|Year : 2020 | Volume
| Issue : 1 | Page : 1-5
Effect of hyaluronidase addition to retrobulbar local anesthesia for phacoemulsification on intraocular pressure
Mahmoud Abd El-Radi1, Mohamed Anwar1, Hassan Lotfy1, Ali Natag1, Eman Yassin2
1 Department of Ophthalmology, Assiut University, Assiut, Egypt
2 Student Hospital/Department of Ophthalmology, Assiut University, Assiut, Egypt
|Date of Submission||17-May-2019|
|Date of Decision||08-Nov-2019|
|Date of Acceptance||16-Nov-2019|
|Date of Web Publication||28-Feb-2020|
MD Mahmoud Abd El-Radi
Department of Ophthalmology, Assiut University, 6th Floor, Assiut University Hospital, Assiut 71516
Source of Support: None, Conflict of Interest: None
Purpose The aim of this study was to evaluate the effect of adding hyaluronidase to local anesthetic agents on intraocular pressure (IOP) following retrobulbar anesthesia for patients scheduled for routine phacoemulsification.
Patients and methods This is a prospective comparative study that included patients scheduled for routine phacoemulsification. Patients were classified into two groups: group A patients were planned to have retrobulbar blocks with lidocaine 2% and hyaluronidase 20 IU/ml, and group B patients were planned to have retrobulbar blocks with lidocaine 2% only without hyaluronidase. IOP was measured immediately before and 2, 5, and 10 min after retrobulbar anesthesia administration in both groups using a calibrated Tono-pen.
Results The study included 60 eyes of 50 patients. The mean preinjection IOP in group A patients (hyaluronidase group) was 16.38±2.41 mmHg, whereas the mean 10-min postinjection IOP was 18.17±3.54 mmHg (P>0.05). The mean preinjection IOP in group B patients (nonhyaluronidase group) was 15.41±2.63 mmHg, whereas the mean 10-min postinjection IOP was 24.34±5.25 mmHg (P<0.001). The mean change in IOP in group A before and after retrobulbar anesthesia (IOP rise) was 1.79±2.96 mmHg, whereas in group B, the mean IOP rise was 8.93±4.74 mmHg (P<0.001).
Conclusion Although the addition of hyaluronidase to lidocaine 2% before cataract surgery had no IOP-lowering effect, it also did not cause any significant rise of postinjection IOP and did keep it within the range of the preinjection IOP.
Keywords: cataract surgery anesthesia, hyaluronidase, intraocular pressure
|How to cite this article:|
Abd El-Radi M, Anwar M, Lotfy H, Natag A, Yassin E. Effect of hyaluronidase addition to retrobulbar local anesthesia for phacoemulsification on intraocular pressure. Delta J Ophthalmol 2020;21:1-5
|How to cite this URL:|
Abd El-Radi M, Anwar M, Lotfy H, Natag A, Yassin E. Effect of hyaluronidase addition to retrobulbar local anesthesia for phacoemulsification on intraocular pressure. Delta J Ophthalmol [serial online] 2020 [cited 2020 Dec 3];21:1-5. Available from: http://www.djo.eg.net/text.asp?2020/21/1/1/279718
| Introduction|| |
Cataract surgery represents the most commonly performed ocular surgery worldwide . Different modalities for delivery of anesthesia during cataract surgery are available . General anesthesia was the preferred modality for cataract surgeries with large incisions, for example, extracapsular cataract extraction . Advances in cataract surgery involved the use of small self-sealing corneal incisions (as in phacoemulsification), which was accompanied with the emergence of local anesthetic techniques achieving patient comfort and allowing for a faster recovery . Different local anesthetic techniques were introduced into practice that included retrobulbar, peribulbar, sub-Tenon’s, and topical anesthesia ,,,. The choice of a certain local anesthetic type and modality should be done on an individual basis and surgeon’s experience and preference .
Complications of regional anesthesia are not common but may include serious complications such as brainstem anesthesia, globe perforation, retrobulbar hematoma, and other less risky complications such as inadequate akinesia and analgesia . Another complication of retrobulbar and peribulbar anesthesia is the possible increase in the intraocular pressure (IOP) that might compromise optic nerve perfusion after injection of the local anesthetic before starting surgery .
Hyaluronidase is an enzyme that breaks down hyaluronan (a connective tissue glycosaminoglycan)  and has the ability to enhance the penetrability and absorption of local anesthetic agents used with various ocular regional anesthetic modalities . It has been reported that adding hyaluronidase to local anesthetic agents before cataract surgery (especially with retrobulbar and peribulbar blocks) enhances their spread and thus the amount of anesthetic used could be reduced with resultant less increase of intraorbital volume and subsequently minor IOP changes .
Few adverse reactions have been described with the use of hyaluronidase adjunctive to local anesthetics for cataract surgery that include minor hypersensitivity reactions, lid edema, and conjunctival chemosis .
The aim of this study was to focus on the effect of adding hyaluronidase to local anesthetic agents on the IOP of patients scheduled for routine phacoemulsification.
| Patients and methods|| |
All patients were fully informed about the study concerning the aim, possible benefits, and complications. Patients signed a written informed consent to participate in the study and for publication of data before enrollment in the study. The study was conducted under the tenets of the Declaration of Helsinki and after approval of the Ethical Committee of the Faculty of Medicine, Assiut University, Egypt.
The study was designed as a randomized comparative interventional study conducted at Assiut University Hospitals, Egypt. It included 60 eyes of 50 patients (10 patients had consecutive bilateral surgeries at least 1 month apart) scheduled for routine phacoemulsification and were classified into two groups according to the constituents of the local anesthetic agent (retrobulbar block): group A patients were planned to have retrobulbar blocks before cataract surgery with lidocaine 2% and hyaluronidase 20 IU/ml (30 eyes), and group B patients were planned to have retrobulbar blocks before cataract surgery with lidocaine 2% without hyaluronidase (30 eyes).
Patients with complicated cataracts, combined cataract and glaucoma, previous ocular surgeries, and narrow palpebral fissure were excluded from the study.
Retrobulbar local anesthetic preparation and injection technique
All patients underwent a complete surgical fitness profile by a specialized internist, and patients unfit for surgery were excluded.
Local anesthesia was delivered by the same doctor with a standard protocol for retrobulbar blockage using 5 ml mixture of lidocaine 2% (Sigma Pharmaceuticals, Johnson County, Iowa, USA) and hyaluronidase 20 IU/ml (Wockhardt, Wrexham, UK) in group A patients and 5 ml of lidocaine 2% only in group B patients.
Each patient was asked to lie down comfortably on his back and to look straight ahead in primary gaze. Then the doctor felt the inferior orbital rim and introduced the syringe needle at the junction of the outer one-third and inner two-thirds of the lower eyelid just above the inferior orbital rim. The needle was initially passed parallel to the orbital floor, and after passing the equator of the globe, the syringe needle was inclined slightly superiorly and medially toward the retrobulbar space. After entering the retrobulbar space, the syringe was aspirated to ensure no blood or cerebrospinal fluid and then the anesthetic was slowly injected. Then the syringe was removed. No ocular compression was applied in the immediate period after delivery of local anesthesia in both groups.
Intraocular pressure measurement
A drop of local anesthetic was instilled in the conjunctival lower fornix, and a calibrated Tono-pen AVIA (TPA, Reichert Inc., New York, New York, USA) (a tonometer based on applanation principle) was applied perpendicular to the corneal surface and touched it at least four times until four valid readings were obtained. Then, the average was calculated.
IOP measurements were all taken by the same eye physician without being informed about the type of local anesthetic used and with the patient seated in the upright position. The initial IOP reading was measured immediately before injecting the local anesthetic (preinjection IOP) and then was measured 2, 5, and finally 10 min after delivery of the local anesthetic (postinjection IOP).
For safety purposes, all patients with significantly increased postinjection IOP received digital ocular compression for 5 min after all postinjection IOP measurements were recorded and just before starting surgery .
Quantitative data were presented in mean±SD. Statistical analysis was carried out by SPSS, version 20.0 (SPSS Inc., New York, New York, USA). The difference was considered statistically significant if the P value was less than 0.05.
| Results|| |
The mean age of the patients in group A was 63.79±6.55 years whereas the mean age in group B was 62.69±7.67 years, with a statistically insignificant difference. The demographic data of the patients are summarized in [Table 1].
The mean IOP before retrobulbar anesthesia administration in group A (hyaluronidase group) was 16.38±2.41 mmHg, whereas in group B (nonhyaluronidase group) was 15.41±2.63 mmHg, with no statistically significant difference (P>0.05, [Table 2]).
|Table 2 Intraocular pressure measurements of the studied groups before and after local anesthesia administration|
Click here to view
The mean IOP before local anesthesia (preinjection IOP) in group A patients (hyaluronidase group) was 16.38±2.41 mmHg, whereas the mean IOP 10 min after local anesthesia (postinjection IOP) was 18.17±3.54 mmHg. The difference between preinjection and postinjection IOP was statistically insignificant (P>0.05, [Table 2]).
On the contrary, the mean IOP before local anesthesia (preinjection IOP) in group B patients (nonhyaluronidase group) was 15.41±2.63 mmHg, whereas the mean IOP 10 min after local anesthesia (postinjection IOP) was 24.34±5.25 mmHg. The difference between preinjection and postinjection IOP was statistically significant (P<0.001, [Table 2]).
The difference in the mean postinjection IOP measurements between the two groups was statistically significant at 2, 5, and 10 min ([Table 2]).
The mean change in IOP in group A before and 10 min after retrobulbar anesthesia (IOP rise) was 1.79±2.96 mmHg, whereas in group B, the mean IOP rise was 8.93±4.74 mmHg ([Table 3] and [Figure 1]).
|Table 3 Intraocular pressure change before and 10-min after retrobulbar anesthesia administration in the studied groups|
Click here to view
|Figure 1 IOP change before and 10 min after retrobulbar anesthesia administration in the studied groups. IOP, intraocular pressure.|
Click here to view
None of group A patients (hyaluronidase group) experienced a significant postinjection IOP rise, and thus no digital ocular compression was required before starting surgery, whereas in group B patients (nonhyaluronidase group), 23 (77%) eyes of 30 eyes required digital ocular compression to decrease the postinjection IOP rise.
| Discussion|| |
Anesthesia in cataract surgery represents a real challenge for ophthalmic surgeons. Advances in cataract surgery involving the new small self-sealing incision surgical techniques such as phacoemulsification necessitated concomitant transition from general to regional anesthetic techniques, including retrobulbar, peribulbar, sub-Tenon’s, intracameral, and topical anesthesia .
Although retrobulbar anesthesia achieves adequate akinesia and satisfactory analgesia for most of the patients with cataract, some serious adverse events have been reported, including rare complications, such as orbital hematoma, globe perforation, and brainstem anesthesia, and other common complications, such as increased orbital volume with subsequent increase in the IOP .
Several techniques have been developed to reduce the IOP following the administration of retrobulbar anesthesia before starting cataract surgery, including the use of IOP-lowering agents before surgery such as mannitol or topical medications or the application of external ocular compression whether digitally or with the help of a balloon ,.
Hyaluronidase has been popularly used in combination with different local anesthetic agents in ocular surgery. It augments the analgesic effect and akinesia of local anesthetics together with reducing their myotoxic effects .
In the present study, we tested the effect of the addition of hyaluronidase to a local anesthetic agent (lidocaine 2%) on the IOP following retrobulbar block for routine phacoemulsification. Patients who were assigned to have retrobulbar blocks before cataract surgery with lidocaine 2% without hyaluronidase experienced a significant increase of the mean postinjection IOP of 8.93±4.74 mmHg, which is comparable to O’Donoghue et al. , who noted increased mean postinjection IOP of 5.8 mmHg. Bowman et al.  also reported a mean rise in IOP induced by the local anesthetic injections of 9.45 mmHg without ocular compression in 20 eyes of 20 patients who underwent cataract surgery with peribulbar anesthesia.
On the contrary, in the present study, the addition of hyaluronidase to local anesthetic agents in patients assigned to have retrobulbar blocks before cataract surgery with lidocaine 2% and hyaluronidase 20 IU/ml neither significantly decreased nor increased the mean postinjection IOP compared with the mean baseline preinjection IOP, which could be attributed to efficient spread, enhanced penetrability, and better absorption of local anesthetic agents when combined with hyaluronidase .
To our knowledge, this is the first study to monitor the effect of adding hyaluronidase to local retrobulbar anesthesia on the IOP before cataract surgery.
Al-Ali et al.  evaluated the effect of adding hyaluronidase to the anesthetic injected on the IOP following sub-Tenon’s local anesthesia before cataract surgery. They concluded that the addition of hyaluronidase to 2% lignocaine has no beneficial lowering effect on IOP when compared with lignocaine 2% alone without hyaluronidase. The results of the present study may be partially inconsistent with Al-Ali and colleagues owing to different technique of local anesthesia administration. The likelihood of IOP rise following sub-Tenon’s anesthesia is much less common than the retrobulbar route of regional anesthesia.
| Conclusion|| |
Although the addition of hyaluronidase to lidocaine 2% before cataract surgery had no IOP-lowering effect, it also did not cause any significant rise of postinjection IOP and did keep it within the range of the preinjection IOP.
The present study has some limitations such as small sample size and the lack of enough prior research studies on that topic to be compared with it.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thompson J, Lakhani N. Cataracts. Prim Care 2015; 42:409–423.
Royal College of Anesthetists. Guidance on the provision of ophthalmic anesthesia services. Chapter 10. London: The Royal College of Anesthetists; 2004. 49–52.
Jaichandran V. Ophthalmic regional anesthesia: a review and update. Indian J Anaesth 2013; 57:7–13.
] [Full text]
Clausel H, Touffet L, Havaux M, Lamard M, Savean J, Cochener B et al.
Peribulbar anesthesia: efficacy of a single injection with a limited local anesthetic volume. J Fr Ophtalmol 2008; 31:781–785.
Alhassan MB, Kyari F, Ejere HO. Peribulbar versus retrobulbar anaesthesia for cataract surgery. Cochrane Database Syst Rev 2008; 16:CD004083.
Eke T, Kumar CM. Preventing adverse events in cataract surgery: sub-Tenon’s block. Anesth Analg 2018; 127:e68–e69.
Nebbioso M, Livani ML, Santamaria V, Librando A, Sepe M. Intracameral lidocaine as supplement to classic topical anesthesia for relieving ocular pain in cataract surgery. Int J Ophthalmol 2018; 11:1932–1935.
Cass GD. Choices of local anesthetics for ocular surgery. Ophthalmol Clin North Am 2006; 19:203–207.
Thevi T, Godinho MA. Trends and complications of local anaesthesia in cataract surgery: an 8-year analysis of 12 992 patients. Br J Ophthalmol 2016; 100:1708–1713.
Watkins R, Beigi B, Yates M, Chang B, Linardos E. Intraocular pressure and pulsatile ocular blood flow after retrobulbar and peribulbar anaesthesia. Br J Ophthalmol 2001; 85:796–798.
Bookbinder LH, Hofer A, Haller MF, Zepeda ML, Keller GA, Lim JE et al.
A recombinant human enzyme for enhanced interstitial transport of therapeutics. J Control Rel 2006; 114:230–241.
Kallio H, Paloheimo M, Maunuksela EL. Hyaluronidase as an adjunct in bupivacaine-lidocaine mixture for retrobulbar/peribulbar block. Anesth Analg 2000; 91:934–937.
Remy M, Pinter F, Nentwich MM, Kampik A, Schofeld CL. Efficacy and safety of hyaluronidase 75 IU as an adjunct to mepivacaine for retrobulbar anesthesia in cataract surgery. J Cataract Refract Surg 2008; 34:1966–1969.
Raichura ND, Alam MS, Jaichandran VV, Mistry S, Mukherjee B. Hyaluronidase allergy mimicking orbital cellulitis. Orbit 2018; 37:149–153.
Palay DA, Stulting RD. The effect of external ocular compression on intraocular pressure following retrobulbar anesthesia. Ophthalmic Surg 1990; 21:503–507.
Palte H. Ophthalmic regional blocks: management, challenges, and solutions. Local Reg Anesth 2015; 8:57–70.
Lee RM, Thompson JR, Eke T. Severe adverse events associated with local anaesthesia in cataract surgery: 1 year national survey of practice and complications in the UK. Br J Ophthalmol 2016; 100:772–776.
Miettinen R, Airaksinen PJ, Pihlajaniemi R, Puhakka K. Preoperative timolol and ocular compression in cataract surgery. Acta Ophthalmol 1982; 60:622–627.
Ling R, Beigi B, Quinn A, Jacob J. Effect of Honan balloon compression on peribulbar anesthesia adequacy in cataract surgery. J Cataract Refract Surg 2002; 28:113–117.
Mantovani C, Bryant AE, Nicholson G. Efficacy of varying concentrations of hyaluronidase in peribulbar anaesthesia. Br J Anaesth 2001; 86:876–878.
O’Donoghue E, Batterbury M, Lavy T. Effect on intraocular pressure of local anaesthesia in eyes undergoing intraocular surgery. Br J Ophthalmol 1994; 78:605–607.
Bowman R, Liu C, Sarkies N. Intraocular pressure changes after peribulbar injections with and without ocular compression. Br J Ophthalmol 1996; 80:394–397.
Al-Ali N, Cheema RA, Abdelaziz MA, Khattak A. Randomized controlled trial to evaluate intraocular pressure following sub-Tenon’s local anesthesia for cataract surgery: with and without hyaluronidase added to anesthetic solution. Saudi J Anaesth 2014; 8 (Suppl 1):S63–S66.
[Table 1], [Table 2], [Table 3]