For most eye surgeries we use eye drops such as lidocaine to numb the eye. This results in excellent pain control for the patient, especially in procedures lasting less than 20-30 minutes. Cataract surgery, LASIK, and DMEK corneal transplant surgery are often performed under topical anesthesia. It is common to augment topical anesthetic drops with a small infusion of preservative-free lidocaine inside of the eye after surgery has begun. This helps to prevent pain from any manipulation of the iris or ciliary body during surgery. Furthermore, a highly experienced nurse anesthetist monitors the patient’s vital signs and will administer a small amount of intravenous pain medication or calming medication during the surgery to ensure the maximum level of patient comfort. These intravenous medications often cause amnesia for the period of time around the surgery. Topical anesthesia is the safest technique for most eye surgeries. There is no increased risk of heart attack, stroke, or death from numbing eye drops with monitored anesthesia care. Patients recover very quickly from this type of anesthesia and can usually return home within 30-60 minutes after surgery. No eye patch is required if topical anesthesia is used, but patients are given a clear protective eye shield. This is the preferred method of anesthesia because we feel it is in the safest option and in the best interest of the patient.
For some eye surgeries an additional level of anesthesia is required. If a surgery will be complex or last for 30-60 minutes or more, then an injection of numbing medicine around the eye may be used. This is referred to as a “retrobulbar block”. This type of anesthesia is often used for full thickness corneal transplants or vitrectomy surgery. The numbing medication may last for several hours causing complete numbness of the eye, inability to move the eye, and decreased vision until the block completely wears off. This injection is given in the pre-operative area under deep sedation and close monitoring by an experienced nurse anesthetist. The deep sedation causes a patient to fall asleep for a few moments while the block is administered. The patient continues to breathe on their own during this time, so no breathing tube is required. After the block is administered the patient wakes up and is taken to the operating room. The surgery proceeds with the patient awake, but relaxed, and still carefully monitored. After surgery an eye patch is usually placed and left until the next morning. The risks of retrobulbar anesthesia include a small chance of damage to the eye or structures surrounding the eye from the needle used to administer the anesthetic. There is an extremely remote chance of the anesthetic medication reaching the fluid around the brain, which could lead to loss of consciousness and the need for supportive measures until the anesthetic dissipates.
The use of general anesthesia for ocular surgery is quite rare. This type of anesthesia carries a small but very real chance of heart attack, stroke, or even death. These severe complications are more common in individuals with chronic medical problems, advanced age, or generally poor health. Rarely healthy people will have an unexpected serious reaction to general anesthesia which can lead to significant complications or even death. Even though these serious complications are rare, there is usually no need to accept these risks for ocular surgery. The only cases where general anesthesia is indicated are severe trauma or patients who cannot cooperate such as young children or those with significant behavioral issues. Due to the risks of general anesthesia we perform these surgeries at the hospital only. Surgery at a hospital entails additional risks of hospital acquired infections and instruments and staff that may not be as familiar to the surgeon as in our ambulatory surgery center. For these reasons we make every attempt to perform surgery using topical or retrobulbar anesthesia in our own surgery center. We have been successful in avoiding general anesthesia in many cases where other surgeons might have chosen to use it. We specialize in using topical or retrobulbar anesthesia with conscious sedation for patients with complex ocular problems, movement disorders, autism, dementia, and developmental conditions that would otherwise require general anesthesia to provide the safest possible experience for our patients.