Elsevier

Ophthalmology

Volume 112, Issue 4, April 2005, Pages 574-579
Ophthalmology

Original article
Comparison of Retrobulbar and Sub–Tenon's Capsule Injection of Local Anesthetic in Vitreoretinal Surgery

Presented in part at: Association for Research in Vision and Ophthalmology Annual Meeting, April 26, 2004; Ft. Lauderdale, Florida.
https://doi.org/10.1016/j.ophtha.2004.10.043Get rights and content

Objective

To compare the efficacy and efficiency of retrobulbar versus sub–Tenon's capsule injection of local anesthetic in vitreoretinal surgery.

Design

Prospective, randomized, double-masked clinical trial.

Participants and Intervention

Sixty-four eyes from 61 patients undergoing vitreoretinal surgery were randomized to receive either retrobulbar or sub–Tenon's capsule injection of 5 ml of a 50:50 mixture of 4% lidocaine and 0.75% bupivacaine.

Main Outcome Measures

The primary outcome measured was intraoperative eye pain, which was rated by patients in both groups using an 11-point (0–10) numerical visual analogue scale immediately after surgery and again the next morning. The surgeons indicated whether they perceived patient discomfort during 4 different stages of the operation: opening of the conjunctiva, vitrectomy (if performed), placement of scleral buckle (if performed), and closing of the conjunctiva. The preincision time, need for supplemental local anesthesia, and use of IV sedation for additional pain control were compared between the two groups.

Results

Thirty-four eyes were randomized to retrobulbar injections, and 30 eyes were randomized to sub–Tenon's capsule injections. There was no significant difference in patient-reported intraoperative pain scores between the retrobulbar and sub–Tenon's capsule groups when assessed immediately after surgery (median, 2.0 vs. 2.0; P = 0.52) or the next day (median, 2.0 vs. 1.0; P = 0.26). The surgeons reported no difference between the two groups in terms of the percentages of patients with pain during opening of the conjunctiva (20.6% vs. 3.3%; P = 0.058), vitrectomy (31% vs. 32%; P = 1.00), placement of scleral buckle (33.3% vs. 40%; P = 1.00), and closing of the conjunctiva (26.5% vs. 26.7%; P = 1.00). There was a suggestion that preincision time was longer in the sub–Tenon's capsule group. Approximately equal percentages of patients in each group required supplemental local anesthesia (38% vs. 37%; P = 0.90) or IV medication (85% vs. 70%; P = 0.14) for pain control.

Conclusions

Sub–Tenon's capsule injection of local anesthetic seems as effective as retrobulbar injection at controlling intraoperative pain in vitreoretinal surgery.

Section snippets

Patient Selection

The study protocol and informed consent form were approved by the institutional review board of the Johns Hopkins Hospital. Between August 2003 and April 2004, 64 eyes from 61 patients undergoing vitreoretinal surgery at the Wilmer Eye Institute were enrolled in the study. Patients 18 years and older were included if they had an indication for a primary vitreoretinal procedure, including scleral buckling, pars plana vitrectomy (PPV) alone, PPV with scleral buckling, and PPV with associated

Patient Characteristics

Of the 64 eyes from 61 patients enrolled in the study, 34 were randomized to retrobulbar injections, and 30 were randomized to sub–Tenon's capsule injections. Baseline characteristics of the eyes in the study were well balanced between the two groups with respect to age and race (Table 1). There was a chance imbalance with respect to gender, with more female patients randomized to sub–Tenon's capsule injections than to retrobulbar injections (53.3% vs. 41.2%); however, our posttrial analyses

Discussion

We have conducted the first prospective, randomized, double-masked clinical trial that directly compares the efficacy of retrobulbar and sub–Tenon's capsule injections of local anesthetic in vitreoretinal surgery. Previous studies have demonstrated that sub–Tenon's capsule anesthesia can be administered safely to patients undergoing posterior segment surgery18, 19, 20, 21, 22, 23, 24, 25; however, its effectiveness had not been compared directly to that of retrobulbar injection, the current

Acknowledgments

The authors thank the entire vitreoretinal faculty at the Wilmer Eye Institute for their support and participation in this clinical trial.

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    Manuscript no. 240523.

    Supported in part by an unrestricted grant from Research to Prevent Blindness and a Wilmer Research Grant Award funded by unrestricted grants from Alcon, Inc., Fort Worth, Texas, and Pfizer Inc., New York, New York.

    None of the authors has a financial interest related to the article.

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    Copyright © 2005 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.