Microsoft Word - 11. Waqar-ul-Huda Pakistan Journal of Ophthalmology Vol. 28, No. 3, Jul – Sep, 2012 157 Original Article Randomized Clinical Trial of Topical Versus Retrobulbur Anesthesia for Phacoemulsification: Comparison of Patient Satisfaction Waqar-ul-Huda, M.S. Fehmi, Sharjeel Sultan, Uzma Fasih, Attiya Rehman, Arshad Shaikh Pak J Ophthalmol 2012, Vol. 28 No. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Waqar Ul Huda R-104 Block 7-D 1 North Karachi …..……………………….. Purpose: Current anesthetic options for phacoemulsification typically include injection techniques, such as retro bulbar block, peribulbar block, sub-Tenon injection and topical anesthesia. Consensus does not yet exist on whether regional or topical anesthesia is the superior option, although topical anesthesia is being more commonly used.1 Material and Methods: This was a randomized clinical trail done at eye Operation theatre at Abbasi Shaheed Hospital Karachi. In group A topical anesthesia (TA), patients received a minimum total of 5 doses of 2% topical proparacaine. For performing retrobulbar (RBA) block in group B, patients received 2 % lidocaine anesthetic solution 1-2 ml into the retrobulbar space. Phacoemulsification was performed using clear corneal phacoemulsification and implantation of IOL. We used a scoring system, the lowa satisfaction with Anesthesia scale (ISAS) a self administered written questionnaire for assessment of patient satisfaction. Results: Mean lowa score in topical group was 2.71 while it was 2.3 in retrobulbar group. Median lowa score in topical group was 3 while it was 2.54 in retrobulbar group. The difference in mean lowa score was found to be statistically significant between two groups (p value < 0.05). Conclusions: Topical anesthesia (TA) is a safe, satisfactory alternative to retrobulbar (RBA) anesthesia without causing discomfort to the patients. ach year, cataract surgery enables millions of people to improve their vision. It is one of the most frequently performed and successful operations in the world today. Although cataract surgery has been performed since ancient times, the last half-century has seen remarkable refinements of the procedure. Despite various modifications that have been devised over the decades to reduce the potential risks of injuring intra orbital structures, the "blind" insertion of a needle into the retrobulbar space has never been completely free of several sight and life-threatening complications which includes8-12. Hemorrhage, Ptosis, Conjunctival or eyelid bruising, Globe penetration, Optic nerve damage, Central vein and artery occlusion, and Brain stem anesthesia and death. The advantages of topical anesthesia include its ease of application, minimal to absent discomfort on administration, rapid onset of anesthesia and, most important, elimination of the potential risks associated with retrobulbar injections13-17. In addition to all of these advantages, the technique is economical, avoids undesirable cosmetic adverse effects, and allows instant visual rehabilitation. E WAQAR-UL-HUDA, et al 158 Vol. 28, No. 3, Jul – Sep, 2012 Pakistan Journal of Ophthalmology MATERIAL AND METHODS This was a randomized clinical trial done at eye operation theatre of Abbasi Shaheed Hospital Karachi. The trial was done for a period of six months having 32 patients in each group (group A topical and Group B retrobulbar). The inclusion criteria were patients with cataract presenting to the outpatient department, Aged 45-65 years, Patients of either gender, first eye operation. Mentally Handicapped patients, patients with history of raised intraocular pressure (>21mm of Hg), known case of lidocaine hypersensitivity and patient who had requested sedation for the operation were excluded. Approval from Institutional ethical committee was taken. Written informed consent was taken from each patient after giving an information leaflet describing the study. The patients were randomly allocated to either of two groups A (topical TA) and B (retrobulbar RBA) by the principal investigator through Non probability purposive technique. In group A (TA), patients received 2 drop (approximately 40 microlites per dose) of 2% lidocaine 3-5 times. For performing retrobulbar block in group B (RBA), 22-27 gauges, 3cm long needle was inserted at the infero lateral border of the bony orbit. Following a negative aspiration for blood, 2.5 ml of local anesthetic solution was injected and the needle was withdrawn. Phaco was performed by a single experienced phaco surgeon who has experience of more than 10 years in phacoemulsification. He had used stand- ardized clear corneal incision with phacoemulsi- fication and implantation of IOL. We used a scoring system, the lowa satisfaction with Anesthesia scale (ISAS) a written questionnaire for patient satisfaction. For each item, patient marked the answer that best showed how well the statement described his/her feeling. Each question had a marking from -3 to +3. A totally satisfied patient had a score of + 3; a totally dissatisfied patient had score -3. The mean of their responses to the 11 statements gave a single number between -3 and +3, which was a quantitative measure of a patient’s satisfaction with their anesthesia care. RESULTS IOWA satisfaction score Data distribution for lowa score was not found to be normal. Mean lowa score in TA group A was 2.71 while it was 2.3 in RBA group B. Median lowa score in topical group was 3 while it was 2.54 in retrobulbar group. The difference in mean lowa score was found to be statistically significant between two groups (p value < 0.05). This showed TA group patients were more satisfied than RBA group. 0.00 1.00 2.00 3.00 Topical Retrobulbar Topical Retrobulbar Fig. I: Mean lowa score of topical and retrobulbar groups of patients DISCUSSION In recent years, there has been considerable discussion in the literature about TA and RBA techniques for phacoemulsification anesthesia18. Choice of local anesthesia technique depends largely on the preferences of anesthesiologists and surgeons, but increasing attention is being paid to patient preferences, their perceptions of intraoperative pain and satisfaction19-20. This is perhaps the first study to investigate levels of patient satisfaction after cataract surgery using a validated reliable and internally consistent assessment tool in Pakistan. M ea n lo w a sc or e Group of Patient RANDOMIZED CLINICAL TRIAL OF TOPICAL VERSUS RETROBULBUR ANESTHESIA FOR PHACOEMULSIFICATION Pakistan Journal of Ophthalmology Vol. 28, No. 3, Jul – Sep, 2012 159 In the present study 87 % of TA group and 69 % of RBA were relaxed during the surgery. In other comparative study done in Iran21, two hundred thirty five patients (83%) in the retrobulbar group and 238 (84%) in the topical group reported minimal discomfort (0 – 2) during phacoemulsification. The mean ± SD pain score in the topical was 1.13 ± 1.36, while in the retrobulbar is 1.14 ± 1.47 (P = 0.92). This showed that Patients undergoing cataract surgery with topical and retrobulbar did not vary in pain score, efficacy of anesthesia and feasibility of surgery. This suggests that cataract surgery can be performed with topical anesthesia without compromising the safety of the procedure. There were some limitations of our study. Although we did use IOWA for patient satisfaction scoring but we did not measure any pain scale like VAS for assessment of pain intra and postoperatively. We did not follow the patient for any surgery or procedure related complications. CONCLUSIONS The topical anesthesia is an effective method in providing a painless surgical procedure in patients undergoing phacoemulsification. It is also safer and non invasive as compared to retrobulbar anesthesia. Also by using topical anesthesia, we can eliminate pain and fear of needle insertion for retrobulbar anaes- thesia. So considering all these, topical anaesthesia for phacoemulsification is worthy of clinical use. Author’s affiliation Dr. Waqar Ul Huda Trainee Registrar Abbasi Shaheed Hospital KMC, Karachi Dr. M.S. Fehmi Professor Abbasi Shaheed Hospital and KMDC KMC, Karachi Dr. Sharjeel Sultan Associate Consultant Abbasi Shaheed Hospital KMC, Karachi Dr. Uzma Fasih Associate Professor Abbasi Shaheed Hospital and KMDC KMC, Karachi Dr. Attiya Rehman Assistant Professor Abbasi Shaheed Hospital and KMDC KMC, Karachi Dr. Arshad Shaikh Professor Abbasi Shaheed Hospital and KMDC KMC, Karachi REFERENCE 1. Bellucci R. Topical anaesthesia for small incision cataract surgery. Dev Ophthalmol. 2002; 34: 1-12. 2. Ezra DG, Allan BD. Topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsi- fication. Cochrane Database Syst Rev. 2007: CD005276. 3. Feibel RM. Current concepts in retrobulbar anesthesia. Surv Ophthalmol. 1985; 30: 102-10. 4. Sullivan KL, Brown GC, Forman AR, et al. Retrobulbar anesthesia and retinal vascular obstruction. Ophthalmology. 1983; 90: 373-7. 5. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology. 1988; 95: 660-5. 6. Nicoll JM, Acharya PA, Ahlen K, et al. Central nervous system complications after 6000 retrobulbar blocks. Anesth Analg. 1987; 66: 1298-302. 7. Maclean H, Burton T, Murray A. Patient comfort during cataract surgery with modified topical and peribulbar anesthesia. J Cataract Refract Surg. 1997; 23: 277-83. 8. Feibel RM. Current concepts in retrobulbar anesthesia. Surv Ophthalmol. 1985; 30: 102-10. 9. Sullivan KL, Brown GC, Forman AR, et al. Retrobulbar anesthesia and retinal vascular obstruction. Ophthalmology. 1983; 90: 373-7. 10. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology. 1991; 95: 660-5. 11. Nicoll JMV, Acharya PA, Ahlen K, et al. Central nervous system complications after 6000 retrobulbar blocks. Anesth Analg. 1987; 66:1298-1302. 12. Maclean H, Burton T, Murray A. Patient discomfort during cataract surgery with modified topical and peribulbar anesthesia. J Cataract Refract Surg. 1997; 23: 277-83. 13. Fichman RA. Use of topical anesthesia alone in cataract surgery. J Cataract Refract Surg. 1996; 22: 612-4. 14. Patel EA, Carlson TA, Crandall A, et al. A comparison of topical versus retrobulbar anesthesia for cataract surgery. Ophthalmology. 1996; 103: 1196-1203. 15. Zehetmayer M, Radax U, Skorpik C, et al. Topical versus retrobulbar anesthesia in clear corneal cataract surgery. J Cataract Refract Surg.1996; 22: 480-4. 16. Koch PS. Efficacy of lidocaine 2% jelly as a topical agent in cataract surgery. J Cataract Refract Surg. 1999; 25: 632-4. 17. Tseng SH, Chen FK. A randomized clinical trial of combined topical-intracameral anesthesia in cataract surgery. Ophthalmology. 1998; 105: 2007-11. 18. Gombos KE. Jakubovits A. Kolos G, et al. Cataract surgery anaesthesia: Is topical anaesthesia really better than retrobulbar? Acta Ophthalmol. Scand. 2007; 85: 309-16. 19. Katz JMA, Feldman EB, Bass LH, et al. Injectable versus WAQAR-UL-HUDA, et al 160 Vol. 28, No. 3, Jul – Sep, 2012 Pakistan Journal of Ophthalmology topical anesthesia for cataract surgery: patient perceptions of pain and side effects. Ophthalmology. 2000; 107: 2054-60. 20. Boezaart AR, Berry, Nell M. Topical anesthesia versus retrobulbar block for cataract surgery: The patient’s perspective. J. Clin. Anesth. 2000; 12: 58-60. 21. Fazel MRZ, Forghani D, Aghadoost, et al. Retrobulbar versus topical anesthesia for phacoemulsification. Pak J Biol. Sci. 2008; 11: 2314-9. 22. Saunder G, Jonas JB. Topical versus peribulbar anaesthesia for cataract surgery. Acta Ophthalmol. Scand. 2003; 81: 596-9. 23. A Comparative Study of Topical Versus Peribulbar Anesthesia in Phacoemulsification and Implantation of Foldable Intraocular Lens in Cataract Surgery K. Said M.