I read with interest the closed claims analysis “Injury and Liability Associated with Monitored Anesthesia Care” by Bhananker et al.  1and the accompanying editorial opinion by Hug.2The 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.  3published 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.4Aside 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.7–9As 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.10,11Anesthesiologists 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.14Topical 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.

Bascom Palmer Eye Institute and University of Miami Miller School of Medicine, Miami, Florida. sgayer@med.miami.edu

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