|Year : 2014 | Volume
| Issue : 3 | Page : 210-215
Proparacaine hydrochloride topical drop and intracameral 0.5% lignocaine for phacotrabeculectomy in patients with primary open angle glaucoma
Rajesh Subhash Joshi
Department of Ophthalmology, Shri Vasantrao Naik Government Medical College, Yavatmal, Maharashtra, India
|Date of Web Publication||19-Jun-2014|
Dr. Rajesh Subhash Joshi
77, Panchtara Housing Society, Manish Nagar, Somalwada, Nagpur - 440 015, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To compare the efficacy and safety of 0.5% intracameral lignocaine to 1% intracameral lignocaine prior to phacotrabeculectomy.
Study Design: Prospective, comparative, observational, and interventional study.
Setting: Tertiary eye care center in central India.
Materials and Methods: This study was comprised of 79 patients (79 eyes) with primary open angle glaucoma scheduled for phacotrabeculectomy. Patients were assigned to 1 of 2 Groups receiving proparacaine 0.5% eye drops and 1% intracameral lignocaine just prior to phacotrabeculectomy (Group 1, n = 39) and 0.5% intracameral lignocaine after completion of phacoemulsification just prior to trabeculectomy (Group 2, n = 40). The visual analogue scale was used to record intraoperative and postoperative pain. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. An anesthetist also noted the vital parameters and the requirement for intravenous medications.
Results: There was no significant difference in the intraoperative pain score (P = 0.0733) or supplemental anesthesia (P = 0.372) between Groups. Postoperative pain score was statistically significant in Group 2 (P < 0.0001). The overall operating conditions in both Groups were comparable (P = 0.7389). A greater number of patients in Group 2 (88.57%) preferred the same anesthetic technique for combined surgery in the fellow eye. There was no difference in inadvertent eye movements and lid squeezing between Groups and they did not interfere with surgery.
Conclusion: Topical anesthetic drops supplemented with 0.5% intracameral lignocaine before performing trabeculectomy is as effective as 1% intracameral lignocaine given at the beginning of phacotrabeculectomy for primary open angle glaucoma.
Keywords: Intracameral Lignocaine, Phacotrabeculectomy, Topical Anesthesia, Visual Analog scale
|How to cite this article:|
Joshi RS. Proparacaine hydrochloride topical drop and intracameral 0.5% lignocaine for phacotrabeculectomy in patients with primary open angle glaucoma. Middle East Afr J Ophthalmol 2014;21:210-5
|How to cite this URL:|
Joshi RS. Proparacaine hydrochloride topical drop and intracameral 0.5% lignocaine for phacotrabeculectomy in patients with primary open angle glaucoma. Middle East Afr J Ophthalmol [serial online] 2014 [cited 2019 May 22];21:210-5. Available from: http://www.meajo.org/text.asp?2014/21/3/210/134669
| Introduction|| |
Topical anesthesia is routinely used in cataract, glaucoma, combined cataract, and glaucoma surgeries and vitrectomy. ,,,, Quick recovery of visual function, no injection related complications of anesthetic agents, and ease of administration make topical anesthesia popular among ophthalmologists.  The short duration of action, repeated administration, intraoperative supplementation via subconjunctival or subtenons' administration or intracameral lignocaine and intraoperative discomfort to the patient are some of the disadvantages of topical anesthesia.
Topical anesthesia in various forms has been attempted for phacotrabeculectomy. These include lignocaine 2% jelly,  repeated application of 2% lignocaine drops,  and intracameral lignocaine 1% along with tetracaine and oxybuprocaine topical drops. 
Injection of ocular anesthesia such as subtenon's and subconjunctival perilimbal anesthesia without affecting the ocular movements have also been attempted. , However, subconjunctival hemorrhage, chemosis, globe perforation can occur with subtenon's or subconjunctival injection of anesthetic agents. Subconjunctival lignocaine has been thought to be associated with cystic and thin walled bleb used for trabeculectomy. 
Topical anesthesia for combined surgery has distinct advantages including prevention of sudden intraocular pressure spikes and exacerbation of glaucomatous optic atrophy due to retrobulbar or peribulbar anesthesia. Additionally, topical anesthesia is useful for monocular patients as the operated eye does require patching.
Cataract and glaucoma frequently occur together. Performing trabeculectomy alone leads to cataractous changes and patients may require cataract surgery in the future.  Therefore, cataract and glaucoma surgeries are frequently performed together to improve the visual acuity and to reduce intraocular pressure in a single sitting.
The advent of clear corneal phacoemulsification and manipulation of pain sensitive intraocular structures are minimal. Phacoemulsification can be performed under topical application of anesthetic drops.  However, trabeculectomy involves performing cauterization of episcleral vessels and peripheral iridectomy, which can be a source of pain for the patient. This stage of surgery requires supplemental anesthesia. We believe intracameral lignocaine during the iridectomy stage is useful for pain relief instead of giving it at the beginning of surgery.
This prospective, comparative, observational, and interventional study evaluates the usefulness of 0.5% intracameral preservative free lignocaine after phacoemulsification, before the start of the trabeculectomy procedure compared to 1% intracameral lignocaine given at the beginning of phacotrabeculectomy in patients with primary open angle glaucoma.
| Materials and Methods|| |
This study recruited patients with primary open angle glaucoma that was uncontrolled with maximal medical therapy with visually significant cataract who presented to the Government Medical College and hospital, a tertiary eye care center in central India. All patients were presented between January 1, 2010, to December 31, 2011. The exclusion criteria were allergy to the topical anesthetics, deafness, nystagmus, barrier to communication, extreme anxiety, neurological disorders, nondilating pupil, patients unable to understand a visual analog pain scale chart, patients having intractable type of glaucoma, previous intraocular surgery, subluxated, traumatic, and complicated cataracts.
Preoperatively, all patients had routine ophthalmic evaluation in relation to the cataract and glaucoma. The hospital ethical committee approved this study. Patients underwent a discussion of the procedure and were required to sign a written informed consent. Patients were instructed to inform the investigator, if they experienced pain anytime during the surgical procedure. The surgeon conversed with the patient during the entire surgical procedure and considered supplemental anesthesia such as topical anesthetic drops, intracameral lignocaine or intravenous sedation as required. Alternate patients were assigned to receive either proparacaine hydrochloride 0.5% (Paracain, SUNWAYS Pvt. Ltd., India) topical anesthetic agent or 0.3 cc of 1% intracameral lignocaine (Xylocaine, ASTRA IDL Ltd., India) at the beginning of phacotrabeculectomy (Group 1, n = 39) or proparacaine hydrochloride at the beginning of the surgery and 0.5% intracameral lignocaine after completion of phacoemulsification with implantation of an intraocular lens (IOL) in the bag just prior to the trabeculectomy (Group 2, n = 40).
Preoperatively, the pupils were dilated with a combination of phenylephrine 5% and tropicamide 0.8% eye drops (Appamide, Appasamy Ocular Devices, Puducherry, India) 30-40 min before the start of the surgery. No nonsteroidal anti-inflammatory drugs were used preoperatively. No patients received preoperative sedation.
One surgeon performed all surgeries. Patients in both groups received a drop of proparacaine hydrochloride 0.5% every 5 min two times prior to the start of the surgery. A universal eye speculum was used to retract the eyelids. A superior rectus suture was not taken in any case. A two site surgical approach was followed in all cases. Phacoemulsification, from the temporal side was performed first. Microscope illumination was minimized intraoperatively and the patient was asked to fixate on the light. Side port incisions were performed as required. Trypan blue dye was injected under the air to stain the anterior capsule in each case. A 2.8 mm clear corneal temporal incision was made and illumination of the microscope light was increased. A continuous curvilinear capsulorhexis, hydrodissection, and phacoemulsification were performed in the bag. Subsequently cortical clean up was performed followed by implantation of a single piece hydrophilic IOL in the bag. The pupil was constricted with 0.5% intracameral pilocarpine (Carpinol, SUNWAYS Pvt.Ltd., India). Patients in Group 2 received 0.3 cc intracameral 0.5% preservative free lignocaine at this stage. Intracameral 0.5% lignocaine was prepared after diluting the commercially available 2% preservative free lignocaine with balanced salt solution.
The microscope was rotated superiorly and the patient was asked to look downward for trabeculectomy. A fornix-based conjunctival flap was fashioned superiorly. Wet field cautery was used for hemostasis. A triangular superficial scleral flap measuring 5 × 5 × 5 mm was constructed. A rectangular 4 × 2 mm sclero-trabecular block was excised. A peripheral iridectomy was performed. The scleral flap was then closed with a 10-0 nylon suture at each corner. The conjunctiva was closed with a 10-0 nylon suture. Anterior chamber irrigation and aspiration were completed to remove viscoelastic and pilocarpine.
No patient received subconjunctival injection of steroid and antibiotics. At the end of surgery, the patient was taken to the recovery room. A standard 10-point visual analog scale was used to assess the patients subjective impression of intraoperative and postoperative pain. 13 Postoperative pain was assessed 30 min after the completion of the surgery by a trained ophthalmic technician. The surgeon was not present for the assessment of the pain score. The patients were also asked whether they would opt for similar anesthesia for combined surgery in the fellow eye.
The surgeons subjective impression of discomfort intraoperatively (grade 0 = nil, 1 = mild, 2 = moderate, 3 = severe), complications, supplemental anesthesia, lid squeezing, and the inadvertent ocular movements were noted.
Intraoperatively, the anesthetist noted the vital parameters such as blood pressure, pulse rate, oxygen saturation, and the requirement for supplemental intravenous sedation.
Data were entered into an Excel spreadsheet (Software version 14.1.0 (110310)/2011) (Microsoft Corporation, Redmond, WA, USA) and statistical analysis performed with SPSS version 13.0 (SPSS Inc, Chicago, IL, USA). Intraoperative and postoperative pain, operating conditions were assessed with the Wilcoxon (Mann-Whitney) rank sum test. Dichotomous comparisons were performed with Fisher's exact tests. A P value less than 0.05 was considered statistically significant.
| Results|| |
Seventy-nine patients were enrolled in the study. Demographic details of the study patients are listed in [Table 1]. Intraoperative details and the surgical complications are presented in [Table 2].
The average intraoperative pain score on the visual analog scale (VAS) in Group 1 was 2.026 + 2.032 (range, 0-7) and 1.325 + 1.385 (range 0-6) in Group 2 (P = 0.0733). A score of zero, that is, no pain was reported by 35.89% of patients in Group 1 (14/39) and 32.5% (13/40) of patients in Group 2. The mean VAS postoperative pain score after 30 min was statistically significantly higher at 0.7179 + 0.7591 in Group 1 compared to 0.2512 + 0.4385 in Group 2 (P < 0.0001).
One patient in Group 1 and 2 patients in Group 2 had posterior capsular rent (PCR). Group 1 patients required anterior vitrectomy and the 6 mm optic for the polymethyl methacrylate IOL was placed over the anterior capsular rim. A 10-0 nylon suture was used to secure the wound. Group 2 patients had PCR while removing the posterior capsular plaque. These two patients had posterior polar cataract. No vitreous loss occurred. A hydrophilic IOL was placed in the bag. One patient in each Group had zonular dehiscence during phacoemulsification. A 13 mm endocapsular ring was placed in the bag and phacoemulsification was completed uneventfully.
Inadvertent eye movements occurred almost equally between Groups (Group 1, n = 11; Group 2, n = 12). Lid squeezing was noted in six patients (15.38%) in Group 1 and seven patients (17.5%) in Group 2 (P = 0.6438)
Two patients, one in each group, were extremely poorly cooperative. The overall operating conditions in both Groups were comparable (P = 0.7389).
Two patients in Group 1 and one patient in Group 2 were bothered by the microscope light. Three patients in Group 1 and 2 patients in Group 2 complained of a touching sensation intraoperatively.
Supplemental anesthesia was required in 19 eyes (48.7%) in Group 1 and in 15 eyes (37.5%) in Group 2 (P = 0.372). Intraoperative painful sensations and delivery of supplemental anesthesia during the various steps of the surgery are presented in [Table 3]. Additional anesthetic drops were required in 10 eyes (25.64%) in Group 1 and 12 eyes (30%) in Group 2. No patients in either Group required supplemental subconjunctival anesthesia, peribulbar anesthesia or systemic sedation. One patient in Group 1 and 2 patients in Group 2 complained of eye discomfort during the conjunctival apposition, but did not require supplemental anesthesia.
|Table 3: Intraoperative painful sensations perceived by patients in two Groups|
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Twenty-three patients (63.89%) in Group 1 and 31 patients (88.57%) in Group 2 preferred the same anesthetic technique for the fellow eye. Eight patients (Group 1 n = 3; Group 2 n = 5) underwent a combined surgical procedure in the fellow eye with peribulbar or retrobulbar anesthesia. Five patients in Group 1 and 3 patients in Group 2 requested either sedation or complete loss of ocular sensation during the surgical procedure.
The overall operating conditions rated by the surgeon were good. The anesthetist noted no significant change in the pulse rate and oxygen saturation.
| Discussion|| |
Our study demonstrates that topical anesthesia supplemented with intracameral 0.5% lignocaine before performing trabeculectomy is as effective as 1% intracameral lignocaine at the beginning of the combined surgery. Pain was well controlled and patients were cooperative during surgery. The postoperative pain score was statistically significantly better in Group 2 (P < 0.0001). This outcome could be due to supplementation of 0.5% intracameral lignocaine before proceeding to trabeculectomy. The safety and efficacy of the intracameral lignocaine during trabeculectomy has been studied by Lai et al. who showed satisfactory intraoperative and postoperative analgesic effects.  Rebolleda et al. compared topical anesthetic drops supplemented with intracameral 1% lignocaine with retrobulbar anesthesia for phacotrabeculectomy.  They showed topical anesthesia supplemented with intracameral lidocaine was an effective alternative to retrobulbar anesthesia for phacotrabeculectomy. The intraoperative (1.1 ± 1.0) and the postoperative (0.7 ± 0.7) pain scores in the topical Group were better than Group 1 in our study. This could be due to the single site incision for the phacotrabeculectomy. We preferred a two-site approach as the author is trained in performing phacoemulsification with a temporal clear corneal incision. The postoperative pain score in-Group 2 of our study was 0.2512 + 0.4385. This could be due to intracameral lignocaine given just prior to trabeculectomy.
With the long duration of the procedure, patient cooperation becomes a concern. Patients requiring cataract surgery can have adequate pain control with topical anesthesia. Dinsmore14 found that patients undergoing combined surgery for cataract and glaucoma required additional anesthetic blocks due to pain arising from conjunctival manipulation, iridectomy, and conjunctival and scleral suturing at the end of the surgery. In Our study, 19 (48.7%) eyes in Group 1 and 15 (37.5%) eyes in Group 2 required supplemental anesthesia. It was either in the form of topical proparacaine drops or intracameral lignocaine. No patient in either Group required supplemental anesthesia while performing phacoemulsification. One patient in Group 1 was uncooperative throughout the trabeculectomy procedure and was given 1 ml 2% lignocaine subconjunctival injection. No patient required peribulbar or retrobulbar block or systemic intravenous sedation during the surgical procedure. Robollede et al. found extra administration of topical anesthesia was significantly more common in the topical Group (93.3%) than the retrobulbar Group (16.7%). 
Inadvertent eye movement (Group 1 n = 11; Group 2 n = 12) and lid squeezing (Group 1 n = 6; Group 2 n = 7) were almost equally seen. They did not interfere with the surgical steps. Preserving eye movements was advantageous as no superior rectus traction suture was performed in any patient. The movements were controlled by verbal command. The patient's ability to move the eye in a particular direction was helpful to bring the area into the surgical field. This was particularly useful while performing trabeculectomy with the superior approach.
Touch sensation (Group 1 n = 3; Group 2 n = 2) was perceived during conjunctival manipulation, cauterization of the episcleral vessels and during creation of the superficial scleral flap. It did not affect the surgical steps. Three patients were bothered with the microscope light during the initial part of the surgical procedure. However, no patients complained of discomfort due to the microscope light. Reducing the illumination of the microscope light to a minimum and increasing it as the surgical steps advanced, helped alleviate potential discomfort from the light. An interesting observation was the instillation of trypan blue dye to stain the anterior capsule that helped reduce discomfort from the microscope light. Under topical anesthesia, to avoid direct illumination of the microscope light, the patient shifts their gaze vertically or laterally. With the injection of trypan blue dye in the anterior chamber these movements decrease as the intensity of light entering the eye is reduced by the stained anterior chamber.
Intraoperative complications were similar in both Groups. We believe they were not related to the type of the anesthesia (zonular dehiscence, iris prolapse and posterior capsular rupture).
Five patients in Group 1 and 3 patients in Group 2 required either sedation or complete loss of ocular sensation during the surgical procedure. However, more patients in Group 2 (Group 1 n = 23; Group 2 n = 31) preferred the same anesthetic technique if they had to undergo combined surgery for the fellow eye in the future. This could be due to injection of intracameral lignocaine after completion of phacoemulsification of the nucleus in Group 2 patients. While intracameral lignocaine was injected in Group 1 patients at the beginning of phacoemulsification. Intracameral lignocaine injected prior to trabeculectomy does reduce the pain arising due to iridectomy. This observation was supported by the reduced postoperative pain score on VAS. Eight patients (Group 1 n = 3; Group 2 n = 5) had combined surgery with peribulbar or retrobulbar anesthesia. These patients were very cooperative for the entire procedure.
The surgeon's expertise and experience are important factors in performing any ocular surgery in patients with minimal anesthesia. If intraoperative problems occur, surgery may be prolonged. A novice surgeon may find it difficult to address this problem due to inadvertent eye or head movements. A systemic sedation or local anesthetic supplementation does help. Only 1 patient in Group 1 and 2 patients in Group 2 complained of ocular discomfort during conjunctival apposition, but did not require supplemental anesthesia. This could be because we actively conversed with the patient during the surgical procedure and proper preoperative counseling did help reduce anxiety and improve patient cooperation in these cases.
This study involves a single surgeon. Involving two or more surgeons with different expertise and conducting a multicenter trial would have been beneficial for this study. The effect of intracameral supplementation of lignocaine on corneal endothelium was not investigated because a specular microscope was not available while this study was being performed. However, the safety and efficacy of 1% intracameral lignocaine has been previously reported in patients undergoing trabeculectomy.  The concentration of supplementary intracameral lignocaine in the current study was minimized down to 0.5%.
The concentration of intracameral lignocaine was minimized to 0.5% for Group 2 compared to 1% for Group 1 as the effect of a high concentration of injected lignocaine at the beginning of the surgery is long acting. However, 19 patients in Group 1 required supplemental anesthesia compared to 15 patients in Group 2. Six patients in Group 1 perceived intraoperative painful sensation compared to 2 patients in Group 2 during iridectomy. This indicates that supplementation of anesthetic agent before the expected painful stimulus does help.
| Conclusion|| |
This study proves that phacotrabeculectomy can be performed with topical application of proparacaine supplemented with 0.5% intracameral lignocaine after phacoemulsification of the nucleus by an experienced surgeon. Both types of anesthetic techniques avoid injection-related complications of peribulbar or retrobulbar anesthesia and provides safe and comfortable surgical environment. We recommend proper case selection and preoperative counseling of the patient before surgery.
| Acknowledgement|| |
I thank Dr. Avinash Turankar, Associate Professor, Pharmacology, Government Medical College, Nagpur, Maharashtra (India) for the statistical analysis
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[Table 1], [Table 2], [Table 3]