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LETTER TO EDITOR |
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Year : 2007 | Volume
: 55
| Issue : 1 | Page : 80-81 |
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25-gauge vitrectomy under topical anesthesia
Suresh Ramchandani, Sushama Ramchandani
Shivam Eye Clinic and Surgical Centre, Snehal Co-Op Housing Society, Plot No 29, Sector 17, Nerul, Navi Mumbai - 400 706, Maharashtra, India
Correspondence Address: Suresh Ramchandani Shivam Eye Clinic and Surgical Centre, Snehal Co-Op Housing Society, Plot No 29, Sector 17, Nerul, Navi Mumbai - 400 706, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0301-4738.29514
How to cite this article: Ramchandani S, Ramchandani S. 25-gauge vitrectomy under topical anesthesia. Indian J Ophthalmol 2007;55:80-1 |
Dear Editor,
We read with interest, the article by Raju et al .[1] We must congratulate the authors for the excellent article but we would like to make a few points which would make the article more relevant.
- The total time required for each of the surgeries was not mentioned anywhere. After practicing as a vitreoretinal surgeon for the last 12 years and having carried out hundreds of retinal procedures, I (first author) know that several patients experience pain after a variable amount of time ranging from 1h onwards even after full peribulbar block. These patients require supplemental parabulbar or subtenon anesthesia to make them comfortable. The surgeries under topical anesthesia would have to be really quick to prevent this problem even though the authors have mentioned that with the 25-G vitrectomy system there is minimal touching of the sclera or the choroid.
- What do the authors mean by no inadvertent movements were noted during surgery? Do they mean that the eyes did not move at all? It has been well documented that topical and even subtenon anesthesia allows significant movement of the eye.[2] The authors have mentioned one case of epiretinal membrane removal; any inadvertent movement at this stage can lead to disasters as we are working on the macula.
- The authors have not mentioned whether the retinal periphery was examined with indirect ophthalmoscope and depression at the end of the procedure to rule out retinal breaks or dialyses induced by insertion of instruments through the sclerotomies. If yes then did the patients get pain or were they restless? Incidence of retinal breaks is as high as 8% in pars plana vitrectomies[3] and should be identified and treated at the time of surgery to prevent retinal detachment in future. We assume a BIOM was used during surgery but even with wide-angle viewing systems it is many a time difficult to see up to the ora and an examination with an indirect ophthalmoscope and depression would be advisable. If there are any iatrogenic breaks or any preexisting peripheral lattice/breaks a cryo would be necessary which would again cause considerable pain. Endo laser or laser indirect ophthalmoscopy are not always possible due to a variety of reasons.
- Vitrectomies are sometimes quite unpredictable and there have been times where I (first author) have had to do additional unplanned buckling procedures for dialyses or giant retinal tears occurring during so-called routine vitrectomies - we wonder how the authors would have managed such cases.
- One case involved removal of the intraocular lens (IOL) in an eye with endophthalmitis together with vitrectomy. Was intracameral lignocaine used in this case? Handling of the normal iris results in considerable pain and we would assume an inflamed iris would be very sensitive. And of course, not pertinent to this discussion - why was the IOL removed? Some cases were labeled as fungal and intravitreal Amphotericin was given. Was the microbiological diagnosis made prior to the surgery or was the drug used empirically?
I (first author) would prefer to switch to topical anesthesia for vitrectomy but we feel the surgeon's comfort, both physical and mental, is necessary for a successful surgical outcome.[4] The only vitreous surgery which is totally predictable is vitreous surgery for endophthalmitis but even in these eyes the inflammation may result in greater than normal pain as we have noted even during intravitreal injections.
References | | |
1. | Raju B, Raju NS, Raju AS. 25 gauge vitrectomy under topical anesthesia: A Pilot study. Indian J Ophthalmol 2006;54:185-8. [ PUBMED] [ FULLTEXT] |
2. | 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. [ PUBMED] [ FULLTEXT] |
3. | Tardif YM, Schepens CL, Tolentino FI. Vitreous surgery. XIV. Complications from sclerotomy in 89 consecutive cases. Arch Ophthalmol 1977;95:235-9. |
4. | Barikh L. Comparing Subtenons anesthesia with Peribulbar technique for cataract surgery. Letters to the editor. Indian J Ophthalmol 2006;54:210-1. |
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