Local anaesthesia for vitreoretinal surgery: a case-control study of 200 cases.

PURPOSE: In the United Kingdom the majority of vitreoretinal (VR) surgery is performed under general anaesthesia (GA). The aim of this study was to demonstrate the scope of local anaesthesia (LA) for VR surgery, to measure the acceptance of LA to patients and surgeons and to compare the surgical outcomes, complication rates and duration of the surgical procedures under LA and GA. METHODS: A case-control study was undertaken to compare 100 cases performed under LA with 100 matched cases performed under GA. The matching of cases was based on multiple criteria such as configuration and complexity of retinal detachment, the involvement of the macula, the number and site of retinal tears, presence and severity of proliferative vitreoretinopathy, experience of the surgeon and the type of the surgical procedure. A clinical audit was also carried out on 65 successive patients using a questionnaire to determine the acceptability of LA to patients and surgeons. RESULTS: Anatomical and visual success rates, and intra-operative and post-operative complications, were similar in cases carried out under LA and GA. The mean duration of the surgery (excluding anaesthetic time) was significantly shorter for LA than GA procedures (p < 0.001). The acceptance for LA was high for both patients and the operating surgeons. CONCLUSIONS: We found that VR surgery can be safely and efficiently performed under LA. Adoption of LA has increased our throughput.

Long-term intraocular pressure control after cataract extraction with trabeculectomy: phacoemulsification versus extracapsular technique.

PURPOSE: To compare long-term intraocular pressure (IOP) control after extracapsular cataract extraction and intraocular lens (IOL) implantation combined with trabeculectomy (ECCE + TRAB) with that after phacotrabeculectomy and IOL implantation. SETTING: Glaucoma Unit, Royal Liverpool University Hospital, Liverpool, England. METHOD: This retrospective study comprised 32 eyes having ECCE + TRAB and 31 eyes having phacotrabeculectomy with a mean follow-up of 37.5 and 41.0 months, respectively. The need for pressure-lowering medication was recorded. Kaplan-Meier curves were created for each group. RESULTS: At every measurement after 3 weeks of follow-up, significantly fewer eyes in the phacotrabeculectomy group required IOP-lowering medication (P = .04). CONCLUSIONS: After both ECCE + TRAB and phacotrabeculectomy, IOP control was achieved in significantly more eyes on fewer pressure-lowering medications than preoperatively. Phacotrabeculectomy with IOL implantation led to better unaided long-term postoperative IOP control than ECCE + TRAB with IOL implantation.

Silicone versus poly(methyl methacrylate) lenses in combined phacoemulsification and trabeculectomy.

PURPOSE: To compare the outcome of phacotrabeculectomy with silicone or poly(methyl methacrylate) (PMMA) intraocular lens (IOL) implantation over the first year. SETTING: Glaucoma Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom. METHOD: Two consecutive groups of 30 eyes each had phacotrabeculectomy with implantation of a foldable, plate-haptic silicone IOL (3.2 mm wide incision) or a PMMA IOL (5.2 mm wide incision) with a loosely or tightly sewn scleral flap, respectively. Early postoperative results and outcomes up to a mean of 1 year postoperatively in both groups were compared. RESULTS: In the early postoperative period, eyes in the silicone IOL group had a lower incidence of postoperative intraocular pressure (IOP) spikes (more than 30 mm Hg) than those in the PMMA IOL group (two and six cases, respectively) but also showed an increase (eight and three cases, respectively) in incidence of ocular hypotony (less than 8 mm Hg). There was also an increased incidence, although not statistically significant, of early postoperative complications in the silicone group; for example, fibrinous reaction in the anterior chamber (26.6 versus 10.0%; P = .18), shallow anterior chamber (16.6 versus 3.3%, P = .20), and choroidal detachment (16.6 versus 3.3%, P = .20). These complications, often associated with ocular hypotony, resolved quickly without serious sequelae. One year after surgery, IOP control (less than 22 mm Hg) was attained without medication in 80.0% in the silicone group and 76.7% in the PMMA group (P = 1.00), and corrected visual acuity of 20/40 or better was attained in 70.0% in the silicone group and 73.3% in the PMMA group (P = 1.00). CONCLUSION: The loosely sutured flap in the silicone group resulted in fewer early pressure spikes but at a cost of an increase in early postoperative hypotony with its associated complications. One year after surgery, there was no significant difference between the two groups in IOP control or visual acuity, showing that both procedures were effective in the surgical management of patients with cataract and glaucoma.