Anaesthesia, 2011, 66, pages 278282 doi:10.1111/j.1365-2044.2011.06627.x .....................................................................................................................................................................................................................

ORIGINAL ARTICLE

Reduction of intra-ocular pressure by ocular compression before combined peri- and retrobulbar block
H. Kallio,1 M. P. Harju,2 T. Ihanama ki,2 E. T. Vesti3 and T. Kivela 4
1 Consultant, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland 2 Consultant, 4 Professor and Chairman, Department of Ophthalmology, University of Turku, Turku University Central Hospital, Turku, Finland 3 Professor and Chairman, Department of Ophthalmology, Helsinki University Hospital, Helsinki, Finland

Summary

The intra-ocular pressure immediately before glaucoma surgery can be raised. We wished to investigate if ocular compression for 20 min before a combined peri- and retrobulbar injection would result in a lower pressure after the block. Sixty consecutive patients scheduled for ltration surgery were randomly assigned to receive ocular compression using an external pressure device for 20 min before combined peri- and retrobulbar injection (intervention group, who also received compression after the block) or to a control group in whom pressure was applied only after the block was completed. The intra-ocular pressure was measured at baseline, after the 20-min pre-injection compression (intervention group), after injecting the block, and after the 10-min post-injection compression. The pressure did not differ between groups at baseline, after the block or after the post-injection compression. In the intervention group, the compression before the block reduced the median (IQR [range]) pressure from 21.0 (17.025.0 [12.040.0]) mmHg to 16.8 (12.522.5 [7.533.5]) mmHg (p < 0.001). We conclude that external ocular compression reduces the intra-ocular pressure, but applying an additional compression for 20 min before injecting the block is not benecial.
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Correspondence to: Dr H. Kallio Email: helena.kallio@hus. Accepted: 11 January 2011

Glaucoma causes progressive visual eld loss in eyes in which the intra-ocular pressure (IOP), in spite of maximal-tolerated medication, is too high compared with the perfusion pressure of the optic nerve head [1]. Deep sclerectomy or trabeculectomy surgery may save the sight of patients with uncontrolled glaucoma by decreasing the IOP [1]. Sub-Tenons anaesthesia is not appropriate [2] and general anaesthesia is often avoided for ophthalmic anaesthesia because of the 2030% risk of postoperative nausea and vomiting [3]. Uncontrolled glaucoma is often associated with systemic disease [4] or advanced age, which further increase the risks of general anaesthesia. A high IOP at the start of glaucoma surgery predisposes the eye to

large and sudden drops in pressure during surgery, increasing the risk of bleeding-related complications such as hyphaema and intra-operative or delayed suprachoroidal haemorrhage [5, 6]. The IOP should be optimised before surgery and any increase related to peri- and retrobulbar injections should be avoided, as far as possible. The aim of this study was to determine, in patients with glaucoma, whether external ocular compression with the Autopressor IOP reducer (Storz, Heidelberg, Germany) before and after injection of local anaesthetic would result in a lower pre-operative IOP compared with external compression performed after injection of the block only.

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Anaesthesia, 2011, 66, pages 278282 H. Kallio et al. Reducing intra-ocular pressure before combined block . ....................................................................................................................................................................................................................

Methods

Approval of the Finnish National Agency for Medicines and the Institutional Review Board was obtained and all participants gave their written, informed consent for inclusion in the study. Sixty consecutive patients scheduled for ltration surgery (either trabeculectomy or deep sclerectomy) for uncontrolled glaucoma were included. Patients with previous penetrating eye injury or penetrating eye surgery during the previous 6 months were not studied. Patients were randomly assigned to an intervention or a control group using sealed envelopes. In the control group, local anaesthetic solution was injected followed by ocular compression (25 mmHg) for 10 min using the Autopressor. Patients in the intervention group underwent ocular compression (25 mmHg) with the Autopressor for 20 min before the block in addition to the 10 min of compression after the injection. The IOP was measured four times in the intervention group: the rst measurement was performed immediately before treating the patient (T1); the second measurement was immediately after 20 min of ocular compression (T2); the third was immediately after injecting the combined peri- and retrobulbar block (T3); and the fourth was immediately after 10 min of ocular compression after the injection (T4). In the control group the IOP was measured three times (T1, T3 and T4). The IOP was measured using the Goldmann applanation tonometer (Haag-Streit, Bern, Switzerland) after topical application of a uorescein 0.25 mg.ml)1 and oxybuprocaine hydrochloride 0.6 mg.ml)1 combination (Oftan-Flurekain; Santen Oy, Tampere, Finland). The measurements were repeated once, and if there was a difference of > 2 mmHg between the two readings, the measurement was repeated again. From the three readings, the two closest ones were used to calculate the mean IOP. Before injecting the local anaesthetic, patients received fentanyl 50 lg and topical anaesthesia with oxybuprocaine hydrochloride (Oftan-Obukain; Santen Oy). The local anaesthetic mixture for the combined peri- and retrobulbar block contained lidocaine 1%, l-bupivacaine 0.375%, and hyaluronidase 3.75 IU.ml)1 [7]. It was prepared at the bedside shortly before injection using a 1:1 mixture of lidocaine 20 mg.ml)1 and l-bupivacaine 7.5 mg.ml)1 (Chirocaine; Abbott Scandinavia AB, Solna, Sweden). One millilitre of hyaluronidase 150 IU.ml)1 (Hylase Dessau; RIEMSER Arzneimittel AG, Greifswald, Germany) was added to 40 ml of the local anaesthetic
2011 The Authors Anaesthesia 2011 The Association of Anaesthetists of Great Britain and Ireland

mixture. The standard approach of our institute was used for the combined peri- and retrobulbar block. First, a peribulbar injection was performed on the nasal side of the caruncle and medial rectus muscle [8] using a 30-G, 13-mm sharp needle. A second, retrobulbar, injection was performed using an inferotemporal approach [8] with a 27-G, 31-mm sharp needle. Both injections contained 3 ml of the local anaesthetic mixture. Lid and ocular movements were tested immediately after the last IOP measurements (T4). If ocular movements persisted, a rescue retrobulbar block was injected. All blocks were performed by one senior anaesthetist (HK) before the start of surgery. Any supplemental blocks and the need for rescue fentanyl during surgery were recorded. After completing the surgery, the surgeon recorded complications of anaesthesia, satisfaction with the anaesthetic (0 = surgery not difcult, 1 = slightly difcult, 2 = difcult and 3 = very difcult), and the co-operation of the patient during surgery (0 = excellent, 1 = good, 2 = compromised and 3 = absent). An ophthalmologist recorded the pre-operative ophthalmic history, examination, surgical complications and the need for postoperative surgical procedures in the rst month. A power analysis was performed using the results obtained by Ling and co-workers [9]. We determined that a 25% decrease in IOP (from 16 to 12 mmHg) at the start of surgery (T4) would be clinically relevant. We used the mean value of the standard deviation (4.25) in the previous study [9] in our calculation. A sample size of 30 patients in each arm gave a power 95% (b = 0.95) at a signicance level (a) of 0.05. Nonnormally distributed data were compared using the MannWhitney rank sum test (between groups). Sequential IOP data were analysed using Friedmans repeated measures ANOVA on ranks and Wilcoxons signed rank test was used post-hoc for within-group comparisons. For continuous, normally distributed data Students t-test was used. Binominal data were tested with the chi-squared test. A p value of < 0.05 was considered signicant. Statistical analyses were performed using SigmaStat, version 3.5 and graphs prepared using SigmaPlot, version 10 (Systat Software Inc., Point Richmond, CA, USA).
Results

There were no differences in patients characteristics, pre-operative ophthalmic data, success of the blocks, complications related to the combined peri- and retrobulbar injections or complications of surgery
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(Table 1). Ten patients (16.7%) required treatment for wound leakage. No patients had subconjunctival haemorrhage, retrobulbar haemorrhage or globe perforation. The median (IQR [range]) duration of surgery did not differ between groups (56.5 (45.0 65.0 [35.0104.0]) min and 61.5 (53.066.0 [45.0 113.0]) min for intervention and control groups, respectively). The baseline (T1) IOP did not differ between groups (Fig. 1; 21.0 (17.025.0 [12.040.0]) mmHg and 20.8 (18.025.0 [15.050.0]) mmHg in the intervention and control groups, respectively). In the intervention group, the 20 min compression before block injection reduced the IOP signicantly (T2) to 16.8 (12.522.5 [7.533.5]) mmHg. Block injection increased the IOP in both groups (T3) to 24.0 (21.028.5 [8.535.0]) mmHg and 24.5 (20.028.0 [14.080.0]) mmHg, for intervention and control groups, respectively. Compression after the injection reduced the IOP in both groups to 19.0 (15.520.0 [10.533.0]) mmHg and 18.8 mmHg (14.024.0 [8.5 45.0]) mmHg, for intervention and control groups, respectively.
Discussion

Minimising the volume of local anaesthetic solution used in retrobulbar [10, 11] and peribulbar [1113] injections can prevent an immediate increase in IOP. However, in patients with glaucoma the increase in IOP after peri- or retrobulbar anaesthesia is greater and persists longer than in non-glaucomatous eyes [14]. In patients without glaucoma, increases in IOP after a retrobulbar block can be normalised by use of an ocular compression device for 1020 min [9, 15, 16]. The IOP decreases most during the rst 1020 min of ocular compression and the effect lasts 35 min [17, 18]. In patients with glaucoma, external ocular compression (at a pressure of 30 mmHg) immediately after a retrobulbar block reduces the IOP more than in non-glaucomatous eyes [19]. Furthermore, in nonglaucomatous eyes external ocular compression before a retrobulbar block can reduce the IOP to a similar degree compared with compression after the injection of the block [20].

External ocular compression for 20 min before injecting a combined peri- and retrobulbar reduced the IOP. Despite this, the post-injection IOP (T3) was comparable with that in control group without pre-injection ocular compression. Furthermore, compression after the injections resulted in a similar IOP in both groups at the start of surgery.

Table 1 Results of combined peri- and retrobulbar block

with (intervention group) and without (control group) pre-injection ocular compression. Values are number (proportion) or median (IQR [range]). See text for denitions of surgical satisfaction and patient co-operation.
Intervention (n = 30) Supplemental block Squeezing of eyelids Eye movements Rescue fentanyl Eyelid haemorrhage Chemosis Surgical satisfaction Co-operation of the patient 0 1 2 3 2 0 0 0 Control (n = 30) 2 2 1 1 3 1 0 0 (6.7%) (6.7%) (3.3%) (3.3%) (10.0%) (3.3%) (00 [01]) (00 [01])

Figure 1 Intra-ocular pressure in the pre-injection com-

p value NS NS NS NS NS NS NS NS

(3.3%) (6.7%) (10.0%) (6.7%) (00 [01]) (00 [01])

pression group (intervention group; grey boxes and circles) and no pre-injection compression group (control group; open boxes and circles). The horizontal line indicates median, the box indicates IQR, the whiskers indicates the 10 90th centiles and the circles indicate outliers. The IOP was measured at baseline (T1), after external ocular compression for 20 min with the Autopressor device (T2), after injecting combined peri- and retrobulbar block (T3) and after external ocular compression for 10 min with Autopressor device (T4) in the intervention group and at T1, T3 and T4 in the control group. For within-group differences over time, p < 0.001 is indicated with *(T1 vs T2 intervention group), (T2 vs T3 intervention group), (T3 vs T4 intervention group), (T3 vs T4, control group), and (T1 vs T4 control group), p = 0.002 with **(T1 vs T4 intervention group), and p = 0.03 with (T1 vs T3 control group). There was no difference between the groups at T1, T3 or T4.
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Anaesthesia, 2011, 66, pages 278282 H. Kallio et al. Reducing intra-ocular pressure before combined block . ....................................................................................................................................................................................................................

In previous studies, the IOP has been shown to increase after injection of local anaesthetic solution [11], and various compression devices have decreased it. These ndings were conrmed in the present study. However, there are no studies identical to our study. In the closest, a Superpinkie rubber ball (no longer marketed) was applied to the eye for 35 min to reduce the IOP in patients without glaucoma before a retrobulbar block, compared with patients in whom compression with the Superpinkie was performed after the block [20]. After the block, the mean increase in IOP was 2.95 mmHg vs 5.50 mmHg in the compression-before and compression-after injection groups, respectively. In the present study, the mean increase in IOP after injection (T3) was 1.88 mmHg vs 2.92 mmHg in our intervention and control groups, respectively. We found that additional compression before local anaesthetic injection did not reduce the magnitude of the increase in IOP caused by the injection. In the Superpinkie study there was a signicantly reduced magnitude of increase in the group receiving compression before the injection [20]. One explanation could be that in this study we used a shorter duration of the compression (20 min vs 35 min). We chose a 20-min compression because the IOP decreases more after 20 min than after 10 mins use of the Autopressor [16]. The present protocol was not planned to test the effect of duration of the compression. In summary, we found that ocular compression treatment (with the Autopressor) for 10 min after a combined peri- and retrobulbar block is an effective method to reduce IOP before surgery. Although a 20min ocular compression before the block injection also reduces the IOP, this has no additional benets when compared with post-injection compression alone.
Competing interests

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No external funding or competing interests declared.

References 1 Infeld DA, OShea JG. Glaucoma: diagnosis and management. Postgraduate Medical Journal 1998; 74: 70915. 2 Jones E, Clarke J, Khaw PT. Recent advances in trabeculectomy technique. Current Opinion in Ophthalmology 2005; 16: 10713. 3 Eberhart LHJ, Geldner G, Ho rle S, Wulf H. Prophylaxe belkeit und Erbrechen in der und Therapie von U

15

16

17

ambulanten Ophthalmoana sthesie. Ophthalmologe 2004; 101: 92530. Hiller R, Podgor MJ, Sperduto RD, Wilson PWF, Chew EY, DAgostino RB. High intra-ocular pressure and survival: the Framingham studies. American Journal of Ophthalmology 1999; 128: 4405. Chu TG, Green RL. Suprachoroidal hemorrhage. Survey of Ophthalmology 1999; 43: 47186. Jeganathan VSE, Ghosh S, Ruddle JB, Gupta V, Coote MA, Crowston JG. Risk factors for delayed suprachoroidal haemorrhage following glaucoma surgery. British Journal of Ophthalmology 2008; 92: 13936. Kallio H, Paloheimo M, Maunuksela E-L. Hyaluronidase as an adjuvant in bupivacaine-lidocaine mixture for retrobulbar peribulbar block. Anesthesia and Analgesia 2000; 91: 9347. Hamilton RC. Techniques of orbital regional anaesthesia. In: Smith GB, Hamilton RC, Carr C, eds. Ophthalmic Anaesthesia. London: Arnold, 1996: 10447. Ling R, Beigi B, Quinn A, Jacob J. Effect of Honan balloon compression on peribulbar anesthesia adequacy in cataract surgery. Journal of Cataract and Refractive Surgery 2002; 28: 1137. Palay DA, Stulting RD. The effect of external ocular compression on intra-ocular pressure following retrobulbar anesthesia. Ophthalmic Surgery 1990; 21: 5037. Meyer D, Hamilton RC, Loken RG, Gimbel HV. Effect of combined peribulbar and retrobulbar injection of large volumes of anesthetic agents on the intra-ocular pressure. Canadian Journal of Ophthalmology 1992; 27: 2302. Gillart T, Bazin JE, Montegaud M, Bevillard F, Amara S, Schoeffler P. The effects of volume and speed of injection in peribulbar anaesthesia. Anaesthesia 1998; 53: 486510. Lung S, Luksch A, Weigert G, et al. Influence of infusion volume on the ocular hemodynamic effects of peribulbar anesthesia. Journal of Cataract and Refractive Surgery 2006; 32: 150912. ODonoghue E, Batterbury M, Lavy T. Effect on intraocular pressure of local anaesthesia in eyes undergoing intra-ocular surgery. British Journal of Ophthalmology 1994; 78: 6057. Bowman R, Liu C, Sarkies N. Intraocular pressure changes after peribulbar injections with and without ocular compression. British Journal of Ophthalmology 1996; 80: 3947. Ropo A, Ruusuvaara P, Paloheimo M, Maunuksela E-L, Nikki P. Effect of ocular compression (Autopressor) on intra-ocular pressure in periocular anaesthesia. Acta Ophthalmologica 1990; 68: 2279. Bolling JP, Kurrle RW, ODay DM. Effect of ocular compression on intra-ocular pressure. Ophthalmic Surgery 1985; 16: 5635.

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18 Constable PH, Porter EJB. Extraocular compression prior to cataract surgery: time course of reduction and subsequent recovery of intra-ocular pressure. Eye 1993; 7: 7314. 19 Quist LH, Stapleton SS, McPherson SD. Preoperative use of the Honan intra-ocular pressure reducer. American Journal of Ophthalmology 1983; 95: 5368.

20 Zabel RW, Clarke WN, Shirley SY, Rock W. Intraocular pressure reduction prior to retrobulbar injection of anesthetic. Ophthalmic Surgery 1988; 19: 868 71.

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