(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
For the VR surgeon to have “peace of mind” during the operation,1 the patient must feel no pain and the eyeball may not move (akinesia, “block”). An anesthesia that permits the sensation of pain or significant eye movement is inadequate for VR surgery.
Pearl
Minimal eye movements are tolerable since the surgeon has rather firm control over the eye by having two instruments inside it. Nevertheless, when fine manipulations are performed, the surgeon should not be forced to divide his attention between the surgical task ahead and the struggle to keep the eye immobile.
There are two types of anesthesia, local and general; both have advantages and disadvantages (see Table 15.1). Either way, the surgeon must have absolute confidence in the anesthesiologist (see the Appendix, Part 2) and look at him as a partner on the team (see Sect. 16.1).
Table 15.1
Anesthesia in VR surgery: types and their advantages
Anesthesia typea | Advantage | Disadvantage |
|---|---|---|
Local | Inexpensive | The akinesia may be imperfect |
Possible to communicate with the patient during surgeryb | The patient may movec or fall asleep due to the intravenous sedation. The latter is not a problem until the patient suddenly wakes up and then inadvertently moves | |
Easy to change the position of the patient’s head: just ask him to do so | The patient is able to hear everything that is being said in the OR during the operationd | |
Short turnover timee | Risk of peribulbar hemorrhage or severe chemosis | |
Patient can lie down on the operating table on his own and enter and leave the OR on his own foot or in a wheelchair – only rarely is an extra person needed to move the patient | Risk of needle penetration into the globe | |
The wonders of VR surgery: a few patients describe an incredibly beautiful experience as they can see even minute details of what is being done inside their eyef | Reinjection may be necessary if the operation is very long | |
An anesthesiologist should be on the premises “just in case” | ||
General | Patient feels absolutely no pain | Expensive equipment needed |
Patient will not move body or eyeball during the operationg | An anesthesiologist and an extra nurse are needed (and paid for) | |
The patient’s systemic condition is closely monitored | There is an issue with N2O diffusion into the intravitreal gas (see Chap. 14) | |
The systemic blood pressure is relatively easy to adjusth | There is a risk of a coughing attack after the tube has been removed; an ECH may result | |
If for some reason the machinery breaks down or the operation is unexpectedly long, there is no extra pressure on the surgeon to finish it | The turnover time is often more than 30 min | |
Longer postoperative recovery |
aThe patient’s systemic condition is another factor that may be decisive in determining which option to choose. In countries with excellent medical care problems, such as patients showing up with poorly controlled diabetes or blood pressure, almost never occur, but in most countries it is a rather common issue.
bSee the text for more details.
cOften due to back or neck pain. If fine work is being done, such as ILM peeling, movement of even the patient’s leg may lead to movement of the head.
dNot necessarily cursing (although that happens, too) but, for instance, the machine breaking down or the surgeon mentioning last night’s football game (“he is not fully concentrating on me!”).
eIn one of the ORs where I work, the average time between finishing one and being able to start the next operation is 7 min. If the facility is equipped properly, this is also achievable when using general anesthesia, but it requires a lot of expensive extra equipment.
fObviously, this does not represent an indication for, or justification of, local anesthesia, but it nevertheless awards these patients a memory they will never forget.
gThe anesthesiologist must not start waking the patient up until hearing the verbal confirmation from the VR surgeon.
hMostly reduced to the normal range; hypotony in PPV for choroidal melanoma.
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