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• W2049367662 abstract "The main feature of the study by Li et al on sub-Tenon’s anesthesia,1Li H.K. Abouleish A. Grady J. et al.Sub-Tenon’s injection for local anesthesia in posterior segment surgery.Ophthalmology. 2000; 107 (discussion 46–7): 41-46Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar is that the injection of a relatively high volume of local anesthetic (11 mL) into the sub-Tenon’s space provides a very efficient anesthesia, including total akinesia of the globe and eyelids. Some concerns need discussion. The authors are convinced that the efficacy of sub-Tenon’s anesthesia is due to a spread of the local anesthetic into the intraconal (retrobulbar) space through the Tenon’s capsule, which is not tightly sealed. This belief is mainly based on the echographic observation by Stevens.2Stevens J.D. Restori M. Ultrasound imaging of no-needle 1 quadrant sub-Tenon’s local anaesthesia for cataract surgery.Eur J Implant Refract Surg. 1993; 5: 35-38Abstract Full Text PDF Scopus (21) Google Scholar Stevens observed “a leakage of solution out of Tenon’s space to the anterior intra-conal space.” He explains that his technique “acted both locally and at distance as an anterior intraconal block. … Posterior diffusion of solution may directly block the ciliary ganglion.” In our opinion, a partial spreading of the local anesthetic from the sub-Tenon’s space to the intraconal space may occur but is not sufficient to explain the high quality of anesthesia provided by a sub-Tenon’s injection. Stevens assumed in the same paper that “a potential sub-Tenon’s space exists and local anesthetic fluid administration allows diffusion of solution throughout this compartment, probably acting on posterior ciliary nerves as they enter the globe.” In two previous works on human cadavers, we described the spread of a dye simulating a sub-Tenon’s anesthesia.3Ripart J. Prat-Pradal D. Vivien B. et al.Medial canthus episcleral (sub-Tenon’s) anesthesia imaging.Clin Anat. 1998; 11: 390-395Crossref PubMed Scopus (28) Google Scholar, 4Ripart J. Metge L. Prat-Pradal D. et al.Medial canthus single injection episcleral (sub-Tenon’s anesthesia) computed tomography imaging.Anesth Analg. 1998; 87: 42-45PubMed Google Scholar Our main conclusion was that the spread of the local anesthetic in the sub-Tenon’s space is sufficient to explain both anesthesia and akinesia of the globe. A small volume (3ml) of local anesthetic injected into the sub-Tenon’s space spreads all around the scleral portion of the globe. As the ciliary nerves, which provide the sensory innervation of the globe pass through the sub-Tenon’s space, they will encounter the local anesthetic, a fact that leads to a good anesthesia of the globe. Moreover, Li et al inject a high volume of local anesthetic (11 ml). The Tenon’s capsule (fascial sheath of the eyeball) is pierced by the tendons of the rectus and oblique muscles near their scleral insertions. The Tenon’s capsule is continued by the fascial sheaths of those muscles. Therefore, increasing the volume injected into the Tenon’s space will force the spreading of the local anesthetic into the muscular sheaths, where the motor nerves will be blocked. This accounts for the good akinesia. In addition, as the Tenon’s capsule is not tightly sealed frontwards, a part of the excess of local anesthetic may leak into the lid. This will provide a good akinesia of the orbicularis muscle of the lids, as it occurs after a peribulbar injection, thus avoiding the need for an additional facial nerve block. So, we assume that the spreading of the local anesthetic from the sub-Tenon’s space to the intraconal space does occur in a small amount, with no clinical relevance. Injecting a high volume of local anesthetic into the sub-Tenon’s space leads to a specific spread that explains the very good efficacy and reproducibility of anesthesia, as compared to peribulbar or retrobulbar injections.3Ripart J. Prat-Pradal D. Vivien B. et al.Medial canthus episcleral (sub-Tenon’s) anesthesia imaging.Clin Anat. 1998; 11: 390-395Crossref PubMed Scopus (28) Google Scholar, 4Ripart J. Metge L. Prat-Pradal D. et al.Medial canthus single injection episcleral (sub-Tenon’s anesthesia) computed tomography imaging.Anesth Analg. 1998; 87: 42-45PubMed Google Scholar, 5Ripart J. Lefrant J.Y. de La Coussaye J.E. et al.Peribulbar versus retrobulbar anesthesia for ophthalmic surgery. An anatomical comparison of extraconal and intraconal injections.Anesthesiology. 2001; 94: 56-62Crossref PubMed Scopus (92) Google Scholar, 6Ripart J. Lefrant J.Y. Vivien B. et al.Ophthalmic regional anesthesia medial canthus episcleral (sub-tenon’s) anesthesia is more efficient than peribulbar anesthesia. A double-blind randomized study.Anesthesiology. 2000; 92: 1278-1285Crossref PubMed Scopus (73) Google Scholar The results of Li et al are in agreement with our experience: in 4,000 patients using a high volume injection, we observed a good efficacy of sub-Tenon’s anesthesia (unpublished data). We used a needle approach instead of the surgical two-handed cannula approach used by Li et al.3Ripart J. Prat-Pradal D. Vivien B. et al.Medial canthus episcleral (sub-Tenon’s) anesthesia imaging.Clin Anat. 1998; 11: 390-395Crossref PubMed Scopus (28) Google Scholar, 4Ripart J. Metge L. Prat-Pradal D. et al.Medial canthus single injection episcleral (sub-Tenon’s anesthesia) computed tomography imaging.Anesth Analg. 1998; 87: 42-45PubMed Google Scholar, 6Ripart J. Lefrant J.Y. Vivien B. et al.Ophthalmic regional anesthesia medial canthus episcleral (sub-tenon’s) anesthesia is more efficient than peribulbar anesthesia. A double-blind randomized study.Anesthesiology. 2000; 92: 1278-1285Crossref PubMed Scopus (73) Google Scholar, 7Ripart J. Lefrant J.Y. L’Hermite J. et al.Caruncle single injection episcleral (sub-Tenon’s) anesthesia for cataract surgery mepivacaine versus a lidocaine-bupivacaine mixture.Anesth Analg. 2000; 91: 107-109PubMed Google Scholar Using a cannula should avoid most of the complications due to an inadvertent misplacement of the needle. However, a needle technique is more simple to perform. It may be performed in a preanesthesia room without surgical drapes and dressing. Therefore, it might hasten the turnover of patients in the operating room. It appears relatively safe in our experience, provided it is performed by well-trained physicians with a good knowledge of anatomy. Li et al assume that increasing the volume of local anesthetic injected should increase the duration of anesthesia. This is a mistake: increasing the volume may increase the area where the local anesthetic will spread, therefore blocking more nerves and increasing the area anesthetized. The duration depends mainly on the drug used. For example, bupivacaine is a long acting drug, as lidocaine and mepivacaine are short acting.7Ripart J. Lefrant J.Y. L’Hermite J. et al.Caruncle single injection episcleral (sub-Tenon’s) anesthesia for cataract surgery mepivacaine versus a lidocaine-bupivacaine mixture.Anesth Analg. 2000; 91: 107-109PubMed Google Scholar Li et al use relatively high doses of sedative/anesthetic drugs. Fentanyl is not an anxiolytic drug but a very potent acting morphine-like drug. As anesthesiologists, we consider that doses of up to 3 mg midazolam and/or 50μg of fentanyl are in fact significant intravenous anesthesia. It might be noted that even at relatively low doses, such drugs might lead to confusion with paradoxical restlessness. Repeated injections of these drugs may lead to respiratory depression and apnea, which might be devastating in a surgery where the anesthesiologist may not gain any access to the airway. In that situation, repeated injections of metohexital or propofol (both are intravenous anesthetics) may lead to unacceptable hazards. We advise surgeons to be extremely cautious with additional sedative/anesthetic drugs during a surgery which precludes any access to the airway. Author replyOphthalmologyVol. 109Issue 2Preview Full-Text PDF" @default.
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