Journal of Clinical Anesthesia (2015) xx, xxx–xxx
Original contribution
Assessing the quality of ophthalmic anesthesia☆,☆☆ Natasha Spiteri FRCOphth a,⁎, Gediminas Sidaras FRCA a , Gabriela Czanner PhD, CStat b , Mark Batterbury FRCOphth a , Stephen B. Kaye MD a,b a
St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Road, Liverpool, Merseyside, L7 8XP, UK University of Liverpool, Liverpool, Merseyside, L69 3BX, UK
b
Received 6 October 2014; accepted 21 January 2015
Keywords: Anesthesia; Cataract; Ophthalmology
Abstract Study objective: The study objective is to evaluate a scoring system to assess the quality of anesthesia used in ophthalmic surgery. Design: This is an observational prospective study. Setting: The setting is at an operating theater. Patients: Patients are all patients undergoing ophthalmic surgery, October 2012. Interventions: Quality of ophthalmic anesthesia was measured using an interval scale by the operating surgeon. Parameters were graded depending on the type and route of anesthetic: central eye position, anesthesia, akinesia of the eye and or body, soft tissue or orbital hemorrhage, and absence of vitreous bulge. Measurements: The measurements are quality score and proportion of optimal and suboptimal cases of anesthesia and number of surgical complications. Main results: Data were collected on 349 consecutive cases including cataract (55%), retinal (14%), corneal transplant (6%), and strabismus surgery (6%). Sub-Tenon was the most commonly performed (31%) followed by peribulbar (PB) (26%), general anesthesia (GA) (20%), topical (17%), and retrobulbar (RB) (6%) anesthesia. There were 11 surgical complications: posterior capsule rupture (7), dislocated lens (2), and orbital hemorrhage (2). Sub-Tenon had lower quality scores than PB (P = .006), RB (P = .028), and GA (P b .001); and PB and RB had lower scores than GA (P b .01). There was a significant association between suboptimal anesthesia and surgical complications (P b .001), odds ratio = 3.94 (95% confidence interval, 1.03-15.12; P = .046). Conclusions: The quality of ophthalmic anesthesia is an important component of the surgical procedure and should be considered in any risk stratification. Suboptimal anesthesia is associated with an increased rate of surgical complications. © 2015 Elsevier Inc. All rights reserved.
1. Introduction ☆
Disclosures: No grants, sponsors, or funding were obtained to support this work. ☆☆ Collected data: Joshua Bellevue de Sylva, Alexander Boeker, Joshim Khan, and Gaik Min Tan. ⁎ Corresponding author: Natasha Spiteri, 8Z Link, St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Road, Liverpool, Merseyside, L7 8XP, UK. Tel.: +44 7828883834. E-mail address: [email protected] (N. Spiteri). http://dx.doi.org/10.1016/j.jclinane.2015.01.008 0952-8180/© 2015 Elsevier Inc. All rights reserved.
There are several available choices of anesthetic in current practice in ophthalmic surgery, including route and type from topical (TA), sub-Tenons (STs), peribulbar (PB), retrobulbar (RB), and general anesthesia (GA). There are advantages and disadvantages associated with each type of anesthesia. The preferences of the surgeon and of the
2 anesthetist influence the choice of anesthesia for a particular operation. Patient choice, suitability, and health are also important considerations. All of these factors make it impossible to have a single type of anesthetic for all ophthalmic procedures. The Royal College of Anaesthetists and the Royal College of Ophthalmologists state that the goal of local anesthetic for ophthalmic surgery is to “provide pain-free surgery, to facilitate the surgical procedure, to minimize the risk of systemic and local complications, and to reduce the risk of surgical complications [1].” To our knowledge, there is no tool available for the surgeon to assess and or compare the quality of the various ophthalmic anesthetic techniques. In particular, it is unclear whether the quality of ophthalmic anesthesia might be a risk for surgical complications. This is clearly an important issue, which may be useful for stratifying risk. For example, undertaking cataract surgery when the position of eye is in abduction or adduction or in the presence of vitreous bulge can make the surgery much more difficult. Whether this
N. Spiteri et al. leads to an increase in surgical complications is, however, unclear. Sparrow et al [2] identified preoperative factors associated with an increased risk of complications in patients undergoing cataract surgery. They developed a risk stratification to help with surgical planning and to minimize risk [3]. The aims of this study therefore were to develop a grading system to assess the quality of anesthesia and whether there was an association with surgical outcome.
2. Materials and methods An interval scale was developed to grade the quality of anesthesia (Fig. 1). A pilot study was initially undertaken (February 2010) after which modifications were made to the system. An observational prospective study was then undertaken on all ophthalmic surgical cases performed at the Royal Liverpool University Hospital, St Paul's Eye Unit, during the month of October 2012. Patients who were
Fig. 1 Proforma used for collection of data. Information gathered by the operating surgeon included whether the anesthetic was completed by the operating surgeon or another individual as well as the type of operation. Depending on the anesthetic technique performed, various criteria (analgesia, eye position, akinesia of eye and body, and eye softness) were graded from 0-2 (0, not accomplished; 1, partially accomplished; 2, fully accomplished). A free text box was available for documentation of complications and other comments.
Assessing the quality of ophthalmic anesthesia undergoing lid or corneal refractive surgery were excluded. The choice of anesthesia (general or local) was decided at a preoperative assessment clinic. If local anesthesia was intended, the type, for example, of ST was decided by the person (surgeon or anesthetist) administering the anesthesia according to their preference and clinical features, for example, axial length in consultation with the patient. Depending on the type of anesthetic used, each of the following parameters was graded at the end of the procedure by the operating surgeon on a scale of 0 (not achieved), 1 (partially achieved), or 2 (fully achieved): eye position central, analgesia, akinesia of the eye and or body, soft tissue or orbital hemorrhage, and absence of vitreous bulge. For example, PB anesthesia is intended to produce analgesia as well as akinesia of the eye with a central eye position. If after administration of PB anesthesia, the position of the eye was in full abduction, the surgeon would grade this as 0. Topical anesthesia, on the other hand, would only be expected to provide pain relief and was therefore not graded on parameters such as akinesia. The number of parameters and scales (nominal, ordinal, or interval) therefore differed according to the type of anesthesia. Regardless of the type of anesthesia, if the intended objective was not fully met, the anesthesia was considered suboptimal. An aggregate score was calculated, expressing the “overall quality score” as a fraction of optimal (1.00), whereas a score of any less than 1.00 was considered suboptimal. Initial attempts were made to evaluate these parameters from video recordings of the operation by an independent observer, but no reliable assessment could be made apart from an indication of eye position. For parameters such as eye position, the surgeon was asked to assess whether the position of the eye was central (2), in maximum deviation (adduction, abduction, elevation, and depression) (0), or between central and maximum deviation (1). All assessments were made by the operating surgeon. Surgical complications were documented, and a free text box was provided for any relevant comments. Statistical analysis: A Fisher exact test was used to test an association between suboptimal anesthesia and complications and an odds ratio calculated for complicated vs uncomplicated surgery in patients with suboptimal anesthesia. A Kruskal-Wallis test followed by Mann-Whitney test using Bonferroni correction for multiple comparisons were used to determine whether there was a difference between the quality scores for the different types of anesthesia. All tests were done with 95% familywise confidence intervals. Institutional review board approval was obtained for this study.
3. Results Data were collected on 349 consecutive cases including cataract (55%), retinal (14%), corneal transplant (6%), and strabismus surgery (6%). Sub-Tenon was most commonly performed (31%) followed by PB (26%), GA (20%), TA
3 (17%), and RB (6%). Of patients undergoing cataract surgery, ST was the most commonly administered route of local anesthetic (74%). Eleven surgical complications were documented: posterior capsule rupture (7), dropped nucleus (1), anterior subluxation of the crystalline lens (1), and cancellation of surgery due to orbital hemorrhage (2). The proportion of optimal vs suboptimal anesthetic scores among the various types of anesthesia by surgical group is shown in Fig. 2. For the individual parameters of anesthesia, akinesia was suboptimal in 43.9% of patients who had ST (47/107 patients) compared with 22.3% of those who had PB (21/ 94 patients) (P = .001) and 23.8% of those who had RB (5/21 patients) (P = .07) anesthesia, respectively. For soft tissue and orbital hemorrhage, these were suboptimal in 52.3% of patients who received ST (56/107 patients), compared with 21.3% of patients who had PB (20/94 patients) (P b .01) and 4.8% of those who had RB (1/21 patients) (P b .01) anesthesia, respectively. Eight patients required anesthetic supplementation on the operating table (6 PB and 2 ST). Of these, 87.5% had suboptimal analgesia and 62.5% had suboptimal akinesia. The odds ratio of complicated vs uncomplicated surgery in patients with suboptimal anesthesia was 3.9 (95% confidence interval, 1.0-15.1; P = .046). An association between suboptimal anesthesia and complications was also confirmed using a Fisher exact test (P b .001). Sub-Tenon achieved significantly lower overall quality scores than PB (P = .006), RB (P = .028), or GA (P b .001). Peribulbar and RB anesthesia were similar (P = .7), but both achieved significantly lower overall quality scores than GA (P b .01).
4. Discussion Risk stratification is important in planning and assessing surgical outcomes [3]. Given the essential role of anesthesia in ophthalmic surgery, there is a need to evaluate the quality of ophthalmic anesthesia, particularly with regard to the development of surgical complications. The parameters that were used to grade the quality of anesthesia are recognized as important components, which may affect the outcome of the procedure. Several studies have compared efficacy, patient satisfaction, and complications among various types of anesthetic in cataract surgery. Pain relief is an important component of ophthalmic anesthesia. It has been reported, that compared with RB, PB, or ST, TA is less effective in providing pain relief in cataract surgery, with a greater requirement for intraoperative supplementary anesthesia [4,5]. Conversely, pain relief has been reported to be similar whether RB, PB, or ST is used [5-7]. Pain may be an important risk factor for the development of surgical complications, as it may be associated with tachycardia and alterations in blood pressure, which are recognized as important risk factors for the development of a suprachoroidal hemorrhage. It is well recognized that the presence of a vitreous bulge or an increase in intraocular pressure can have a significant
4
N. Spiteri et al.
Fig. 2 Percentage of patients achieving optimal and suboptimal anesthetic for TA, ST, PB, RB, and GA, respectively, by surgical group. The dark bars on the chart represent optimal anesthesia, whereas the light bars represent suboptimal anesthesia (Abbreviations: ivit, intravitreal injections; strab, strabismus surgery; glau, glaucoma surgery; misc EO, miscellaneous extraocular surgery; PPV, pars plana vitrectomy; phaco, cataract surgery; grafts, corneal transplant surgery; misc IO, miscellaneous intraocular surgery).
impact on surgery. Both local and general anesthetic techniques have an effect on intraocular pressure. For example, blood pressure, anesthetic vapors, and drugs such as neuromuscular blockers all affect intraocular pressure [8-13]. It has been reported that intraocular pressure is initially higher after PB than ST, with equalization after 5 minutes [6]. Not surprisingly, ST has been reported to cause more chemosis and subconjunctival hemorrhage than TA, although this was deemed purely aesthetic and not to interfere with surgery [5]. A Cochrane Database systematic review compared PB with RB anesthesia and reported that conjunctival chemosis was more common after PB, whereas lid hematoma was more common after RB. Retrobulbar hemorrhage was, however, uncommon [7]. In our study, 2 patients after PB required cancellation of surgery due to the development of periorbital and orbital hematoma. One of the roles of local anesthesia as set out in the Royal College of Anaesthetists and the Royal College of Ophthalmologists joint guidelines on local anesthesia for intraocular surgery is to facilitate the surgical procedure and reduce the risk of intraoperative complications. Although the experienced surgeon may be able to manage easily with a kinetic eye, akinesia is needed for higher risk cases and desired for surgeons in training, who carry out a substantial proportion of cataract surgery in the National Health Service in the United Kingdom. Although there is some evidence to suggest that akinesia of the eye does not vary significantly between PB and ST [6] or between PB and RB [7], we found that akinesia varied significantly and was suboptimal in 44%
of cases after ST, compared with 23% and 24% after PB and RB, respectively. This may be relevant because 74% of cataract surgery in this study was performed under ST. This does not, however, provide sufficient evidence to indicate that ST was inferior to PB or RB, as the anesthetic was administered by different grades of surgeons and anesthetists possibly with different levels of skill and expertise. Most reported studies have largely failed to show any influence of anesthetic type on surgical complications. Lee et al [14] reported that posterior capsule rupture rates did not differ between akinetic and kinetic local anesthesia. Topical achieved similar surgical outcomes to RB and PB in the study of Zhao et al [4], and surgery-related complications were similar to ST [8]. A further study comparing TA, ST, and RB found that none of the techniques interfered with surgery [15]. In contrast, a review study found the more serious complication of posterior capsule tear and vitreous loss to have occurred twice as often in TA than ST [5]. We focused on anesthetic quality, rather than technique and found a statistically significant association between suboptimal anesthetic and surgical complications. There are several weaknesses in this study. We were not able to have an independent observer grade the quality of anesthesia throughout the surgical procedure, particularly as some of the parameters may only be apparent to the operating surgeon. Some of these parameters can only be judged on a nominal scale, whereas others lend themselves to an ordinal or interval scale. Although initial attempts were made to evaluate these parameters from video recordings of the
Assessing the quality of ophthalmic anesthesia operation by an independent observer, no reliable assessment could be made, for example, of vitreous bulge or analgesia. All assessments were therefore made by the operating surgeon. It is also recognized that the surgeon may have been more likely to report suboptimal anesthesia when a complication occurred. There may, in addition, have been an underreporting of surgical complications, although this is unlikely, as there is a requirement to report all complications. Despite the potential bias in this study, our results suggest that the quality of ophthalmic anesthesia can be graded and that suboptimal anesthesia appears to be associated with an increased risk of surgical complications. We present a quality score for the ophthalmic surgeon to assess the quality of ophthalmic anesthesia. Although subjective, it is applicable to the various types of anesthetic used in ophthalmic surgery, including GA, to assess efficacy in terms of surgeon satisfaction, taking into account various factors including analgesia and akinesia. Furthermore, with a recent trend toward auditing and monitoring of surgical outcomes [16], anesthetic quality is highly relevant. There is a need to achieve the best working and operating conditions for the patient, surgeon, and anesthetist. Optimizing these conditions may achieve the best outcomes for the patient. A surgical scoring system can also be used alongside a patient-reported outcome measure, which might better match anesthetic technique with patient characteristics and correlate the surgeon's with the patient's experience. Changes in anesthetic technique have been driven by surgeon and system needs, such as “high throughput” surgery. A patient centered–approach is also now necessary. There is therefore a need to evaluate and audit current practice in ophthalmic anesthesia. Here, we present a simple tool, which can be used to this effect. This will allow for consideration of both the type and quality of ophthalmic anesthesia and risk stratification in surgical planning and in evaluating surgical outcome.
Acknowledgments The authors thank the support of all contributing surgeons and anesthetists.
5
References [1] Local anaesthesia for ophthalmic surgery. Joint guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists; 2012[Available from: http://www.rcophth.ac.uk/page.asp?section=451. Accessed on 21st February 2014]. [2] Sparrow JM, Taylor H, Qureshi K, Smith R, Birnie K, Johnston RL, et al. The Cataract National Dataset electronic multi-centre audit of 55 567 operations: risk indicators for monocular visual acuity outcomes. Eye (Lond) 2012;26(6):821-6. [3] Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, et al. The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye (Lond) 2009;23:31-7. [4] Zhao LQ, Zhu H, Zhao PQ, Wu QR, Hu YQ. Topical anaesthesia versus regional anaesthesia for cataract surgery: a meta-analysis of randomized controlled trials. Ophthalmology 2012;119:659-67. [5] Davison M, Padroni S, Bunce C, Rüschen H. Sub-Tenon's anaesthesia versus topical anaesthesia for cataract surgery. Cochrane Database Syst Rev 2007;18:CD006291. [6] Budd JM, Brown JP, Thomas J, Hardwick M, McDonald P, Barber K. A comparison of sub-Tenon's with peribulbar anaesthesia in patients undergoing sequential bilateral cataract surgery. Anaesthesia 2009;64: 19-22. [7] Alhassan MB, Kyari F, Ejere HO. Peribulbar versus retrobulbar anaesthesia for cataract surgery. Cochrane Database Syst Rev 2008;16: CD004083. [8] Samuel JR, Beaugié A. Effect of carbon dioxide on the intraocular pressure in man during general anaesthesia. Br J Ophthalmol 1974;58:62-7. [9] Adams AP, Freedman A, Henville JD. Normocapnic anaesthesia for intraocular surgery. Br J Ophthalmol 1979;63:204-10. [10] Murphy DF, Eustace P, Unwin A, Magner JB. Atracurium and intraocular pressure. Br J Ophthalmol 1985;69:673-5. [11] Memarzadeh F, Ying-Lai M, Azen SP, Varma R. Associations with intraocular pressure in Latinos: the Los Angeles Latino Eye Study. Am J Ophthalmol 2008;146:69-76. [12] Lamb K, James MF, Janicki PK. The laryngeal mask airway for intraocular surgery: effects on intraocular pressure and stress responses. Br J Anaesth 1992;69:143-7. [13] Holden R, Morsman CD, Butler J, Clark GS, Hughes DS, Bacon PJ. Intra-ocular pressure changes using the laryngeal mask airway and tracheal tube. Anaesthesia 1991;46:922-4. [14] Lee RM, Foot B, Eke T. Posterior capsule rupture rate with akinetic and kinetic block anaesthetic techniques. J Cataract Refract Surg 2013; 39:128-31. [15] Nielsen PJ, Allerød CW. Evaluation of local anaesthesia techniques for small incision cataract surgery. J Cataract Refract Surg 1998;24:1136-44. [16] Sparrow JM, Taylor H, Qureshi K, Smith R, Johnston RL. The cataract national data set electronic multi-centre audit of 55 567 operations: case-mix adjusted surgeon's outcomes for posterior capsule rupture. Eye (Lond) 2011;25(8):1010-5.
Original contribution
Assessing the quality of ophthalmic anesthesia☆,☆☆ Natasha Spiteri FRCOphth a,⁎, Gediminas Sidaras FRCA a , Gabriela Czanner PhD, CStat b , Mark Batterbury FRCOphth a , Stephen B. Kaye MD a,b a
St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Road, Liverpool, Merseyside, L7 8XP, UK University of Liverpool, Liverpool, Merseyside, L69 3BX, UK
b
Received 6 October 2014; accepted 21 January 2015
Keywords: Anesthesia; Cataract; Ophthalmology
Abstract Study objective: The study objective is to evaluate a scoring system to assess the quality of anesthesia used in ophthalmic surgery. Design: This is an observational prospective study. Setting: The setting is at an operating theater. Patients: Patients are all patients undergoing ophthalmic surgery, October 2012. Interventions: Quality of ophthalmic anesthesia was measured using an interval scale by the operating surgeon. Parameters were graded depending on the type and route of anesthetic: central eye position, anesthesia, akinesia of the eye and or body, soft tissue or orbital hemorrhage, and absence of vitreous bulge. Measurements: The measurements are quality score and proportion of optimal and suboptimal cases of anesthesia and number of surgical complications. Main results: Data were collected on 349 consecutive cases including cataract (55%), retinal (14%), corneal transplant (6%), and strabismus surgery (6%). Sub-Tenon was the most commonly performed (31%) followed by peribulbar (PB) (26%), general anesthesia (GA) (20%), topical (17%), and retrobulbar (RB) (6%) anesthesia. There were 11 surgical complications: posterior capsule rupture (7), dislocated lens (2), and orbital hemorrhage (2). Sub-Tenon had lower quality scores than PB (P = .006), RB (P = .028), and GA (P b .001); and PB and RB had lower scores than GA (P b .01). There was a significant association between suboptimal anesthesia and surgical complications (P b .001), odds ratio = 3.94 (95% confidence interval, 1.03-15.12; P = .046). Conclusions: The quality of ophthalmic anesthesia is an important component of the surgical procedure and should be considered in any risk stratification. Suboptimal anesthesia is associated with an increased rate of surgical complications. © 2015 Elsevier Inc. All rights reserved.
1. Introduction ☆
Disclosures: No grants, sponsors, or funding were obtained to support this work. ☆☆ Collected data: Joshua Bellevue de Sylva, Alexander Boeker, Joshim Khan, and Gaik Min Tan. ⁎ Corresponding author: Natasha Spiteri, 8Z Link, St Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Road, Liverpool, Merseyside, L7 8XP, UK. Tel.: +44 7828883834. E-mail address: [email protected] (N. Spiteri). http://dx.doi.org/10.1016/j.jclinane.2015.01.008 0952-8180/© 2015 Elsevier Inc. All rights reserved.
There are several available choices of anesthetic in current practice in ophthalmic surgery, including route and type from topical (TA), sub-Tenons (STs), peribulbar (PB), retrobulbar (RB), and general anesthesia (GA). There are advantages and disadvantages associated with each type of anesthesia. The preferences of the surgeon and of the
2 anesthetist influence the choice of anesthesia for a particular operation. Patient choice, suitability, and health are also important considerations. All of these factors make it impossible to have a single type of anesthetic for all ophthalmic procedures. The Royal College of Anaesthetists and the Royal College of Ophthalmologists state that the goal of local anesthetic for ophthalmic surgery is to “provide pain-free surgery, to facilitate the surgical procedure, to minimize the risk of systemic and local complications, and to reduce the risk of surgical complications [1].” To our knowledge, there is no tool available for the surgeon to assess and or compare the quality of the various ophthalmic anesthetic techniques. In particular, it is unclear whether the quality of ophthalmic anesthesia might be a risk for surgical complications. This is clearly an important issue, which may be useful for stratifying risk. For example, undertaking cataract surgery when the position of eye is in abduction or adduction or in the presence of vitreous bulge can make the surgery much more difficult. Whether this
N. Spiteri et al. leads to an increase in surgical complications is, however, unclear. Sparrow et al [2] identified preoperative factors associated with an increased risk of complications in patients undergoing cataract surgery. They developed a risk stratification to help with surgical planning and to minimize risk [3]. The aims of this study therefore were to develop a grading system to assess the quality of anesthesia and whether there was an association with surgical outcome.
2. Materials and methods An interval scale was developed to grade the quality of anesthesia (Fig. 1). A pilot study was initially undertaken (February 2010) after which modifications were made to the system. An observational prospective study was then undertaken on all ophthalmic surgical cases performed at the Royal Liverpool University Hospital, St Paul's Eye Unit, during the month of October 2012. Patients who were
Fig. 1 Proforma used for collection of data. Information gathered by the operating surgeon included whether the anesthetic was completed by the operating surgeon or another individual as well as the type of operation. Depending on the anesthetic technique performed, various criteria (analgesia, eye position, akinesia of eye and body, and eye softness) were graded from 0-2 (0, not accomplished; 1, partially accomplished; 2, fully accomplished). A free text box was available for documentation of complications and other comments.
Assessing the quality of ophthalmic anesthesia undergoing lid or corneal refractive surgery were excluded. The choice of anesthesia (general or local) was decided at a preoperative assessment clinic. If local anesthesia was intended, the type, for example, of ST was decided by the person (surgeon or anesthetist) administering the anesthesia according to their preference and clinical features, for example, axial length in consultation with the patient. Depending on the type of anesthetic used, each of the following parameters was graded at the end of the procedure by the operating surgeon on a scale of 0 (not achieved), 1 (partially achieved), or 2 (fully achieved): eye position central, analgesia, akinesia of the eye and or body, soft tissue or orbital hemorrhage, and absence of vitreous bulge. For example, PB anesthesia is intended to produce analgesia as well as akinesia of the eye with a central eye position. If after administration of PB anesthesia, the position of the eye was in full abduction, the surgeon would grade this as 0. Topical anesthesia, on the other hand, would only be expected to provide pain relief and was therefore not graded on parameters such as akinesia. The number of parameters and scales (nominal, ordinal, or interval) therefore differed according to the type of anesthesia. Regardless of the type of anesthesia, if the intended objective was not fully met, the anesthesia was considered suboptimal. An aggregate score was calculated, expressing the “overall quality score” as a fraction of optimal (1.00), whereas a score of any less than 1.00 was considered suboptimal. Initial attempts were made to evaluate these parameters from video recordings of the operation by an independent observer, but no reliable assessment could be made apart from an indication of eye position. For parameters such as eye position, the surgeon was asked to assess whether the position of the eye was central (2), in maximum deviation (adduction, abduction, elevation, and depression) (0), or between central and maximum deviation (1). All assessments were made by the operating surgeon. Surgical complications were documented, and a free text box was provided for any relevant comments. Statistical analysis: A Fisher exact test was used to test an association between suboptimal anesthesia and complications and an odds ratio calculated for complicated vs uncomplicated surgery in patients with suboptimal anesthesia. A Kruskal-Wallis test followed by Mann-Whitney test using Bonferroni correction for multiple comparisons were used to determine whether there was a difference between the quality scores for the different types of anesthesia. All tests were done with 95% familywise confidence intervals. Institutional review board approval was obtained for this study.
3. Results Data were collected on 349 consecutive cases including cataract (55%), retinal (14%), corneal transplant (6%), and strabismus surgery (6%). Sub-Tenon was most commonly performed (31%) followed by PB (26%), GA (20%), TA
3 (17%), and RB (6%). Of patients undergoing cataract surgery, ST was the most commonly administered route of local anesthetic (74%). Eleven surgical complications were documented: posterior capsule rupture (7), dropped nucleus (1), anterior subluxation of the crystalline lens (1), and cancellation of surgery due to orbital hemorrhage (2). The proportion of optimal vs suboptimal anesthetic scores among the various types of anesthesia by surgical group is shown in Fig. 2. For the individual parameters of anesthesia, akinesia was suboptimal in 43.9% of patients who had ST (47/107 patients) compared with 22.3% of those who had PB (21/ 94 patients) (P = .001) and 23.8% of those who had RB (5/21 patients) (P = .07) anesthesia, respectively. For soft tissue and orbital hemorrhage, these were suboptimal in 52.3% of patients who received ST (56/107 patients), compared with 21.3% of patients who had PB (20/94 patients) (P b .01) and 4.8% of those who had RB (1/21 patients) (P b .01) anesthesia, respectively. Eight patients required anesthetic supplementation on the operating table (6 PB and 2 ST). Of these, 87.5% had suboptimal analgesia and 62.5% had suboptimal akinesia. The odds ratio of complicated vs uncomplicated surgery in patients with suboptimal anesthesia was 3.9 (95% confidence interval, 1.0-15.1; P = .046). An association between suboptimal anesthesia and complications was also confirmed using a Fisher exact test (P b .001). Sub-Tenon achieved significantly lower overall quality scores than PB (P = .006), RB (P = .028), or GA (P b .001). Peribulbar and RB anesthesia were similar (P = .7), but both achieved significantly lower overall quality scores than GA (P b .01).
4. Discussion Risk stratification is important in planning and assessing surgical outcomes [3]. Given the essential role of anesthesia in ophthalmic surgery, there is a need to evaluate the quality of ophthalmic anesthesia, particularly with regard to the development of surgical complications. The parameters that were used to grade the quality of anesthesia are recognized as important components, which may affect the outcome of the procedure. Several studies have compared efficacy, patient satisfaction, and complications among various types of anesthetic in cataract surgery. Pain relief is an important component of ophthalmic anesthesia. It has been reported, that compared with RB, PB, or ST, TA is less effective in providing pain relief in cataract surgery, with a greater requirement for intraoperative supplementary anesthesia [4,5]. Conversely, pain relief has been reported to be similar whether RB, PB, or ST is used [5-7]. Pain may be an important risk factor for the development of surgical complications, as it may be associated with tachycardia and alterations in blood pressure, which are recognized as important risk factors for the development of a suprachoroidal hemorrhage. It is well recognized that the presence of a vitreous bulge or an increase in intraocular pressure can have a significant
4
N. Spiteri et al.
Fig. 2 Percentage of patients achieving optimal and suboptimal anesthetic for TA, ST, PB, RB, and GA, respectively, by surgical group. The dark bars on the chart represent optimal anesthesia, whereas the light bars represent suboptimal anesthesia (Abbreviations: ivit, intravitreal injections; strab, strabismus surgery; glau, glaucoma surgery; misc EO, miscellaneous extraocular surgery; PPV, pars plana vitrectomy; phaco, cataract surgery; grafts, corneal transplant surgery; misc IO, miscellaneous intraocular surgery).
impact on surgery. Both local and general anesthetic techniques have an effect on intraocular pressure. For example, blood pressure, anesthetic vapors, and drugs such as neuromuscular blockers all affect intraocular pressure [8-13]. It has been reported that intraocular pressure is initially higher after PB than ST, with equalization after 5 minutes [6]. Not surprisingly, ST has been reported to cause more chemosis and subconjunctival hemorrhage than TA, although this was deemed purely aesthetic and not to interfere with surgery [5]. A Cochrane Database systematic review compared PB with RB anesthesia and reported that conjunctival chemosis was more common after PB, whereas lid hematoma was more common after RB. Retrobulbar hemorrhage was, however, uncommon [7]. In our study, 2 patients after PB required cancellation of surgery due to the development of periorbital and orbital hematoma. One of the roles of local anesthesia as set out in the Royal College of Anaesthetists and the Royal College of Ophthalmologists joint guidelines on local anesthesia for intraocular surgery is to facilitate the surgical procedure and reduce the risk of intraoperative complications. Although the experienced surgeon may be able to manage easily with a kinetic eye, akinesia is needed for higher risk cases and desired for surgeons in training, who carry out a substantial proportion of cataract surgery in the National Health Service in the United Kingdom. Although there is some evidence to suggest that akinesia of the eye does not vary significantly between PB and ST [6] or between PB and RB [7], we found that akinesia varied significantly and was suboptimal in 44%
of cases after ST, compared with 23% and 24% after PB and RB, respectively. This may be relevant because 74% of cataract surgery in this study was performed under ST. This does not, however, provide sufficient evidence to indicate that ST was inferior to PB or RB, as the anesthetic was administered by different grades of surgeons and anesthetists possibly with different levels of skill and expertise. Most reported studies have largely failed to show any influence of anesthetic type on surgical complications. Lee et al [14] reported that posterior capsule rupture rates did not differ between akinetic and kinetic local anesthesia. Topical achieved similar surgical outcomes to RB and PB in the study of Zhao et al [4], and surgery-related complications were similar to ST [8]. A further study comparing TA, ST, and RB found that none of the techniques interfered with surgery [15]. In contrast, a review study found the more serious complication of posterior capsule tear and vitreous loss to have occurred twice as often in TA than ST [5]. We focused on anesthetic quality, rather than technique and found a statistically significant association between suboptimal anesthetic and surgical complications. There are several weaknesses in this study. We were not able to have an independent observer grade the quality of anesthesia throughout the surgical procedure, particularly as some of the parameters may only be apparent to the operating surgeon. Some of these parameters can only be judged on a nominal scale, whereas others lend themselves to an ordinal or interval scale. Although initial attempts were made to evaluate these parameters from video recordings of the
Assessing the quality of ophthalmic anesthesia operation by an independent observer, no reliable assessment could be made, for example, of vitreous bulge or analgesia. All assessments were therefore made by the operating surgeon. It is also recognized that the surgeon may have been more likely to report suboptimal anesthesia when a complication occurred. There may, in addition, have been an underreporting of surgical complications, although this is unlikely, as there is a requirement to report all complications. Despite the potential bias in this study, our results suggest that the quality of ophthalmic anesthesia can be graded and that suboptimal anesthesia appears to be associated with an increased risk of surgical complications. We present a quality score for the ophthalmic surgeon to assess the quality of ophthalmic anesthesia. Although subjective, it is applicable to the various types of anesthetic used in ophthalmic surgery, including GA, to assess efficacy in terms of surgeon satisfaction, taking into account various factors including analgesia and akinesia. Furthermore, with a recent trend toward auditing and monitoring of surgical outcomes [16], anesthetic quality is highly relevant. There is a need to achieve the best working and operating conditions for the patient, surgeon, and anesthetist. Optimizing these conditions may achieve the best outcomes for the patient. A surgical scoring system can also be used alongside a patient-reported outcome measure, which might better match anesthetic technique with patient characteristics and correlate the surgeon's with the patient's experience. Changes in anesthetic technique have been driven by surgeon and system needs, such as “high throughput” surgery. A patient centered–approach is also now necessary. There is therefore a need to evaluate and audit current practice in ophthalmic anesthesia. Here, we present a simple tool, which can be used to this effect. This will allow for consideration of both the type and quality of ophthalmic anesthesia and risk stratification in surgical planning and in evaluating surgical outcome.
Acknowledgments The authors thank the support of all contributing surgeons and anesthetists.
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