FP1866 : Comparison of peribulbar versus topical anaesthesia for cataract surgery in patients with underlying cardiovascular disease

Dr. AKHILESH KOTHARI, Dr. GEETA BEHERA, Dr. SENDHAMIZHAN RENE

 ABSTRACT

PURPOSE :

An observational comparative study between topical and peribulbar anaesthesia for hemodynamic changes, rate of complications and degree of patient satisfaction in patients with cardiovascular disease undergoing routine cataract surgery.

MATERIAL AND METHODS:

150 patients above 40 years with treated/controlled hypertension and cardiovascular diseases, were scheduled for cataract surgery under topical and peribulbar anaesthesia. Heart rate, blood pressure (BP), ophthalmic and systemic complications were noted: preoperatively, immediately after block, intra-operatively, immediate post-operatively and 1 hour post-operatively. In addition, pain scores – Visual Analogue Scale(VAS) were also recorded 1 hour after the surgery.

RESULTS : There was  statistically significant rise in pulse rate and BP after peribulbar injection and   intraoperatively, that gradually reduced to baseline 1hour after surgery in both groups(p<0.001), with systolic blood pressure(SBP) intra-operatively  being significantly greater in peribulbar group (peribulbar: 155.49±18.14mmHg, topical:147.95±17.71mmHg; p~0.01). We found that topical group(1.12±0.99) had slightly lower VAS scores compared to peribulbar(1.44±0.90), p~0.04.

CONCLUSIONS:

Cataract surgery appears to reasonably safe in patients with cardiovascular disease. There is slight rise of heart rate and blood pressure immediately after giving injection of peribulbar anaesthesia probably due to injection related anxiety and pain. Therefore, in uncomplicated cataract surgery, where patient is consenting, topical anaesthesia may be preferable due to non-invasiveness, adequate analgesia and minimal effect on haemodynamic parameters.

Key words: 

Cataract, topical anaesthesia, peribulbar anaesthesia, cardiovascular disease, haemodynamic.

INTRODUCTION:

Cataract is the leading cause of blindness in the world being particularly common in low-income countries. Lens opacity in cataract disturbs vision and contrast sensitivity. There are 39 million people reported to be blind worldwide. With ageing its incidence increases and reaches almost 100% by 90 years. Since most of these patients are elderly, they often have chronic coronary diseases or risk factors for the same.

Systemic hypertension affects one billion individuals worldwide(1)and is endemic particularly in elderly population(2). Previous studies have shown an increased incidence of haemodynamic instability, myocardial ischaemia and cardiac arrhythmias in patients with severe hypertension (SBP>180,diastolic blood pressure(DBP)>110) but there is little evidence of perioperative complications with BP<180/110.(3)

Patients undergoing cataract surgery tend to be susceptible to ischaemic heart disease due to risk factors like hypertension, old age, atherosclerosis, diabetes.(4) Therefore, anaesthesia carries the risk of haemodynamic instability in these patients.(5)Among all the anaesthesia methods, two were selected for this study; one was peribulbar injection of local anaesthetic, and the other was, use of topical anaesthetic drops/gels.

OBJECTIVE:

We aimed to compare peribulbar block with topical anaesthesia for pre-injection/post-injection(peribulbar group), pre-operative(topical anaesthesia), intra-operative and postoperative changes inhemodynamic parameters/complications and overall patient satisfaction in a tertiary care hospital in South India.

MATERIAL AND METHODS: 

This hospital based prospective comparative clinical study was performed from June 2016 to may 2017 in line with the declaration of Helsinki after approval of the hospital EthicsCommittee.

After explaining the study to patients and obtaining informed consent, the study was conducted on 150 patients scheduled for cataract surgery (phacoemulsification/MSICS) in our hospital, aged 40yrs and above with concomitant controlled cardiovascular disease receiving treatment from Internal Medicine/Cardiology after physician approval. Exclusion criteria were patients allergic to lignocaine 2%, bupivacaine 0.5% or proparacaine 0.5%, patients with severe hypertension (SBP>180 mm Hg, DBP>110 mm Hg), patients who were haemodynamically unstable and patients with complicated cataract, traumatic cataract, uveitic cataract, pseudo-exfoliation, and lens induced glaucoma. Patients were recruited under two groups based on their willingness for topical anaesthesia.

Antiplatelet medications were discontinued for 5 days prior to surgery in patients who were on the same. All patients were assigned based on willingness for type of anaesthesia into two groups, each group consisting of 75 patients. Group Aà topical proparacaine 0.5% with or without lignocaine 2% gel. Group Bàperibulbar bupivacaine 0.5%, lignocaine 2%and hyalase.

Depending on the group which patients chose to be in, patients in Group A received 4 doses (approximately40 µl per dose) of unpreserved proparacaine 0.5% drops that was instilled on the ocular surface (two doses on the cornea, and one each in the superior and inferior conjunctivalcul de sac) 10 min before surgery. Five minutes before surgery two further doses were instilled on the cornea. If necessary, lignocaine 2% gel was also used.Patients in Group B received 5ml mixture of bupivacaine 0.5%, hyaluronidase and lignocaine 2% that was injected into peribulbar area at the junction of outer one third and inner two third of inferior orbital rim 10 min before surgery with a one inch 26 gauge needle, with an additional 4ml injected at the junction of inner one third and outer two third of superior orbital rim, if necessary.

In topical anaesthesia group, pulse rate and blood pressure was monitored preoperatively in waiting area, intraoperatively, immediately after surgery and 1 hour after surgery in ward.

In peribulbar group, pulse rate and blood pressure was measured before giving peribulbaranaesthetic injection in waiting area, after giving peribulbaranaesthetic injection, intraoperatively, immediately and 1 hour after surgery.

Preoperative and postoperative electrocardiaogram was taken and intraoperative ECG monitoring was done. Any intraoperative complications during the surgery were recorded. Patients were given a questionnaire postoperatively to assess their comfort levels during surgery.Total surgical time was noted from the start of incision to closure of the wound. For visual analogue score, questionnaire was administered to patient 1 hour after the surgery.

Statistical analysis:

Two sample continuous variables were analyzed with student’s t-test or Mann-Whitney U test. Pre and post comparison were done using paired t-test or Wilcoxon sign rank test.P-value less than 0.05 considered as statistically significant. All statistical analysis was done using a statistical software SPSS version 20.  

RESULTS:

The study was conducted on 150 patients aged 40yrs and above with underlying cardiovascular diseases who were candidates for cataract surgery.

There was no statistically significant difference in gender between thetwo groups. Patients undergoing cataract surgery under topical anaesthesia were significantly younger than patients undergoing cataract surgery under peribulbaranaesthesia. (Table 1)

Patients under both groups were comparable in terms of co-morbidities. There was no significant difference noted in the pulse rate between the two groups pre-operatively, intra-operatively, immediate and in the late post-operative period. However, a slight rise in the pulse rate above baseline was noted immediately after injection in the peribulbar group, though this was not statistically significant (Table 2)

There was no significant difference noted in the SBP between the two groups pre-operatively, immediate and in the late post-operative period. A rise in the SBP above baseline was noted immediately after injection in the peribulbar group. During the intraoperative period SBP in topical group (147.95±17.71mmHg) was significantly higher than the peribulbar group (155.49±18.14mmHg), p ~ 0.01 (table 2)

There was no significant difference noted in the diastolic DBP between the two groups pre-operatively, intra-operatively, immediate and late post-operative period. However, a slight rise in the DBP above baseline was noted immediately after injection in the peribulbar group, but this was not statistically significant (table 2).

Total surgical time was comparable between both groups. No systemic and ophthalmic complications were notedin both topical and peribulbar group.

There was significant difference in VAS between topical group (1.12±0.99) and peribulbar group (1.44±0.90) (table 3). This indicates that patient satisfaction was greater under topical as compared to peribulbar anaesthesia. There was no statistically significant difference between two groups in terms of patient discomfort.

DISCUSSION:

In this prospective comparative clinical study, we compared theeffect of topical and peribulbar anaesthesia on haemodynamic and ECG changes. In addition, complication rates (systemic and ophthalmic), patient discomfort and total surgical time were also noted.

In our study, patients undergoing cataract surgery under topical anaesthesia (58.91±8.17 years) were significantly younger, than patients undergoing cataract surgery under peribulbar block (64.83±8.15 years). This is similar to findings reported by Jacobi et al on  patients scheduled for cataract surgery using phacoemulsification technique under retrobulbar anaesthesia (73.1 ± 5.6 years) versus topical anaesthesia (72.1 ± 6.8 years).(6) Younger patients who are more alert and co-operative (motility) chose topical anaesthesia.  Our study also had a slightly greater number of women as compared to men.Pant et al reported similar figures in a study of differential cataract blindness by sex in India(7)Haddadi et al too had anage and gender distribution verysimilar to ours.(5)

We found the rise in pulse rate greatest after peribulbar injection with gradual return to baseline in the post-operative period, with no significant difference between two groups, similar to earlier reports. (5)(8)Wealso observed significant difference inintraoperative SBP changes, being higher in peribulbar group. The SBP peaked after peribulbar injection. However, no significant difference was noted in DBP between the two groups.There was slight increase in DBPafter peribulbar injection.Glantz et al too reported a few minutes of transient hypertension when block was performed.(4)Ryu et al reported significantly higherSBP after regional anaesthesia as compared to those in topical and sub-tenon’s group which is verysimilar toour findings.(8)Yap et alreportedsignificant rise inSBP intra-operatively, at the pre-assessment and anaesthetic room.(9)Fichmannet al reported that only 1% patients had raised blood pressure when topical anaesthesia alone was used  in cataract surgery.(10) Hence, it appears that topical anaesthesia has a lower propensity to affect hemodynamic changes due to its non-invasiveness.

Agarwal et al observeda significant increase in the number of hypertensives (n=198) who developed isolated systolic hypertension in the holding area while studying the effect of perioperative blood pressure on intraoperative complications during phacoemulsification surgery under local anaesthesia (n=734 hypertensives and n=740 normotensives)(11). We too noted a sudden rise in BP in a few patients in the holding area, but we deferred surgery for these patients, pending further physician evaluation. Only those patients, whose cardiovascular status was subsequently controlled to meet our criteria, were operated upon later and included in the study. This may be one of the reasons contributing to the relative lack of adverse events in our study which is similar to previous reports(12)(13). Basta et alprospectively studied systemic adverse events during phacoemulsification under monitored anaesthesia care and observed that arterial hypertension and agitation were the  most frequent adverse events.(14)

We did not find any new ECG changes prior to, during or after surgery in any of the patients. The total surgical time was similar between the two groups. All the surgeries were performed by expert surgeons and we did not observe any complications during cataract surgery.

Weobserved that patients who underwent cataract surgery under topical anaesthesia perceived slightly less pain as compared to patients who underwent cataract surgery under peribulbar block.A similar finding was reported by Coelho et al when they performed phacoemulsification without sedation using topical and peribulbar anaesthesia.(15)Zehetmayer et alalso evaluated the efficacy of topical anaesthesia as an alternative to peribulbar anaesthesia in clear corneal cataract surgery and observed that subjective pain was comparable whether topical or peribulbar anaesthesia was used. They reported good patient cooperation (motility) in topical anaesthesia and no significant differences in complications.(16) The slightly favourable results in topical anaesthesia group in our study may be due to the fact that significantly younger patients who chose topical anaesthesia over regional block were administered the same. Younger, alert patients are more likely to co-operate with the surgery requirements. Comparable VAS scores prove that topical anaesthesia is very effective in controlling pain.

We recommend that in the presence of adequate pre-operative cardiovascular control and in consenting patients, topical anaesthesia for cataract surgery may be the most optimum option in patients with concomitant cardiovascular disease.

REFERENCES:

1. Chobanian A V., Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Vol. 42, Hypertension. 2003. p. 1206–52.
2. Priebe HJ. The aged cardiovascular risk patient. Br J Anaesth. 2000 Nov;85(5):763–78.
3. Howell SJ, Sear JW, Foëx P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth. 2004;92(4):570–83.
4. L. G, B. D, Y. G. Perioperative myocardial ischemia in cataract surgery patients: General versus local anesthesia. Anesth Analg. 2000;91(6):1415–9.
5. Haddadi S, Marzban S, Fazeli B, Heidarzadeh A, Parvizi A, Naderinabi B, et al. Comparing the effect of topical anesthesia and retrobulbar block with intravenous sedation on hemodynamic changes and satisfaction in patients undergoing cataract surgery (phaco method). Anesthesiol pain Med. 2015;5(2):e24780.
6. Jacobi PC, Dietlein TS, Jacobi FK. A comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery. Arch Ophthalmol. 2000;118(8):1037–43.
7. Pant HB, Bandyopadhyay S, John N, Chandran A, Gudlavalleti MVS. Differential cataract blindness by sex in India: Evidence from two large national surveys. Indian J Ophthalmol. 2017 Feb;65(2):160–4.
8. Ryu JH, Kim M, Bahk JH, Do SH, Cheong IY, Kim YC. A comparison of retrobulbar block, sub- Tenon block, and topical anesthesia during cataract surgery. Eur J Ophthalmol. 2009;
9. Yap YC, Woo WW, Kathirgamanathan T, Kosmin A, Faye B, Kodati S. Variation of blood pressure during topical phacoemulsification. Eye (Lond). 2009;23(2):416–20.
10. Fichman RA. Use of topical anesthesia alone in cataract surgery. J Cataract Refract Surg. 1996 Jun;22(5):612–4.
11. Agarwal PK, Mathew M, Virdi M. Is there an effect of perioperative blood pressure on intraoperative complications during phacoemulsification surgery under local anaesthesia? Eye. 2010 Jul 5;24(7):1186–92.
12. Katz J, Feldman MA, Bass EB, Lubomski LH, Tielsch JM, Petty BG, et al. Injectable versus topical anesthesia for cataract surgery: patient perceptions of pain and side effects. The Study of Medical Testing for Cataract Surgery study team. Ophthalmology. 2000 Nov;107(11):2054–60.
13. Rocha G, Turner C. Safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring. Can J Ophthalmol. 2007 Apr;42(2):288–94.
14. Basta B, Gioia L, Gemma M, Dedola E, Bianchi I, Fasce F, et al. Systemic adverse events during 2005 phacoemulsifications under monitored anesthesia care: A prospective evaluation. Minerva Anestesiol. 2011;77(9):877–83.
15. Coelho RP, Biaggi RH, Jorge R, Rodrigues M de LV, Messias A. Clinical study of pain sensation during phacoemulsification with and without cryoanalgesia. J Cataract Refract Surg. 2015 Apr;41(4):719–23.
16. Zehetmayer M, Radax U, Skorpik C, Menapace R, Schemper M, Weghaupt H, et al. Topical versus peribulbar anesthesia in clear corneal cataract surgery. J Cataract Refract Surg. 1996 May;22(4):480–4.

 TABLES:

Table 1: Comparison of age and gender among study participants between peribulbar and topical group

	Peribulbar (n=75)	Topical (n=75)	p  value
Gender Men/Women	28/47	26/49	0.734
Age (Mean±SD)	64.83±8.15 years	58.91±8.17 years	0.0001

Table 2: Comparison of vitals (pulse, blood pressure and ECG) between topical and peribulbar groups

		Pre-operative	After injection	Intraoperative	Immediate post-operative	1hr post-operative
Pulse Rate/min (Mean±SD)	Topical	83.28±10.93	–	83.57± 9.71	81.77±9.78	81.37±10.56
	Peribulbar	83.15±12.26	89.28±13.44	85.04±11.06	81.57±10.12	80.11±9.41
	p-value	0.944	–	0.390	0.902	0.439
SBP (mmHg) Mean±SD	Topical	148.47±18.67	–	147.95±17.71	145.20±19.42	143.61±19.53
	Peribulbar	148.59±17.68	161.52±19.11	155.49±18.14	147.00±15.76	142.95±13.67
	p-value	0.968	–	0.011	0.534	0.809
DBP (mmHg) Mean±SD	Topical	84.88±9.29	–	85.97±9.63	84.72±9.81	82.91±9.54
	Peribulbar	84.47±10.72	91.07±11.32	87.29±10.02	85.28±9.65	83.01±9.16
	p-value	0.801	–	0.412	0.725	0.944
ECG changes(n)	Topical	7	–	none	None	none
	Peribulbar	5	none	none	None	none
	p-value	0.547	–	none	None	none

Table 3: Comparison of visual analogue score between topical and peribulbar group

	Group	N	Mean±Std. Deviation	P value
Visual analogue scale	Topical	75	1.12±.99	0.042
	Peribulbar	75	1.44±.90