My anesthetic method for “anticipated routine” cataract surgery is based on two premises: that it is always best to be prepared for unanticipated events, no matter how straightforward a surgery seems, and that it is important to choose the technique with the fewest potential complications, whenever possible.

In ocular anesthesia today, we are presented with a greater variety of choices than ever before. In applying my two basic ideals to the list of general, retrobulbar with or without facial block, peribulbar with or without facial block, parabulbar/sub-Tenon's, and topical anesthesia with or without intraocular or external sponge supplementation, the choice seems clear. First, between now and forever, “routine” phacoemulsification may be complicated by trauma to the iris, lens capsule, or vitreous, or by instability of the cataractous or implanted lens; and intraocular anesthesia and some degree of akinesia might be highly desirable in these circumstances. Second, the literature on using needles to achieve these goals speaks for itself: sooner or later someone gets a perforation, respiratory depression, diplopia, or a retrobulbar hemorrhage. The literature on achieving just intraocular anesthesia without a decrease in extraocular muscle function through intraocular lidocaine injection, is so far relatively silent. One published report<sup>1Greenbaum S. Parabulbar anesthesia Am J Ophthalmol 1992 ;  114 : 776

Cliquez ici pour aller à la section Références</sup> of three cases of inadvertent intraocular lidocaine injection refers mainly to retinal toxicity. One patient had a permanent scotoma, and animal studies revealed sporadic vacuolization of the nerve fiber layer in half of the lidocaine and hyaluronidase injected eyes. Although intraocular lidocaine supplementation of topical anesthesia has many advocates, I think all would agree more animal and clinical study needs to be done.

Parabulbar anesthesia<sup>1Greenbaum S. Parabulbar anesthesia Am J Ophthalmol 1992 ;  114 : 776

Cliquez ici pour aller à la section Références</sup> is a simple, safe,<sup>4Stewart M., Lambrou F. The management of preoperative, intraoperative, and postoperative complications of cataract surgery from the perspective of vitreo-retinal surgeons Adv Clin Ophthalmol 1994 ;  1 : 63

Cliquez ici pour aller à la section Références</sup> inexpensive method for providing topical and intraocular anesthesia, as well as dose-dependent akinesia and reduced optic nerve function. In routine cases, it requires no intravenous support. In patients who are already anxious about surgery, a standard dose of benzodiazepine is administered.

Anesthesia begins preoperatively, with patient counseling. The patient is informed of the type of anesthesia to be used and is assured that there will be no pain (because there will not be any) and that no needle will be used near their eye. It is my experience that a large percentage of my patients know or have heard of someone who has had a “black eye” or other problem following cataract surgery, which they attribute to the anesthetic injection. It is reassuring to show such an individual a small, blunt, flexible plastic tube (Greenbaum anesthesia cannula) and to tell them that it will be used to bathe the wall of the eye in anesthetic. The patient is also told that they might have a red spot on the front of their eye for a few days, but that no bleeding would occur inside or behind the eye.

At the time of surgery, the patient is brought directly into the operating room after the pupil has been dilated and four drops of a fluoroquinolone has been administered over a period of 40 minutes. The eye is prepped with one drop of tetracaine and two drops of betadine solution (5%). After betadine swabbing of the lids, the eye is draped, and the microscope is brought in place. The patient is reassured that the light may be bright because anesthesia has not yet been given. Once in focus, one drop of tetracaine is placed over the quadrant chosen for anesthetic administration. It is easiest to use the quadrant directly opposite the dominant hand, so that a right-handed surgeon operating from the temporal position on a right eye would choose the superonasal quadrant. If cosmesis is a prime concern, the superior quadrants can be used on all cases. A wet field cautery is used to cauterize an area two-tip widths in diameter 2 mm posterior to the limbus by gently placing the cautery near the conjunctiva. The goal is to have the conjunctiva and Tenon's capsule bunch up toward the cautery tip. A Vannas scissors is opened halfway, and a snip is made within the cautery burn while lifting the conjunctiva behind it with a Bonn forceps (Color Plate 3, Fig. 13). By remaining within the cautery burn, one limits hemorrhage and enlargement of the opening. It is important to see bare sclera through the incision. Further spreading with the scissors is done if any Tenon's remnants persist. A 3-mL syringe is filled with 1 mL of lidocaine (4% if available, 2% if not) and 1 mL of bupivicaine (0.75%). No hyaluronidase is required. A Greenbaum anesthesia cannula is placed on the syringe and oriented with its flat side down. A slight bend is made in the cannula, and it is introduced through the incision until the hub creates tension in the conjunctiva (Color Plate 3, Figs. 14 and 15). The sealing of the incision by the cannula hub is crucial. If the opening is made too large, the loose tissue is tightly pulled over the hub with the forceps. A rapid infusion of 1 to 1.5 mL is then given to hydraulically dissect the solution posteriorly (Color Plate 3, Fig. 16). If any conjunctival bleeding occurs, cautery is again applied. Surgery then begins with no down time, as the anesthetic effect is immediate and no ocular compression is required.<sup>3Stevens J., Giubilei M., Lanigan L., et al. Sub-Tenon, retrobulbar, and peribulbar local anesthesia: The effect upon intraocular pressure Eur J Implant Refract Surg 1993 ;  5 : 25

Cliquez ici pour aller à la section Références</sup> A surgical sponge can be used to ballot any chemosis, if present.

At the end of surgery, the cannula is removed from the anesthesia syringe and is placed on one that is filled with gentamycin (20 mg), cefazolin (50 mg), and methylprednisolone (20 mg). The infusions can be made separately and are administered through the same opening that was used to deliver the anesthetic. This last step eliminates the risk of intraocular antibiotic injection and the cost of collagen shields.