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• W2227604555 abstract "The article by Koolwijk et al1Koolwijk J. Fick M. Selles C. et al.Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.Ophthalmology. 2015; 122: 281-287Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar is welcomed, but we believe the title should be reworded. The authors looked at nearly 7000 consecutive cataract operations using topical/intracameral anesthesia without sedation, and concluded that “Cataract surgery can be safely performed in an outpatient clinic, in the absence of the anesthesia service and with limited workup and monitoring. Basic first aid and basic life support skills seem to be sufficient in case of an adverse event. A medical emergency team provides a generous fail-safe for this low-risk procedure.” We generally agree with this conclusion, but disagree with the title, which states that “Incident and Procedural Risk Analysis Do Not Support Current Clinical Ophthalmology Guidelines.”We co-chaired the committee that produced the 2012 Guideline “Local Anaesthesia (LA) for Ophthalmic Surgery,”2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar published jointly by Royal College of Anaesthetists and the Royal College of Ophthalmologists, United Kingdom. We attempted to produce an evidence-based guideline, and wrote that, “Ideally, robust guidelines are based on numerous high-quality studies which have been designed to answer important clinical questions. For many aspects of these guidelines, it is apparent that the literature is not adequate.” For this reason, many of our recommendations were based on expert consensus. Koolwijk's case series is a welcome addition to the body of evidence for future clinical guidelines: the low rate of life-threatening complications with topical LA is in agreement with similar prospective case series that looked at sub-Tenons LA.3Guise P.A. Sub-Tenon anesthesia: a prospective study of 6,000 blocks.Anesthesiology. 2003; 98: 964-968Crossref PubMed Scopus (116) Google Scholar, 4Clarke J.P. Plummer J. Adverse events associated with regional ophthalmic anaesthesia in an Australian teaching hospital.Anaesth Intensive Care. 2011; 39: 61-64PubMed Google ScholarThe system described by Koolwijk is almost fully compliant with the 2012 UK LA guideline,2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar and also with the previous (2001) version.5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar The main difference is that the UK guideline recommends pulse oximetry as the minimum for monitoring; Koolwijk et al instead measured blood pressure during surgery. The 2001 UK LA Guideline stated that routine preoperative blood tests and electrocardiography are not necessary, and cases using topical or sub-Tenon anesthesia (without sedation) may be monitored by a nonanesthetist using clinical observation and pulse oximetry only. It went on to say that all clinical staff should have training in life support, resuscitation equipment should be available, and there should be at least 1 person in the operating theater suite with more advanced life-support training.5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar The 2012 guideline has repeated this recommendation, with the clarification that “all ophthalmic units should have formal policy for dealing with medical emergencies should they occur. Appropriate backup from a cardiac arrest/Medical Emergency Team should always be available.” For isolated units, away from a main hospital, we recommended that there should be “a clear, agreed and regularly tested pathway to enable the patient to receive appropriate advanced medical care, including intensive care.”2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar While preparing the 2012 guideline, the committee believed that more than one-half of UK cataract surgeries were already being performed in this way. Therefore, Koolwijk's system would not be considered innovative to a British ophthalmologist.As far as we are aware, the UK LA guideline2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar, 5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar is the only one in the world that is dedicated to anesthesia for eye surgery. The 4 national guidelines cited by Koolwijk et al1Koolwijk J. Fick M. Selles C. et al.Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.Ophthalmology. 2015; 122: 281-287Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar are for cataract surgery; the American, Canadian, and Dutch guidelines are indeed more conservative, and recommend fuller workup and monitoring. The exception is the 2010 UK guideline on cataract, which cites the 2001 UK LA guideline.5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar The UK LA guidelines have proved to be noncontroversial, and have been widely disseminated, with nearly 7000 free downloads of the 2012 LA guideline to date. The article by Koolwijk et al does support the UK LA guideline, and the UK LA guideline supports the practice of Koolwijk et al. We hope that the article by Koolwijk et al will encourage others to adopt a UK-style approach, which we believe to be patient friendly, safe, and cost effective. The UK LA guideline should be read in full; the easiest way for readers to access it is through the website of the British Ophthalmic Anaesthesia Society, www.boas.org. The article by Koolwijk et al1Koolwijk J. Fick M. Selles C. et al.Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.Ophthalmology. 2015; 122: 281-287Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar is welcomed, but we believe the title should be reworded. The authors looked at nearly 7000 consecutive cataract operations using topical/intracameral anesthesia without sedation, and concluded that “Cataract surgery can be safely performed in an outpatient clinic, in the absence of the anesthesia service and with limited workup and monitoring. Basic first aid and basic life support skills seem to be sufficient in case of an adverse event. A medical emergency team provides a generous fail-safe for this low-risk procedure.” We generally agree with this conclusion, but disagree with the title, which states that “Incident and Procedural Risk Analysis Do Not Support Current Clinical Ophthalmology Guidelines.” We co-chaired the committee that produced the 2012 Guideline “Local Anaesthesia (LA) for Ophthalmic Surgery,”2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar published jointly by Royal College of Anaesthetists and the Royal College of Ophthalmologists, United Kingdom. We attempted to produce an evidence-based guideline, and wrote that, “Ideally, robust guidelines are based on numerous high-quality studies which have been designed to answer important clinical questions. For many aspects of these guidelines, it is apparent that the literature is not adequate.” For this reason, many of our recommendations were based on expert consensus. Koolwijk's case series is a welcome addition to the body of evidence for future clinical guidelines: the low rate of life-threatening complications with topical LA is in agreement with similar prospective case series that looked at sub-Tenons LA.3Guise P.A. Sub-Tenon anesthesia: a prospective study of 6,000 blocks.Anesthesiology. 2003; 98: 964-968Crossref PubMed Scopus (116) Google Scholar, 4Clarke J.P. Plummer J. Adverse events associated with regional ophthalmic anaesthesia in an Australian teaching hospital.Anaesth Intensive Care. 2011; 39: 61-64PubMed Google Scholar The system described by Koolwijk is almost fully compliant with the 2012 UK LA guideline,2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar and also with the previous (2001) version.5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar The main difference is that the UK guideline recommends pulse oximetry as the minimum for monitoring; Koolwijk et al instead measured blood pressure during surgery. The 2001 UK LA Guideline stated that routine preoperative blood tests and electrocardiography are not necessary, and cases using topical or sub-Tenon anesthesia (without sedation) may be monitored by a nonanesthetist using clinical observation and pulse oximetry only. It went on to say that all clinical staff should have training in life support, resuscitation equipment should be available, and there should be at least 1 person in the operating theater suite with more advanced life-support training.5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar The 2012 guideline has repeated this recommendation, with the clarification that “all ophthalmic units should have formal policy for dealing with medical emergencies should they occur. Appropriate backup from a cardiac arrest/Medical Emergency Team should always be available.” For isolated units, away from a main hospital, we recommended that there should be “a clear, agreed and regularly tested pathway to enable the patient to receive appropriate advanced medical care, including intensive care.”2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar While preparing the 2012 guideline, the committee believed that more than one-half of UK cataract surgeries were already being performed in this way. Therefore, Koolwijk's system would not be considered innovative to a British ophthalmologist. As far as we are aware, the UK LA guideline2Kumar C.M. Eke T. Dodds C. et al.Local anaesthesia for ophthalmic surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2012www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-247-Local-Anaesthesia-in-Ophthalmic-Surgery-2012.pdfCrossref Google Scholar, 5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar is the only one in the world that is dedicated to anesthesia for eye surgery. The 4 national guidelines cited by Koolwijk et al1Koolwijk J. Fick M. Selles C. et al.Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.Ophthalmology. 2015; 122: 281-287Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar are for cataract surgery; the American, Canadian, and Dutch guidelines are indeed more conservative, and recommend fuller workup and monitoring. The exception is the 2010 UK guideline on cataract, which cites the 2001 UK LA guideline.5Astbury N. Bagshaw H. Desai P. et al.Local Anaesthesia for Intra-ocular Surgery (guideline). Royal College of Anaesthetists, Royal College of Ophthalmologists, London2001Google Scholar The UK LA guidelines have proved to be noncontroversial, and have been widely disseminated, with nearly 7000 free downloads of the 2012 LA guideline to date. The article by Koolwijk et al does support the UK LA guideline, and the UK LA guideline supports the practice of Koolwijk et al. We hope that the article by Koolwijk et al will encourage others to adopt a UK-style approach, which we believe to be patient friendly, safe, and cost effective. The UK LA guideline should be read in full; the easiest way for readers to access it is through the website of the British Ophthalmic Anaesthesia Society, www.boas.org. Outpatient Cataract Surgery: Incident and Procedural Risk Analysis Do Not Support Current Clinical Ophthalmology GuidelinesOphthalmologyVol. 122Issue 2PreviewTo evaluate whether an ophthalmologist-led, non–anesthesia-supported, limited monitoring pathway for phacoemulsification/intraocular lens cataract surgery, can be performed safely with only a medical emergency team providing support. Full-Text PDF ReplyOphthalmologyVol. 122Issue 11PreviewWe thank Eke et al for their critical appraisal of our article. Also we are delighted to learn that they, as co-chairs of the committee that produced the 2012 guideline “Local Anesthesia (LA) for Ophthalmic Surgery” find our work a welcome addition to the body of evidence for future clinical guidelines.1 Full-Text PDF" @default.
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