A detached retina occurs when the retina, or the thin layer at the back of the eye, becomes loose. A retinal detachment may warrant surgery within a few days to reattach the retina to the back of the eye. The frequency of hospital admissions for retinal detachment and vitreoretinal surgery has been steadily increasing, as demonstrated in a British study focused on the last two decades [1]. Three types of surgery can fix a detached retina, including a pneumatic retinopexy, a scleral buckle, and a vitrectomy [2]. The type of surgery required will depend on a few elements, including where and how much of the retina was detached [3]. Retina surgery has specific anesthesia needs given the unique conditions of operating inside the eye.
Ideally, the anesthetic agent should provide the patient with the most possible comfort while still allowing the ophthalmologist to operate fluidly. Local or general anesthesia can be used, each of which comes with a number of advantages and disadvantages.
The development of targeted anesthesia for the eye revolutionized vitreoretinal surgery, enabling procedures to be performed efficiently and safely while patients remain awake [4]. Different types of local anesthetics can be administered to this end, including in the form of topical anesthetics or regional blocks (e.g., a sub-Tenon, peribulbar, or retrobulbar block) when both akinesia and analgesia are warranted [5].
General anesthesia can be administered for all types of retina surgery, but is most frequently used for long and complex cases, as well as for patients with multiple underlying health conditions [6]. In addition, since regional blocks can temporarily affect vision by impacting the optic nerve, general anesthesia may be the best option for a patient with only one functioning eye. Several general anesthetics are available, administered either via inhalation or intravenous routes [7].
In the context of vitreoretinal surgery, the position of the eye undergoing the procedure is an important consideration. Some clinicians suggest that a neutral gaze is optimal for retina surgery, which may require specific anesthesia techniques and approaches, including the use of mechanical ventilation and muscle relaxants. Monitoring neuromuscular transmission when muscle relaxants are used is critical to ensuring that the relaxation does not wear off too swiftly.
The choice of the best anesthetic agent requires a comprehensive understanding of the patient’s medical and surgical history since individuals with retinal conditions often suffer from comorbidities, including cardiac disease, hypertension, or diabetes mellitus, and may be on multiple medication therapies. When opting for general anesthesia, a patient’s underlying health condition must be taken into account, ensuring that patients can continue taking their medications and effectively manage their comorbidities while receiving retina surgery [8].
References
1. Madi, H. A. & Keller, J. Increasing frequency of hospital admissions for retinal detachment and vitreo-retinal surgery in England 2000–2018. Eye 2021 368 36, 1610–1614 (2021). doi: 10.1038/s41433-021-01647-2.
2. Surgery for Retinal Detachment | National Eye Institute. Available at: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/retinal-detachment/surgery-retinal-detachment. (Accessed: 28th September 2023)
3. Detached retina (retinal detachment) – NHS. Available at: https://www.nhs.uk/conditions/detached-
retina-retinal-detachment/. (Accessed: 28th September 2023)
4. McCloud, C., Harrington, A. & King, L. A qualitative study of regional anaesthesia for vitreo-retinal surgery. J. Adv. Nurs. (2014). doi:10.1111/jan.12263
5. Pucchio, A. et al. Anesthesia for ophthalmic surgery: an educational review. International Ophthalmology (2023). doi:10.1007/s10792-022-02564-3
6. Young, S. & Basavaraju, A. General anaesthesia for ophthalmic surgery. Anaesthesia and Intensive Care Medicine (2022). doi:10.1016/j.mpaic.2022.08.009
7. Kong, K. L. & Kirkby, G. Anaesthesia for vitreo-retinal surgery. Curr. Anaesth. Crit. Care (2010). doi:10.1016/j.cacc.2009.11.008
8. Retinal Physician – Anesthesia for Retinal Surgery. Available at: https://www.retinalphysician.com/issues/2023/july-august-2023/anesthesia-for-retinal-surgery#reference-23. (Accessed: 2nd October 2023)