Int Ophthalmol (2023) 43:1761–1769
https://doi.org/10.1007/s10792-022-02564-3
REVIEW
Anesthesia for ophthalmic surgery: an educational review
Aidan Pucchio · Daiana R. Pur ·
Anuradha Dhawan · Simrat K. Sodhi ·
Austin Pereira · Netan Choudhry
Received: 30 March 2022 / Accepted: 16 October 2022 / Published online: 27 November 2022
© The Author(s), under exclusive licence to Springer Nature B.V. 2022
Abstract
Purpose Selecting an anesthetic agent for ophthal-
mic surgery has crucial implications for the surgeon,
anesthesiologist, and patient. This educational review
explores the common classes of anesthesia used in
ophthalmology. Additionally, we discuss the consid-
erations unique to cataract, glaucoma, strabismus,
orbital, oculoplastic, and ocular trauma surgeries.
Supplementary Information The online version
contains supplementary material available at https://​doi.​
org/​10.​1007/​s10792-​022-​02564-3.
A. Pucchio
School of Medicine, Queen’s University, Kingston, ON,
Canada
D. R. Pur
Schulich School of Medicine & Dentistry, Western
University, London, ON, Canada
A. Dhawan · N. Choudhry (*)
Vitreous Retina Macula Specialists of Toronto, 3280 Bloor
Street West, Suite 310, Toronto, ON M8X3X3, Canada
e-mail: netan.choudhry@vrmto.com
S. K. Sodhi
School of Clinical Medicine, University of Cambridge,
Cambridge, UK
A. Pereira · N. Choudhry
Department of Ophthalmology and Visual Sciences,
University of Toronto, Toronto, ON, Canada
N. Choudhry
Cleveland Clinic Canada, Toronto, ON, Canada
Methods A comprehensive Embase search was
performed using combinations of the subject head-
ings “anesthesia”, “eye surgery”, “ophthalmology”
and “cataract extraction”, “glaucoma”, “strabismus”,
“vitreoretinal surgery”, “retina surgery”, “eye injury”,
and “eyelid reconstruction”.
Results Topical anesthetics are the most commonly
used form of ocular anesthesia, used in both an office
and surgical setting, and carry a minimal side effect
profile. Notably, topical anesthetics offer analgesia,
but do not provide akinesia or amnesia. Regional
blocks, such as are sub-Tenon’s, peribulbar, and ret-
robulbar blocks, are used when akinesia is required
in addition to analgesia. Recently, sub-Tenon’s blocks
have recently gained popularity due to their improved
safety profile compared to other regional blocks.
General anesthesia is considered for long, complex
surgery, surgery in patients with multiple comorbidi-
ties, surgery in young pediatric patients, or surgery in
patients intolerant to local or regional anesthetic.
Conclusion Anesthetizing the eye has rapidly
evolved in recent years, supporting the safety, efficacy
and comfort of ocular surgery. Since there are many
viable options of anesthetics available for ophthalmic
surgery, a robust understanding of the patients needs,
the skill of the surgical team, and surgery-specific
factors ought to be considered when creating an anes-
thetic plan for surgery.
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Keywords Anesthesia · Ophthalmology · Cataract ·
Glaucoma surgery · Strabismus surgery · Oculoplastic
surgery
Introduction
Selecting an anesthetic agent for ophthalmic surgery
has crucial implications for the surgeon, the anes-
thesiologist and most importantly, the patient [1, 2].
Various anesthetic options offer differing levels of
analgesia, amnesia, akinesia and as such, appropriate
selection can contribute to successful and comfort-
able surgery [3]. The indications for anesthetizing
the eye are continually evolving with use of topical
agents growing in recent years due to the ease of
administration and rarity of severe complications,
while the popularity of regional blocks and gen-
eral anesthesia has decreased [2]. In this educational
review we will explore the common classes of anes-
thesia used in ophthalmology, their implications for
surgery and specific considerations in common oph-
thalmic surgeries.
Methods
A comprehensive Embase search was performed for
articles dating back to 1947, with emphasis on arti-
cles published from 2000 to present day. Combina-
tions of the subject headings “anesthesia”, “eye sur-
gery”, “ophthalmology” and “cataract extraction”,
“glaucoma”, “strabismus”, “vitreoretinal surgery”,
“retina surgery”, “eye injury”, “eyelid reconstruction”
were used in the search. Additional keywords were
utilized where required. The authors collated the cur-
rently available literature to provide an overview of
anesthesia in ophthalmology. This educational review
is intended for use by ophthalmologists and medical
trainees as a brief overview of current use and trends
in ocular anesthesia.
Classes of anesthesia
Topical anesthetics are the most commonly used form
of ocular anesthesia, used in both an office and surgi-
cal setting. Proparacaine hydrochloride 0.5% and tet-
racaine hydrochloride 1%, the two most widely used
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Int Ophthalmol (2023) 43:1761–1769
agents, are indicated for many common procedures
such as tonometry, anterior chamber paracentesis, or
adjunct use for injected anesthetics [4]. In addition,
4% lidocaine solution (± epinephrine) and subcon-
junctival lidocaine are can be administered topically
and are effective for shorter surgeries such as cataract
extraction [4]. The side effect profile of topical anes-
thetics is often minimal, whereby the most notable
complications are hypersensitivity reactions, along-
side other adverse effects including; headache and
conjunctival hyperemia [1, 4]. While topical anesthet-
ics offer analgesia, they do not provide akinesia or
amnesia [3, 5].
Regional blocks are used when akinesia is required
in addition to analgesia. The three commonly used
regional blocks are sub-Tenon’s, peribulbar, and ret-
robulbar block, with a 1:1 mixture of 2% lidocaine
and 0.5% bupivacaine being the most commonly used
compounds. A sub-Tenon’s block involves the crea-
tion of a small incision in the sclera (Fig. 1) [6]. A
curved cannula is passed through this scleral opening
and local anesthetic is injected under Tenon’s fascia
surrounding the globe and allowing for analgesia and
akinesia of the eye. Sub-Tenon’s blocks have recently
gained popularity due to their improved safety pro-
file compared to other regional blocks [7]. While
rare, complications of sub-Tenon’s blocks include
Fig. 1  Sub-Tenon’s block demonstrating a curved cannula
injecting anesthetic through a sclera incision
Int Ophthalmol (2023) 43:1761–1769
subconjunctival hemorrhage, chemosis, pain, and
globe perforation [6, 8]. The exact incidences of com-
plications associated with sub-Tenon’s blocks are not
known [9, 10].
Peribulbar blocks, also known as extra-conal
blocks, are inserted lateral to the eye and injected into
the space outside of the intraconal orbital compart-
ment [4]. Peribulbar blocks offer akinetic and analge-
sic effects analogous to sub-Tenon injections, but may
be more painful for the patient and more challenging
to administer [1, 6]. While regional blocks anesthetic
methods carry higher risk than both local anesthetic
and sub-Tenon’s blocks, serious complications such
as ocular perforations are exceedingly rare; peribulbar
blocks have a reported incidence of perforation, cen-
tral retinal vein occlusion, and acute ischemic optic
neuropathy of 1 in 16,224 (0.006%), incidence of
increased posterior pressure requiring a vitreous tap
of 9 in 16,224 (0.055%), and an incidence of orbital
hemorrhage of 12 in 16,224 (0.074%) [10–12]. More
severe complications such as central nervous sys-
tem involvement or brainstem anesthesia have been
reported at even lower rates [13]. The final common
regional block, the retrobulbar block, involves injec-
tion into the intraconal orbital compartment. Ret-
robulbar blocks offer the strongest akinesia of any
regional block, but due to the posterior location of
injection and potential to make contact with the optic
nerve they have the greatest rates and severity of
complications, including optic nerve injury, retrobul-
bar hemorrhage and globe perforation [7, 14]. Despite
a more severe risk profile, the rates of serious com-
plications are still low for retrobulbar blocks, with
perforation reported in 1 in 13,428 cases (0.007%),
central nervous system complications reported in
0.09% to 1.50% of patients, and orbital hemorrhage
in 1.7% [11, 12]. However, given the associated risks,
retrobulbar blocks are steeply declining in popularity
in modern ophthalmic surgery [11, 12].
General anesthesia is used in ophthalmology for
long, complex surgery, surgery in patients with multi-
ple comorbidities, surgery in young pediatric patients,
or in patients intolerant to local or regional anesthetic
[15]. There are many general anesthetics available
and selection requires a comprehensive understanding
of patients medical history and surgical factors [16].
The adjunct use of relaxants, such as midazolam, is
often used during intraocular surgery to reduce anxi-
ety in patients who are awake, but will not be detailed
1763
in this review. The utility and complication profiles
for each common class of ocular anesthesia is sum-
marized in Table 1. Studies comparing the analgesic
effects of two or more classes of ocular anesthesia are
summarized in the Supplemental Materials.
Anatomical considerations
Analysis of the anatomy of the eye and the structures
relevant in anesthesia have been detailed elsewhere
[1, 2]. In brief, myopic eyes with a longer axial length
are at increased risk of perforation during peribulbar
or retrobulbar injections [1]. There are seven muscles
that are typically relevant in ocular surgery: levator
palpebrae superioris, the four recti and two oblique
muscles. A membrane connects the recti, forming
the intraconal orbital compartment that contains the
optic, oculomotor, nasociliary and abducens nerves
alongside the ophthalmic artery.
Injection of local anesthetic into the intraconal
orbital compartment during a retrobulbar block allows
for blocking of all of the nerves within this space
[1]. During anesthetic injections into the intraconal
orbital compartment the optic nerve is particularly
vulnerable to injury. Note that while the oculomo-
tor and abducens nerves are blocked in a retrobulbar
block, the trochlear nerve is not, which can allow for
movement of the superior oblique muscle. Peribul-
bar blocks are injected into the extra-conal space
(outside of the intraconal orbital compartment) and
require larger volumes of anesthetic as the agent must
diffuse through a higher volume to be effective. In a
sub-Tenon’s block, local anesthesia is injected under
the Tenon’s fascia which surrounds the entire globe,
allowing for diffusion to the surrounding nerves and
muscles [1].
Considerations for specialized surgery
Cataract surgery
Modern day cataract surgery is marked by its short
duration with safety and comfort being the two cru-
cial considerations. In addition, since patients often
desire to return to daily routine in the shortest time
possible, topical anesthesia has become the mainstay
for uncomplicated cataract surgery in adults. Lack of
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Table 1  Features of common classes of ocular anesthetic
Class of anesthesia Route of administration Common agents Anesthetic features Complications
Analgesia Akinesia Amnesia

Topical Drops, cotton swab applicator Proparacaine hydrochloride 0.5%, Yes No No Eyelid numbness, hyperemia in conjunc-
tetracaine hydrochloride 1%, 4% tiva, headache, allergic reactions such
lidocaine (± epinephrine) as allergic contact dermatitis or severe
local hypersensitivity reactions
Sub-Tenon block Scleral incision and injection under 1:1 mixture of 2% lidocaine and 0.5% Yes Yes No Common: chemosis, subconjunctival
Tenon’s fascia with blunt cannula bupivacaine hemorrhage
Peribulbar block Needle passed posteriorly through per- Yes Yes No Rare: ecchymosis, retrobulbar hemor-
conjunctival puncture in inferotempo- rhage, globe injury, optic nerve dam-
ral corner of the eye age, brainstem anesthesia
Retrobulbar block Needle passed parallel to orbital floor Yes Yes No
through percutaneous or perconjunc-
tival puncture
General anesthesia Inhaled, intravenous line Propofol, ketamine, etomidate Yes Yes Yes Postoperative nausea and vomiting, ana-
phylaxis or allergic reaction, malignant
hyperthermia, respiratory depression,
embolic event
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Int Ophthalmol (2023) 43:1761–1769
akinesia may prove challenging for the surgeon with
a theoretically increased rate of risk of posterior cap-
sule rupture (PCR). However, a study by Lee et al.
demonstrated no significant difference in rate of PCR
with topical anesthesia versus an akinetic block [17].
Efficacy of topical anesthesia could be enhanced
by use of intracameral lidocaine as an adjunct, a con-
cept first introduced by Gills [18]. Intracameral use
is thought to produce direct anesthetic effect on iris-
ciliary body-zonular complex. This was further evalu-
ated by Carino et al. in a double-blind study where
patients experiences of pain were recorded in real
time throughout surgery [19]. A significantly lower
patient pain score was seen in the intracameral lido-
caine group than placebo [19]. The final choice of
anesthesia among the options of topical, peribulbar/
retrobulbar block or general anesthesia will take into
consideration the age of the patient, complexity of the
cataract, comorbidities and the skill of the surgeon.
Glaucoma surgery
Most glaucoma surgery involves the anterior part of
the globe and can be performed under regional or top-
ical anesthetic. An important consideration is the fact
that injections behind the globe can increase pressure
and reduce blood supply to the optic nerve. As the
optic nerve is already compromised to some extent in
glaucoma patients and prone to further insult, injec-
tions behind the eye should be avoided to reduce the
likelihood of optic nerve damage [20]. Other global
considerations for anesthetic selection in glaucoma
surgeries are medication use, topical glaucoma medi-
cation and intraocular pressure (IOP) control [20, 21].
Trabeculectomy can be performed under any local
or general anesthesia. If nerve block is the preferred
method of the surgical team, anterior sub-Tenon’s
block is recommended as it puts less stress on the
optic nerve [22]. While topical anesthesia use in tra-
beculectomy and aqueous shunt surgery is associated
with higher pain and increased need for intraopera-
tive IV anesthetic than regional blocks, this must be
weighed against reduced of severe complications such
as globe perforation, retrobulbar hemorrhage, optic
nerve injury, and central nervous system depression
[21]. As such, topical anesthesia has emerged as an
effective option for trabeculectomy [21]. It is impor-
tant to note that subconjunctival 2% lidocaine may
impair trabeculectomy healing; however, there is a
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paucity of research examining the effect of anesthetic
technique on glaucoma surgery outcomes [20].
In non-penetrating surgeries such as deep sclerec-
tomy and viscocanalostomy, all anesthetic classes
can be used, although general anesthetic is typically
not considered [20]. When considering minimally
invasive glaucoma surgeries, including the insertion
of drainage devices and shunts, topical anesthesia is
the safest and most tolerated option [23]. A study by
Rebolleda et al. [23] comparing topical anesthetic and
retrobulbar blocks during implantation of a drain-
age device found that the retrobulbar block group
reported higher discomfort during anesthetic injec-
tion, no difference in intraoperative or postoperative
pain and a better safety profile for the topical agents.
Finally, topical agents are the only anesthesia indi-
cated for peripheral iridotomy in cases of angle-clo-
sure glaucoma.
Strabismus and pediatric surgery
Strabismus surgery has historically used general
anesthesia to circumvent anatomical modifications
caused by periocular injection [5]. However, recent
studies have reported positive results in adjustable
suture strabismus surgery using retrobulbar blocks
or subconjunctival anesthesia combined with topical
agents [24, 25]. While these options might be appro-
priate in the adult population, strabismus surgery and
other surgeries in young pediatric patients are almost
always be performed under general anesthetic, as
this population is less tolerant of surgery and may
be more mobile during surgery. In addition, regional
blocks or local anesthesia can be used for additional
analgesic effect.
The oculocardiac reflex (OCR), a slowing of the
heart following pressure applied to the globe, is com-
mon in strabismus surgery. Anesthetic selection has
influence over OCR severity; a recent study of pediat-
ric strabismus surgery found that propofol or remifen-
tanil was associated with a higher incidence of OCR
when compared to sevoflurane and desflurane anes-
thesia [26]. With other studies demonstrating conflict-
ing findings, there remains no definitive method to
reduce OCR occurrence during surgery on the extra-
ocular muscles [27]. Sub-Tenon’s block with general
anesthesia has also been found to reduce intraopera-
tive OCR and postoperative nausea and vomiting in a
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pediatric population when compared to fentanyl with
general anesthesia [28].
Vitreoretinal surgery
Significant advancements in instrumentation and the
growing sophistication of surgical techniques have
led to shorter and more predictable surgeries, which
in turn have allowed vitreoretinal surgery to transition
from general anesthetic to regional eye anesthesia
with the patient awake during surgery [29]. For exam-
ple, the introduction of suture-less 23- and 25-gauge
vitrectomy using peribulbar block for epiretinal mem-
brane surgery and 25-gauge transconjunctival suture-
less vitrectomy under retrobulbar block for various
vitreoretinal procedures were found to be safe, effec-
tive and reduce surgical time [30].
A prospective, randomized clinical trial including
23- or 25-gauge vitrectomies compared the safety and
efficacy of topical anesthesia combined with subcon-
junctival anesthesia (referred to as “two-step anesthe-
sia”) to peribulbar and retrobulbar anesthesia, finding
similar pain scores between the two methods [31].
An analogous clinical trial comparing topical anes-
thesia with retrobulbar technique reported similar
results with regard to pain control, safety and efficacy
[32]. While topical analgesia does not produce ocu-
lar akinesia, with modern small gauge instruments,
eye movement can be reduced by the surgeon once
the vitrectomy procedure is started, thus requiring a
moderate level of patient cooperation. Ultimately,
this approach can be used in carefully selected cases.
Special consideration should be given for macular
surgical cases, as even slight ocular movement could
severely impact the success of the surgery [33].
Orbital and oculoplastic surgery
Most oculoplastic procedures such as blepharoplast-
ies and ptosis repairs are performed under local anes-
thesia, while traditionally orbital surgery is performed
under general anesthesia. In the case of eyelid surger-
ies, topical pre-anesthetic gels and drops can reduce
discomfort of typical injectable local anesthetics such
as lidocaine, prilocaine, mepivacaine, bupivacaine,
levobupivacaine, and ropivacaine [34]. Epinephrine
is typically used to augment the duration of action
of agents such as lidocaine and bupivacaine [35].
However, local anesthetics without epinephrine may
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be preferred as the addition of epinephrine has been
reported to contribute to a poorer estimation of post-
operative eyelid height in aponeurotic blepharoptosis
surgery [36].
Recent reports indicate that local anesthesia com-
bined with moderate sedation can be a safe alterna-
tive to general anesthesia for certain orbital surgeries
such as external dacryocystorhinostomy and orbital
interventions without bone removal [37, 38]. Gold-
berg et al. [39] report removing benign orbital tumors
through minimally invasive, soft-tissue incisions
under a local block. This approach may be appropri-
ate if the pathology is consistent with a benign tumor
and imaging delineates a well-defined mass without
tethering or infiltration into surrounding tissue into
bone or the sinuses, with the major advantage being
avoidance of a bony marginotomy [39]. In such cases,
patient selection is important as some level of cooper-
ation is necessary. Anxiolytics are helpful in patients
with moderate anxiety [34, 40].
Special considerations are required for patients
with thyroid eye disease undergoing orbital decom-
pression surgery. This patient population often has
multiple comorbidities (e.g., autoimmune disorders,
diabetes, or smoking-related issues) with long-term
corticosteroid use being common, all factors that
could affect wound healing. Additional challenges
may arise with airway management in the presence
of goiter [41]. Enucleation also warrants special
anesthetic considerations as patients can experience
significant postoperative discomfort; postoperative
retrobulbar pain catheters or parabulbar butterfly
catheters can allow patients to self-administer local
anesthetic postoperatively as needed [34]. Eviscera-
tion with orbital implant placement is often conducted
under general anesthesia due to difficulty achieving
sufficient analgesia using local anesthesia [42]. The
addition of local anesthetic to general anesthesia is
recognized to improve hemostasis, postoperative
comfort and reduce OCR [43]. Preemptive anesthe-
sia, injection of anesthetic drugs into the orbit, can be
considered to reduce the occurrence of postoperative
pain and nausea. A retrospective study of 39 individu-
als who underwent enucleation indicated that patients
who received periocular anesthesia with sedation
required less postoperative analgesic and antiemetic
drugs than those in using general anesthesia.
Local anesthetic options have been explored in
a limited number of studies: combined retro-upper
Int Ophthalmol (2023) 43:1761–1769
peribulbar and subconjunctival anesthesia with intra-
venous sedation (i.e., combination of lidocaine with
epinephrine and bupivacaine injection, and sedation
with midazolam and fentanyl) for evisceration plus
orbital implant placement, and retrobulbar block
with intravenous sedation for enucleations and evis-
cerations (i.e., combined lidocaine with epinephrine
mixed with bupivacaine with hyaluronidase) [43, 44].
Only one of 116 evisceration patients (0.9%) required
transition to general anesthesia due to severe anxiety
[44]. Caleda et al. [45] performed eye enucleations
and eviscerations under local anesthetic injected into
the inferior orbital and the supraorbital notch (i.e.,
lidocaine with epinephrine and bupivacaine with
epinephrine) for 17 cases, reporting both decreased
bleeding from the operative area and less need for
additional analgesia pre and postoperative analgesia.
Ocular trauma
The main challenge in anesthetic management of
patients with penetrating eye injury is risk of extru-
sion of intraocular contents secondary to raised IOP.
The age of patients influences anesthetic choice, as
nearly one third of the eye injuries are encountered
in patients less than 18 years of age. Furthermore,
associated orbital or head traumas are common in this
population.
General anesthesia is typically preferred for repair
of open globe injuries due to the complete akine-
sia and anesthesia obtained. It is also the method of
choice for the pediatric or uncooperative patients,
exploratory surgeries, or when the extent of the
trauma can not be predetermined. Special considera-
tions for general anesthesia include avoiding the use
of succinylcholine for open globe injuries, as it can
raise IOP by up to 10 mmHg leading to extrusion of
ocular contents. Alternatively, inhalational and intra-
venous anesthetics generally lower the IOP. When
managing limited, smaller open globe injuries, such
as corneal lacerations, regional blocks can be used
along with intravenous sedation [46, 47]. This offers
the advantage of earlier surgical management, as
these options are not dependent upon the fasting sta-
tus of the patient. Select studies have also employed
topical anesthesia with intracameral anesthesia for
repair of selected open globe injuries [48, 49].
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Conclusion
Ocular surgery is continuously evolving in the direc-
tion of improved safety and reduced case times. As
such, the indications for topical anesthesia continue
to expand as the strong efficacy and safety profiles of
topical anesthetics are detailed [2]. However, regional
blocks remain a safe and effective option when aki-
nesia is required, while general anesthesia is indi-
cated when amnesia is preferable or in populations
less tolerant of surgery [4]. Regardless, anesthetizing
the eye has rapidly evolved in recent years, support-
ing the safety, efficacy and comfort of ocular surgery
[2]. Since there are many viable options of anesthet-
ics available for ophthalmic surgery, a robust under-
standing of the patients needs, the skill of the surgical
team, and surgery-specific factors ought to be consid-
ered when creating an anesthetic plan for surgery.
Author contributions All authors contributed to the con-
ception, search design, synthesis of the data, and manuscript
preparation.
Funding This research did not receive any specific grant
from funding agencies in the public, commercial, or not-for-
profit sectors.
Declarations
Conflict of interest The authors have conflicts of interest to
disclose. The authors do not have any proprietary interests in the
materials described in the article.
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