RU2811285C1 - Method of pain relief during ophthalmological operations on anterior and posterior segments of eye - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: invention can be used for pain relief during ophthalmological operations on the anterior and posterior segment of the eye. The method involves introducing a lidocaine mixture into the sub-Tenon's space in the lower inner quadrant. In 3 min. immediately before performing anesthesia, the anesthetic oxybuprocaine hydrochloride is instilled into the operated eye, then a mixture of 1.7 UE of lidase diluted in 4 ml of a 2% lidocaine solution is injected into the sub-Tenon's space in the lower inner quadrant, the moment of onset of anesthesia is determined by drug mydriasis, and surgery is performed.

EFFECT: use of the invention makes it possible to provide fast and safe anesthesia during surgery on the anterior and posterior segment of the eye, regardless of the severity of concomitant pathology, reducing the risk of developing severe intra- and postoperative complications associated with the use of anesthetic agents.

3 cl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for pain relief during ophthalmological operations on the anterior and posterior segment of the eye.

The trend in the development of ophthalmic surgery is to reduce the time of surgical intervention, minimize surgical trauma, increase the degree of predictability of surgical results, and increase the rate of patient convalescence, including after the use of anesthesia. Therefore, anesthesia must provide the required depth and duration of anesthesia, the absence of postoperative complications, and be as reliable and safe as possible.

Features of ophthalmological operations on the anterior and posterior segment of the eye are the longer duration of the operation due to the large volume and complexity of the surgical intervention. Many patients who require, for example, vitreoretinal surgery are comorbid, with a large number of severe concomitant pathologies of various organs and systems (cardiovascular diseases, endocrine diseases, diseases of the respiratory system, kidney diseases).

Carrying out general anesthesia for such patients is associated with the following problems: the difficulty of direct laryngoscopy and tracheal intubation; the undesirability of using a laryngeal mask due to the risk of aspiration of gastric contents during anesthesia; a tendency to reduce pulmonary perfusion and the risk of hypoxemia due to reduced lung capacity; increased oxygen demand and increased carbon dioxide production, which is important when performing anesthesia with low or minimal flow [1]. General anesthesia with artificial ventilation is a significant change in homodynamic parameters, respiratory biomechanics, the risk of difficult intubation, hypoxia, complications from the cardiovascular and respiratory systems, cognitive impairment, decompensation of diabetes mellitus and other chronic concomitant diseases. Adequate, safe anesthetic management, which reduces the risk of intra- and postoperative complications in such cases, is even more important for these patients.

Existing methods of anesthesia for ophthalmological operations have a number of disadvantages. A method of performing retrobulbar anesthesia during abdominal surgery on the eyeball, including retinal detachment, eye trauma, etc., is known from the prior art (patent RU 2400260 C1, published 09/27/2010). The essence of anesthesia is that a 2% solution of lidocaine or a 0.5% solution of bupivacaine is administered as an anesthetic, while the anesthetic is administered retrobulbarly in a volume of 4-5 ml 45-60 minutes before surgery. Disadvantages of this method:

1. When inserting a needle into the muscular funnel without visual control, there is a risk of developing retrobulbar hematoma, damage to the optic nerve, extraocular muscles, and perforation of the eyeball.

2. The possibility of administering an anesthetic outside the muscular funnel - peribulbar. This is safer in terms of the development of potential complications, but incomplete blockade of the ciliary ganglion is possible and, as a result, insufficient anesthesia.

3. Bupivacaine has the maximum neuro- and myotoxicity among amide local anesthetics.

4. Administration of the drug without visual control does not guarantee its entry into the muscular infundibulum and blockade of the ciliary ganglion. In this case, the level of anesthesia may be insufficient to perform ophthalmological operations on the anterior and posterior segments of the eye. Also, when using a needle, accidental unintentional intravascular injection of the drug is possible. In addition, there are a number of reports in the literature regarding the cardiotoxicity of bupivacaine [2].

There is a known method of general anesthesia for vitreoretinal operations (RU patent No. 2304963 C1, published: 08/27/2007). This method is as follows. Premedication is carried out followed by induction of anesthesia by administering the hypnotic propofol at a dose of 1.2-1.5 mg/kg and the muscle relaxant Tracrium at a dose of 0.5-0.6 mg/kg. Then the trachea is intubated or a laryngeal mask is installed, after which the surgeon performs sub-Tenon anesthesia in the lower inner quadrant by introducing 2 ml of 0.5% naropin and begins the intervention. Anesthesia is maintained with a mixture of nitrous oxide and oxygen in a ratio of 2:1 and the inhalational anesthetic sevoran at a dose of 0.5-1.2 vol.%. Additionally, Tracrium is administered at a dose of 0.03 mg/kg/h using a micro-jet syringe dispenser. Also, at the beginning or at the end of the operation, the antiemetic zofran is administered at a dose of 4 mg. Disadvantages of this method: high risk of complications in patients with severe concomitant pathology during general anesthesia, the need for postoperative observation by an anesthesiologist in the intensive care ward, and infusion therapy; the risk of cognitive impairment in patients after general anesthesia.

There is also a known method for performing retrobulbar anesthesia during vitreoretinal operations (RU patent No. 2462278 C1, published 09/27/2012). In this method, premedication is first administered (intravenous promedol at a dose of 0.2 mg/kg, suprastin at a dose of 0.25 mg/kg). 40-45 minutes before the start of the operation, a mixture of 2% lidocaine solution and 0.75% naropin (ropivacaine) solution is injected retrobulbarly in a 1:1 ratio in a volume of 4-5 ml. During the operation, 1-2 minutes before the start of the introduction of silicone oil, at the surgeon’s signal, a 0.01% solution of nitroglycerin is administered intravenously by titration, starting from 1 ml. Nitroglycerin administration is stopped when the patient's systolic blood pressure becomes 10-20% lower than baseline. The disadvantages of this method are: a large number of side effects of nitroglycerin, a wide range of contraindications to its use, the need for constant intraoperative monitoring of the electrocardiogram and blood pressure; the need for postoperative observation by an anesthesiologist in the intensive care unit and infusion therapy due to the use of nitroglycerin; high risk of developing such serious intraoperative complications of retrobulbar anesthesia as perforation of the eyeball, damage to the optic nerve and, as a consequence, its atrophy due to the lack of objective visual control over the course of the needle when injecting into the retrobulbar space, as well as the occurrence of retrobulbar hematoma, occlusion of the central artery retina.

The prototype is a method for performing sub-Tenon anesthesia during vitreoretinal operations using 2 ml of 2% lidocaine and 2 ml of 0.5% naropin (patent RU 2662423 C1, published: 07/25/2018). The essence of the method is as follows. 10-15 minutes before surgery, premedication is administered: 5-10 mg of sibazon, 0.05-0.1 mg of fentanyl and 0.5-1.0 mg of atropine are administered intravenously. Then anesthesia is performed by introducing a mixture of 2 ml of 2% lidocaine and 2 ml of 0.5% naropin into the sub-Tenon's space in the lower inner quadrant. Oculocompression is performed for 3-5 minutes. After this, vitreoretinal intervention is performed using classical technology through a three-port access.

The disadvantages of the prototype are:

1. The use of opiates and benzodiazepines for premedication can cause nausea, vomiting, decreased blood pressure, respiratory depression, especially in elderly and debilitated patients, patients with obesity and other concomitant pathologies.

2. Opiates and benzodiazepines have effects on cognitive function. In some cases, contact with the patient may be difficult, criticism and control over involuntary movements may be reduced.

3. We consider the use of drug sedation before ophthalmic surgery to be necessary only in a small number of patients. In the vast majority of cases, establishing verbal contact between the doctor and the patient, the patient’s understanding of the need for the operation and the sequence of actions of the medical personnel in the operating room, relieves the patient’s anxiety and psycho-emotional stress, and significantly increases the degree of his trust in the doctor and medical staff.

4. The use of atropine in all patients to prevent oculocardial reflexes may cause side effects such as tachycardia, dry mucous membranes, thirst and difficulty swallowing saliva, and sore throat due to hyposalivation. We believe that adequate regional anesthesia prevents oculocardial reflexes, and the use of atropine sulfate is possible according to indications in individual patients when bradycardia or other signs of the development of oculocardial reflexes are detected.

5. The need for oculopressure and waiting for the onset of anesthesia for 3-5 minutes after sub-Tenon administration of the anesthetic.

The technical problem that the invention applied for registration is aimed at is to offer a method of reliable and safe anesthesia that guarantees surgery on the anterior and posterior segments of the eye in patients, regardless of the severity of the concomitant pathology.

The technical result is to provide fast and safe anesthesia during surgery on the anterior and posterior segments of the eye, regardless of the severity of concomitant pathology, reducing the risk of developing severe intra- and postoperative complications associated with the use of anesthetic agents.

The technical result is achieved due to the fact that in the method of anesthesia during ophthalmological operations in the anterior and posterior segments, it takes 3 minutes. immediately before performing anesthesia, the anesthetic oxybuprocaine is instilled into the operated eye, then a mixture of 1.7 UE lidase diluted in 4 ml of a 2% lidocaine solution is injected into the sub-Tenon space in the lower inner quadrant, the moment of onset of anesthesia is determined by drug mydriasis, and surgery is performed.

The use of a mixture of 4 ml of 2% lidocaine solution with 1.7 UE lidase for sub-Tenon anesthesia is explained as follows. Lidocaine is an anesthetic that has a short period of development of anesthesia and a short period of its action (60-90 minutes), and lidase is an enzyme preparation that increases the speed of onset of anesthesia - up to 1 minute after administration. Thus, the use of a mixture of these drugs is sufficient for the rapid development of anesthesia, successful surgical intervention and does not require additional postoperative pain relief. If there is a need to prolong anesthesia, you can repeat the administration of drugs through the already created access. Thus, the proposed method makes it possible to provide adequate intraoperative anesthesia for an operation of any duration and rapid restoration of visual and oculomotor functions in the postoperative period.

With sub-Tenon administration of drugs, it is possible to control the entry of the cannula into the sub-Tenon space and the introduction of anesthetic, and to exclude perforation of the eyeball.

Advantages of the proposed method:

- rapid restoration of visual functions and movements of the eyeball;

- no effect of anesthesia on the cardiovascular, respiratory system, cognitive functions;

- allows you to provide adequate intra- and postoperative anesthesia;

- can be used in patients with severe concomitant pathology;

- does not require long-term postoperative observation in the intensive care unit and infusion therapy;

- absence of complications inherent in retrobulbar anesthesia;

- rapid rehabilitation of the general condition of patients after surgery, since the side effects of the drugs used for premedication are minimal.

The method is carried out as follows. 3 minutes before surgery, before processing the surgical field and immediately before performing sub-Tenon anesthesia, the anesthetic oxybuprocaine hydrochloride (inocaine) 0.4% in the amount of 2 drops is instilled into the operated eye. Anesthesia is performed by introducing into the sub-Tenon's space in the lower inner quadrant a mixture of 4 ml of 2% lidocaine with 1.7 UE of lidase. Lidocaine provides a rapid onset of anesthesia, and lidase ensures rapid distribution of the anesthetic in the retrobulbar space and orbit, which ensures complete blockade of the ciliary ganglion, comparable in effectiveness to retrobulbar anesthesia. After this, surgery is performed. The method provides adequate and safe anesthesia if it can be used in patients, regardless of the severity of the concomitant pathology. The moment of onset of anesthesia is determined by drug mydriasis. Catheterization of the cubital vein is performed to ensure, if necessary, the possibility of quickly providing emergency care or potentiating anesthesia. There is no premedication.

Sub-Tenon anesthesia using the proposed method (4 ml of 2% lidocaine with 1.7 UE lidase) during vitreoretinal operations was performed in 21 patients. After surgery, patients were given questionnaires in which they could rate the level of pain during surgery on a visual analogue scale (VAS) from 0 to 10 points. The severity of pain in the intraoperative period varied from 0 to 3 points (average value - 1.2/10). These indicators indicate that none of the patients experienced pain requiring additional pain relief.

During the survey, attention was paid to the presence of discomfort, visual sensations and changes in vision, as well as minor unpleasant sensations during the intraoperative period when performing anesthesia using the proposed method.

The following unpleasant sensations were identified:

- Burning sensation - 4 people (19%);

- Tingling 7 people (33%);

- One person had pain when touched (4.8%);

- Absence of any discomfort - 10 people (48%).

Unpleasant sensations were usually noted in the first minutes of the operation and did not cause significant discomfort.

At the beginning of the operation, patients noted the following visual sensations:

- saw a bright light - 15 people (71%);

- saw tools and manipulations - 13 people (61.9%);

- did not see any of the above - 2 patients (9.5%).

Subsequently, during the operation, 5 minutes after sub-Tenon anesthesia was performed, vision disappeared in 11 people (52.4%), and did not disappear in 10 people (47.6%). Vision was restored in all patients within 30 minutes after surgery. Temporary loss of vision, as well as the appearance of akinesia of the eyeball in half of the patients, indicates the development of a blockade of the ciliary ganglion and optic nerve after sub-Tenon anesthesia, comparable in its effectiveness to the blockade after retrobulbar anesthesia.

The pain level on the visual analogue scale the next day after surgery at 9:00 a.m. ranged from 0 to 3 (mean 1.7/10). Thus, none of the patients had severe or moderate pain in the postoperative period.

In the postoperative period, 13 patients (62%) did not show any complaints, and 8 patients (38%) indicated in the questionnaire the following unpleasant sensations:

- tingling (8 people, 38%);

- pain when touched (8 people, 38%);

- lacrimation (8 people, 38%);

- periodic aching pain (1 person, 4.8%);

- sensation of a foreign body in the eye (5 people, 24%).

Thus, the proposed technique provides good intraoperative pain relief and rapid recovery of oculomotor and visual functions in the postoperative period and allows vitreoretinal surgery to be performed in conditions that are comfortable for the surgeon and the patient with minimal risk of complications.

The method is illustrated by the following examples.

Example 1. Patient V., 76 years old. On March 13, 2023, she was admitted with complaints of decreased vision in the right eye. Upon admission: visual acuity of the right eye - 0.1 without correction, with correction Sph -1.5 D - 0.2, intraocular pressure (IOP) - 16 mm Hg. The anterior segment of the eye is within normal limits, the vitreous body is transparent. On the fundus: in the macular area there is a gap, the periphery is without features, the optic disc is pale pink, the contours are clear, the excavation is physiological, A:B = 1:3. A diagnosis was made: IV degree macular hole in the right eye. Pseudophakia of both eyes. He has a history of phacoemulsification cataract surgery in both eyes in 2018 and 2021.

A vitreoretinal operation was performed, which included a 3-port vitrectomy, injection of gas and platelet-rich plasma. Anesthesia was performed according to the principle described above. The rate of onset of anesthesia was assessed using drug-induced mydriasis.

Ocular akinesia occurred in the second minute after injection of the anesthetic into the sub-Tenon's space and persisted until the end of the operation. The operation time is 30 minutes. The effectiveness of intraoperative analgesia was assessed objectively: by indicators of systemic hemodynamics, the absence of autonomic reactions, and also subjectively by the presence/absence of complaints of pain during surgery and in the postoperative period. Pain and discomfort in the intra- and postoperative period were assessed using a specially developed questionnaire. No postoperative pain relief was required.

Throughout the entire operation, the patient was conscious and available for productive verbal contact. No surgical complications were observed. A complete absence of pain was achieved at all stages of surgery. Immediately after the operation, the patient was transferred to the general ward. The postoperative period was uneventful, visual acuity on the 1st day after surgery was 0.005, intraocular pressure was 10. The optical media were transparent, and there was gas in the vitreal cavity. The patient was discharged on the 1st day of the postoperative period; her general condition was stable.

Example 2. Patient A., 50 years old. On March 13, 2023, he was admitted with complaints of a sharp decrease in vision in the right eye since the beginning of March 2023.

History of vitrectomy + gas + endolaser coagulation of the retina of the right eye for hemophthalmos. Concomitant diseases: type 1 diabetes mellitus for 30 years, subcompensation, arterial hypertension. On admission: visual acuity of the right eye - 0.01, IOP - 14 mm Hg. The cornea is transparent, the depth of the anterior chamber is 3 mm, the moisture is transparent. Cloudiness of the posterior capsule of the lens. In the vitreous body there is a diffuse suspension of blood. The fundus of the eye is not ophthalmoscoped. According to ultrasound examination: intense opacification in all parts of the vitreous body. The diagnosis was made: recurrent hemophthalmos, complicated posterior capsular cataract, avitria of the right eye. III degree myopia, complex myopic astigmatism, proliferative diabetic retinopathy of both eyes.

A vitreoretinal operation was performed, which included a 3-port vitrectomy, removal of a blood suspension, injection of silicone oil, and endolaser coagulation of the retina. Anesthesia was performed according to the principle described above. Ocular akinesia occurred in the second minute after injection of the anesthetic into the sub-Tenon's space and persisted until the end of the operation. The operation was successful; no bleeding from the retinal vessels or other intraoperative complications were observed.

Throughout the entire operation (30 minutes), the course of anesthesia is smooth. A complete absence of pain was achieved at all stages of surgery. No postoperative pain relief was required.

When examined the next day: visual acuity - 0.3 without correction, 0.45 with correction Sph +2.5 D, IOP - 15 mm Hg, optical media are transparent, silicone oil completely fills the vitreal cavity, there are no hemorrhages. The patient was discharged on the 1st postoperative day; his general condition was stable.

Bibliography:

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2. Clarkson C.W., Hondeghem L.M. // Anesthesiology. - 1985. Vol. 62. - P. 396-405; Marx G.F. // Anesthesiology. - 1984. Vol. 60. - R. 3-5.

Claims (3)

1. A method of pain relief during ophthalmological operations on the anterior and posterior segments of the eye, including the introduction of a mixture of lidocaine into the sub-Tenon’s space in the lower inner quadrant, characterized in that in 3 minutes. immediately before performing anesthesia, the anesthetic oxybuprocaine hydrochloride is instilled into the operated eye, then a mixture of 1.7 UE of lidase diluted in 4 ml of a 2% lidocaine solution is injected into the sub-Tenon's space in the lower inner quadrant, the moment of onset of anesthesia is determined by drug mydriasis, and surgery is performed. 2. The method according to claim 1, characterized in that additional catheterization of the cubital vein is performed. 3. The method according to claim 1, characterized in that 0.4% inocaine in the amount of 2 drops is instilled as an anesthetic.