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L. J. Perry, M. T. Andreoli, R. Wee, C. M. Andreoli, D. Vavvas; Comparison of General Anesthesia Versus Monitored Anesthesia Care in the Repair of Open Globes. Invest. Ophthalmol. Vis. Sci. 2008;49(13):622.
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We compared the characteristics and outcomes of open globe injuries that were repaired under monitored anesthesia care (MAC) and general anesthesia (GA) to identify patients who would benefit from open globe repair (OGR) with MAC.
We reviewed all cases of OGR performed at the Massachusetts Eye and Ear Infirmary between January '00 and April '07. Cases performed under GA were compared with cases performed under MAC, with assessment of pre-operative visual acuity (VA), retinal detachment, choroidal hemorrhage, vitreous hemorrhage, and location of wound, as well as post-operative VA. Cases performed under MAC were chosen at the surgeon’s discretion with attention to patient tolerability and safety of chosen local anesthetic method.
A total of 575 cases of OGR were performed during the study period. Forty-four patients had OGR performed under MAC, including 16/44 (36%) with peribulbar anesthesia, 20/44 (46%) with retrobulbar anesthesia, 1/44 (2%) with subtenons anesthesia, and 7/44 (16%) with topical anesthesia. The remaining 529 cases were performed under GA. Patients tolerated MAC well with no complications from the injection of local anesthetic and no cases requiring conversion to GA. Patients ranged in age from 23 to 65 years old (average 44) for MAC, and 2 to 97 years old (average 38) for GA. Of 44 patients who underwent OGR with MAC, 34% had pre-operative VA of 20/40 or better and 43% had pre-operative VA of hand motions (HM) or worse. In comparison, patients who underwent OGR under GA were statistically less likely (P = 0.006) to have good pre-operative VA (14% had 20/40 or better), with 58% having pre-operative VA of HM or worse. Patients selected for OGR under MAC compared to GA were less likely to have retinal detachment (0% vs. 2.8%), vitreous hemorrhage (9.1% vs. 10.6%), choroidal hemorrhage (0% vs. 2.6%), or optic nerve injury (0% vs. 5.3%); however, none of these differences was statistically significant. Among OGR repairs performed under MAC, there was a trend towards injuries involving more anterior wounds such as corneal lacerations classified as zone 1 (72% MAC cases vs. 56% general, P=0.059), compared to more posterior injuries. Final post-operative VA of 20/50 or better occurred in 89% of patients repaired under MAC compared to 47% of patients repaired under GA.
Middle-aged patients with good pre-operative VA or anterior wounds were more likely to be selected for OGR repair under MAC. With appropriate selection, patients with open globe injuries can safely undergo repair under local anesthesia.
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