Intraocular Surgery With General Anesthesia Gerald L. Wolf, MD; Seamus
Lynch, MD; Irving Berlin,
A specialized technique developed specifically for ophthalmic surgery has led surgeons at the Manhattan Eye, Ear and Throat Hospital to perform most private cataract extractions\p=m-\morethan 1,000 per year\p=m-\withpatients under general anesthesia. Because this practice is followed by so few ophthalmic surgeons elsewhere, an evaluation of the relative safety and benefits of local vs general anesthe-
sia was undertaken. A retrospective study comparing 2,217 consecutive patients operated on under general anesthesia with 561 patients operated on under local analgesia leads us to believe that general anesthesia provides the surgeon with optimum operating conditions. General anesthesia has proved to be a safe procedure, with a minimum of complications. The ophthalmic surgeon is assured of absolute patient immobility, with safety equivalent to that seen with procedures performed with local analgesia, despite the advanced age and resulting physiological degeneration of the patient population.
MD
increasing sophistication of Thetoday's techniques for ophthal¬ essential
mic surgery makes it that the surgeon be able to work in a delib¬ erate, unhurried fashion, undisturbed by the possibility of patient move¬ ment. These needs can best be met by the use of general anesthesia. A technique of general anesthesia was developed specifically for oph¬ thalmic surgery at the Manhattan Eye, Ear and Throat Hospital. Be¬ cause general anesthesia is used rou¬ tinely by so few surgeons elsewhere, an evaluation of the relative safety and benefits of this technique was warranted. We designed a computerized inves¬ tigation of 2,217 cataract extractions conducted over two years under gen¬ eral anesthesia, and compared the re¬ sults with those seen in 561 similar patients operated on under local anal¬ gesia during the same period. MATERIALS AND METHODS
Submitted for publication May 10, 1974. From the departments of anesthesiology, Manhattan Eye, Ear and Throat Hospital and New York Hospital. Dr. Wolf is now at the Hackensack (NJ) Hospital. Reprint requests to 161 N Woodland St, Englewood, NJ 07631 (Dr. Wolf).
In order to determine what information would be most useful in establishing the potential hazard or value of the two modal¬ ities, a series of conferences was held with ophthalmologists and anesthesiologists. The discussions covered the complications that should be investigated for possible re¬ lationship to either type of anesthetic tech¬ nique. Two hundred cataract procedures performed with patients under general an¬ esthesia were selected by a random sam-
pling procedure,
a
pilot study
was
made,
and an interim report prepared.1 A data sheet was subsequently drawn up in con¬ junction with a medical biostatistician, and the cases were prepared for the computer. Correlations were subsequently deter¬ mined, and the results analyzed. The general anesthesia and local anal¬ gesia populations showed no material dif¬ ferences in pertinent characteristics. The patients who received general anesthesia had an average age of 70 years, with a range of from 1 year to as high as 98 years. The average age of the patients receiving local analgesia was similarly within the seventh decade. Sixty percent (1,362 pa¬ tients) of the general anesthesia popu¬ lation were female and 40% (855 patients) were male. Among those receiving local analgesia, 56% (313 patients) were female and 44% (248 patients) were male. Approximately 56% of the general anes¬ thesia group and 59% of the local analgesia patients had some form of cardiovascular disease. The most common, hypertensive cardiovascular disease, occurred in 25% (567 patients) of the general anesthesia population and 24% (133 patients) of the lo¬ cal analgesia group. Arteriosclerotic cardi¬ ovascular disease occurred in 12% of both groups. Anginal syndrome, histories of congestive heart failure or myocardial in¬ farction, and rheumatic and congenital heart disease were also seen. Sixty-four (2.9%) of the general anesthesia patients had a history of heart attacks, seven within the year before surgery; 16 (2.9%) of those patients receiving local analgesia had had heart attacks, two within the year before the operative procedure.
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
Incidence of
Preexisting Diseases
General Anesthesia Group Diseases
Diabetes Metabolic diseases (other than diabetes)
No. of Patients 252 392
% 11.0 18.0
156
0.4 7.0
Hepatomegaly Neurological diseases, including cerebral vascular
accident and Parkin¬ son disease Pulmonary disease
(or history) Emphysema
No. of Patients
90'
% 16.0 1.6
0.9
No neurological
patients operated under local analgesia
on
126
5.7
26
4.6
62
2.8 1.6 1.3
13
2.3 0.5 1.8
35*
Tuberculosis Asthma
Local
Analgesia Group
29
3t 10
*
All but one case inactive. t All cases inactive.
These considerations point up an impor¬ tant element in the successful use of gen¬ eral anesthesia for elective intraocular sur¬ gery, such as cataract extractions. It is a firm policy at the Manhattan Eye, Ear and Throat Hospital that no patients should undergo elective procedures unless they are in optimum condition. At least six months must have elapsed between the time of a myocardial infarction and an op¬ eration for cataract extraction, and evi¬ dence of congestive heart failure, such as pitting edema of the extremities, rales, or hepatomegaly must be adequately con¬ trolled. The value of this policy in pre¬ venting surgical loss has been borne out by the recent work of Petruscak et al2 who found that the preexisting medical condi¬ tion was the major factor contributing to the deaths of patients undergoing ocular surgery. The incidence of other preexisting diseases is summarized in the Table. Forty percent of the patients in each group had undergone previous cataract surgery. There were three patients with a history of retinal detachment and 347 with glaucoma in the general anesthesia popu¬ lation; of those receiving local analgesia, five patients had previous retinal detach¬ ments and 57 had glaucoma. Twenty-seven of the general anesthesia patients and four of those receiving local analgesia were blind in one eye.
Techniques
of Anesthesia
Halothane (Fluothane) was the general anesthetic used in the entire series under study. Premedication, at a dosage level that would cause the patient to arrive in the operating room in an awake but re¬ laxed condition, usually consisted of a bar-
as secobarbital, 100 mg, meperidine (Demerol) hydrochloride, 12.5 to 50 mg, and atropine sulfate, 0.5 mg, ad¬ ministered intramuscularly one hour preoperatively. The orders were written the day before surgery, when the patient was routinely visited by the anesthesiologist
biturate such
and his medical condition evaluated. Ocular hypotensive agents ordered by the ophthalmologist were administered ei¬ ther in the patient's own. room or after ar¬ rival in the operating room. Acetazolamide (Diamox) was used in 51% of the cases, mannitol in 26%, and urea in 0.7%. The use of orally administered glycerine is avoided prior to general anesthesia, since it can load the gastrointestinal tract with fluid and thus cause the danger of régurgitation and aspiration during anesthesia. One of the major objections to general anesthesia voiced by most ophthalmic sur¬ geons concerns intubation, which we con¬ sider necessary to assure airway patency while giving the surgeon total accessibility to the eye. Two major criticisms have gen¬ erally been aimed at the intubation proce¬ dure. Primarily, it has been considered rel¬ atively hazardous because of its tendency to cause patient coughing and bucking. However, since the introduction of suc¬ cinylcholine chloride, which produces the total muscular relaxation necessary for atraumatic intubation, it has become vir¬ tually free of complications. Although succinylcholine does cause a rise in intraocular tension of approxi¬ mately 6.7 mm Hg,' the effect is of short duration and the tension returns to base line in two to five minutes. Thus, when suc¬ cinylcholine is used only to facilitate tra¬ chea! intubation during induction of gen-
eral anesthesia, the intraocular tension is at base line levels before the start of sur¬ gery. However, it is extremely important that the surgeon notify the anesthesiologist if the patient is receiving echothiophate io¬ dide because of the interaction of this drug with succinylcholine.4 Although the risk of prolonged apnea is slight during proce¬ dures of the sort in this investigation, in which the succinylcholine is not adminis¬ tered throughout the operative procedure, the policy at our hospital is to administer one single half dose of succinylcholine to patients receiving echothiophate iodide
therapy.5 Secondarily, most ocular surgeons have objected to the intrusion by the anesthesi¬ ologist into the operative field. This prob¬ lem has been overcome in our procedure by the use of equipment that makes it pos¬ sible to position the anesthesia machine at about the level of the patient's knees. In addition, the entire head and shoulder area is kept free by the shape of the endotracheal tubes. The Magill tube has a curved adaptor that lies on the patient's lower lip and is then connected to the anesthesia
equipment. The Sanders tube bends over the lower lip and also lies unobtrusively. The endotracheal tube is connected to the anesthesia machine by two 122-cm (4foot) lengths of corrugated rebreathing tubing, longer than those ordinarily used in anesthetic procedures. The directional valves are positioned at the machine in or¬ der to keep the bulk of the equipment away from the operative field. Also of particular importance to the oph¬ thalmologist are the following features of present-day general anesthesia relating to induction, maintenance, and emergence: 1. Short-acting intravenous agents that establish surgical levels of anesthesia within minutes make it possible to achieve rapid induction, free of the excitement
stage. 2. With the
use
of modern inhalation
agents, maintenance of anesthesia is
asso¬
ciated with a distinct lowering of intraocu¬ lar tension. 3. Emergence is relatively free of nau¬ sea and vomiting. Should these occur, how¬ ever, there are now available a number of effective antiemetic drugs. More im¬ portantly, modern surgical techniques have improved in recent years, to the point where vomiting does not cause the eye damage previously feared by the surgeon. During surgery, a 10° to 15° Fowler po¬ sition is used in order to reduce even fur¬ ther the intraocular tension. There is no contraindication to the instillation of epi¬ nephrine onto the cornea or into the ante¬ rior chamber.6
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
RESULTS
only major complication, vit¬ reous loss, occurred equally among patients receiving general anesthesia and those who were operated on un¬ der local analgesia. The incidence of vitreous loss was 3.5% (77 patients) in the general anesthesia group and 3.6% (20 patients) among the local analgesia patients. Although there is no indication for retrobulbar block with general anes¬ The
thesia, many surgeons tend to use the
block when first using this procedure. As a result, two incidents of retrobul¬ bar hemorrhage, which we believe should not have occurred, were seen in the general anesthesia group. Gen¬ erally, the surgeons who employ ret¬ robulbar block when they first turn to general anesthesia discontinue its use after their experience with the first several patients shows it to be unnec¬ essary. The same situation holds with respect to Van Lint akinesia. There were no retrobulbar hemorrhages among the patients who received lo¬ cal analgesia. No intraoperative deaths occurred during either of the series.
Complications Emergence from general anesthe¬ sia was generally smooth and free of obstruction and laryngospasm. Ninety percent of the patients felt no eye pain on emergence, although the rest did experience some degree of Recovery
Room
pain. There was only one case of vom¬ iting, but no aspiration. There were 16 incidents of coughing, none of them with sequelae of any impor¬ tance.
Postrecovery Room Complications The incidence of postrecovery room
was extremely low in both groups, with relatively few dif¬ ferences seen between those patients receiving general anesthesia and those who were given local analgesia. There was an incidence of 0.4% (10 patients) of flat anterior chamber, and just less than 3% (63 patients) of shallow chamber in the general anes¬ thesia group. Among the local anal¬ gesia patients, there was a l.C% (seven patients) incidence of flat
complications
chamber, and
1.9% (11 patients) of shallow chamber. The incidence of hyphema was exactly the same in both groups (8%). The incidence of wound separation was also identical in both groups
(0.2%).
There
was one death caused by a myocardial or pulmonary infarcì four days postoperatively in the general
anesthesia group, for an incidence of less than 0.05%. This is comparable to the deaths in a random, nonhospitalized population of the same age group in this country. Figures from the Public Health Service, National Center for Health Statistics, show a death rate in 1970 of 47.8 per 1,000 (4.78% per year, or 0.09% per week) for white men aged 65 to 74. Women in the same age group had a death rate of 25.3 per 1,000 (or 0.05% per week). There were no deaths in the lo¬ cal analgesia group. Of particular interest, in view of the implication of halothane as a fac¬ tor in postoperative hepatitis, is the fact that we found no hepatitis in the entire series of 2,217 patients oper¬ ated on under this anesthetic. This is especially noteworthy since more than 560 patients in the series had two cataract extractions under gen¬ eral anesthesia within four to seven days, while more than 1,000 under¬ went two procedures with the same anesthetic agent within 12 months. Despite these results, and the fact that we have found halothane in con¬ junction with succinylcholine to be a most ideal technique for intraocular surgery, we have been forced to stop the routine use of this agent until the medicolegal climate of posthalothane hepatitis has been clarified. We are currently studying other general an¬ esthetics in order to find a procedure that is equally safe and as well-suited for ophthalmic procedures. Nausea and vomiting occurred with greater frequency in the general an¬ esthesia than in the local analgesia group. However, the incidence of iris prolapse was 0.09%, occurring in just two patients who received general anesthesia. There was one prolapse in the local group, for an incidence of 0.17%. Another important point with re¬ spect to postoperative nausea and
vomiting is the finding of a definite relationship between this condition and the administration of meperidine postoperatively. The incidence of vomiting in the recovery room after general anesthesia was only 0.5%, but this rose to 7% when the patient was
returned to his room and medicated with meperidine. These findings con¬ firm data gathered during an earlier
study (S. Lynch, MD, unpublished data) that indicated the greatest inci¬ dence of vomiting occurred coincidentally with the first dose of meperidine from two to four hours postopera¬
tively.
It is our opinion that the habit of writing routine postoperative orders for tranquilizers and narcotics may give rise to unnecessary complica¬ tions. In particular, meperidine should be administered only when pain cannot be managed with such analgesics as aspirin, propoxyphene hydrochloride (Darvon), propoxy¬ phene with aspirin, caffeine, and phenactin (Davron Compound), aceta¬ minophen (Tylenol), or pentazocine (Talwin). Further, when meperidine is necessary, it should be accompanied by concomitant doses of potent antiemetic drugs,7 such as prochlorperazine (Compazine), perphenazine (Trilafon), or droperidol (Inapsine).
We consider the greater need for
meperidine among the general anes¬ thesia patients to be due to the fact that the blockade of pain by local analgesia carries over into the post¬ operative period. By contrast, pa¬ tients operated on under general an¬ esthesia perceive pain soon after awakening. Catheterization
Despite the common practice of routinely catheterizing all men in this age group who receive general anes¬ thesia and mannitol, we have found
need for this. The incidence of full bladder syndrome in the recovery room was a relatively low 1.2%, and only 0.9% of this group required cath¬ eterization. The postrecovery room incidence was 1.6%, with only one pa¬ tient requiring catheterization. Our experience indicates that not every patient with full bladder syndrome requires catheterization. In addition, no
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
since completion of this series, we have instituted use of neostigmine (Prostigmin) bromide, 1 mg given in¬
tramuscularly or intravenously, or bethanechol (Urecholine) chloride, 5 mg given subcutaneously, which de¬ crease the need for catheterization by approximately 50%. In the local anal¬ gesia population, full bladder syn¬ drome occurred in three patients, all of whom required catheterization. It
necessary to transfer one of the members of this group to another hospital for prostatectomy. was
COMMENT The ideal cataract extraction de¬ mands a maximization of (1) safety for the patient, and (2) freedom from distraction for the surgeon, so that he may concentrate fully on his particu¬ lar operative task. At the same time, it demands a minimization of (1) trauma to the eye and its environs, (2) drain on the physiological and psy¬ chological capacities of the patient, (3) possibility of movement of the eye or lids, (4) possibility of other move¬ ment by the patient, and (5) inter¬ ference from the parasurgical envi¬ ronment, such as the anesthesiologist
and his equipment. Our study shows that these criteria are met by the procedure we have de¬ scribed. While local analgesia does serve to decrease pain, it also tends to increase patient apprehension. The danger of acute anxiety reactions is a very real one, but even a less severe emotional trauma may lead to serious problems when the second cataract extraction or another surgical pro¬ cedure is required. Although local analgesia also causes a minimum of interference from the parasurgical environment, there is always the pos¬ sibility that the patient may move, or may even squeeze the lids during in¬ traocular manipulation, should incom¬ plete muscle blockade have occurred.
Additionally, however,
our
study
shows that general anesthesia ex¬ poses even the older-age cataract pa¬ tient to no greater risk than does lo¬ cal analgesia. When the anesthesia and other drugs are correctly admin¬ istered, there is no need for the in¬ traoperative coughing and bucking or the postoperative retching and vomit¬ ing that have led most ophthalmic surgeons to use local analgesia. Results in terms of the success of
the surgery and the physiological con¬ dition of the patient have been substantially similar whether local analgesia or general anesthesia was employed. We believe our series indi¬ cates that general anesthesia is a most suitable technique for cataract extraction. References 1. Wolf GL, Sanger C, Berlin I, et al: General anesthesia for intraocular surgery in Turtz AI (ed): Proceedings of the Centennial Symposium, Manhattan Eye, Ear and Throat Hospital, Ophthalmology. St. Louis, CV Mosby Co, 1969, vol 1, chap 29, pp 290-294. 2. Petruscak J, Smith RB, Breslin P: Mortality related to ophthalmology surgery. Arch Ophthalmol 89:106-109, 1973. 3. Schwartz H, DeRoetth A: Effect of succinylcholine on intraocular pressure in human beings. Anesthesiology 19:112-113, 1958. 4. Pantuck EJ: Ecothiopate iodide eye drops and prolonged response to suxamethonium. Br J Anaesth 38:406-407, 1966. 5. Cavallaro RJ, Krumperman LW, Kugler F: The effect of echothiophate therapy on the metabolism of succinylcholine in man. Anesth Analg 47:570-574, 1968. 6. Katz RL, Matteo RS, Papper EM: The injection of epinephrine during general anesthesia with halogenated hydrocarbons and cyclopropane in man. Anesthesiology 23:597-601, 1962. 7. Bellville JW, Bross IDJ, Howland WS: Postoperative nausea and vomiting: Antiemetic efficacy of trimethobenzamide and perphenazine. Clin Pharmacol Ther 1:590-596, 1960.
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
Lynch, MD; Irving Berlin,
A specialized technique developed specifically for ophthalmic surgery has led surgeons at the Manhattan Eye, Ear and Throat Hospital to perform most private cataract extractions\p=m-\morethan 1,000 per year\p=m-\withpatients under general anesthesia. Because this practice is followed by so few ophthalmic surgeons elsewhere, an evaluation of the relative safety and benefits of local vs general anesthe-
sia was undertaken. A retrospective study comparing 2,217 consecutive patients operated on under general anesthesia with 561 patients operated on under local analgesia leads us to believe that general anesthesia provides the surgeon with optimum operating conditions. General anesthesia has proved to be a safe procedure, with a minimum of complications. The ophthalmic surgeon is assured of absolute patient immobility, with safety equivalent to that seen with procedures performed with local analgesia, despite the advanced age and resulting physiological degeneration of the patient population.
MD
increasing sophistication of Thetoday's techniques for ophthal¬ essential
mic surgery makes it that the surgeon be able to work in a delib¬ erate, unhurried fashion, undisturbed by the possibility of patient move¬ ment. These needs can best be met by the use of general anesthesia. A technique of general anesthesia was developed specifically for oph¬ thalmic surgery at the Manhattan Eye, Ear and Throat Hospital. Be¬ cause general anesthesia is used rou¬ tinely by so few surgeons elsewhere, an evaluation of the relative safety and benefits of this technique was warranted. We designed a computerized inves¬ tigation of 2,217 cataract extractions conducted over two years under gen¬ eral anesthesia, and compared the re¬ sults with those seen in 561 similar patients operated on under local anal¬ gesia during the same period. MATERIALS AND METHODS
Submitted for publication May 10, 1974. From the departments of anesthesiology, Manhattan Eye, Ear and Throat Hospital and New York Hospital. Dr. Wolf is now at the Hackensack (NJ) Hospital. Reprint requests to 161 N Woodland St, Englewood, NJ 07631 (Dr. Wolf).
In order to determine what information would be most useful in establishing the potential hazard or value of the two modal¬ ities, a series of conferences was held with ophthalmologists and anesthesiologists. The discussions covered the complications that should be investigated for possible re¬ lationship to either type of anesthetic tech¬ nique. Two hundred cataract procedures performed with patients under general an¬ esthesia were selected by a random sam-
pling procedure,
a
pilot study
was
made,
and an interim report prepared.1 A data sheet was subsequently drawn up in con¬ junction with a medical biostatistician, and the cases were prepared for the computer. Correlations were subsequently deter¬ mined, and the results analyzed. The general anesthesia and local anal¬ gesia populations showed no material dif¬ ferences in pertinent characteristics. The patients who received general anesthesia had an average age of 70 years, with a range of from 1 year to as high as 98 years. The average age of the patients receiving local analgesia was similarly within the seventh decade. Sixty percent (1,362 pa¬ tients) of the general anesthesia popu¬ lation were female and 40% (855 patients) were male. Among those receiving local analgesia, 56% (313 patients) were female and 44% (248 patients) were male. Approximately 56% of the general anes¬ thesia group and 59% of the local analgesia patients had some form of cardiovascular disease. The most common, hypertensive cardiovascular disease, occurred in 25% (567 patients) of the general anesthesia population and 24% (133 patients) of the lo¬ cal analgesia group. Arteriosclerotic cardi¬ ovascular disease occurred in 12% of both groups. Anginal syndrome, histories of congestive heart failure or myocardial in¬ farction, and rheumatic and congenital heart disease were also seen. Sixty-four (2.9%) of the general anesthesia patients had a history of heart attacks, seven within the year before surgery; 16 (2.9%) of those patients receiving local analgesia had had heart attacks, two within the year before the operative procedure.
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
Incidence of
Preexisting Diseases
General Anesthesia Group Diseases
Diabetes Metabolic diseases (other than diabetes)
No. of Patients 252 392
% 11.0 18.0
156
0.4 7.0
Hepatomegaly Neurological diseases, including cerebral vascular
accident and Parkin¬ son disease Pulmonary disease
(or history) Emphysema
No. of Patients
90'
% 16.0 1.6
0.9
No neurological
patients operated under local analgesia
on
126
5.7
26
4.6
62
2.8 1.6 1.3
13
2.3 0.5 1.8
35*
Tuberculosis Asthma
Local
Analgesia Group
29
3t 10
*
All but one case inactive. t All cases inactive.
These considerations point up an impor¬ tant element in the successful use of gen¬ eral anesthesia for elective intraocular sur¬ gery, such as cataract extractions. It is a firm policy at the Manhattan Eye, Ear and Throat Hospital that no patients should undergo elective procedures unless they are in optimum condition. At least six months must have elapsed between the time of a myocardial infarction and an op¬ eration for cataract extraction, and evi¬ dence of congestive heart failure, such as pitting edema of the extremities, rales, or hepatomegaly must be adequately con¬ trolled. The value of this policy in pre¬ venting surgical loss has been borne out by the recent work of Petruscak et al2 who found that the preexisting medical condi¬ tion was the major factor contributing to the deaths of patients undergoing ocular surgery. The incidence of other preexisting diseases is summarized in the Table. Forty percent of the patients in each group had undergone previous cataract surgery. There were three patients with a history of retinal detachment and 347 with glaucoma in the general anesthesia popu¬ lation; of those receiving local analgesia, five patients had previous retinal detach¬ ments and 57 had glaucoma. Twenty-seven of the general anesthesia patients and four of those receiving local analgesia were blind in one eye.
Techniques
of Anesthesia
Halothane (Fluothane) was the general anesthetic used in the entire series under study. Premedication, at a dosage level that would cause the patient to arrive in the operating room in an awake but re¬ laxed condition, usually consisted of a bar-
as secobarbital, 100 mg, meperidine (Demerol) hydrochloride, 12.5 to 50 mg, and atropine sulfate, 0.5 mg, ad¬ ministered intramuscularly one hour preoperatively. The orders were written the day before surgery, when the patient was routinely visited by the anesthesiologist
biturate such
and his medical condition evaluated. Ocular hypotensive agents ordered by the ophthalmologist were administered ei¬ ther in the patient's own. room or after ar¬ rival in the operating room. Acetazolamide (Diamox) was used in 51% of the cases, mannitol in 26%, and urea in 0.7%. The use of orally administered glycerine is avoided prior to general anesthesia, since it can load the gastrointestinal tract with fluid and thus cause the danger of régurgitation and aspiration during anesthesia. One of the major objections to general anesthesia voiced by most ophthalmic sur¬ geons concerns intubation, which we con¬ sider necessary to assure airway patency while giving the surgeon total accessibility to the eye. Two major criticisms have gen¬ erally been aimed at the intubation proce¬ dure. Primarily, it has been considered rel¬ atively hazardous because of its tendency to cause patient coughing and bucking. However, since the introduction of suc¬ cinylcholine chloride, which produces the total muscular relaxation necessary for atraumatic intubation, it has become vir¬ tually free of complications. Although succinylcholine does cause a rise in intraocular tension of approxi¬ mately 6.7 mm Hg,' the effect is of short duration and the tension returns to base line in two to five minutes. Thus, when suc¬ cinylcholine is used only to facilitate tra¬ chea! intubation during induction of gen-
eral anesthesia, the intraocular tension is at base line levels before the start of sur¬ gery. However, it is extremely important that the surgeon notify the anesthesiologist if the patient is receiving echothiophate io¬ dide because of the interaction of this drug with succinylcholine.4 Although the risk of prolonged apnea is slight during proce¬ dures of the sort in this investigation, in which the succinylcholine is not adminis¬ tered throughout the operative procedure, the policy at our hospital is to administer one single half dose of succinylcholine to patients receiving echothiophate iodide
therapy.5 Secondarily, most ocular surgeons have objected to the intrusion by the anesthesi¬ ologist into the operative field. This prob¬ lem has been overcome in our procedure by the use of equipment that makes it pos¬ sible to position the anesthesia machine at about the level of the patient's knees. In addition, the entire head and shoulder area is kept free by the shape of the endotracheal tubes. The Magill tube has a curved adaptor that lies on the patient's lower lip and is then connected to the anesthesia
equipment. The Sanders tube bends over the lower lip and also lies unobtrusively. The endotracheal tube is connected to the anesthesia machine by two 122-cm (4foot) lengths of corrugated rebreathing tubing, longer than those ordinarily used in anesthetic procedures. The directional valves are positioned at the machine in or¬ der to keep the bulk of the equipment away from the operative field. Also of particular importance to the oph¬ thalmologist are the following features of present-day general anesthesia relating to induction, maintenance, and emergence: 1. Short-acting intravenous agents that establish surgical levels of anesthesia within minutes make it possible to achieve rapid induction, free of the excitement
stage. 2. With the
use
of modern inhalation
agents, maintenance of anesthesia is
asso¬
ciated with a distinct lowering of intraocu¬ lar tension. 3. Emergence is relatively free of nau¬ sea and vomiting. Should these occur, how¬ ever, there are now available a number of effective antiemetic drugs. More im¬ portantly, modern surgical techniques have improved in recent years, to the point where vomiting does not cause the eye damage previously feared by the surgeon. During surgery, a 10° to 15° Fowler po¬ sition is used in order to reduce even fur¬ ther the intraocular tension. There is no contraindication to the instillation of epi¬ nephrine onto the cornea or into the ante¬ rior chamber.6
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
RESULTS
only major complication, vit¬ reous loss, occurred equally among patients receiving general anesthesia and those who were operated on un¬ der local analgesia. The incidence of vitreous loss was 3.5% (77 patients) in the general anesthesia group and 3.6% (20 patients) among the local analgesia patients. Although there is no indication for retrobulbar block with general anes¬ The
thesia, many surgeons tend to use the
block when first using this procedure. As a result, two incidents of retrobul¬ bar hemorrhage, which we believe should not have occurred, were seen in the general anesthesia group. Gen¬ erally, the surgeons who employ ret¬ robulbar block when they first turn to general anesthesia discontinue its use after their experience with the first several patients shows it to be unnec¬ essary. The same situation holds with respect to Van Lint akinesia. There were no retrobulbar hemorrhages among the patients who received lo¬ cal analgesia. No intraoperative deaths occurred during either of the series.
Complications Emergence from general anesthe¬ sia was generally smooth and free of obstruction and laryngospasm. Ninety percent of the patients felt no eye pain on emergence, although the rest did experience some degree of Recovery
Room
pain. There was only one case of vom¬ iting, but no aspiration. There were 16 incidents of coughing, none of them with sequelae of any impor¬ tance.
Postrecovery Room Complications The incidence of postrecovery room
was extremely low in both groups, with relatively few dif¬ ferences seen between those patients receiving general anesthesia and those who were given local analgesia. There was an incidence of 0.4% (10 patients) of flat anterior chamber, and just less than 3% (63 patients) of shallow chamber in the general anes¬ thesia group. Among the local anal¬ gesia patients, there was a l.C% (seven patients) incidence of flat
complications
chamber, and
1.9% (11 patients) of shallow chamber. The incidence of hyphema was exactly the same in both groups (8%). The incidence of wound separation was also identical in both groups
(0.2%).
There
was one death caused by a myocardial or pulmonary infarcì four days postoperatively in the general
anesthesia group, for an incidence of less than 0.05%. This is comparable to the deaths in a random, nonhospitalized population of the same age group in this country. Figures from the Public Health Service, National Center for Health Statistics, show a death rate in 1970 of 47.8 per 1,000 (4.78% per year, or 0.09% per week) for white men aged 65 to 74. Women in the same age group had a death rate of 25.3 per 1,000 (or 0.05% per week). There were no deaths in the lo¬ cal analgesia group. Of particular interest, in view of the implication of halothane as a fac¬ tor in postoperative hepatitis, is the fact that we found no hepatitis in the entire series of 2,217 patients oper¬ ated on under this anesthetic. This is especially noteworthy since more than 560 patients in the series had two cataract extractions under gen¬ eral anesthesia within four to seven days, while more than 1,000 under¬ went two procedures with the same anesthetic agent within 12 months. Despite these results, and the fact that we have found halothane in con¬ junction with succinylcholine to be a most ideal technique for intraocular surgery, we have been forced to stop the routine use of this agent until the medicolegal climate of posthalothane hepatitis has been clarified. We are currently studying other general an¬ esthetics in order to find a procedure that is equally safe and as well-suited for ophthalmic procedures. Nausea and vomiting occurred with greater frequency in the general an¬ esthesia than in the local analgesia group. However, the incidence of iris prolapse was 0.09%, occurring in just two patients who received general anesthesia. There was one prolapse in the local group, for an incidence of 0.17%. Another important point with re¬ spect to postoperative nausea and
vomiting is the finding of a definite relationship between this condition and the administration of meperidine postoperatively. The incidence of vomiting in the recovery room after general anesthesia was only 0.5%, but this rose to 7% when the patient was
returned to his room and medicated with meperidine. These findings con¬ firm data gathered during an earlier
study (S. Lynch, MD, unpublished data) that indicated the greatest inci¬ dence of vomiting occurred coincidentally with the first dose of meperidine from two to four hours postopera¬
tively.
It is our opinion that the habit of writing routine postoperative orders for tranquilizers and narcotics may give rise to unnecessary complica¬ tions. In particular, meperidine should be administered only when pain cannot be managed with such analgesics as aspirin, propoxyphene hydrochloride (Darvon), propoxy¬ phene with aspirin, caffeine, and phenactin (Davron Compound), aceta¬ minophen (Tylenol), or pentazocine (Talwin). Further, when meperidine is necessary, it should be accompanied by concomitant doses of potent antiemetic drugs,7 such as prochlorperazine (Compazine), perphenazine (Trilafon), or droperidol (Inapsine).
We consider the greater need for
meperidine among the general anes¬ thesia patients to be due to the fact that the blockade of pain by local analgesia carries over into the post¬ operative period. By contrast, pa¬ tients operated on under general an¬ esthesia perceive pain soon after awakening. Catheterization
Despite the common practice of routinely catheterizing all men in this age group who receive general anes¬ thesia and mannitol, we have found
need for this. The incidence of full bladder syndrome in the recovery room was a relatively low 1.2%, and only 0.9% of this group required cath¬ eterization. The postrecovery room incidence was 1.6%, with only one pa¬ tient requiring catheterization. Our experience indicates that not every patient with full bladder syndrome requires catheterization. In addition, no
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
since completion of this series, we have instituted use of neostigmine (Prostigmin) bromide, 1 mg given in¬
tramuscularly or intravenously, or bethanechol (Urecholine) chloride, 5 mg given subcutaneously, which de¬ crease the need for catheterization by approximately 50%. In the local anal¬ gesia population, full bladder syn¬ drome occurred in three patients, all of whom required catheterization. It
necessary to transfer one of the members of this group to another hospital for prostatectomy. was
COMMENT The ideal cataract extraction de¬ mands a maximization of (1) safety for the patient, and (2) freedom from distraction for the surgeon, so that he may concentrate fully on his particu¬ lar operative task. At the same time, it demands a minimization of (1) trauma to the eye and its environs, (2) drain on the physiological and psy¬ chological capacities of the patient, (3) possibility of movement of the eye or lids, (4) possibility of other move¬ ment by the patient, and (5) inter¬ ference from the parasurgical envi¬ ronment, such as the anesthesiologist
and his equipment. Our study shows that these criteria are met by the procedure we have de¬ scribed. While local analgesia does serve to decrease pain, it also tends to increase patient apprehension. The danger of acute anxiety reactions is a very real one, but even a less severe emotional trauma may lead to serious problems when the second cataract extraction or another surgical pro¬ cedure is required. Although local analgesia also causes a minimum of interference from the parasurgical environment, there is always the pos¬ sibility that the patient may move, or may even squeeze the lids during in¬ traocular manipulation, should incom¬ plete muscle blockade have occurred.
Additionally, however,
our
study
shows that general anesthesia ex¬ poses even the older-age cataract pa¬ tient to no greater risk than does lo¬ cal analgesia. When the anesthesia and other drugs are correctly admin¬ istered, there is no need for the in¬ traoperative coughing and bucking or the postoperative retching and vomit¬ ing that have led most ophthalmic surgeons to use local analgesia. Results in terms of the success of
the surgery and the physiological con¬ dition of the patient have been substantially similar whether local analgesia or general anesthesia was employed. We believe our series indi¬ cates that general anesthesia is a most suitable technique for cataract extraction. References 1. Wolf GL, Sanger C, Berlin I, et al: General anesthesia for intraocular surgery in Turtz AI (ed): Proceedings of the Centennial Symposium, Manhattan Eye, Ear and Throat Hospital, Ophthalmology. St. Louis, CV Mosby Co, 1969, vol 1, chap 29, pp 290-294. 2. Petruscak J, Smith RB, Breslin P: Mortality related to ophthalmology surgery. Arch Ophthalmol 89:106-109, 1973. 3. Schwartz H, DeRoetth A: Effect of succinylcholine on intraocular pressure in human beings. Anesthesiology 19:112-113, 1958. 4. Pantuck EJ: Ecothiopate iodide eye drops and prolonged response to suxamethonium. Br J Anaesth 38:406-407, 1966. 5. Cavallaro RJ, Krumperman LW, Kugler F: The effect of echothiophate therapy on the metabolism of succinylcholine in man. Anesth Analg 47:570-574, 1968. 6. Katz RL, Matteo RS, Papper EM: The injection of epinephrine during general anesthesia with halogenated hydrocarbons and cyclopropane in man. Anesthesiology 23:597-601, 1962. 7. Bellville JW, Bross IDJ, Howland WS: Postoperative nausea and vomiting: Antiemetic efficacy of trimethobenzamide and perphenazine. Clin Pharmacol Ther 1:590-596, 1960.
Downloaded From: http://archopht.jamanetwork.com/ by a West Virginia University Library User on 06/21/2015
