Shifting Paradigm: From General Anesthesia to  
Local Anesthesia in Posterior Segment Surgeries  
Sidrah Riaz1, Muhammad Tariq Khan2, Munir Ahmad3, Nadeem Hafeez Butt4, Shabana Chaudhay5  
1-3Akhtar Saeed Medical and Dental College, 4Allama Iqbal Medical and Dental college, 5Mayo Hospital, Lahore  
Purpose: To evaluate the type and methods of anesthesia used in posterior segment ocular surgeries.  
Study Design: Cross sectional survey.  
Place and Duration of Study: Akhtar Saeed Medical College, from April 2017 to May 2019.  
Material and Methods: Two hundred and three patients who underwent posterior segment surgeries were  
selected by convenient sampling technique. Average surgery time was 45 minutes under local anesthesia (LA)  
but all patients whose surgery was performed in general anesthesia (GA), had at least 6 hours hospital stay and  
four hour nothing by mouth before and after procedure, under observation of doctor/anesthetist and nursing staff.  
Patient age, gender, indication for surgery, type of surgery performed and type of anesthesia were noted. Data  
was analyzed by using SPSS 25.  
Results: Total 203 patients were included in study, 122 (60.1%) male and 81 (39.9%) females. General  
anesthesia (GA) was used in 18.2% surgeries and local anesthesia (LA) was opted in 81.8%. Mean age of  
patients who underwent GA was 30.62 years and 51.71 years for LA. Three major indications for LA were retinal  
attachment surgery 64 (38.6%), vitreous hemorrhage 20 (12%) and endophthalmitis in 12 (7.2%) patients.  
Indications for surgery under GA were surgery for retinal detachment in 23 (62.2%), endophthalmitis 6 (16.2%)  
and removal of silicon oil 2 (5.4%). PPV was done in 64.5% patients under LA and 9.8% in GA but all combined  
procedures (PPV and scleral buckling) were done under GA.  
Conclusion: The local anesthesia is favorable for posterior segment ocular surgeries in term of less hospital  
stay, no need of NPO, fast recovery and cost effectiveness.  
Key Words: Local anesthesia (LA), General anesthesia (GA), Scleral buckling, Retinal detachment (RD), Pars  
plan vitrectomy (PPV).  
How to Cite this Article: Riaz S, Khan MT, Ahmad M, Butt NH. Shifting Paradigm: From General Anesthesia to  
Local Anesthesia in Posterior Segment Surgeries. Pak J Ophthalmol. 2020; 36 (3): 263-266.  
Doi: 10.36351/pjo.v36i3.1001  
Holmes3. Alcohol is oldest known sedative 4. An ideal  
anesthetic agent is good analgesic, cost effective, long  
acting and free of side effects. Over the last two  
decades vitreoretinal surgeries have increased and new  
techniques, instruments and modalities have been  
introduced for pars plana vitrectomies (PPV)5-7.  
Initially the trend was towards general anesthesia and  
nearly all pars plana vitrectomies, sclera buckling and  
retinopexies were performed under general anesthesia.  
For last one decade there is increased frequency of  
posterior segment surgeries under local anesthesia  
with or without intravenous sedation. Local anesthesia  
History of anesthesia dates back to 3400 BC1,2. There  
is a deep desire inside human, since ancient times that  
they want to be pain free. First evidence of use of term  
anesthesia came in 1846, coined by Oliver Wendell  
Correspondence to: Sidrah Riaz  
Akhtar Saeed Medical and Dental College, Lahore  
Email: sidrah893@yahoo.com  
Received: February 8, 2020  
Accepted: May 4, 2020  
Revised: May 4, 2020  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 263-266  
Sidrah Riaz, et al  
has many advantages over general anesthesia  
including less hospital stay, ambulatory surgery, no  
need of specialized theatre facilities, early recovery  
and cost effectiveness. Pakistan is a developing  
country and delayed presentation of retinal detachment  
added with fewer resources like unavailability of  
retinal surgeon and special operation theaters are  
major factors leading to poor visual outcomes after  
surgery. The ability and facility to perform ocular  
posterior segment surgeries under local anesthesia  
significantly decreases recovery time and cost.  
whom 25 (67.6%) were males and 12 (32.4%) were  
females. Local anesthesia was opted in majority of  
patients; 166 (81.8%) including 97 males (58.4%) and  
69 females (41.6%). Age ranged from 2 years to 83  
years and mean age of patients who underwent surgery  
in general anesthesia was 30.62 years and 51.71 years  
for local anesthesia patients (shown in table 1). Three  
top most indications for LA were retinal detachment  
(RD) in 64 (38.6%) patients, vitreous hemorrhage in  
20 (12%) and endophthalmitis in 12 (7.2%) patients  
(Pie chart 1). Most common indication for surgery  
under GA were RD in 23 (62.2%), endophthalmitis in  
6 (16.2%) and removal of silicone oil in 2 (5.4%)  
patients (Pie Chart 2). The common procedure for RD  
repair was PPV with or without scleral buckling. Out  
of 203 posterior segment ocular surgeries, 131 (64.5%)  
were performed under LA and 20 (9.8%) in GA. All  
patients of scleral buckling were operated in GA  
except 2 in whom LA with sedation.  
Rationale of this study was to find out the  
feasibility of posterior segment surgeries under local  
anesthesia by evaluating the type and methods of  
anesthesia used in posterior segment ocular surgeries.  
Over the last two years, from April 2017 to May 2019,  
all patients who underwent posterior segment ocular  
surgeries were included in study. Informed consent  
was taken by all patients and patient fitness for general  
anesthesia was checked by consultant anesthetist.  
Before surgery blood pressure, serum sugar, hepatitis  
B and C tests were checked by anesthetist in all  
patients and ECG for selected patients and intravenous  
access was secured. The technique for local anesthesia  
was peri-bulbar and facial block, performed by  
ophthalmologist himself, using lignocaine injection  
2% and bupivacaine 0.5%. Nearly 3cc of combined  
lignocaine and bupivacaine was injected in peri-bulbar  
area of the eye to be operated and also in pre-auricular  
area of ipsilateral side. Anesthetist was available for  
monitoring of vitals and to counteract any unforeseen  
events. The main drugs used by the anesthetist for  
sedation were Propofol, Ketamine and Midazolam in  
general anesthesia with endotracheal intubation.  
Average surgery time was 40 minutes but all patients  
whose surgery was performed in general anesthesia,  
had at least 6 hour hospital stay and 4 hour nothing by  
mouth after procedure, under the observation of  
doctor/anesthetist and nursing staff. Patient age,  
gender, indication for surgery, type of surgery  
performed and type of anesthesia were noted. Data  
was analyzed by SPSS version 25.  
Table 1:  
was used. All combined procedures (PPV & scleral  
buckling) were done under GA.  
Vitreoretina has recently been recognized as a separate  
specialty and is flourishing in ophthalmology. New  
trends and techniques are being evolving.8-10  
Previously, almost every posterior segment surgery  
was performed under general anesthesia, but now  
more posterior segment surgeries are being performed  
under local anesthesia. General anesthesia is used only  
in selected cases, reserved for children, mentally  
handicapped patients, for scleral buckling and patients  
with complex or complicated medical history. Scleral  
buckling is traditionally performed under GA, but in  
our study out of total 10 patients, one patient was done  
under LA combined with IV sedation.  
The painful steps during vitreoretinal surgery are  
sclerectomies (trocar cannula placement and  
withdrawal), application of endolaser, and scleral  
indentation for peripheral vitreous shaving.11-15  
Total 203 patients were included in the study,  
including 122 (60.1%) males and 81 (39.9%) females.  
General anesthesia was used in 37 (18.2%), out of  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 263-266  
Shifting Paradigm: From General Anesthesia to Local Anesthesia in Posterior Segment Surgeries  
Anesthesia is required to make patient comfortable  
during these steps. Duration of vitreoretinal procedure  
is usually from 35 to 55 minutes.  
The surgical practices change with time according to  
resources and prevalent conditions. Now there is a  
trend of performing anterior segment surgeries in  
topical anesthesia rather local anesthesia and posterior  
segment surgery under local anesthesia rather general  
anesthesia. The local anesthesia is favourable and  
beneficial for posterior segment ocular surgeries in  
terms of less hospital stay, no need of NPO, fast  
recovery and cost effectiveness especially in  
developing countries. The patient is also able to  
maintain required head positioning within hour after  
surgery, if it is performed under local anesthesia.  
Lignocaine 2% combined with bupivacaine 0.5%  
is safe, effective and acceptable anesthetic agent in  
ocular surgery providing anesthetic effect up to 60  
minutes16,17. Lignocaine and bupivacaine combined  
mixture is better in analgesia and akinesia for longer  
duration than lignocaine alone. The retro-bulbar  
injection is safe in expert and trained hands with  
minimal side effects. Its complications are very rare  
but sight threatening. Retrobulbar block is rarely  
associated with complications like ocular perforation,  
brain stem infarction18 as patient co-operation is very  
important during peri-bulbar or retro-bulbar injections  
and patient looking toward wrong direction can lead to  
undesirable effects. In our study we did not have any  
of these complications.  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
The different pharmacological agents, depending  
upon patient age, comorbid associations and  
anesthetist preference, used in GA are Propofol,  
Ketamine and Midazolam which have average  
Conflict of Interest  
Authors declared no conflict of interest.  
duration of 10, 20 and 30 minutes respectively19,20,21  
Authors’ Designation and Contribution  
Sidrah Riaz; Associate Professor: Data collection,  
Data Analysis, Manuscript writing.  
An ideal anesthetic agent is of sufficient duration  
with least side effects so that patient and surgeon both  
are comfortable. LA has certain advantages over GA  
including less hospital stay, less cost, less surgical  
time, no NPO required, quick and early recovery. LA  
is usually given by eye surgeon and anesthetist  
monitors patient’s vitals. GA is associated with more  
significant side effects in geriatric patients.  
Muhammad Tariq Khan; Associate Professor: Primary  
Surgeon, final review.  
Munir Ahmad; Associate Professor: Concept, final  
Nadeem Hafeez Butt; Professor: Concept, Final  
As we are living in a developing country and  
resources do matter; LA is cheaper than GA. Small  
gauge 23 G vitrectomies are also being done under  
topical anesthesia22 as in report by Mahajan et al. but it  
also depends upon patient factors (threshold of pain  
varies from person to person) and surgeon expertise23  
(duration of surgery and skills). In a study by Gupta et  
al. in neighboring country India, intracameral  
preservative free lignocaine 2%, augmented with  
topical anesthesia with proparacaine 0.5% was found  
Shabana Chaudhary; Assistant Professor: Concept,  
Final review.  
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