Medial Canthus Single Injection Peribulbar Anesthesia Using 13

Medial Canthus Single Injection Peribulbar Anesthesia Using 13 x 0. 45 mm Needle: Technique Presentation. 32 nd Annual Scientific Conference of the Ophthalmic Anesthesia Society ALEXANDRE ROTH DE OLIVEIRA MD, MSc NO CONFLICT OF INTEREST CHICAGO - 2018

Picetti E. MD Ophthalmologist Severo N. MD Ophthalmologist Kronbauer AK. MD Ph. D Ophthalmologist Oliveira JBR. MD Anesthesiologist

OBJECTIVES SAFE LIFE DEATH SEIZURES OC REFLEX EFFICACY SIGHT PERFORATION HEMORRAHGE OPTIC NERVE RETINAL VASCULAR ANALGESIA AKINESIA GOOD IOP

ALMOST NOTHING !!! NEW GLANCE for and OLD KNOWLEDGE.

EFFICACY

WHAT’S NEW ? ? ? NEEDLE !!!

25 mm needle BUT inserted ONLY (? ) 15 – 20 mm

NEEDLE 13 x 0, 45 mm

WHAT A BIG DIFFERENCE !!!!

LA 13 mm 25 mm LA 24 mm 12 mm GENTLY PRESSURE 13 mmm

SAFETY

SAFER SITES: ▪ INFERO-TEMPORAL (DANGER) ▪ MEDIAL CANTHUS

Posterior Staphyloma Ophthalmology. 2014; 121: 1798 -1809.

TECHNIQUE ▪ Monitors – IV access ▪ Topical anesthesia/ Mydriatic drops ▪ Conscious sedation (only Propofol) EYE 2002, 16: 60 -62. ▪ Neutral position of the patient’s head ▪ 90º- 90º Approach Rule ▪ Local anesthetic of choice with Hyalozime (Journal App Res 12(1) 2012) ▪ Needle 13 x 0, 45 mm (sharp) ▪ Volume 5 m. L (Journal of Cataract & Refractive Surgery , 32(9), 1509 – 1512. 2006) ▪ Point of Puncture: Up-caruncle ▪ Chandler’s Maneuver (30 s On/ 5 s Off – 2 times) ▪ 10 -15 min until surgery.

Point of Puncture

90 -90º Rule PATIENT’S HEAD ROTATED = ADAPT YOUR POSITION

Right-handed Anesthesiologist LEFT EYE RIGHT EYE

“Baby steps” Migration: • FROM Lateral-inferior TO Caruncular as PRIMARY approach. Use rules (LI: CRC) 4: 2 m. L/3: 3 m. L/2: 4 m. L/6 m. L/5 m. L • FROM 25 mm needle TO 13 mm needle. Use 25 mm Infero-lateral and 13 mm Caruncular.

NOT IN the Plica Semilunaris ▪ Pinkish crescentric fold of conjunctiva present in medial canthus. ▪ Highly vascularized and rich in goblet cells.

PROBLEMS ? ! ▪ Deviation of the eye to nasal side (mass-effect of anesthethic solution in medial rectus muscle? ) Gawęckiand, M and Grzybowski, A. J Ophthalm 2016. Hogan, K. et al Anesthesiology 1994. ▪ Akinesia/Analgesia not 100% with 5 m. L (first cases). Remember: DIGITAL PRESSURE ! ▪ Palpebral hematoma (plica semilunaris).

THANK YOU