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cataract surgery who were deemed fit to receive local include atrial fibrillation, heart valve disease, pulmonary
anaesthesia for cataract extraction. Experienced ophthal- embolus, deep vein thrombosis and transient ischaemic
mic nurses undertook the screening procedure, which attacks. Prophylactic measures are aimed at reducing
included a thorough medical history and assessment for the risk of thrombosis. The main complication from
the patients ability to lie still for at least 45 min. The this therapy is haemorrhage. The Royal Colleges of
patients were randomised to receive the local anaesthetic Ophthalmologists and Anaesthetists produced guidelines
via a plastic cannula or the commercially available curved on local anaesthesia for intraocular surgery in 2001 [1].
metallic cannula. A questionnaire was completed for The recommendations are that in procedures invol-
every patient. ving sharp needles or sub-Tenons block, it is important
that the international normalised ratio (INR) is known.
The level should be within the recommended therapeutic
Results
ratio, which is determined by the condition for which the
During the three-month study period 82 patients had the patient is being anticoagulated. The therapeutic range for
sub-Tenons block for cataract surgery. Metallic cannulae oral anticoagulant control is that proposed by the British
were used in 26 (32%) patients and plastic cannulae in Society for Haematology: atrial fibrillation (AF) INR 2.0
56 (68%). Four to six millilitres of lidocaine 2% were used (2.03.0), heart valve disease INR 3.8 (3.04.5) and
in over 95% of patients. Eyelid akinesia was achieved in pulmonary embolus (PE) or deep vein thrombosis (DVT)
51(63%) patients and globe akinesia in 72 (88%). Mild or INR 2.5 (2.03.0). The aims of this project were to
moderate pain was experienced by a small number of determine whether the unit was practising within these
patients during establishment of the block; however, no guidelines, and to ascertain the rate of complications as a
patient suffered severe pain at the time of injection or direct result of anticoagulation.
during the operation and 90% of the patients reported no
pain during the operation. There were no complications
Methods
recorded in the three-month follow-up.
A retrospective study was undertaken on patients under
the care of two consultant ophthalmic surgeons. The
Discussion
notes of 50 patients receiving anticoagulation therapy
Sub-Tenons anaesthesia using a plastic cannula is an who underwent phakoemulsification between 1999 and
effective and reliable method, and can be successfully 2002 were analysed. Data recorded included sex; age;
achieved with little training. Use of a plastic cannula to reason for anticoagulation therapy; drug and dosage;
establish the block is a much cheaper alternative to the pre-operative INR; length of time between INR
commercially available metallic cannula. Much larger assessment and day of surgery; type of anaesthetic; pre-
randomised studies are needed to compare the two peri- and postoperative (up to 4 weeks) complications;
techniques more fully. and any changes made to anticoagulation therapy for the
surgery.
References
Results
1 Hamilton RC. Techniques of orbital regional anaesthesia.
British Journal of Anaesthesia 1995; 75: 8892. Average age was 77 years. The most common indica-
2 Stevens JD. A new local anaesthesia technique for cataract tions for anticoagulation were AF (48%), heart valve
extraction by one quadrant sub-Tenons infiltration. British disease (28%), transient ischaemic attacks (14%) and
Journal of Ophthalmology 1992; 76: 6704.
DVT (4%). All patients were on warfarin, the average
3 Kumar CM. A simple method of sub-Tenon anaesthesia
dose being 3 mg. Their INR was measured 314 days
delivery. Anaesthesia 2000; 55: 61213.
pre-operatively. In 6% of the patients, pre-operative
INRs were reported above the therapeutic range, while
Anticoagulation and intra-ocular surgery 26% of patients had pre-operative INRs below the
under local anaesthesia therapeutic range. In 76% of patients, peribulbar anaes-
thetic was used and in the remainder, sub-Tenons;
J. Singh and K. Barber 58% of patients who had sub-Tenons anaesthesia
Department of Ophthalmology, Worcestershire Royal Hospital,
suffered pre-operative subconjunctival haemorrhage.
Worcester WR5 1DD, UK
No peri-operative problems were reported. Only one
The number of patients undergoing anticoagulation postoperative problem was reported, a spontaneous sub-
therapy is increasing. Indications for anticoagulation conjunctival haemorrhage.

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Fourteen patients had more than one indication. Of the

Discussion
35 patients, 33 had a history of hyperthyroidism whereas
The data revealed that complication rates were excep- the remaining two were clinically and biochemically
tionally low and complications minor in nature. On euthyroid. In all cases, T4/TSH levels were normal pre-
reviewing compliance with the Royal Colleges guide- operatively. Two thirds were smokers (the majority
lines, however, a more interesting and unexpected feature smoking 1020 cigarettes/day). Pre-operative morbidities
of the dataset was the fact that 32% of patients pre- were as follows: diabetes mellitus (n 5), chronic airflow
operative INRs were outside the therapeutic range. limitation (n 4), asthma (n 4), hypertension (n 4),
Although one patient had surgery postponed due to a obesity (n 3), ischaemic heart disease (n 2), arrhyth-
high INR, the remainder underwent surgery nevertheless mias (n 2) and CVA (n 1). Five had 23 com-
and without any complication. This study has raised orbidities. Fifty-one percent were taking prednisolone
several issues including whether there is a lower limit of pre-operatively (dose range 1080 mg).
INR below which local anaesthesia and intraocular Average duration of anaesthesia was 119 min for
surgery would be contra-indicated; where the responsi- unilateral surgery and 184 min for bilateral surgery. In
bility lies for abnormal levels of anticoagulation; and who 88% of cases, balanced anaesthesia involved a volatile
should be informed with regard to further management of agent (isoflurane > sevoflurane > enflurane), O2 /N2 O
these under-anticoagulated patients. mixture and either remifentanil or fentanyl morphine,
whereas in the remaining 12% of cases remifentanil,
target-controlled infusion of propofol and O2/air mix-
Reference
tures were used. Normotensive anaesthesia was used
1 Royal College of Ophthalmologists and Royal College of throughout. Intravenous acetazolamide was given on
Anaesthetists. Local anaesthesia for intraocular surgery. London, induction to reduce intraocular pressure. Subcutaneous
2001. local anaesthetic (bupivacaine with epinephrine) was
infiltrated under the eyelid before starting surgery.
Anaesthesia for surgical decompression Ketorolac and pethidine were given as adjuncts in 29%
of the orbit in severe thyroid orbitiopathy and < 1% of cases respectively. In 26% of cases, anticho-
linergic therapy was required for bradycardia resulting
L. Stannard, R.M. Slater and B. Leatherbarrow from orbital traction.
Department of Anaesthesia, Central Manchester and Manchester
Postoperatively, nausea and/or vomiting was absent in
Childrens University Hospitals, Manchester, UK
93% of cases, 57% of whom had not had antiemetic
Anaesthesia for surgical decompression of the orbit in therapy intraoperatively. Postoperative pain scores of zero
severe thyroid orbitiopathy has rarely been reported in were recorded in 88% of cases, with the use of simple
the literature. This review highlights patients, anaesthetic analgesics (paracetamol/codeine) or no analgesics recor-
and surgical factors of relevance. ded in 43% and 36%, respectively (for the entire hospital
stay). Discharge home was on the first postoperative day
in 76% of cases.
Methods
Significant peri-operative complications were as fol-
We carried out a retrospective analysis over a 3-year lows: one patient suffered a CVA two days postopera-
period of the records of 35 patients who had undergone tively and a CSF leak developed intra-operatively in
surgical orbital decompression via a trans-lid approach another case (this resolved within 24 h and according to
under general anaesthesia. protocol a lumbar drain was inserted). Infraorbital anaes-
thesia was experienced in five cases (9%) (with complete
resolution of symptoms after several months) and diplopia
Results
developed (15%) or worsened (22%) overall in 37% of
A total of 58 decompressions were performed on 35 cases.
subjects (26 women, 9 men; age range 3476 years).
Twenty-four patients had bilateral decompressions (seven
Discussion
had both sides performed simultaneously, whereas 17 had
each side performed separately at least one month apart). In our experience, anaesthesia for surgical decompression
Eleven required unilateral decompression only. Surgery of the orbit is generally safe, has a low incidence of
was repeated on six occasions in four of the 35 patients. postoperative pain and nausea and vomiting and requires
The main indications for surgery were compressive optic only a short hospital stay. However, one must be aware of
neuropathy (n 17) and disfiguring proptosis (n 19). the need to provide anaesthesia of long duration, and of

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2003 Blackwell Publishing Ltd

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