A Comparison of Topical and

Retrobulbar Anesthesia for

Cataract Surgery

Bhupendra C. K. Patel, MD, FRCS, FRCOphth,l Thomas A. Burns, MD, 2

Alan Crandall, MD,1 Samuel T. Shomaker, MD,z Nathan L. Pace, MD,z
Akira van Eerd,l Thomas Clinch, MDI

Purpose: To evaluate and compare the efficacy of topical and retrobulbar anesthesia
for cataract extraction with intraocular lens implantation.
Methods: One hundred thirty-eight patients prospectively were assigned to the
topical (group 1 ; n= 69) or retrobulbar (group 2; n = 69) anesthesia groups by permuted
block restricted randomization. Group 1 received topical 0.75% bupivacaine and intra-
venous midazolam and fentanyl for anesthesia. Group 2 received intravenous metho-
hexital followed by retrobulbar block with an equal mixture of 2% lidocaine and 0.75%
bupivacaine plus hyaluronidase (150 U). A visual pain analogue scale was used to assess
the degree of pain during the administration of anesthesia, during surgery, and post-
operatively. The degree to which eye movement, touch, and light caused patient dis-
comfort was assessed. Complications and surgical conditions were recorded.
Results: There was no difference in the surgical conditions (P = 0.5) or pain during
surgery (P = 0.35) between the two groups. There was more discomfort during admin-
istration of topical anesthesia (P < 0.0001) and postoperatively (P < 0.05) in the topical
group. Chemosis, subconjunctival hemorrhage, and eyelid hemorrhage were seen almost
exclusively in the retrobulbar group. One patient in group 2 had a retrobulbar hemorrhage.
Although eyeball movement and squeezing of the eyelids were present more frequently
in the topical group, neither was a problem to the surgeon.
Conclusion: Topical anesthesia can be used safely for cataract extraction. The
degree of patient discomfort is only marginally higher during administration of the anes-
thesia and postoperatively. However, surgical training and patient preparation are the
keys to the safe use of topical anesthesia. Ophthalmology 1996; 103: 1196-1203

Originally received: October 30, 1995.

Revision accepted: April 29, 1996.
I John A. Moran Eye Center, University of Utah School of Medicine,
Salt Lake City.
2 Department of Anesthesia, University of Utah School of Medicine,
Salt Lake City.
Presented at the American Academy of Ophthalmology Annual Meeting,
Atlanta, Oct/Nov 1995.
Supported in part by a grant from Research to Prevent Blindness. Inc,
New York, New York, to the Department of Ophthalmology, University
of Utah. Salt Lake City, Utah.
The authors have no proprietary interest in any of the materials used in
this study.
Reprint requests to Bhupendra C. K. Patel, MD, FRO;, FRCOphth,
Moran Eye Center, 50 North Medical Dr, University of Utah School of
Medicine, Salt Lake City, UT 84132.
Local anesthesia has become preferable to general anes-
thesia for cataract surgery due to improvement in tech-
niques and instrumentation. The advantages of local
anesthesia are well known and include more rapid am-
bulation, the ability to perform the procedure as an out-
patient, avoidance of complications of general anesthesia,
and quicker surgery.
Methods of local anesthesia for cataract extraction
currently include retrobulbar, I peribulbar,2-5 subcon-
junctival, 6 and sub-Tenon application oflocal anesthetic
solution. 7 Retrobulbar anesthesia has been associated with
a number of potentially serious complications, including
inadvertent globe perforation, retrobulbar hemorrhage,
orbital infection, central retinal artery occlusion, chronic
mydriasis, contralateral amaurosis, damage to the optic

1196
 Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery
nerve, intravascular or intrathecal injection, respiratory
depression, apnea, and death. 8- 18 Other more common
complications include postoperative diplopia, ptosis,
nausea, and systemic hypertension. 19 ,2o
Peri bulbar anesthesia eliminates the risk of optic nerve
trauma and lessens the chance of retrobulbar hemorrhage.
However, the risk of globe perforation still remains. 21 The
peribulbar technique is time-consuming and requires a
greater volume of anesthetic than the retrobulbar tech-
nique. 22
The use of intercapsular phacoemulsification and in-
traocular lens implantation has introduced the opportu-
nity to perform cataract surgery with less-invasive anes-
thetic techniques. Topical anesthesia, using clear corneal
and scleral tunnel approaches, has been suggested for cat-
aract extraction. However, reports suggest that careful pa-
tient selection is important. Anxious and uncooperative
patients should be excluded. 23 ,24 Although Kershner25 re-
ported encouraging results with topical anesthesia for cat-
aract extraction, Fukasaku and Marron 23 found unac-
ceptable levels of discomfort during surgery and they
abandoned the technique in favor of a peribulbar tech-
nique. We designed a prospective randomized study to
compare the effectiveness of topical and retrobulbar anes-
thesia for cataract extraction.
Patients and Methods
Approval was obtained from the University of Utah In-
stitutional Review Board. Consecutive patients under-
going elective cataract extraction and intraocular lens im-
plantation were entered into the study between March
and July 1995. Informed consent was obtained, and the
patients prospectively were assigned to either the topical
or the retrobulbar anesthesia group by permuted block
restricted randomization. The patients included in the
study were between 45 and 85 years of age and American
Society of Anesthesiology (ASA) physical status class 1,
2, or 3. Patients with communication difficulties, mon-
ocular patients, and patients taking anticoagulation med-
ication were excluded. All types of cataracts (posterior
subcapsular, nuclear sclerosis, dense brunescent, etc.) were
included in this study. Preoperatively, baseline vital signs
were taken in all patients, and an intravenous line with
Ringer lactate solution was placed. Each patient received
topical diclofenac sodium 0.1 % (Voltaren), two drops ev-
ery 20 minutes times two; phenylephrine hydrochloride
2.5% (Mydfrin), one drop every 5 minutes times three;
and cyclopentolate hydrochloride 1% (Cyclogyl), one drop
every 5 minutes times three.
The patients randomized to the topical group received,
while still in the preoperative area, two drops of bupiva-
caine hydrochloride (Marcaine) 0.75% every 5 minutes
times three, beginning 20 minutes before the procedure.
In the operating room, all patients received continuous
nasal prong oxygen 4 lfminute, and baseline vital signs
were obtained. The patients in the topical group were
given midazolam hydrochloride (Versed) 0.015 mg/kg
intravenously and (Sublimaze citrate) 1 JLg/kg intrave-
nously and an additional two drops bupivacaine 0.75%
were placed in the eye. Surgery was undertaken after a
routine preparation and draping. The protocol established
for breakthrough pain, if it should occur, during surgery
was as follows. If the patient is in pain, an additional two
drops bupivacaine 0.75% would be placed in the eye. If
this is not effective within 2 minutes, the patient would
receive additional fentanyl (0.5 JLg/kg) intravenously, to
be repeated in three minutes, if necessary. Finally, if the
pain persisted, a peribulbar or retrobulbar block would
be used.
The patients randomized to the retrobulbar group were
brought to the operating room where they received con-
tinuous nasal prong oxygen 4 lfminute, and vital signs
were recorded. After 2 minutes of additional pre-oxygen-
ation with 100% oxygen by face mask, the patients were
given methohexital 1% (Brevital) titrated to unconscious-
ness (approximate dose required, 0.5-1 mg/kg). A retro-
bulbar block was performed with a 23-gauge retrobulbar
needle using a solution oflidocaine 2% (2 ml), bupivacaine
0.75% (2 ml), and hyaluronidase (Wydase) 150 U. Surgery
was undertaken after a routine preparation and draping.
No ocular compression was performed. Facial nerve or
eyelid blocks were not used. If the patients in the retro-
bulbar group had breakthrough pain, a protocol similar
to the topical group was followed.
The methods of sedation used in the two groups were
different. Methohexital with retrobulbar anesthesia briefly
brings the patient to unconsciousness while the block is
being placed. These patients are amnestic for the block
placement and rarely receive additional sedation or an-
algesia for the remainder of the procedure. With the small
doses of midazolam and fentanyl used for the topical
group, patients are awake and cooperative, with total recall
of the procedure. We designed the study to compare the
accepted standard of retrobulbar anesthesia using me-
thohexital with the form of topical anesthesia and light
intravenous sedation that we have found useful. If the
same doses of midazolam and fentanyl had been used for
retrobulbar anesthesia, we would have had an unaccept-
ably high incidence of pain and recall during the place-
ment of the block.
All surgical procedures in this study were performed
by one surgeon. A wire speculum was placed. Patients in
the topical group were asked to look down. No superior
rectus sutures were used in either group. The patients in
the topical group were informed that they would be aware
of the sensation of touch and would be able to move their
eyeballs. A 3.2-mm, 400-JLm groove was made in clear
temporal cornea. A stab incision was made for insertion
of a second instrument at the 10 o'clock position in the
right eye and at the 4 o'clock position in the left. A 1.75-
mm entry incision was made into the clear corneal groove
with a diamond knife. A 5-mm wide capsulorrhexis was
performed. Hydrodissection was performed with balanced
salt solution using a curved cannula. A divide and conquer
type ofphacoemulsification technique was used. Amvisc+
was injected into the capsular bag. Foldable implants were
inserted and included plate lenses (Starr [Monrovia, CAl
and Chiron [Huntington, WV]) and acrylic and silicone
1197
 Ophthalmology Volume 103, Number 8, August 1996

Unbearable pain 1 0 lution. A collagen shield soaked in dexamethasone and

cephalexin was placed on the cornea at the end of the
procedure. Patients in group I did not receive a patch,
whereas an eye patch was applied to patients in group 2
until the following morning. The operating microscope
light was kept at its lowest level and gradually increased
9 in intensity. The level was up to the usual operating levels
after the hydrodissection.
After the surgery, the patients were taken to the post-
operative area where vital signs were obtained, and one
constant observer collected patient assessment responses.
8 Questions were presented to the patients from a stan-
dardized written form . Each patient was shown a lO-point
visual analogue graphic pain scale with numeric and de-
Severe Pain scripti ve ratings 26 (Fig I) and asked to grade the level of
discomfort or pain at the time of administration of anes-
7 thesia, during surgery, and postoperatively on separate
scales. If the patients were unable to see the scale or read
the accompanying text, the scale was described and a ver-
bal score was obtained. Patients also were asked to assess
the degree to which they were bothered by the ability to
6 move their eyes, by the sensation of touch, and by the
operating microscope light. The degree to which each of
these bothered the patient was graded as "none," "a little,"
or "a lot." The patients were kept in the recovery area for
a minimum of 30 minutes. The surgeon also completed
a questionnaire on the surgical conditions, complications,
Moderate Pain 5 and need for supplemental anesthesia. The surgeon rated
surgical conditions on an analogue scale, with 10 repre-
senting excellent, 7.5 good, 5 fair, 2.5 poor, and 0 being
extremely poor.
Comparisons between the topical and retrobulbar
4 anesthesia groups for the surgical conditions, pain during
administration of anesthesia, pain during surgery, and
postoperative pain was by a linear rank test. The Per-
mutation test with exact non parametric inference was
used from the StatXact statistical package (CYTEL Soft-
3 ware Corp, Cambridge, MA). Dichotomous comparisons
were performed by Fisher's exact test. The null hypothesis
Mild Discomfort was rejected for P < 0.05.

2 Results
Sixty-nine patients were entered into each group. Surgery
averaged 16.6 minutes (range, 11-21 minutes) for the
topical group (group I) and 15.8 minutes (range, 10-19
1 minutes) for the retrobulbar group (group 2; P> 0.05).
The surgical conditions and complications are given in
Table I. No patients in either group required supplemental
periocular anesthesia or a superior rectus suture. A wick
was required for pooling of fluid in two patients in group
No pain 0 I and in five in group 2 (P > 0.05). The surgeon noted
squeezing of the eyelids during surgery in 14 and 2 patients
Figure 1. A descriptive and numerical visual pain analogue scale.
in groups I and 2, respectively (P < 0.005). The degree
of squeezing was noted as mild in all patients and did not
interfere with the surgery. Eyelid injections were not re-
three-piece foldable lenses (Alcon [Ft. Worth, TX] and quired for any of these patients. Both groups rarely re-
AMOT [Irvine, CA]). The Amvisc+ was r~moved, and quired supplemental anesthesia. One patient in the topical
the anterior chamber was injected with balanced salt so- group required topical bupivacaine and one patient re-

1198
 Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery
70
Table 1. Surgical Conditions and Complications
60
Group 1 Group 2
Topical Retrobulbar 50
(n = 69) (n = 69)
40
Supplemental periocular anesthesia 0 0
Number 01
Superior rectus suture required 0 0 Patients
30
Need for a wick (%) 2 (3) 5 (7)
20
Squeezing of eyelids present (%) 14 (20) 2 (3)
Iris prolapse 0 0 10
Miosis 0 0
Inadvertent movement (%) 22 (32) 4 (6) 0
0 2 3 4 5 6 7 8 10
Capsule rupture (%) 1 (1.5) 0 Pain level
Vitreous loss 0 1 (1.5)
Figure 3. Pain scores recorded for surgery. Solid bars = topical; hatched
Retrobulbar hemorrhage 0 1 (1.5) bars = retrobulbar.
Globe perforation 0 0
Chemosis (%) 0 48 (70)
Eyelid hemorrhage (%) 0 28 (41)
There was no significant difference (P = 0.35) between
Subconjunctival hemorrhage (%) 1 (1.5) 12 (17) the two groups regarding level of pain during surgery. 1 he
Successful IOL insertion (%) 69 (100) 69 (100) median and mean pain scores were 0 and 1.13, respec-
Cooperation (%) tively, for group I and 0 and 0.203 group 2, respectively
Excellent 64 (93) 66 (96) (Fig 3). Fifty-seven patients (S3%) in group I and 63 (91 %)
Good 3 (4.5) 1 (1.5) in group 2 scored 0 (P > 0.05). There was one patient
Poor 2 (3) 1 (1.5)
who scored a 5 (moderate pain) in the topical group.
10L = intraocular lens. There was more discomfort postoperatively in ' he top-
ical group (P < 0.05). The median and mean pain scores
were 0 and 0.406 for group I and 0 and 0.OS7 for group
2 (Fig 4). The postoperative pain levels were scored as 0
quired topical bupivacaine and fentanyl (0.5 1g/kg). In by 56 (SI %) patients in group I and 66 patients (96%) in
the retrobulbar group, one patient required topical bu- group 2 (P < 0.05). Thirteen patients had mild discomfort
pivacaine during surgery. in the topical group compared with three in the retro-
There was more discomfort in patients in group I while bulbar group. The patients in the topical group described
anesthesia was administered (P < 0.00 I). Visual analogue an aching feeling.
pain scores produced a median score of I and a mean Inadvertent movement of the eyeball was noted by the
score of 1.13 for applying anesthesia in patients in group surgeon in 22 patients in group I and 4 in group 2 (P <
I, and a median and mean of 0 and O.ISS, respectively, 0.00 I). This movement of the eyeball was a problem to
for patients in group 2 (Fig 2). Twenty-eight patients (41 %) the surgeon during surgery in only two patients in group
in group I and 66 (96%) in group 2 (P < 0.000 I) reported I and I patient in group 2. The surgeon was able to make
no pain during delivery of anesthesia. all patients in the topical group move the eyeball and this

70 70

60 60

50 50

40 40
Number 01
Number 01 Patient.
Patients 30 30

20 20

10 10

0 0
0 2 3 4 5 6 7 8 9 10 0 2 3 4 5 6 7 8 9 10
Pain level Pain level

Figure 2. Pain scores recorded for delivery of anesthesia. Solid bars = Figure 4. Pain scores recorded for postoperative period. Solid bars =
topical; hatched bars = retrobulbar. topical; hatched bars = retrobulbar.

1199
 Ophthalmology Volume 103, Number 8, August 1996
was noted to be helpful in 52 patients (75%) by the sur-
geon.
There was one case of radial anterior capsule rupture
in a patient in group 1. The tear did not extend posteriorly,
and no further intervention was required. Intraocular lens
insertion was uneventful. The one patient with vitreous
loss associated with a capsular rupture in group 2 was
treated with anterior vitrectomy and intraocular lens in-
sertion into the capsular bag without need for any further
periocular anesthesia.
Patient cooperation was good or excellent in 67 (97%)
patients in each of the groups 1 and 2. Two patients in
the topical group showed poor cooperation. Both of these
were elderly patients requiring repeated instruction during
the course of surgery. One patient in the retrobulbar group
had poor cooperation. This patient was slightly disorien-
tated and moved during surgery. Surgery was uneventful.
The overall surgical conditions in the two groups as as-
sessed by the surgeon were comparable (P> 0.5; Fig 5).
The degree to which patients were bothered by eye
movement, sensation of touch, and microscope light is
shown in Figure 6. Twelve patients (17%) in group 1 and
1 in group 2 were bothered a little by the ability to move
their eyes during surgery (P < 0.01). Seventeen patients
(25%) in group 1 were bothered a little by touch sensation
during surgery, the majority identifying the lid speculum
as the source of the sensation. One patient in the topical
group also had "a lot of" discomfort (level 5 on the pain
analogue scale), again related to the lid speculum. Seven
patients (10%) in the retrobulbar group also had some
discomfort from touch sensation. Seven patients (10%) in
the topical group and one in the retrobulbar group indi-
cated that the microscope light was a little uncomfortable
(P> 0.05).
Eyelid hemorrhage and chemosis were seen exclusively
in group 2 (41% and 70%, respectively). Subconjunctival
hemorrhage defined as hemorrhage over one quadrant of
the conjunctiva was seen superiorly in one patient in group
1 and in 12 (17%) patients in group 2. There was one
60
50
40
No. of 30
Patients
20
10
0 quadrant with instillation of I ml local anesthetic gave
2 4 6 7 8 9 10
Operation Conditions
Figure 5. Operating conditions rated by the surgeon pn an analogue
scale, with 10 representing excellent, 7.5 good, 5 fair, 2.5 poor, and 0
extremely poor. Solid bars = topical; hatched bars = retrobulbar.
1200
70
60
50
40
30
No. of
Patients
20
10
o
None Little Lot None Little Lot None Little Lot
Eye movement Touch sensation Light
Figure 6. Patient perception of eye movement, touch sensation, and
microscope light during surgery. Patients were asked at assess whether
each of these bothered them "a lot, a little, or not at all." Solid bars =
topical; hatched bars = retrobulbar.
patient in group 2 with limited retrobulbar hemorrhage.
Surgery was uneventful.
Twenty patients had cataract extractions performed on
both eyes during the course of the study. Three patients
had bilateral retrobulbar nerve blocks, 4 had bilateral top-
ical procedures, and 13 patients had one eye that had
undergone with each technique. Of these 13 patients, 8
preferred the topical procedure and 5 preferred the ret-
robulbar technique.
Discussion
The first successful use of topical anesthesia for cataract
extraction was reported by Knapp27 in 1884. He used
frequent drops of 5% cocaine. Topical anesthesia has been
used recently for strabismus surgery.28 Shule~9 reported
the use of topical anesthesia without intravenous sedation
for phacoemulsification cataract extraction with intra-
ocular lens implantation in a patient with a history of
retrobulbar hemorrhage. He advocated the use of topical
anesthesia in such patients with a high risk of complica-
tions associated with needle anesthesia. Kershne~5 eval-
uated 100 patients undergoing cataract extraction under
topical anesthesia and concluded that topical anesthesia
was safe, decreased intraoperative and postoperative
complications, and allowed rapid return of vision. How-
ever, when Fukasaku and Marron 23 compared topical
anesthesia with retrobulbar anesthesia, they found more
intraoperative pain with the topical technique. They found
that a sub-Tenon technique in the superior temporal
better intraoperative pain control than topical anesthesia.
Fukasaku and Marron 23 did not mention preoperative
patient counseling or using intravenous sedation.
Stevens26 has advocated one quadrant sub-Tenon in-
filtration anesthesia in preference to retrobulbar or peri-
 Patel et al . Topical and Retrobulbar Anesthesia for Cataract Surgery
bulbar anesthesia. However, he noted more conjunctival
chemosis than usually seen with peribulbar or retrobulbar
anesthesia. Subconjunctival hemorrhage extending to
more than one quadrant occurred in 32% of his patients,
and 46% required an additional Van Lint facial block
immediately before surgery. Advantages of his technique
include reduced likelihood of injury to the vortex vein in
the inferior nasal quadrant where the vortex vein is more
posteriorly situated than the inferior temporal quadrant,
avoidance of damage to the superior conjunctiva, delivery
of adequate anesthesia, and akinesia. There is risk of
hemorrhage, especially in patients receiving anticoagu-
lants. In addition, there is a theoretical risk of spread of
infection via the conjunctival and sub-Tenon incision to
the retrobulbar space.
To achieve akinesia, the nerve supply to the extraocular
muscles should be inhibited. This is generally regarded as
desirable for safe intraocular surgery. Akinesia of the globe
is not achieved with topical anesthesia, which only affects
the trigeminal nerve to the cornea and the conjunctiva.
However, none of our patients undergoing topical anes-
thesia required a superior rectus suture. Twelve patients
stated that they were "a little bothered" by movement of
the eye during surgery. It is surprising that most of the
patients (83%) were unaware of eye movement during
surgery. However, the use of midazolam may have con-
tributed to the lack of recollection regarding movements.
The surgeon noted movement of the eyeball during sur-
gery in 22 patients. Of these patients, the movement was
helpful because the patient was able to assist in positioning
the eyeball in all except two patients. In two patients, the
movement was a problem and the eye was stabilized by
using forceps at the limbus. It is our belief that with ad-
equate preoperative explanation, movement of the eyeball
is not a concern to the patient and can be useful to the
surgeon. The overall surgical conditions, as assessed by
the surgeon, were comparable in the two groups. However,
as the surgeon was aware of the type of anesthesia being
used, there remains a risk of bias in this assessment.
With topical anesthesia, the globe may rest more pos-
teriorly because there is no retrobulbar fluid volume.
Kershner25 found that the use of a wick during the pro-
cedure was necessary because of pooling of fluid in "sev-
eral patients." We required the use of a wick in fewer
patients using topical anesthesia than with retrobulbar
anesthesia. A number of other factors, including globe
size (high hypermetropes with small eyes, etc.), deep-set
eyes, and a prominent supraorbital ridge necessitate the
need for a wick because of pooling. We did not attempt
to identify the individual predisposing factors in our pa-
tients. Although we did not use any compression of the
eyeball, the Honan balloon is used commonly with ret-
robulbar anesthesia. With the Honan balloon, the eyeball
tends to return to its resting place in the absence of a
retrobulbar hemorrhage; therefore, one would not expect
a greater degree of pooling of fluid in the topical anesthesia
group.
To eliminate pain sensation, pain fibers exiting from
the eye must be blocked. Ocular pain sensation is me-
diated by the long sensory root of the ciliary ganglion.
These fibers pass through the ganglion and provide sen-
sation from the cornea, iris, and ciliary body. 3D Intraocular
manipulation and, in particular, iris manipulation would
be expected to be uncomfortable for the patient with top-
ical anesthesia.
There was a greater level of pain reported during the
administration of anesthesia with the topical group. This
is not surprising because the patient is rendered uncon-
scious by the methohexital during the course of giving
retrobulbar anesthesia. Also, the mean and median levels
of pain in the topical group were only I (a level just above
the no pain level). The two patients who reported pain at
level 5 in the retrobulbar group both had pain during
intravenous administration of medications rather than
during retrobulbar injection. However, pain during ret-
robulbar injection is certainly possible because titration
of methohexital to induce unconsciousness occasionally
can be difficult to judge.
During surgery, all except one patient in the topical
group graded the pain at level 3 or lower (mild discomfort
or less) on the pain analogue scale. One patient had pain
at level 5 (moderate discomfort). As expected, most pa-
tients with retrobulbar anesthesia had no pain during sur-
gery, with six patients reporting mild discomfort (levels
3 or less). The speed with which phacoemulsification can
be performed and the minimal intraocular manipUlations
involved may explain the minimal discomfort reported
in the topical group. In the topical group, we had no in-
cidence of miosis, iris prolapse, or vitreous loss requiring
iris manipulation. The one incidence of capsular rupture
was an anterior radial tear which did not extend poste-
riorly and did not require any further intervention. This
tear was not related to ocular movement. It is possible
that in the presence of any of the above complications,
intraocular manipulation may be uncomfortable for the
patient requiring supplemental peribulbar anesthesia.
However, Kershner 5 reported two incidences of capsular
rupture requiring vitrectomy with topical anesthesia. He
did not require supplemental anesthesia and was able to
successfully perform a vitrectomy and insert an intraocu-
lar lens into the capsule in each patient.
Postoperative pain was more common in the topical
group. However, the median and mean scores were 0 and
0.406, respectively, at levels just above the no-pain level
on the analogue scale. It is not surprising that as patients
recover from the topical anesthesia, they have some degree
of discomfort. Although patients were kept in the recovery
room for up to I hour, some patients would have had
more discomfort several hours later when the retrobulbar
anesthesia had worn off.
None of the patients were severely bothered by the op-
erating microscope light. More patients (10%) were mod-
erately bothered by the light with topical anesthesia. Most
of these patients were bothered by the light initially but
none had discomfort throughout the procedure. As
Kershner 5 indicated, manipUlation of the eyeball gen-
erally moves the light off the visual axis, accounting for
the low incidence of discomfort reported by patients.
Keeping the light intensity low initially also helps avoid
discomfort. As a result of our experience with lower light
1201
 Ophthalmology Volume 103, Number 8, August 1996
intensities, we tend to use lower intensities for patients
undergoing any type of intraocular surgery with no
detriment to visibility.
Careful patient selection is required especially early in
the surgeon's conversion. Anxious or uncooperative pa-
tients are poor candidates. Patients may have pain during
surgery from zonular stretch, iris chafing by instruments,
iris prolapse, or injection of miotic agents into the anterior
chamber. Iris pain and iris sensitivity can lead to miosis
especially in patients with diabetes.
Some patients whose one eye had already undergone
surgery using the topical technique expressed a preference
for this technique. These patients did not wish to be ran-
domized to the retrobulbar group; therefore, we found it
difficult to recruit patients as the study progressed. Eight
of the 13 patients who had a different type of anesthesia
in each eye said they preferred the topical technique. Sev-
eral reasons were given for this preference. Patients liked
being aware of "what was going on." Also, patients liked
"not being put to sleep." The lack of a patch postopera-
tively, immediate improved vision, and no need for "a
needle in my eye" were other reasons given. Reasons for
preference of retrobulbar anesthesia by five patients in-
cluded "did not want to feel anything," "wanted to be
completely out of it," and "bothered by ability to move
eye" (1 patient).
Topical anesthesia essentially eliminates the risk of
globe perforation, retrobulbar hemorrhage, damage to the
optic nerve, dural perforation, and significant conjunctival
chemosis. Subconjunctival hemorrhage is rarely seen. The
topical technique appears to provide acceptable analgesia
during surgery, wears off rapidly after surgery, and does
not interfere with the patient's ability to blink, see, or
move the eye. Patients are able to follow commands, and
the ability to move the eyeball in the desired position was
found to be useful. Movement of the eyeball is rarely a
problem. Usually, no patch is required as the corneal sen-
sation recovers rapidly and there is no ptosis. Patients are
therefore able to see immediately after the surgery. Com-
munication with the patients is vital for the topical tech-
nique to be used successfully. Patients need to be informed
that they will be able to move their eyes and also have
some sensation in their eyes during surgery. It is apparent
from this study that intraocular procedures can be per-
formed without akinesia. The degree to which intraocular
manipulation can be safely undertaken remains unan-
swered by this study because we had no complications
requiring such manipulations. We currently are prospec-
tively evaluating the use of topical anesthesia in combined
trabeculectomy and cataract extraction.
As with adoption of any new technique, the true in-
cidence of complications as well as other undescribed
complications will present themselves over time as more
experience is gained. Surgery in this study was undertaken
by surgeons who had experience with topical anesthesia.
The difficulties and complications that would be encoun-
tered by a surgeon converting to the use of topical anes-
thesia currently are being evaluated.
Acknowledgments. The authors thank Deborah Harri-
son for her assistance in the design of this study.
1202
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I. Ellis PP. Retrobulbar injections. Surv Ophthalmol 1974; 18:
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Centennial Advertisement
From Soemmerring S. Abblidungen des menschlichen auges, Frankfurt, 1801. Soemmerring's work
is known for its accurate and detailed plates on the structure of the eye. Soemmerring's text was
translated later into French and, along with the plates, published by A. P. Demours in 1818.*

* Centennial advertisement provided courtesy of the Museum of Ophthalmology, Foundation of the American Academy of
Ophthalmology, San Francisco, California

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