British Journal of Anaesthesia 104 (5): 57781 (2010)

doi:10.1093/bja/aeq056

Advance Access publication March 25, 2010

Role of the anaesthetist during cataract surgery under local anaesthesia in the UK: a national survey
K. Chandradeva 1*, V. Nangalia 1 3 and C. E. Hugkulstone 2
1

Department of Anaesthesia and 2Department of Ophthalmology, Queen Marys Hospital, Sidcup, Kent DA14 6LT, UK. 3University College London Hospital, London NW1 2PG, UK
*Corresponding author. E-mail: kchandradeva@doctors.net.uk
Background. Recent advances in cataract surgery techniques have enabled these to be performed under less invasive local anaesthetic techniques. As a result, ophthalmic surgeons are increasingly prepared to give the local anaesthesia to the patient themselves without the need for the presence of an anaesthetist. Methods. A national postal survey was conducted in 2008, asking all consultant ophthalmic surgeons for their choice of local anaesthetic technique, whether an anaesthetist or a surgeon performs the block, the current level of anaesthetic cover for the ophthalmic operating sessions, and the need for anaesthetists for phacoemulsication under local anaesthesia in future. No reminders were sent to the non-respondents.
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Results. The response rate was 62%. The choice of local anaesthetic technique was subTenons 47%, topical 33%, peribulbar 16%, retrobulbar 2%, and others 2%. Twenty-eight per cent of sub-Tenons blocks were given by the surgeons and 47% by the anaesthetists. Of peribulbar blocks, 9% were given by the surgeons and 85% by the anaesthetist. Seventy-ve per cent of ophthalmic operating sessions had allocated anaesthetic cover. Ophthalmic surgeons felt that in their judgement, only 10% of the phacoemulsications under local anaesthesia would necessitate the presence of an anaesthetist. Conclusions. The consultant eye surgeons, based on their judgement, are prepared to undertake a bigger proportion of cataract surgeries under local anaesthesia without the presence of an anaesthetist. This development is bound to have a signicant impact on manpower planning for ophthalmic anaesthetists. Br J Anaesth 2010; 104: 57781 Keywords: anaesthesia, local; anaesthetist; surgery, cataract; survey Accepted for publication: January 20, 2010

There has been an exponential increase in the number of cataract operations performed in the National Health Service in the UK over the last 20 yr. In 1990, 105 000 cataract operations were performed in the UK,1 increasing to 201 682 in 1998 9 and 289 500 by 2006 72 in England alone. There has also been a shift in the delivery of cataract surgery; inpatient surgery has all but been replaced by day-care surgery3 and phacoemulsication has become the procedure of choice.3 Anaesthesia for cataract surgery has also changed dramatically. Not only has there been a move from general (46% in 1992)1 to regional/local anaesthesia (95.5%),4 but the specic type of local anaesthetic technique has also changed. Two national audits from the Royal College of Ophthalmologists (in 19965 and 20036) documented a

decrease in both peribulbar and retrobulbar techniques (from 65% to 30.6% and from 15% to 3.5%, respectively) with a corresponding increase in topical (from 4.1% to 20.9%) and sub-Tenons techniques (from 7% to 42.6%). The purpose of this survey is to provide a national update of current anaesthetic practice and trends in anaesthesia for cataract surgery, and also to establish a baseline for who administers the anaesthetic.

Methods
In 2008, we obtained a list of names and addresses of all consultant ophthalmologists in the UK from the Royal College of Ophthalmologists. This survey had the approval

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of the Honorary Secretary of the Royal College of Ophthalmologists. We sent a questionnaire (Appendix) to each consultant. The survey was self administered and condential, with no reminder letters sent. A covering letter explained that the data collected would be anonymous and be non-attributable. Questions elicited whether the surgeon performed phacoemulsication under local anaesthesia (PULA), PULA volume per month, anaesthetic technique, anaesthetic administrator, current provision of an anaesthetist, and also their opinion of the future need for an anaesthetist. The questions involved either a numeric response (number or percentage) or a tick implying yes for anaesthetic administrator.

Table 2 Results of the local anaesthetic block administrator. Per cent is calculated from the total 18 540. Per cent of total, number of blocks administered/18 540 Administrator Surgeon Anaesthetist Nurse Surgeon/anaesthetist Surgeon/nurse Anaesthetist/nurse Surgeon/anaesthetist/nurse No. of blocks administered 6948 7042 1723 2243 212 86 286 Per cent of total 37.5 38 9.3 12.1 1.2 0.5 1.5

Results
Nine hundred and thirty questionnaires were sent out, and 572 replies were returneda response rate of 61.5%. Fifty-four (9.4%) respondents did not perform any cataract operations, and 19 (3.3%) forms had missing elds. These were excluded, leaving 499 questionnaires for further analysis. A total of 18 540 cases of PULA were performed in 1 month by the respondents, with a median of 34 (range 4 200) per surgeon. The median number of different local anaesthetic techniques was 2 (range 1 4) and the median number of administrators of these blocks was also 2 (range 1 3). The data for the number of cases per surgeon and the type of block performed were not normally distributed (Table 1). There was also no correlation between the number of cases of PULA performed by a surgeon and the type of anaesthetic block they used. The total number of blocks administered by the different combination of administrators is shown in Table 2, and the administrators of each type of block are shown in Table 3. Where there are combinations of more than one administrator, this indicates that the block could have been performed by either one of the administrators listed. The median current allocation of anaesthetists for PULA lists was 75% (IQR 25 100%). This should be contrasted with the ophthalmologists perceived requirement for an anaesthetist of only 10% (IQR 0 100%), which was signicantly lower (P0.0000 with the Wilcoxon signed-rank test). Figure 1 displays the pattern of change in current allocation vs perceived requirement for PULA cases for each surgeon.
Table 1 The type of local anaesthetic block used. The total number of cases is the sum of the number calculated for each surgeon: monthly casesanaesthetic block per cent. Per cent, total number of cases/18 540 Anaesthetic block used Median (%) IQR (%) Total no. of cases Per cent Topical Sub-Tenon Peribulbar Retrobulbar Other 2 50 0 0 0 0 80 5 95 0 20 0 0 0 0 6178 8666 2988 373 335 33 47 16 2 2

There was no correlation between the number of cases of PULA performed by a surgeon and their perceived requirement for an anaesthetist (Spearmans rank correlation coefcient 20.0558). This is illustrated in Figure 2. Correlation (Spearmans rank correlation coefcient) between block performed and perceived requirement for an anaesthetist is shown in Table 4. Only topical anaesthesia and perceived requirement were moderately correlated (in this case negatively: 20.47 P,0.001).
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Discussion
The response rate of the survey was 61.5%. This is comparable with the response rate for surveys to ophthalmologists in the UK, which has previously been documented at 66%.6 The response rate is similar to surveys in Canada (358/698, 67%)7 and Singapore (88/144, 61.1%),8 and better than those in Japan (457/930, 49%)9 and the USA (985/6350, 15.5%).10 A survey in New Zealand which sent reminder letters did have a higher response rate (84/103, 84%).11 A signicant nding of the survey was the difference between current anaesthetic allocation for ophthalmic surgical sessions (75%) compared with the perceived requirement for an anaesthetist to be present for cases of PULA (10%). These data indicate that if an operating session was devoted entirely to PULA cases, then there could be a 65% reduction in the necessity for an anaesthetist to be present. Technical advances in regional ophthalmic anaesthesia and operative surgery for cataract and economical factors have probably contributed to the low percentage requirement of an anaesthetist for PULA cases. The type of block used for PULA, however, did not strongly correlate with the perceived requirement for an anaesthetist, except in the case for topical where there was a moderate negative correlation, that is, the greater the use of topical anaesthesia, the lower the perceived requirement for an anaesthetist. However, it must be noted that overall all surgeons had a lower perceived requirement for an anaesthetist. Internationally, there has been a change in practice of the type of anaesthetic administered for cataract surgery. In New Zealand, a preference for sub-Tenons anaesthesia increased from 24% in 1997 to 65% in 200712 along with a decrease in periocular anaesthesia (from 40% to 10%) over

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Table 3 The percentage of different blocks performed by the different administrators Administrator Surgeon Anaesthetist Nurse Surgeon/anaesthetist Surgeon/nurse Anaesthetist/nurse Surgeon/anaesthetist/nurse Topical (%) 61 3 27 2 3 1 4 Sub-Tenon (%) 28 47 1 22 0 2 3 Peribulbar (%) 9 85 0 6 0 0 0 Retrobulbar (%) 47 46 0 7 0 0 0 Other (%) 87 8 0 5 0 0 0

Perceived requirement for an anaesthetist (%)

100 80 60

Table 4 Correlation coefcient (Spearmans rank) between block preference of each surgeon vs perceived requirement for an anaesthetist Correlation coefcient Topical Sub-Tenon Peribulbar 20.4722 0.1 0.2664 P-value ,0.001 0.04 0.001

Line of equality

40

20 0

20 40 60 80 Current allocation of an anaesthetist (%)

100

Fig 1 Scatterplot of the perceived requirement vs the actual allocation of an anaesthetist. Every point below the line of equality indicates that the perceived requirement is less than the current session allocation of an anaesthetist.

100 80 60

40

20 0 0

50

100 150 Cases of PULA per month

200

Fig 2 Scatterplot of the monthly cases performed by each individual surgeon vs their perceived requirement for an anaesthetist.

the same time period. The American Society of Cataract and Refractive Surgery members survey13 also shows similar trends towards less invasive anaesthetic techniques with topical anaesthesia increasing from 8% in 1995 to 61% in 2003 and retrobulbar blocks decreasing from 76% to 20% over the same period. Sub-Tenons anaesthesia, however, remained below the 5% level. The 2004 survey

data from Singapore showed that the two most preferred anaesthetic techniques were peribulbar (43%) and topical (36%).8 However, Leaming13 also noted that anaesthetic technique varied by surgical volume; only 38% of surgeons performing one to ve cataract procedures per month used topical anaesthesia compared with 76% of surgeons performing 75 or more procedures. Interestingly, this nding was not reected in the current survey. These data highlight considerable variability in anaesthetic preference for cataract surgery both geographically and over time. Besides changes in anaesthetic technique over time, there may also be a change in the anaesthetic administrator. In our survey, more than 90% of topical anaesthesia was administered by non-anaesthetists (i.e. surgeon, nurse, anaesthetic assistant); however, anaesthetists were the primary administrators for sub-Tenon (47 72%) and peribulbar (85 91%) blocks. Although the Cataract National Database14 establishes trends of other cataract-related variables, it does not possess data of the anaesthetic administrator. We believe that establishing a baseline of anaesthetic administrator is also important, as this could help with workforce planning in future. Furthermore, in the event of the introduction of PULA operating lists without anaesthetists, the healthcare providers ought to ensure that a robust process is in place for the selection of patients and appropriately trained paramedical personnel needs to be allocated to monitor these patients intraoperatively as stipulated in the intercollegiate guidelines.15 A signicant number of PULA cases will still need anaesthetic input and the challenge is to identify these patients accurately and get them onto the lists manned by anaesthetists. In conclusion, we present the ndings of a national survey of current practice of local anaesthesia in cataract surgery in the UK. It shows the potential reduction in the need for ophthalmic anaesthetists and the need to establish a database of local anaesthesia administrator. Our ndings

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may be of relevance to future workforce planning, particularly for anaesthetic departments in the UK.

Funding
This survey was supported by the South East Thames Society of Anaesthetists.

Conict of interest
None declared.

Appendix

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References
1 Courtney P. The National Cataract Surgery Survey: I. Method and descriptive features. Eye 1992; 6: 487 92 2 Available from www.hesonline.nhs.uk/Ease/servlet/ContentServer? siteID=1937&categoryID=19 3 Johnston RL, Sparrow JM, Canning CR, Tole D, Price NC. Pilot National Electronic Cataract Surgery Survey: I. Method, descriptive, and process features. Eye 2005; 19: 788 94 4 El-Hindy N, Johnston RL, Jaycock P, et al. UK EPR user group. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: anaesthetic techniques and complications. Eye 2009; 23: 50 5 5 Eke T, Thompson JR. The National Survey of Local Anaesthesia for Ocular Surgery. II. Safety proles of local anaesthesia techniques. Eye 1999; 13: 196 204 6 Eke T, Thompson JR. Serious complications of local anaesthesia for cataract surgery: a 1 year national survey in the United Kingdom. Br J Ophthalmol 2007; 91: 470 5 7 Bellan L, Dunn E, Black C. Practices associated with cataract surgery in Canada: results of a national survey. Can J Ophthalmol 1997; 32: 315 23

8 Wagle AA, Wagle AM, Bacsal K, Tan CS, Chee SP, Au Eong KG. Practice preferences of ophthalmic anaesthesia for cataract surgery in Singapore. Singapore Med J 2007; 48: 287 90 9 Oshika T, Amano S, Araie M, Majima Y, Leaming DV. Current trends in cataract and refractive surgery in Japan: 1999 survey. Jpn J Ophthalmol 2001; 45: 383 7 10 Leaming DV. Practice styles and preferences of ASCRS members 2003 survey. J Cataract Refract Surg 2004; 30: 892900 11 Elder M, Leaming D. The New Zealand cataract and refractive surgery survey 2001. Clin Experiment Ophthalmol 2003; 31: 11420 12 Pick ZS, Leaming DV, Elder MJ. The fourth New Zealand cataract and refractive surgery survey: 2007. Clin Experiment Ophthalmol 2008; 36: 604 19 13 Leaming DV. Practice styles and preferences of ASCRS members 2002 survey. J Cataract Refract Surg 2003; 29: 141220 14 Jaycock P, Johnston RL, Taylor H, et al., UK EPR user group. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye 2009; 23: 38 49 15 Local Anaesthesia for Intraocular Surgery. The Royal College of Anaesthetists and The Royal College of Ophthalmologists, 2001; 1 24

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