Topical Anesthesia

With the advent of small-incision phacoemulsification cataract surgery, topical

anesthesiah as grown in popularity. Topical anesthesiap rovides anesthesiato
the cornea, conjunctiva, and anterior sclera, but sensation is maintained in the
eyelids, posterior sclera, intraocular tissues, and extraocular muscles. Therefore,
when using topical anesthesiait is important to avoid excessive cautery,
placement of a bridle suture, or manipulation of the iris. A modification in
surgical technique is required when using topical anesthesiab ecauses udden
eye movements may be dangerous when instrumenting the eye. The surgeon
should immobilize the globe using his or her nondominant hand whenever
instruments are being used.
Appropriate patient selection is critical when considering topical anesthesia.
A cooperative patient who is able to follow instructions during surgery is
required. The patient's response to tonometry and A-scan ultrasonography
appears to be a good predictor of how he or she will tolerate ocular surgery
with this technique. Monocular patients may benefit from topical anesthesia
because of their unique need for quick recovery of vision from the operated
eye. Inappropriate candidates include patients who are very young, have a
strong blink reflex, are unable to fixate (eg, because of macular degeneration),
or have difficulty following commands (eg, because of dementia, deafness, or
language barriers). Patients for whom surgery will be longer (more than 30 to
40 minutes) or difficult (eg, dense cataracts, small pupils, or weak zonules) are
best managed with other forms of anesthesia.
Table 9.4 lists the advantagesa nd disadvantageso f topical anesthesiaT. he
obvious advantage is avoidance of complications associated with injection into
the orbit. Additionally, topical anesthesiae liminates the need to patch the eye
after surgery because it avoids the temporary visual loss from the eye undergoing
surgery. Furthermore, there is no need to interrupt anticoagulant or anti basic
principles of ophthalmic surgery
platelet therapy. Disadvantagesin clude patient awarenessd uring the surgical
procedure, discomfort with the eyelid speculum and microscope light, pain
associated with intraocular manipulation or intraocular pressure fluctuation,
lack of akinesia, and reliance on patient cooperation.
Delivery of Topical Anesthesia
An anesthetic agent is instilled topically onto the eye just before prepping
the eye. The patient is instructed to fixate on the microscope light during the
surgery to keep the eye stationary. Anesthetic drops are administered during
the surgical procedure as needed. A variation of the technique involves placing
pieces of Weck-cel or instrument wipe sponges (pledgets) saturated with anesthetic
in the superior and inferior fornices. The pledgets are removed at the
beginning or conclusion of the surgery. Sedative drugs can be helpful but are
generally used minimally with topical anesthesiato allow retention of patient
cooperation.

Basic principles of ophthalmic surgery

AMERICAN ACADEMY OF OPHTHALMOLOGY