To the Editor:—
I read with interest the closed claims analysis “Injury and Liability Associated with Monitored Anesthesia Care” by Bhananker et al.1
and the accompanying editorial opinion by Hug.2
The study indicated that more than one in five monitored anesthesia care claims in the database occurred with patients undergoing elective eye surgery. It also reiterated that the most common causes of patient eye injury and anesthesiologist liability linked to ophthalmic anesthesia consisted of complications related to the eye block and perioperative patient movement. More than four fifths (83%) of ophthalmic anesthesia monitored anesthesia care cases associated with inadequate anesthesia and/or patient movement, either during the block or intraoperatively, resulted in ocular injury and, presumably, poor visual outcome. A previous American Society of Anesthesiologists Closed Claims Project, “Eye Injuries Associated with Anesthesia” by Gild et al.3
published in the Journal identified 21 cases of blindness allegedly the result of intraoperative movement during ophthalmic surgery. Movement was the foremost mechanism of injury cited. Five of those claims occurred during regional anesthesia and were attributed to “restlessness” or coughing during the procedure.
Regional anesthesia is a vital part of the scope of anesthesia practice. Because of its safety and efficacy, it is a preferred option for many ophthalmic surgical procedures.4
Aside from intraoperative analgesia and akinesia, advantages of conduction anesthesia for ophthalmic surgery patients include suppression of the oculocardiac reflex and provision of postoperative pain relief. In those eye cases where general anesthesia has been the traditional modality of choice, such as open-globe injuries, regional anesthesia may be a fitting alternative when general anesthesia confers an unacceptable level of systemic or ophthalmic risk.5,6
Globe puncture is a dreaded complication of needle-based ophthalmic regional anesthesia. Its incidence varies inversely with education and experience. This is confirmed by a number of previous reports of adverse sequelae by inadequately trained/educated anesthesia personnel.7–9
As noted in a previous letter to the Journal, no formal training or education in ophthalmic regional anesthesia is provided to anesthesia residents in the majority of programs.10,11
Anesthesiologists can acquire these skills via
university programs, Refresher Courses, and workshops at the annual American Society of Anesthesiologists meeting or though an organization such as the Ophthalmic Anesthesia Society. In addition, newer ophthalmic anesthesia techniques may minimize the risk of iatrogenic globe puncture. Ultrasound guidance allows for direct visualization of the needle, whereas sub-Tenon regional anesthesia replaces needles altogether with blunt cannulas.12,13
Topical anesthesia has gained acceptance for surgical procedures of the anterior segment of the eye. Its use, particularly for cataract operations, has surged in recent years.14
Topical anesthesia does not render the eye akinetic, and requires the patient to focus on the microscope light. Because oversedation may precipitate patient movement and depth of analgesia may be less than with traditional regional anesthesia techniques, the term “vocal local” has been used to describe the occasional reality of ophthalmic anesthesia via
topical anesthesia and minimal sedation.15
Regional and topical anesthesia for ophthalmic surgery are certainly not without inherent risks. Unlike general anesthesia, these techniques mandate patient cooperation. Because the majority of ophthalmic surgical cases are elective, the article by Bhananker et al.
, as well as others, attests to the wisdom of postponing surgery until such time that the patient is in optimal condition to remain still if an increased risk of perioperative movement is noted during the anesthesiologist’s preoperative assessment.1,3,16
Patient movement during block or intraoperatively due to cough, fluctuating levels of consciousness, rebreathing of carbon dioxide under occluded drapes, or restlessness with prolonged duration of surgery can induce dire visual consequences. Deliberate patient selection and judicious choice of suitable anesthesia technique is requisite to determine the optimal anesthesia care prescription.
Steven Gayer, M.D., M.B.A.
Bascom Palmer Eye Institute and University of Miami Miller School of Medicine, Miami, Florida. firstname.lastname@example.org
1. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB: Injury and liability associated with monitored anesthesia care: A closed claims analysis. Anesthesiology 2006; 104:228–34
2. Hug CC: MAC should stand for maximum anesthesia caution, not minimal anesthesiology care. Anesthesiology 2006; 104:221–3
3. Gild WM, Posner KL, Caplan RA, Cheney FW: Eye injuries associated with anaesthesia: A closed claims analysis. Anesthesiology 1992; 76:204–8
4. Eke T, Thompson JR: The National Survey of Local Anaesthesia for Ocular Surgery: II. Safety profiles of local anaesthesia techniques. Eye 1999; 13:196–204
5. Scott IU, McCabe CM, Flynn HW Jr, Lemus DR, Schiffman MS, Gayer S: Local anaesthesia with intravenous sedation for surgical repair of selected open globe injuries. Am J Ophthalmol 2002; 134:707–11
6. Scott IU, Gayer S, Voo I, Flynn HW Jr, Diniz JR, Venkatraman A: Regional anaesthesia with monitored anaesthesia care for surgical repair of selected open globe injuries. Ophthalmic Surg Lasers Imaging 2005; 36:122–8
7. Grizzard WS, Kirk NM, Pavan PR, Antworth MV, Hammer ME, Roseman RL: Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991; 98:1011–6
8. Hay A, Flynn HW Jr, Hoffman JI, Rivera AH: Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991; 98:1017–24
9. Duker JS, Belmont JB, Benson WE, Brooks HL Jr, Brown GC, Federman JL, Fisher DH, Tasman WS: Inadvertent globe perforation during retrobulbar and peribulbar anesthesia: Patient characteristics, surgical management, and visual outcome. Ophthalmology 1991; 98:519–26
10. Gayer S, Cass G: Sub-Tenon techniques should be one option among many (letter). Anesthesiology 2004; 100:196
11. Miller-Meeks MJ, Bergstrom T, Karp KO: Prevalent attitudes regarding residency training in ocular anesthesia. Ophthalmology 1994; 101:1353–6
12. Birch AA, Evans M, Redembo E: The ultrasonic localization of retrobulbar needles during retrobulbar block. Ophthalmology 1995; 102:824–6
13. Guise PA: Sub-Tenon anesthesia: A prospective study of 6,000 blocks. Anesthesiology 2003; 98:964–8
14. Leaming DV: Practice styles and preferences of ASCRS members: 2003 survey. J Cataract Refract Surg 2004; 30:892–900
15. Claoué C: Simplicity and complexity in topical anaesthesia for cataract surgery. J Cataract Refract Surg 1998; 24:1546–7
16. Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW: Injuries associated with regional anesthesia in the 1980s and 1990s: A closed claims analysis. Anesthesiology 2004; 101:143–52
© 2006 American Society of Anesthesiologists, Inc.