Investigators compared features and outcomes of open-globe repair based on the choice of anesthesia: regional block with monitored anesthesia care (RA-MAC) or general anesthesia (GA).
Study design
This retrospective, nonrandomized case series included 448 adult patients treated at a single university eye center over a period of 11 years. Within the cohort, 351 patients received RA-MAC and 97 received GA during non-enucleation surgeries.
Outcomes
The authors found that selection of RA-MAC was associated with injury in anterior zones 1 and 2, and the use of GA increased with more posterior zones of injury. For eyes with zone 3 injuries, the ratio of RA-MAC to GA was equal.
General anesthesia was more often selected for patients with longer wound lengths, younger age and longer operation times (all P<0.001). Conversely, local anesthesia was more common in patients with less severe globe injury and greater age. Regional block cases also had better presenting and final visual acuity (P<0.001), however, neither type of anesthesia was correlated with a greater improvement from preoperative VA, and final visual outcomes were believed to be linked to the degree and location of injury.
Overall, the comparable visual and safety outcomes presented in the study confirm that RA-MAC is a reasonable alternative to GA for open-globe repair in selected adult patients.
Limitations
The retrospective nature of the study provides little information on what specific criteria led the surgical team to choose one type of anesthesia over another. The surgeon’s preference may also bias these results. In particular, concerns of GA comorbidity may have significantly contributed to the trend of surgeons selecting RA-MAC for older patients.
Clinical Significance
Both anesthesia types carry a risk of extrusion of intraocular contents during surgery. In the past, RA-MAC was avoided for open-globe cases because a localized injection could induce extrusion by displacing volume. Yet factors associated with GA, such as placement of an endotracheal tube, may likewise lead to expulsion by raising IOP. No cases in this series showed record of this complication.
Currently, many hospitals choose GA for open-globe repair, but more eye surgeries are performed at outpatient surgical centers under topical anesthesia. Transferring all possible open-globe cases to outpatient centers would be time- and cost-effective while providing comparable outcomes.