Skip to main content

Acute Pain Management Protocol for Ophthalmic Procedures

  • Chapter
  • First Online:
First Aid Perioperative Ultrasound

Abstract

Anesthesia for ophthalmic procedures involves an understanding of the local structures of the eye and various sensory and motor nerve blocks that may be used to facilitate procedures or improve post-procedural pain. Historically, retrobulbar injection of local anesthetic was the gold standard for anesthesia and akinesia, though newer techniques such as peribulbar and sub-Tenon’s blocks have reduced the risks associated with the originally described retrobulbar approach. Nerve blocks of the branches of the ophthalmic and maxillary divisions of the trigeminal nerve, collectively termed periorbital blocks, are commonly used in oculoplastics procedures or for the management of postoperative pain. Less commonly, motor nerve blocks of the facial nerve at various points along its path can be performed if required for a particular procedure. During ophthalmic procedures involving the extraocular muscles, extra care must be taken to manage the oculocardiac or trigeminovagal reflex, which may lead to bradycardia and cardiac injury secondary to rapid increase in vagal tone.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Bartfield JM, Holmes TJ, Raccio-Robak N. A comparison of proparacaine and tetracaine eye anesthetics. Acad Emerg Med. 1994;1:364–7.

    Article  CAS  PubMed  Google Scholar 

  2. Moshirfar M, Mifflin MD, McCaughey MV, Gess AJ. Prospective, randomized, contralateral eye comparison of tetracaine and proparacaine for pain control in laser in situ keratomileusis and photorefractive keratectomy. Clin Ophthalmol. 2014;8:1213–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Carino NS, Slomovic AR, Chung F, Marcovich AL. Topical tetracaine versus topical tetracaine plus intracameral lidocaine for cataract surgery. J Cataract Refract Surg. 1998;24:1602–8.

    Article  CAS  PubMed  Google Scholar 

  4. Tok OY, Tok L, Atay IM, Argun TC, Demirci N, Gunes A. Toxic keratopathy associated with abuse of topical anesthetics and amniotic membrane transplantation for treatment. Int J Ophthalmol. 2015;8:938–44.

    PubMed  PubMed Central  Google Scholar 

  5. Licina A, Sidhu S, Xie J, Wan C. Local versus general anaesthesia for adults undergoing pars plana vitrectomy surgery. Cochrane Database Syst Rev. 2016;9:CD009936.

    PubMed  Google Scholar 

  6. Nouvellon E, Cuvillon P, Ripart J. Regional anesthesia and eye surgery. Anesthesiology. 2010;113:1236–42.

    Article  PubMed  Google Scholar 

  7. Fahmi A, Bowman R. Administering an eye anaesthetic: principles, techniques, and complications. Community Eye Health. 2008;21:14–7.

    PubMed  PubMed Central  Google Scholar 

  8. Rizzo L, Marini M, Rosati C, Calamai I, Nesi M, Salvini R, Mazzini C, Campana F, Brizzi E. Peribulbar anesthesia: a percutaneous single injection technique with a small volume of anesthetic. Anesth Analg. 2005;100:94–6.

    Article  PubMed  Google Scholar 

  9. Benedetti S, Agostini A. Peribulbar anesthesia in vitreoretinal surgery. Retina. 1994;14:277–80.

    Article  CAS  PubMed  Google Scholar 

  10. Ripart J, Lefrant JY, Vivien B, Charavel P, Fabbro-Peray P, Jaussaud A, Dupeyron G, Eledjam JJ. Ophthalmic regional anesthesia: medial canthus episcleral (sub-tenon) anesthesia is more efficient than peribulbar anesthesia: a double-blind randomized study. Anesthesiology. 2000;92:1278–85.

    Article  CAS  PubMed  Google Scholar 

  11. Ghali AM, Hafez A. Single-injection percutaneous peribulbar anesthesia with a short needle as an alternative to the double-injection technique for cataract extraction. Anesth Analg. 2010;110:245–7.

    Article  PubMed  Google Scholar 

  12. Kumar CM, Williamson S, Manickam B. A review of sub-Tenon’s block: current practice and recent development. Eur J Anaesthesiol. 2005;22:567–77.

    Article  CAS  PubMed  Google Scholar 

  13. Tokuda Y, Oshika T, Amano S, Yoshitomi F, Inouye J. Anesthetic dose and analgesic effects of sub-Tenon’s anesthesia in cataract surgery. J Cataract Refract Surg. 1999;25:1250–3.

    Article  CAS  PubMed  Google Scholar 

  14. Kumar CM. Orbital regional anesthesia: complications and their prevention. Indian J Ophthalmol. 2006;54:77–84.

    Article  CAS  PubMed  Google Scholar 

  15. El-Hindy N, Johnston RL, Jaycock P, Eke T, Braga AJ, Tole DM, Galloway P, Sparrow JM, UK EPR User Group. The Cataract National Dataset Electronic Multi-centre Audit of 55,567 operations: anaesthetic techniques and complications. Eye. 2009;23:50–5.

    Article  CAS  PubMed  Google Scholar 

  16. Rubin AP. Complications of local anaesthesia for ophthalmic surgery. Br J Anaesth. 1995;75:93–6.

    Article  CAS  PubMed  Google Scholar 

  17. Iganga ON, Fasina O, Bekibele CO, Ajayi BGK, Ogundipe AO. Comparison of peribulbar with posterior sub-tenon’s anesthesia in cataract surgery among Nigerians. Middle East Afr J Ophthalmol. 2016;23:195–200.

    Article  PubMed  PubMed Central  Google Scholar 

  18. McGoldrick KE. Complications of regional anesthesia for ophthalmic surgery. Yale J Biol Med. 1993;66:443–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  19. Tomaszewska A, Kwiatkowska B, Jankauskas R. The localization of the supraorbital notch or foramen is crucial for headache and supraorbital neuralgia avoiding and treatment. Anat Rec. 2012;295:1494–503.

    Article  Google Scholar 

  20. Situ S, Gupta P, Thirunavukkarasu M, Chaudhary G. Unilateral complete ptosis after scalp block: a rare complication of common procedure. Indian J Anaesth. 2020;64:1077–8.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Yaghoubian JM, Aminpour S, Anilus V. Supertrochlear nerve block. StatPearls; 2021.

    Google Scholar 

  22. Molliex S, Navez M, Baylot D, Prades JM, Elkhoury Z, Auboyer C. Regional anaesthesia for outpatient nasal surgery. Br J Anaesth. 1996;76:151–3.

    Article  CAS  PubMed  Google Scholar 

  23. Hwang K, Jin S, Park JH, Chung IH. Cutaneous distribution of zygomaticofacial nerve. J Craniofac Surg. 2007;18:575–7.

    Article  PubMed  Google Scholar 

  24. Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: a multifactorial concept. Reg Anesth Pain Med. 2004;29:564–75. discussion 524

    CAS  PubMed  Google Scholar 

  25. Sheikh R, Dahlstrand U, Memarzadeh K, Blohmé J, Reistad N, Malmsjö M. Optimal epinephrine concentration and time delay to minimize perfusion in eyelid surgery: measured by laser-based methods and a novel form of extended-wavelength diffuse reflectance spectroscopy. Ophthalmic Plast Reconstr Surg. 2018;34:123–9.

    Article  PubMed  Google Scholar 

  26. Koenig SB, Snyder RW, Kay J. Respiratory distress after a Nadbath block. Ophthalmology. 1988;95:1285–7.

    Article  CAS  PubMed  Google Scholar 

  27. Schimek F, Fahle M. Techniques of facial nerve block. Br J Ophthalmol. 1995;79:166–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Atkinson WS. Local anesthesia in ophthalmology. Trans Am Ophthalmol Soc. 1934;32:399–451.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Ghisi D, Fanelli A, Tosi M, Nuzzi M, Fanelli G. Monitored anesthesia care. Minerva Anestesiol. 2005;71:533–8.

    CAS  PubMed  Google Scholar 

  30. Oksuz H, Tamer C. Efficacy of lidocaine 2% gel in pterygium surgery. Acta Ophthalmol Scand. 2005;83:206–9.

    Article  CAS  PubMed  Google Scholar 

  31. Kaderli B, Avci R. Comparison of topical and subconjunctival anesthesia in intravitreal injection administrations. Eur J Ophthalmol. 2006;16:718–21.

    Article  CAS  PubMed  Google Scholar 

  32. Pereira F, Shiroma HF, Urias MG, Yamada VH, de Souza Lima AA, Hofling-Lima AL, Farah ME, Rodrigues EB. Pilot study comparing topical anesthetic agents in pterygium surgery: subconjunctival injection versus 2% lidocaine gel versus 5% lidocaine gel. Cornea. 2018;37:194–8.

    Article  PubMed  Google Scholar 

  33. Chua AW, Chua MJ, Leung H, Kam PC. Anaesthetic considerations for strabismus surgery in children and adults. Anaesth Intensive Care. 2020;48:277–88.

    Article  PubMed  Google Scholar 

  34. Shin SY, Kim MJ, Joo J. Oculocardiac reflex and oculorespiratory reflex during strabismus surgery under general anesthesia using the laryngeal mask airway with maintenance of spontaneous respiration: a retrospective study. J Int Med Res. 2020;48:300060520945158.

    Article  PubMed  Google Scholar 

  35. Ha S-G, Huh J, Lee B-R, Kim S-H. Surgical factors affecting oculocardiac reflex during strabismus surgery. BMC Ophthalmol. 2018;18:103.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Tramèr M, Moore A, McQuay H. Prevention of vomiting after paediatric strabismus surgery: a systematic review using the numbers-needed-to-treat method. Br J Anaesth. 1995;75:556–61.

    Article  PubMed  Google Scholar 

  37. Gilani SM, Jamil M, Akbar F, Jehangir R. Anticholinergic premedication for prevention of oculocardiac reflex during squint surgery. J Ayub Med Coll Abbottabad. 2005;17:57–9.

    PubMed  Google Scholar 

  38. Steib A, Karcenty A, Calache E, Franckhauser J, Dupeyron J-P, Speeg-Schatz C. Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery. Reg Anesth Pain Med. 2005;30:478–83.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ji Liu .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Dhodapkar, R.M., Jin, A., Liu, J. (2023). Acute Pain Management Protocol for Ophthalmic Procedures. In: Li, J., Jiang, W., Vadivelu, N. (eds) First Aid Perioperative Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-031-21291-8_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-21291-8_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-21290-1

  • Online ISBN: 978-3-031-21291-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics