minimum of 58 patients. Assuming loss of 20% to follow-up, the study aimed to randomise at least144 patients. Permission was obtained from the ethical committee of the H. V. Desai Eye Hospital, Pune. Both techniques of anaesthesia are acceptable standards of care and have been in use for more than a decade. The consent form and information sheets for the patients were designed as per the Helsinki protocol guidelines and translated into Marathi. Informed consent was obtained from all the patients who participated.

The randomisation schedule for each surgeon was generated by an epitable. The schedule was generated for 200 surgeries but the trial was stopped after 168 surgeries.

Each patient was randomly assigned by opening an envelope on entering the recovery (preanaesthetic) room. The peribulbar anaesthesia was administered by the anaesthetist and the subtenon anaesthesia was given by the surgeon on table. Any extra anaesthetic needed was noted. The patients and the surgeon was masked till 10 min before surgery.

The patient was asked to gauge for the pain during administration of the anaesthetic, pain during surgery and after it was completed. Postoperative pain after 4 h was also recorded. After each surgery the surgeon was asked to score for akinesia and to grade for positive pressure during surgery, chemosis, subconjunctival haemorrhage and overall 'discomfort'. Intraoperative complications were noted. All patients underwent MSICS; any change in technique, if needed, was noted.

The patients were followed on the first postoperative day, first week and sixth week after surgery. The postoperative complications were noted, as also the best corrected postoperative visual acuity and refraction.

Subtenon anaesthesia

The eye to be operated was painted with povidone iodine. After draping, a lid speculum was applied and two drops of topical 4% lignocaine were instilled. The patient was instructed to look upwards and outwards. Blunt Westcott's scissors were used to make a small nick on the conjunctiva and the tenons capsule in the inferonasal quadrant, 4 mm from limbus. The scissors were then skewed through the nick to create a path in the subtenons space. Conjunctival forceps were used to grip the conjunctiva and a curved subtenon cannula was then inserted on to bare sclera and glided along the contour of the globe. One ml of 2% lignocaine with 1:10 000 adrenaline was injected slowly in the posterior subtenon space.

Peribulbar anaesthesia

Four ml of 2% lignocaine with 1:10 000 adrenaline was injected using a 24G needle at junction of middle and outer third of the lower orbital margin with the needle directed towards floor of orbit. A supplementary injection of 1 ml. was given at the supra orbital notch with needle directed towards orbital roof. The eyelid was then closed and pressure was applied for 5 min.

Visual analog pain scale

The patients were asked to grade the pain they felt on a linear scale of 0-4 (No pain = grade 0, mild pain= grade 1, moderate pain =grade 2, severe pain = grade 3 and maximum pain imaginable = grade 4). Patients were asked to grade separately for pain during administration of anaesthesia, pain during surgery and pain 4 h after surgery. The last was taken when the patient was shifted to the wards.

The ophthalmologists also graded for chemosis, subconjunctival haemorrhage after administration of anaesthesia and positive pressure during surgery on a scale of 0-4, of increasing severity. 'Akinesia' was scored on a scale designed to measure ocular movements in each quadrant (no movement = score 0, mild = 1, moderate = 2, severe = 3 in each quadrant, minimum score possible = 0, maximum score possible = 3 x 4 = 12).

The surgeon also graded for the 'discomfort' he felt during surgery (grade 0 = no discomfort, grade 1 = mild discomfort, grade 2 = moderate, grade 3 = severe, grade 4 = surgery not possible).

  Results Top

About 146/168 (86.9%) patients completed the six-week follow-up. About 168 patients underwent MSICS between August 2002 and April 2003 and were operated upon by four surgeons [Table - 1]. 87 (52.1%) were males, 40/88 (47.15 %) in peribulbar group and 47/80 (58.7%) in the subtenon group. Average age in the two groups was 58 and 56 years, respectively. There was no statistically significant difference between the two groups with respect to age ( p = 0.133) and sex. ( p = 0.213).

The various grades of pains during anaesthesia are depicted in [Table - 2]. Chi square test shows that there is a significant difference between both the groups with regards to pain on administration of the anaesthesia for grades 0 and 1 ( p < 0.0001). p = 0.09 for grade 2, p = 2 for grade 3 by figure exact test, there being no statistically significant difference for grade 2 or more. The average for pain during anaesthesia was grade 0.82 for the peribulbar group and 0.26 for subtenon group on a range of 0-4.

[Table - 3] shows the various grades of pain during surgery in both the groups. Average for pain during surgery was 0.15 for peribulbar and 0.07 for subtenon on a range 0-4.

[Table - 4] describes the various scores of ocular movement after anaesthesia. Eighty-five out of 88 (96.6%) of patients in peribulbar group had scores of 4 or less; 72/80 (90%) of patients of subtenon group scores of 6 or more, with the mode score of 10. The mode for peribulbar group was 0. This was statistically very significant ( p < 0.0001). Average score for akinesia was 1.2 in peribulbar group and 8.4 in subtenon group on a range0-12.

About 88/88 (100%) patients of peribulbar group and 79/80 (98.8%) patients of subtenon group did not have any positive pressure during surgery. Only one patient of subtenon group had minimal pressure rise.

Various grades of subconjunctival haemorrhage in both the groups is described in [Table - 5] whereas [Table - 6] describes various grades of conjunctival chemosis in both the groups. In 85/88 (96.6%) surgeries under peribulbar anaesthesia and in 70/80 (87.5%) surgeries under subtenon anaesthesia, the surgeons experienced no discomfort. In 10/80 (12.5%) experienced some discomfort under peribulbar anaesthesia, there being an intra surgeon variation one surgeon accounting for 6 of 10 cases.

All patients of the peribulbar group (88/88) reported no pain for 4 h after surgery compared to 79/80 patients in the subtenon group. There were two posterior capsular rents in the peribulbar group. One patient in the subtenon group had buttonholing during scleral tunnel creation. The incidence of postoperative complication in both arms was similar. There was no significant difference in both the groups with regards to uncorrected and corrected visual acuity after 6 weeks postoperatively. 70/75(93.3%) of patients in peribulbar group and 76/82(92.71) in subtenon group had postoperative corrected visual acuity >6/9. No patient had visual acuity less than 6/60.

One patient in the peribulbar group needed additional anaesthesia of 3 cm3 of 2% xylocaine. One MSICS in subtenon group was converted to ECCE due to difficulty in delivering the nucleus.

  Discussion Top

Subtenon anaesthesia was more comfortable for the patient at the time of anaesthetic administration. They also had good analgesia intraoperatively, but the surgeons had to operate with incomplete akinesia, which some may find discomforting. The incidence of subconjunctival haemorrhage was also slightly more as compared to the peribulbar group. The surgery was started immediately after administration of anaesthesia in subtenon group. As lesser amount of the anaesthetic agent was used for subtenon, the chances of adverse effects are also minimised. In a large hospital or in a community eye care setting, the cost would also be less.

There was no difference in chemosis, positive pressure rise during surgery and postoperative pain between both the techniques of anaesthesia.

An audit of subtenon and peribulbar anesthesia for cataract surgery in UK demonstrated sub-Tenon's methods to be more effective than the peribulbar technique, with significantly fewer patients experiencing unacceptable levels of pain.[8] It was significantly less uncomfortable on administration than the peribulbar methods and reduced the interval between administration of anaesthesia and surgery. On the range of 1-10, pain on administration of anaesthetic had a mean of 2.4 for the peribulbar group and 1.4 for the subtenon group. This correlated with results of our study.

The subtenon technique appeared to be the safest method of introducing anaesthetic fluid into the retrobulbar space without the potential complication of a sharp needle injection.[11] But a single case of globe perforation was reported [12] in a patient who had underwent detachment surgery and had thinned sclera.

It is likely that subtenons anaesthesia offers a significantly reduced risk of complication such as scleral perforation, retro bulbar haemorrhage, optic nerve injury and injection of anaesthetic solution into the subarachnoid space, as no sharp instrument is passed into the orbit. It should, however, be used with caution in patients with compromised sclera.

A randomised study in Denmark comparing retrobulbar, subtenon and topical anaesthesia for phacoemulcification found retrobulbar techniques had less discomfort/pain during surgery but patient preferred subtenon or topical anaesthesia, as it did not involve the needle prick during anaesthesia.[9]

Subtenon anaesthesia has also been used for optic nerve sheath fenestration.[13] Subtenon anaesthesia has been found to be more comfortable for the patient, reliable, long lasting and with deeper anaesthesia as compared to topical anaesthesia for phacoemulcification patients. It was also more comfortable for the surgeon with better pupillary dilatation.[14] A randomised trial in the UK[15] found the difference between the pain score in the subtenon and topical groups to be highly statistically significant, with subtenon being more pain free, for phacoemulcification patients.

Limitations of the study include subjective nature of the visual analog pain scales and that the field testing or optic nerve damage analysis was not done. But past studies and postoperative visual acuity results indicate that it would not be significant.

  Conclusion Top

The subtenon's technique for administration of anaesthesia during MSICS is as safe as the peribulbar technique giving equally good analgesia during and after the surgery. It is recommended as a safe and effective alternative to peribulbar anaesthesia for MSICS.

  Acknowledgements Top

We thank Mr. Krishnaiah from ICARE, L.V. Prasad Eye Institute, Hyderabad for statistical analysis. The study was funded by a grant from H.V. Desai Eye Hospital, Pune. We thank Dr.Milind Joshi & Dr.Deepak Anpat for the anaesthesia.

  References Top

Davis DB, Mandel MR. Efficacy and complication rate of 16,224 causative peribulbar blocks. A postoperative multi Centre study. J Cataract Refract surg 1994;20:327-37.   Back to cited text no. 1
Mount AM, Seward HC. Sceral perforations during peribulbar anesthesia. Eye 1993;7:766-7.   Back to cited text no. 2
Murdoch IE. Peribulbar versus retro bulbar anesthesia. Eye 1990;4:445-9.   Back to cited text no. 3
Stevens JD. A new local anesthetics techniques for cataract extraction by one quadrant sub-Tenon's infiltration. Br J Ophthalmol 1992;76:670-4.  Back to cited text no. 4
de la Marnieere E, Maye R, Albertim, Batissc JL, Baltenneck. Comparison between Greenbachs Parabulbar Anaesthesia and Ripart's subtenon anaesthesia in the anterior. segment surgery. J Fr Ophthalmol 2002;25:161-5.   Back to cited text no. 5
Hansen EA, Mein CE, Mazzoli R. Ocular anesthesia for cataract surgery: a direct sub-Tenons's approach. Ophthalmic Surg 1990; 21 :696-9.   Back to cited text no. 6
Gogate PM, Deshpande M, Wormald RP. Is manual small incision cataract surgery affordable to developing countries? A cost comparison with extra capsular cataract extraction. Br J Ophthalmol 2003;87:843-6.   Back to cited text no. 7
Briggs MC, Back SA, Esakowitz L. Subtenons versus peribulbar anesthesia for cataract . Eye 1997; 11 :611-43.  Back to cited text no. 8
Davis DB, Mandel MR. Nileson PJ Alerod CW. Evaluation of local anesthesia technique for small incision cataract surgery. J Cataract Refract Surg 1998;24:1136-44.  Back to cited text no. 9
Gogate PM, Deshpande M, Wormald RP, Deshpande RD, Kulkarni SK. Extra capsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: a randomized control trial. Br J Ophthalmol 2003;87:667-72.   Back to cited text no. 10
Loinder S, Walka SB, Atth HR. Ultrasonic localization of anesthetic fluid in subtenon, peribulbar and retro bulbar techniques. J Cataract Refract Surg 1949;25:56.   Back to cited text no. 11
Freiman BJ. Friedberg MA. Globe Perforation associated with sub tenon's anesthesia. Am J Ophthalmol 2001;131 : 520-1.   Back to cited text no. 12
Rizzuto PR, Spoor TC, Ramock JM, McHenry JG. Subtenon's local anesthesia for optic nerve sheath fenestration. Am J Ophthalmol 1996;121:326-7.   Back to cited text no. 13
Vielpeau I, Billotte L, Kreidie J, Lecoq P. Comparative study of topical anesthesia and subtenon anesthesia for cataract surgery. J Fr Ophthalmol 1999;22:48-51.   Back to cited text no. 14
Manner TB, Burton RL. Randomized trial of topical versus subtenon local anesthesia for small incision cataract surgery. Eye 1997;10:367-20.  Back to cited text no. 15


  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]

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