Anaesthesia for cataract surgery.

Cataract surgery is the most frequent surgical procedure requiring anaesthesia in developed countries. It is performed mainly in elderly patients, who present with many coexisting diseases that induce subsequent hazards from general anaesthesia. Cataract anaesthesia is performed following various techniques of regional anaesthesia, which are detailed in this review. Needle block carries a low but real risk of complications, mainly because of needle misplacement. Correct teaching and training are mandatory to prevent complications. The main patient risk factor for inadvertent globe perforation is the presence of a myopic staphyloma. Retrobulbar block has been progressively phased out and replaced by peribulbar block, sub-Tenon's block (STB) or topical anaesthesia (TA). The requirement for very deep block with total akinesia has greatly decreased with the use of phacoemulsification for cataract surgery, allowing for use of TA or low-volume STB. However, non-akinesia techniques may give rise to impaired surgical conditions, which have the potential to result in surgical complications. A surgical approach to accessing sub-Tenon's space avoids needle block, but does not totally prevent complications. When deep anaesthesia is required, low-volume STB, performed using either the needle technique or a surgical approach, appears to be the technique of choice in terms of efficacy. Increasing the anaesthetic volume provides reproducible akinesia. Various local anaesthetics may be used, depending on their availability and respective properties. The most useful adjuvant to local anaesthetic is hyaluronidase.

Neurolytic blockade of the obturator nerve for intractable spasticity of adductor thigh muscles.

Neurolytic blockade is one of the therapeutic possibilities to treat spasticity of various muscles. In patients with spasticity of the adductor thigh muscles, a percutaneous approach to the obturator nerve is often difficult. We describe a new approach to the obturator nerve and we examine its feasibility. The second objective was to assess the efficacy of obturator neurolysis for the management of adductor thigh muscle pain and spasticity associated with hemiplegia or paraplegia. Nerve blocks were performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. Neurolysis was performed by injection of 65% ethanol. We performed 27 blocks in 23 patients. Technical evaluation was achieved in terms of number of attempted needle insertions, time to accurate location of the nerve and success rate. The efficacy of the block was assessed using four scores: degree of alleviation of muscle spasm and triple flexion of the lower limb, improvement of gait and facilitation of hygienic care. Success rate of the technique was 100% with a time to accurate nerve location of 130+/-35 s. Compared with scores measured immediately before the block, all studied parameters were significantly improved. Efficiency was significant on adductor muscle spasticity (p<0.001 at 1 day and p<0.01 at 60 and 120 months). Triple flexion was also significantly improved (p<0.05 from 1 to 120 days), as well as gait (p<0.02) and hygiene (p<0.01) scores. No complications occurred. The combined approach of the obturator nerve represents a new technique which proved to be accurate, fast, simple, highly successful and reproducible. Obturator neurolysis was confirmed as an efficient and cost-effective technique to reduce adductor muscle spasm and related pain and to improve gait and hygienic care in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurone.