IV. OPTIMAL CONDITIONS AND INTRACAMERAL ANESTHESIA
A. Operative Time
Cases should be completed in 30 minutes or less and thus, early resident surgery may require retrobulbar, peribulbar, or sub-Tenon anesthesia until surgical skill and operative times are reduced. It may take 30 or more cases for residents to become skilled and efficient enough to finish cases from start to finish in less than 30 minutes. I believe topical and intracameral anesthesia cases should only be reserved for surgeons who have proven that they are far along the learning curve and are beyond the stage of stumbling over various stages of the case.
B. Relative Contraindications
Topical anesthesia is also not ideal when there is an anticipated need to enlarge the incision. Examples of these situations include potential conversion of a phaco case to an extracapsular cataract extraction with a dense brunescent cataract, in complex cases such as small pupil cases, traumatic cataracts, or those surgeries involving a combined cataract and glaucoma procedure. Thus, this underscores the gradual transition from more invasive anesthesia to topical with or without intracameral anesthesia in accordance with the resident surgeon’s progression.
C. Transitioning to Intracameral Anesthesia
The posterior capsular tear incidence should be under 10% before a resident surgeon should consider converting to topical/intracameral anesthesia. There is no urgency to transition to topical anesthesia until the surgeon is entirely comfortable with his or her technique and able to operate efficiently and safely. It is much more difficult to manage a capsular tear issue under topical anesthesia. The goal of anesthesia is to enable the cataract surgery to be performed safely and successfully, while providing comfort to the patient in a relatively stress-free environment for the surgeon. Sometimes the authors find that the residents forget that there is a patient under the drape and that their experience, comfort, and ultimate result are the most important aspects of the surgery. The transition to topical/intracameral anesthetic cases will come with time and may arrive sooner for some than others.
Modern cataract surgery involving self-sealing sutureless incisions, femtosecond lasers, advanced phacoemulsification technology, and premium IOLs has pushed the degree of anesthesia needed for this now rapid, minimally invasive procedure to even further heights. In fact, it has made topical and/or intracameral anesthesia for cataract surgery the standard of care in most places once beyond the early stages of the learning curve.Conclusions about the effectiveness of intracameral anesthesia as an adjunct to a topical agent are mixed. This combination is likely to be most beneficial to the 10% of the population undergoing phacoemulsification that have pain during the course of surgery.Perhaps the “as needed” approach is the most prudent and resource-sensitive approach at this time. Overall, conservative use of these agents regarding their concentrations and the volume administered is advised.
It seems the short-term safety of intracameral anesthesia, particularly a small volume (0.1 to 0.5 mL) of PF lidocaine 1% with regard to the lack of corneal, retinal, and systemic toxicity, has been established.
Deciding whether or not intracameral anesthesia would be appropriate to use in cataract surgery depends on the surgeon’s level of comfort and experience. Some objective benchmarks to consider are a surgeon’s poste- rior capsular tear rate to be less than 10% for residents in training, and less than 5% for more experienced surgeons, and a surgical time of less than 20 to 30 minutes. In addition, the patient’s ability to cooperate and communi- cate pain or problems to the surgeon, the anticipated possibility of increased complexities or complications, the axial length, the anticoagulation status, the use of alpha blockers, dense lenses, pseudoexfoliation, and traumatic cata- racts are factors to consider in deciding the appropriateness of a certain anes- thetic modality in cataract surgery.
Anesthesia in cataract surgery can optimize the potential for success by minimizing patient discomfort and the surgeon’s stress. Adjunctive intracameral anesthesia can be useful when used appropriately.
*Dikutip dari Buku Essentials of Cataract Surgery 2nd Ed, halaman 47-48