Prospective evaluation of topical versus retrobulbar anesthesia: a converting surgeon's experience

To evaluate and compare the efficacy of topical versus retrobulbar anesthesia for cataract surgery performed by a surgeon newly converting to the topical technique.

Department of Ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

Ninety patients were prospectively assigned by permuted block restricted randomization to receive topical (Group 1; n = 45) or retrobulbar (Group 2; n = 45) anesthesia. Group 1 received topical bupivacaine 0.75% and intravenous midazolam and fentanyl for anesthesia. Group 2 received intravenous methohexital followed by retrobulbar block with an equal mixture of lidocaine 2% and bupivacaine 0.75% plus hyaluronidase 150 units. A visual pain analog scale was used to assess the degree of pain during anesthesia administration and surgery and postoperatively. The degree to which eye movement, touch, and light caused patient discomfort was assessed. Intraoperative conditions and complications were recorded.

Intraoperative operating conditions were significantly better in Group 2 (P < .05). There was a small but statistically significant difference in the degree of discomfort during anesthesia administration and surgery (P < .05). There was no difference in postoperative discomfort. Chemosis, subconjunctival hemorrhage, and eyelid hemorrhage occurred only in Group 2, in which there was one retrobulbar hemorrhage. Although eyelid squeezing and ocular motility were present more frequently in Group 1, neither was a problem to the surgeon.

Cataract surgery was safely performed by a surgeon converting to topical anesthesia. After a distinct learning curve, the procedure was performed with minimal patient discomfort. Surgical training and patient preparation are the key to safe use of topical anesthesia.