Sub-Tenon's injection for local anesthesia in posterior segment surgery

Objective: To determine whether the sub-Tenon's parabulbar approach for local anesthesia is a safe and effective choice for posterior segment surgery. Design: Prospective, noncomparative case series. Participants: Two hundred seventy-six consecutive patients underwent posterior segment surgery at the University of Texas Medical Branch. Intervention: Two hundred patients received sub-Tenon's parabulbar anesthesia containing an 11-ml mixture of 5- ml 2% lidocaine (Xylocaine), 5-ml 0.5% bupivacaine (Marcaine), and 1 ml of 150 hyaluronidase (Wydase) units as primary anesthesia. The method did not involve a separate transcutaneous lid nerve or subconjunctival injection. Main Outcome Measures: The proportion of cases receiving supplementation (significant intravenous anesthesia, intraoperative local anesthesia, or both) was estimated. Its relationship to duration of surgery and surgical procedures deemed painful was assessed. Surgery lasting 3 hours or more was considered a long duration. Both scleral buckle and cryotherapy were considered painful procedures. The proportion of cases receiving additional local anesthesia preoperatively was also evaluated. Complications associated with sub-Tenon's parabulbar injection were monitored. Results: There were 101 instances of patients receiving additional anesthesia. Nineteen received additional preoperative sub-Tenon's anesthesia, 12 received intraoperative local anesthesia supplementation, and 70 received intravenous medication. Of these 70, 19 required what the authors defined as a significant amount of intravenous medication, three of whom also received intraoperative local anesthesia supplementation. Consequently, 28 of 200 patients (14%; 95% confidence interval: 9.5, 19.6) received supplementation (significant intravenous anesthesia, intraoperative local anesthesia, or both). The proportion of cases receiving supplementation was directly related to duration of surgery. Patients involved in longer cases (51.7% vs. 7.6%; P < 0.001) and those involved in more painful procedures (48.2% vs. 8.7%; P < 0.001) were more likely to receive supplementation. Adjusting for surgery duration, a greater proportion of patients undergoing painful procedures required supplementation (31.3% vs. 0.5% for surgery < 3 hours, P = 0.003; 72.7% vs. 38.9% for surgery ≥ 3 hours, P = 0.13). No associated ocular or systemic complications were observed. Conclusions: The results of this large study demonstrate that a single injection of sub-Tenon's anesthesia is relatively safe and effective for achieving local anesthesia during vitrectomies, with or without other intraocular procedures, lasting less than 3 hours. Other types of posterior segment surgery may require supplementation if they are more painful procedures, such as scleral buckle or cryotherapy, or last longer than 3 hours. (C) 2000 by the American Academy of Ophthalmology.