Anesthesia for Cataract Surgery

Andi Ayu Lestari

 Anesthesia for Cataract Surgery
Consideration of the options for anesthesia is an important part of preoperative planning. A general review of
the advantages and risks of the different types of anesthesia is part of the informed consent process. A discussion
of what the patient will experience in the operating room increases the likelihood of comfort and cooperation on
the day of surgery.

topical and intracameral

Retrobulbar anesthesia anesthesia

Peribulbar anesthesia facial nerve block

Sub-Tenon General anesthesia

 Retrobulbar Anesthesia

Retrobulbar anesthesia for cataract surgery provides excellent

ocular akinesia and anesthesia and reduces sensitivity to the
microscope light. The basic technique of retrobulbar injection.
first described in 1945 by Walter Atkinson, involves
administration of lidocaine into the muscle cone via a 25-
gauge, 1.5-inch (38-mm) blunt retrobulbar needle. Many
surgeons now use a 27-gauge, 1.25-inch sharp needle and
supplement the lidocaine with vitrase and bupivacaine, and
sometimes bicarbonate.
• These modifications can enhance the patient’s comfort, speed of onset, and duration of the
retrobulbar block.
• Complications resulting from retrobulbar anesthesia are uncommon but include
- retrobulbar hemorrhage
- globe penetration
- optic nerve trauma
- extraocular muscle toxicity
- inadvertent intravenous injection associated with cardiac arrhythmia
- inadvertent intradural injection with associated seizures
- respiratory arrest
- brainstem anesthesia.
Any preexisting diplopia or ocular misalignment should be documented.
 Peribulbar anesthesia
theoretically eliminates the risk of
complications such as optic nerve injury
and intradural injection. However, it is
slightly less effective than the retrobulbar
method for providing akinesia and
anesthesia and is more likely to give
conjunctival chemosis. In this technique, a
shorter (1-inch) 25-gauge or 27-gauge needle
is used to introduce anesthetic solution
Hamilton RC. Techniques of orbital regional anaesthesia. Br J Anaesth 2001;86:473–6.)

external to the muscle cone, underneath the

Tenon capsule.
 Sub-Tenon
Sub-Tenon infusion of lidocaine has
become a popular method of anesthesia
during surgery. The risk of muscle injury
or toxicity associated with this method is
lower. A small, posterior incision is
made through anesthetized conjunctiva
and the Tenon capsule, and a small
cannula is used to administer the
anesthetic
 Topical and Intracameral anesthesia

The use of topical and intracameral anesthesia has increased. With topical anesthesia,
the risk of ocular perforation, extraocular muscle injury, and central nervous system
depression is eliminated, and visual recovery is accelerated.
• Topical anesthesia is administered via proparacaine or tetracaine drops, cellulose
pledgets soaked in anesthetic, or lidocaine jelly.
• Intracameral preservative-free lidocaine (which often includes a mydriatic agent)
can supplement or even replace topical anesthesia.
Lidocaine/phenylephrine (Shugarcaine) has the added advantage of increasing pupil dilation and
reducing the effects of intraoperative floppy iris syndrome (IFIS). Only nonpreserved 1% or 2%
lidocaine should be used for anterior chamber instillation, because of the toxic effect of some preservative
agents on intraocular structures. Disadvantages of topical anesthesia include blepharospasm, lack of
akinesia, and potential patient discomfort, which can interfere with the surgeon’s ability to perform
delicate maneuvers

Topical and intracameral anesthesia is typically reserved for short cataract surgeries, generally under 30
minutes in length, with cooperative patients who are well dilated and can tolerate the microscope. light.
Topical and intracameral anesthesia can be supplemented with oral or intravenous sedation to help reduce
patient anxiety.
 Facial Nerve Block

A facial nerve block, common in the era of large-incision intracapsular

cataract extraction (ICCE) and extracapsular cataract extraction
(ECCE), is not generally necessary with small-incision surgery.
However, patients with essential or reactive blepharospasm may benefit
from a facial nerve block to control squeezing during surgery.
Types of facial nerve blocks include the O’Brien block, directed
proximally and peripherally at the nerve trunk; the van Lint block,
directed proximally and peripherally at the terminal branches; and the
Atkinson block, directed between these two regions. Patient preference
can also be considered as an indication. General anesthesia may require
clearance from the patient’s primary care physician or an
anesthesiologist.
https://webeye.ophth.uiowa.edu/eyeforum/tutorials/greenhorns/greenhorns-handout-training-plan.pdf
 Antimicrobial Therapy

Endophthalmitis remains one of the most serious complications of

cataract surgery. Therefore, a major objective of preoperative
preparation and intraoperative management of the patient is to reduce
the introduction of pathogenic organisms into the anterior chamber.
 Before Surgery

• Before the day of surgery, the surgeon should identify and reduce infectious risk factors as much
as possible through preoperative treatment of coexisting eyelid disorders such as conjunctivitis,
blepharitis, hordeolum, and chalazion. Systemic infections should also be identified and treated.

• Cataract surgery is not considered to be an invasive procedure that induces transient

bacteremia; thus, systemic antibiotic prophylaxis is not required. If questions arise
about whether antibiotic prophylaxis is advisable in the perioperative period, the surgeon
may wish to consult with the physicians involved in the patient’s systemic care.
• Although no studies have convincingly demonstrated the efficacy of topical antibiotics in
reducing the risk of endophthalmitis in routine cataract surgery, there is some evidence
supporting an association between the use of preoperative topical antibiotics and a
reduction in ocular surface bacterial counts, as well as a lower incidence of positive
aqueous cultures after surgery. Many cataract surgeons prescribe preoperative topical
antibiotics.

• For patients with a history of herpetic eye disease, a prescription of prophylactic antiviral
medications can be considered
 In Surgery
In the operating room, sterilization of the fornix is important.
A 5% povidone-iodine solution (not scrub or soap) placed
in the conjunctival fornix prior to surgery has been
associated with a reduction in bacterial colony counts in
cultures from the ocular surface at the time of surgery and a
decreased risk of culture-proven endophthalmitis. In addition,
preparation of the skin around the eye with a 10%
povidone-iodine solution can reduce bacterial counts
on the eyelid margins. Because eyelid margins may
harbor pathogens, it is important to drape the eyelashes Figure 7-6 Sterile draping of the eye for surgery.

out of the operative field

• It is important not only to limit the number of times that instruments are introduced into
the eye but also to check for signs of lint, cilia, and other debris on the tips of all
instruments inserted. Meticulous wound closure is imperative. Despite surgeons’ best
efforts, however, 7%–35% of cataract surgeries result in bacterial inoculation of the
anterior chamber.
• The low incidence of endophthalmitis is a testament to the ability of the anterior chamber
to clear itself of a potentially pathologic inoculum. The risk of endophthalmitis increases
with a torn posterior lens capsule, vitreous loss, and prolonged surgery.
• Some surgeons add antibiotics to the irrigating solution or inject them into the
anterior chamber at the conclusion of the operation.
• The Endophthalmitis Study Group reported a significant reduction in
endophthalmitis with the use of intracameral cefuroxime, which has not been
universally adopted in the United States because of the lack of commercial antibiotic
preparations for intracameral use.

• Intracameral vancomycin is a popular alternative; however, this antibiotic has been

associated with a rare hypersensivity reaction that causes a hemorrhagic vasculitis.
Intracameral moxifloxacin has become more popular; to date, it has been
predominantly safe and cost-effective. There have been reported cases of
pigmentary dispersion and diffuse iris depigmentation after intracameral use as well
as systemic use of moxifloxacin.
Haripriya A. Antibiotic prophylaxis in cataract surgery - An evidence-based approach. Indian J Ophthalmol.
2017;65(12):1390-1395. doi:10.4103/ijo.IJO_961_17
• Subconjunctival corticosteroids can be used in conjunction with intracameral antibiotics. Another
option is the injection of a bolus of antibiotic and corticosteroid medications at the conclusion of surgery
via transzonular or intravitreal injection, so that the medications are able to act over time
postoperatively. “Dropless” cataract surgery can refer to any of these methods in which medications are
instilled at the time of surgery and reduce or eliminate the need for postoperative drops.

• Whether the risk of endophthalmitis is increased after cataract surgery performed using a sutureless clear corneal
wound is controversial. After tracking the flow of fluorescein into the anterior chamber, some have suggested that
inflow of bacteria from the ocular surface may be possible via a sutureless incision. For this reason, hydrating
the corneal stroma to reapproximate the anterior and posterior aspects of the wound may reduce the risk of
wound separation. Any possibility of leakage can be addressed with wound closure by suture or tissue
adhesive.
 After Surgery
After routine cataract surgery, use of antibiotic eyedrops is
commonly continued or instituted. Although reduced bacterial
counts have been documented with the administration of topical
antibiotics, there is no definitive evidence that their use reduces
the incidence of endophthalmitis.
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