Med. J. Cairo Univ., Vol. 79, No. 2, September: 115-119, 2011

www.medicaljournalofcairouniversity.com

Topical Anesthesia Versus Topical Anesthesia Plus Intracameral

Xylocaine for Phacoemulsification Surgery

DALIA SAMIR TAWFIK, M.D.*; HALA M. BAHY EL DIN ABDEL HAKEEM, M.D.*; MOHAMED ABDEL MONEIM MAHMOUD, M.D.** and KHALED ABDEL RAHMAN HASHEM, M.D.***

The Departments of Anesthesia Research Institute of Ophthalmology*, National Hepatology & Tropical Medicine,

Research Institute** and Ophthalmology, El Fayoum University***

Abstract

Aim of the Study: The aim of the study is to compare preservative-free xylocaine over topical anesthesia alone

during phaco surgery regarding patients' comfort and pain

during the procedure.

Methods: Our study was conducted on two groups: Group

(1) using intracameral preservative-free Xylocaine combined

with topical anesthesia, and group (2) receiving topical anes-thesia only.

Exclusion criteria included hearing impairment, dementia, movement disorders, excessive anxiety and poor fixation.

In the group receiving intracameral anesthesia, a 5mm

capsulorrhexis hydrodissection was performed by injecting 0.5ml of preservative-free Xylocaine 1%.

Measurements:

• Hemodynamics included heart rate (HR), mean arterial

pressure (MAP), and arterial oxygen saturation (Spo2).

• For eye movements, a score, 0=no movements, 1=nystagmoid

movements and 3=Bell's movements. • Pain was measured by visual analog scale (VAS) score

immediately at the end of the procedure.

• Time of surgery was recorded, patient's and surgeon’s satisfaction were also measured.

Results: There was no difference in surgeon’s and patient’s

satisfaction in both groups. Eye movements during surgery were more frequent in group (2), yet there was no statistical

significant difference in both groups. Although the majority

of patients in both groups of our study experienced no or

minimal discomfort and pain, the difference in mean pain score for the two groups was statistically significant.

Conclusion: Combining topical and intracameral anesthe-sia for phaco surgery offers significant benefits over topical

anesthesia alone in terms of patient's comfort.

Key Words: Topical anesthesia — Intracameral xylocaine — Phacoemulsification.

Correspondence to: Dr. Dalia Samir Tawfik, The Department

Anesthesia, Research Institute of Ophthalmology, E-mail: dsamirt@hotmail. com.

Introduction

PHACOEMULSIFICATION surgery is one of the most commonly performed elective surgical procedures. As cataract surgery has developed into

a rapid turn-over day-case procedure, the options

for anesthesia have also evolved.

There are currently several options for cataract

surgery anesthesia. General anesthesia has a well established role when local anesthesia is deemed unsuitable, and general anesthesia is still possible

in day-case setting [1] .

Regional anesthesia is also widely used, many procedures have been developed to reduce the risks

of injuring intraorbital structures (as peribulbar, or sub-tenon’s capsule injections), but none are completely devoid of complications [2,3] .

Topical anesthesia for phacoemulsification was

first described by Fichman in April 1992 in a paper presented at the symposium on Cataract, IOL and

Refractive surgery, San Diego, California.

It involves instilling anesthetic eye drops into

the conjunctival fornices before and during surgery.

It is cost-effective and provides for more rapid

post operative visual recovery than regional or

general anesthesia without post operative diplopia

and ptosis. This anesthetic technique has been increasingly accepted as the number of surgeons

performing clear corneal phacoemulsification in-creases [4,5] .

Aim of the work:

The aim of this study is to compare preservative-free xylocaine over topical anesthesia alone during

phaco surgery regarding patients’ comfort and pain during surgery.

115

116 Topical Anesthesia Versus Topical Anesthesia Plus Intracameral Xylocaine

Patients and Methods

This controlled study included 54 eyes of 54 patients who were admitted to the Ophthalmic

Department, Faculty of Medicine, El Fayoum Uni-versity, and at the Research Institute of Ophthal-mology (Giza).

Written permission was obtained from patients

after the procedure has been explained thoroughly.

The study was performed with suitable approval from the institutional review boards.

The patients were divided in two groups, group

1 (n=30) were anesthesized by intracameral pre-servative free xylocaine combined by topical an-esthesia (Xylocard). The second group (n=24)

received only topical anesthesia.

The following patients were excluded: Patients having a history of hearing impairment, dementia, movement disorders, excessive anxiety; had poor fixation due to nystagmus, strabismus. Patients

with small pupils, and patients with corneal endot-helial dystrophy, with a base line endothelial cell

count lower than 1500/mm 2 were also excluded.

Technique of topical anesthesia:

All patients in both groups received 1mg Mi-dazolam I.V and 20mic Fentanyl I.V as preoperative

sedation. Ten minutes before surgery, two drops

of Benoxinate hydrochloride (0.4%) were instilled

into the superior and inferior fornices. This is

followed by additional 2 drops at 5 minutes and immediately before the start of surgery.

Surgical procedure and intracameral anesthesia:

Preoperatively, phenylephrine hydrochloride

and tropicamide (Visumidriatic Fenilefrina) were administered to achieve mydriasis. All patients received intravenous Midazolam (1mg) and Fent-anyl (20mic) before the procedure. The lids, peri-orbital skin, and conjunctival cul-de-sac were

cleaned using povidone-iodide. An open-wire speculum was placed. The surgery was performed by an experienced surgeon using clear corneal

phacoemulsification and a chop technique. Soft shell OVDs technique was done in all cases using dispersive and cohesive OVDs. 5mm capsulorrhexis hydrodissection was performed by injecting 0.5ml preservative-free xylocaine 1%. Balanced salt

solution (BSS) was used for automated irrigation/

aspiration (I/A). Foldable intraocular lenses (IOLs) were implanted in all cases.

Parameters:

Hemodynamic parameters Heart rate (H.R),

Mean arterial pressure (MAP), and arterial oxygen saturation (SPO 2) were recorded at 3 intervals (preoperative, 5 minutes after onset of surgery and

at the end of the procedure).

Because topical and intracameral anesthesia

can not achieve akinesia, some patients exhibited blink-Bell’s phenomenon and some nystagmoid movements during surgery. When this occurred, the “psycholinguistics” technique described by Fichman was used [6] .

Eye movements were recorded during the pro-cedure and graded as follow: 0=no movements,

1=nystagmoid movements and 2=Bell’s move-ments.

After surgery, the patients used a standard 10 points visual analog scale (VAS) to asses their

intraoperative pain [7] . The scale was administered in the recovery room immediately after surgery.

Time of surgery, as well as both patient’s and

surgeon’s satisfaction was noted in both groups.

Statistical analysis:

SPSS package for Windows, version 15 (SPSS Inc., Chicago, Illinois, USA) was used. Comparison

between the techniques was done by Log-rank test. p-value less than 0.05 was considered significant.

Results

There was no statistical significant difference

in age, or time of surgery in both groups (p=0.564 and p=0.072 respectively).

Also there was no difference in both groups

regarding patient’s and surgeon’s satisfaction (Ta-bles 1,2 respectively).

Hemodynamic parameters differences in both

groups were insignificant (Tables 3,4).

Light intensity and other stimuli were decreased to calm the patient and improve his or her ability to concentrate on the microscope light.

Eye movements during surgery were more fre-quent in group 2, yet there was no statistical sig-nificant difference in both groups (p=0.08).

Measurement of pain by VAS showed signifi-cant statistical difference between both groups

(p=0.005), as pain was higher in group 2.

73.0

72.0

71.0

70.0

69.0

68.0 Xylocard Topical

67.0 HR 1 HR 2 HR 3

MAP 1 MAP 2 MAP 3

103 102 101 100 99 98 97 96 95 94 93 92

Xylocard Topical

VA

S sc

ore

4.0

2.0

5.0

3.0

0.0

1.0

Dalia S. Tawfik, et al. 117

Table (1): Patient’s satisfaction in group using nonpreserved

xylocaine (xylocard), and in group using topical technique only.

Group Total

Xylocard Topical

Patient’s satisfaction: Count 30 24 54 % within group 100% 100% 100%

Total: Count 30 24 54 % within group 100% 100% 100%

Table (2): Surgeon’s satisfaction in group using nonpreserved xylocaine (xylocard), and in group using topical technique only.

Group Total

Xylocard Topical

Surgeon’s satisfaction: Count 30 24 54 % within group 100% 100% 100%

Total: Count 30 24 54 % within group 100% 100% 100%

Table (3): Hemodynamics parameters in the group using

nonpreserved xylocaine (xylocard).

Mean score Std Deviation

HR1 69.3 12.7 HR2 69.6 11.8 HR3 69.1 11.6 MAP 1 101.6 16.8 MAP2 99.9 15.9 MAP3 99.9 15.1 Spo2-1 99.3 0.8 Spo2-2 99.9 0.4 Spo2-3 99.9 0.4

Table (4): Hemodynamics parameters in the group using only

topical anesthesia.

Mean score Std Deviation

HR1 72.7 15.0 HR2 72.4 14.7 HR3 71.4 14.5 MAP 1 97.1 15.5 MAP2 95.3 15.2 MAP3 97.1 16.6 Spo2-1 99.1 0.8 Spo2-2 99.8 0.4 Spo2-3 99.8 0.4

Table (5): Pain Score in both groups.

Xylocard group Topical group

Valid number 30 24 Mean ± Std 1.6± 1.5 2.8± 1.5

(Std = Standard deviation).

Fig. (1): Heart rate changes in both groups.

Fig. (2): Mean arterial blood pressure changes in both groups.

Xylocard Topical

Fig. (3): A boxplot showing the VAS score of the two studied

groups.

Discussion

The efficacy of topical anesthesia for pha-coemulsification has been widely reported [8,9] and topical anesthesia is now the preferred tech-nique for many cataract surgeons.

Preserved ocular motility can be used to im-prove the operating conditions by optimizing the red reflex and wound access. There is no risk of

118 Topical Anesthesia Versus Topical Anesthesia Plus Intracameral Xylocaine

globe perforation. Compared to regional anesthetic techniques, such as peribulbar anesthesia, the

topical approach produces less vitreous pressure,

and there is no effect on optic nerve blood flow. Postoperative recovery is quicker, postoperative

pain is reduced, and patients may prefer the tech-nique [9,10] .

However, topical anesthesia alone does not

prevent pain sensation experienced by some pa-tients, caused by movement of the iris-lens dia-phragm.

To achieve analgesia during intraocular surgery,

impulses in pain fibers exiting the eye must be blocked completely, including impulses in the long fibers from the cornea, the iris, and the ciliary body

to the ciliary ganglion.

Failure of topical anesthesia to block sensations

in all these fibers makes intraoperative manipulation

of the iris particularly uncomfortable for patients

undergoing intraocular procedures with topical anesthesia only.

Various techniques have been advocated to alleviate patient’s discomfort associated with

intraoperative manipulation.

Grabow [11] emphasized the importance of adequate cycloplegia to minimize stretching of

zonules and ciliary muscle. Novak and Koch [12] recommended lowering of the irrigating solution

bottle to minimize the hydrostatic pressure that

could cause pain by stretching the ciliary body.

Pandey et al. [13] , stated that gradual increase in microscope luminance, minimal intraocular and

iris manipulation and keeping phaco power as low

as possible to avoid excessive heating of the phaco

tip are important factors to reduce pain.

The intracameral xylocaine technique which was designed to overcome these problems uses

0.5ml nonpreserved xylocaine 1%, which is injected into the anterior chamber at the beginning of sur-gery. It was first described by Gills et al. [14] . Several studies have assessed the dosage regimens,

efficacy, and safety of the technique [15-17] .

In our study, there was no difference in sur-geon’s and patient’s satisfaction in both groups,

and eye movements during surgery were more frequent in group 2, yet there was no statistical significant difference in both groups. These results

may be attributed to the high skills of the surgeon and short time of the surgical procedure.

Although the majority of patients in both groups

of our study experienced no or only minimal dis-comfort and pain, the difference in mean pain score

for the two groups was statistically significant.

The efficacy of intracameral block was partic-ularly striking when intraoperative manipulation

was required. Patients who received only topical

anesthesia were more likely to experience discom-fort during iris manipulation, zonular stretching, and spasm of the ciliary body. In contrast, patients

who received intracameral anesthesia were practi-cally oblivious to such manipulations.

These results seemed to agree with those of Pandey et al. [13] , Gills et al. [14] , and Koch [15] , who reported that irrigation of the anterior chamber

with unpreserved xylocaine alleviate the intraocular

discomfort of some patients undergoing cataract extraction and implantation of IOL while under topical anesthesia.

Conclusion: In conclusion, combining topical and intracam-

eral anesthesia for cataract surgery offers significant

benefits over topical anesthesia alone in terms of

patient’s comfort.

We believe that the combined topical–intrac-ameral technique will probably become the standard

ophthalmic anesthetic technique for phacoemulsi-fication.

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