Oculofacial Anesthesia

Key Points

•Anesthetic agents utilized in periorbital surgery include topical ophthalmic drops and skin creams, oral and injectable agents, intravenous medications, inhaled anesthetics, and regional nerve blocks. All modalities have risks that the surgeon should be familiar with.

•Modern anesthesia techniques provide surgeons the ability to perform more procedures on conscious patients, avoiding the risks of deeper sedation.

•Management of preoperative anxiety with oral medications is an important element of care. Familiarization with these medications is critical before they are administered.

•Local injectable anesthetics have the potential for significant toxic side effects.

•Local injectable anesthetics can be used effectively alone, or in conjunction with intravenous medications or deeper sedation to provide effective analgesia.

•Conscious sedation must be performed with adequate monitoring in a credentialed setting.

•Postoperative pain management, which is an important part of care, can be accomplished with a variety of oral, injectable, and intravenous medications.

•Intravenous monitored anesthesia care (MAC) or general anesthesia is safe and effective when administered by a trained anesthesia specialist.

•Regional motor and sensory blocks can aid greatly in facilitating surgery and potentially avoiding the need for riskier forms of anesthesia.

•The physician administering any form of anesthesia should be prepared to address all possible complications related to treatment.

J.A. Woodward (*)

Associate Professor, Chief Division of Oculofacial Surgery, Department of Ophthalmology, Duke University,

Durham, NC, USA

e-mail: juliewoodward1@mac.com

5.1Introduction

Aesthetic eyelid and periorbital procedures require particular attention to the appropriate anesthetic choice. The procedures may be performed at the physician’s office, a minor procedure room, or an operating room. As such, it is important to evaluate the procedure and patient selection criteria for procedure location and anesthesia type. Options for anesthesia include topical medications (drops, skin creams), local injectable agents, tumescent infiltration, oral medications, intravenous sedation, and general anesthesia. Factors in determining the appropriate type of anesthesia include procedure length, invasiveness, patient comorbidities, age, anxiety level, prior history of similar procedures, and pain tolerance. Selection should reflect a team approach involving the patient, family, and care providers.

5.2Topical Anesthesia

5.2.1Eye Drops

Topical ophthalmic drops can be used to anesthetize the ocular surface, place protective shields in the eye for surgery, remove small conjunctival lesions, and epilate lashes. They are also useful when examining patients who are intolerant of light or instruments approaching the eye. In addition, they prevent eye burning from surgical preparation solutions, such as betadine, that may contact the eye. The surgeon should be aware that topical anesthetics break down the hemidesmosomes that attach the corneal epithelium to Bowman’s layer of the cornea which predisposes to corneal abrasion [1]. These drops delay corneal wound healing and should be used for procedural and diagnostic purposes only. Anesthetic drops should not be given to patients to take home for pain control, as corneal decomposition, nonhealing abrasions, or ulcers may develop [2].

Proparacaine hydrochloride 0.5% ophthalmic solution is the most commonly used topical medication for surface