Int Ophthalmol (2023) 43:1761–1769

https://doi.org/10.1007/s10792-022-02564-3

REVIEW

Anesthesia for ophthalmic surgery: an educational review

Aidan Pucchio · Daiana R. Pur ·
Anuradha Dhawan · Simrat K. Sodhi ·
Austin Pereira · Netan Choudhry

Received: 30 March 2022 / Accepted: 16 October 2022 / Published online: 27 November 2022
© The Author(s), under exclusive licence to Springer Nature B.V. 2022

Abstract Methods A comprehensive Embase search was

Purpose Selecting an anesthetic agent for ophthal- performed using combinations of the subject head-
mic surgery has crucial implications for the surgeon, ings “anesthesia”, “eye surgery”, “ophthalmology”
anesthesiologist, and patient. This educational review and “cataract extraction”, “glaucoma”, “strabismus”,
explores the common classes of anesthesia used in “vitreoretinal surgery”, “retina surgery”, “eye injury”,
ophthalmology. Additionally, we discuss the consid- and “eyelid reconstruction”.
erations unique to cataract, glaucoma, strabismus, Results Topical anesthetics are the most commonly
orbital, oculoplastic, and ocular trauma surgeries. used form of ocular anesthesia, used in both an office
and surgical setting, and carry a minimal side effect
Supplementary Information The online version
profile. Notably, topical anesthetics offer analgesia,
contains supplementary material available at https://​doi.​ but do not provide akinesia or amnesia. Regional
org/​10.​1007/​s10792-​022-​02564-3. blocks, such as are sub-Tenon’s, peribulbar, and ret-
robulbar blocks, are used when akinesia is required
A. Pucchio
in addition to analgesia. Recently, sub-Tenon’s blocks
School of Medicine, Queen’s University, Kingston, ON,
Canada have recently gained popularity due to their improved
safety profile compared to other regional blocks.
D. R. Pur General anesthesia is considered for long, complex
Schulich School of Medicine & Dentistry, Western
surgery, surgery in patients with multiple comorbidi-
University, London, ON, Canada
ties, surgery in young pediatric patients, or surgery in
A. Dhawan · N. Choudhry (*) patients intolerant to local or regional anesthetic.
Vitreous Retina Macula Specialists of Toronto, 3280 Bloor Conclusion Anesthetizing the eye has rapidly
Street West, Suite 310, Toronto, ON M8X3X3, Canada
evolved in recent years, supporting the safety, efficacy
e-mail: netan.choudhry@vrmto.com
and comfort of ocular surgery. Since there are many
S. K. Sodhi viable options of anesthetics available for ophthalmic
School of Clinical Medicine, University of Cambridge, surgery, a robust understanding of the patients needs,
Cambridge, UK
the skill of the surgical team, and surgery-specific
A. Pereira · N. Choudhry factors ought to be considered when creating an anes-
Department of Ophthalmology and Visual Sciences, thetic plan for surgery.
University of Toronto, Toronto, ON, Canada

N. Choudhry
Cleveland Clinic Canada, Toronto, ON, Canada

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Keywords Anesthesia · Ophthalmology · Cataract · agents, are indicated for many common procedures
Glaucoma surgery · Strabismus surgery · Oculoplastic such as tonometry, anterior chamber paracentesis, or
surgery adjunct use for injected anesthetics [4]. In addition,
4% lidocaine solution (± epinephrine) and subcon-
junctival lidocaine are can be administered topically
Introduction and are effective for shorter surgeries such as cataract
extraction [4]. The side effect profile of topical anes-
Selecting an anesthetic agent for ophthalmic surgery thetics is often minimal, whereby the most notable
has crucial implications for the surgeon, the anes- complications are hypersensitivity reactions, along-
thesiologist and most importantly, the patient [1, 2]. side other adverse effects including; headache and
Various anesthetic options offer differing levels of conjunctival hyperemia [1, 4]. While topical anesthet-
analgesia, amnesia, akinesia and as such, appropriate ics offer analgesia, they do not provide akinesia or
selection can contribute to successful and comfort- amnesia [3, 5].
able surgery [3]. The indications for anesthetizing Regional blocks are used when akinesia is required
the eye are continually evolving with use of topical in addition to analgesia. The three commonly used
agents growing in recent years due to the ease of regional blocks are sub-Tenon’s, peribulbar, and ret-
administration and rarity of severe complications, robulbar block, with a 1:1 mixture of 2% lidocaine
while the popularity of regional blocks and gen- and 0.5% bupivacaine being the most commonly used
eral anesthesia has decreased [2]. In this educational compounds. A sub-Tenon’s block involves the crea-
review we will explore the common classes of anes- tion of a small incision in the sclera (Fig. 1) [6]. A
thesia used in ophthalmology, their implications for curved cannula is passed through this scleral opening
surgery and specific considerations in common oph- and local anesthetic is injected under Tenon’s fascia
thalmic surgeries. surrounding the globe and allowing for analgesia and
akinesia of the eye. Sub-Tenon’s blocks have recently
gained popularity due to their improved safety pro-
Methods file compared to other regional blocks [7]. While
rare, complications of sub-Tenon’s blocks include
A comprehensive Embase search was performed for
articles dating back to 1947, with emphasis on arti-
cles published from 2000 to present day. Combina-
tions of the subject headings “anesthesia”, “eye sur-
gery”, “ophthalmology” and “cataract extraction”,
“glaucoma”, “strabismus”, “vitreoretinal surgery”,
“retina surgery”, “eye injury”, “eyelid reconstruction”
were used in the search. Additional keywords were
utilized where required. The authors collated the cur-
rently available literature to provide an overview of
anesthesia in ophthalmology. This educational review
is intended for use by ophthalmologists and medical
trainees as a brief overview of current use and trends
in ocular anesthesia.

Classes of anesthesia

Topical anesthetics are the most commonly used form

of ocular anesthesia, used in both an office and surgi-
cal setting. Proparacaine hydrochloride 0.5% and tet- Fig. 1  Sub-Tenon’s block demonstrating a curved cannula
racaine hydrochloride 1%, the two most widely used injecting anesthetic through a sclera incision

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subconjunctival hemorrhage, chemosis, pain, and in this review. The utility and complication profiles
globe perforation [6, 8]. The exact incidences of com- for each common class of ocular anesthesia is sum-
plications associated with sub-Tenon’s blocks are not marized in Table 1. Studies comparing the analgesic
known [9, 10]. effects of two or more classes of ocular anesthesia are
Peribulbar blocks, also known as extra-conal summarized in the Supplemental Materials.
blocks, are inserted lateral to the eye and injected into
the space outside of the intraconal orbital compart-
ment [4]. Peribulbar blocks offer akinetic and analge- Anatomical considerations
sic effects analogous to sub-Tenon injections, but may
be more painful for the patient and more challenging Analysis of the anatomy of the eye and the structures
to administer [1, 6]. While regional blocks anesthetic relevant in anesthesia have been detailed elsewhere
methods carry higher risk than both local anesthetic [1, 2]. In brief, myopic eyes with a longer axial length
and sub-Tenon’s blocks, serious complications such are at increased risk of perforation during peribulbar
as ocular perforations are exceedingly rare; peribulbar or retrobulbar injections [1]. There are seven muscles
blocks have a reported incidence of perforation, cen- that are typically relevant in ocular surgery: levator
tral retinal vein occlusion, and acute ischemic optic palpebrae superioris, the four recti and two oblique
neuropathy of 1 in 16,224 (0.006%), incidence of muscles. A membrane connects the recti, forming
increased posterior pressure requiring a vitreous tap the intraconal orbital compartment that contains the
of 9 in 16,224 (0.055%), and an incidence of orbital optic, oculomotor, nasociliary and abducens nerves
hemorrhage of 12 in 16,224 (0.074%) [10–12]. More alongside the ophthalmic artery.
severe complications such as central nervous sys- Injection of local anesthetic into the intraconal
tem involvement or brainstem anesthesia have been orbital compartment during a retrobulbar block allows
reported at even lower rates [13]. The final common for blocking of all of the nerves within this space
regional block, the retrobulbar block, involves injec- [1]. During anesthetic injections into the intraconal
tion into the intraconal orbital compartment. Ret- orbital compartment the optic nerve is particularly
robulbar blocks offer the strongest akinesia of any vulnerable to injury. Note that while the oculomo-
regional block, but due to the posterior location of tor and abducens nerves are blocked in a retrobulbar
injection and potential to make contact with the optic block, the trochlear nerve is not, which can allow for
nerve they have the greatest rates and severity of movement of the superior oblique muscle. Peribul-
complications, including optic nerve injury, retrobul- bar blocks are injected into the extra-conal space
bar hemorrhage and globe perforation [7, 14]. Despite (outside of the intraconal orbital compartment) and
a more severe risk profile, the rates of serious com- require larger volumes of anesthetic as the agent must
plications are still low for retrobulbar blocks, with diffuse through a higher volume to be effective. In a
perforation reported in 1 in 13,428 cases (0.007%), sub-Tenon’s block, local anesthesia is injected under
central nervous system complications reported in the Tenon’s fascia which surrounds the entire globe,
0.09% to 1.50% of patients, and orbital hemorrhage allowing for diffusion to the surrounding nerves and
in 1.7% [11, 12]. However, given the associated risks, muscles [1].
retrobulbar blocks are steeply declining in popularity
in modern ophthalmic surgery [11, 12].
General anesthesia is used in ophthalmology for Considerations for specialized surgery
long, complex surgery, surgery in patients with multi-
ple comorbidities, surgery in young pediatric patients, Cataract surgery
or in patients intolerant to local or regional anesthetic
[15]. There are many general anesthetics available Modern day cataract surgery is marked by its short
and selection requires a comprehensive understanding duration with safety and comfort being the two cru-
of patients medical history and surgical factors [16]. cial considerations. In addition, since patients often
The adjunct use of relaxants, such as midazolam, is desire to return to daily routine in the shortest time
often used during intraocular surgery to reduce anxi- possible, topical anesthesia has become the mainstay
ety in patients who are awake, but will not be detailed for uncomplicated cataract surgery in adults. Lack of

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Table 1  Features of common classes of ocular anesthetic
Class of anesthesia Route of administration Common agents Anesthetic features Complications
Analgesia Akinesia Amnesia

Topical Drops, cotton swab applicator Proparacaine hydrochloride 0.5%, Yes No No Eyelid numbness, hyperemia in conjunc-
tetracaine hydrochloride 1%, 4% tiva, headache, allergic reactions such
lidocaine (± epinephrine) as allergic contact dermatitis or severe
local hypersensitivity reactions
Sub-Tenon block Scleral incision and injection under 1:1 mixture of 2% lidocaine and 0.5% Yes Yes No Common: chemosis, subconjunctival
Tenon’s fascia with blunt cannula bupivacaine hemorrhage
Peribulbar block Needle passed posteriorly through per- Yes Yes No Rare: ecchymosis, retrobulbar hemor-
conjunctival puncture in inferotempo- rhage, globe injury, optic nerve dam-
ral corner of the eye age, brainstem anesthesia
Retrobulbar block Needle passed parallel to orbital floor Yes Yes No
through percutaneous or perconjunc-
tival puncture
General anesthesia Inhaled, intravenous line Propofol, ketamine, etomidate Yes Yes Yes Postoperative nausea and vomiting, ana-
phylaxis or allergic reaction, malignant
hyperthermia, respiratory depression,
embolic event
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akinesia may prove challenging for the surgeon with paucity of research examining the effect of anesthetic
a theoretically increased rate of risk of posterior cap- technique on glaucoma surgery outcomes [20].
sule rupture (PCR). However, a study by Lee et al. In non-penetrating surgeries such as deep sclerec-
demonstrated no significant difference in rate of PCR tomy and viscocanalostomy, all anesthetic classes
with topical anesthesia versus an akinetic block [17]. can be used, although general anesthetic is typically
Efficacy of topical anesthesia could be enhanced not considered [20]. When considering minimally
by use of intracameral lidocaine as an adjunct, a con- invasive glaucoma surgeries, including the insertion
cept first introduced by Gills [18]. Intracameral use of drainage devices and shunts, topical anesthesia is
is thought to produce direct anesthetic effect on iris- the safest and most tolerated option [23]. A study by
ciliary body-zonular complex. This was further evalu- Rebolleda et al. [23] comparing topical anesthetic and
ated by Carino et al. in a double-blind study where retrobulbar blocks during implantation of a drain-
patients experiences of pain were recorded in real age device found that the retrobulbar block group
time throughout surgery [19]. A significantly lower reported higher discomfort during anesthetic injec-
patient pain score was seen in the intracameral lido- tion, no difference in intraoperative or postoperative
caine group than placebo [19]. The final choice of pain and a better safety profile for the topical agents.
anesthesia among the options of topical, peribulbar/ Finally, topical agents are the only anesthesia indi-
retrobulbar block or general anesthesia will take into cated for peripheral iridotomy in cases of angle-clo-
consideration the age of the patient, complexity of the sure glaucoma.
cataract, comorbidities and the skill of the surgeon.
Strabismus and pediatric surgery
Glaucoma surgery
Strabismus surgery has historically used general
Most glaucoma surgery involves the anterior part of anesthesia to circumvent anatomical modifications
the globe and can be performed under regional or top- caused by periocular injection [5]. However, recent
ical anesthetic. An important consideration is the fact studies have reported positive results in adjustable
that injections behind the globe can increase pressure suture strabismus surgery using retrobulbar blocks
and reduce blood supply to the optic nerve. As the or subconjunctival anesthesia combined with topical
optic nerve is already compromised to some extent in agents [24, 25]. While these options might be appro-
glaucoma patients and prone to further insult, injec- priate in the adult population, strabismus surgery and
tions behind the eye should be avoided to reduce the other surgeries in young pediatric patients are almost
likelihood of optic nerve damage [20]. Other global always be performed under general anesthetic, as
considerations for anesthetic selection in glaucoma this population is less tolerant of surgery and may
surgeries are medication use, topical glaucoma medi- be more mobile during surgery. In addition, regional
cation and intraocular pressure (IOP) control [20, 21]. blocks or local anesthesia can be used for additional
Trabeculectomy can be performed under any local analgesic effect.
or general anesthesia. If nerve block is the preferred The oculocardiac reflex (OCR), a slowing of the
method of the surgical team, anterior sub-Tenon’s heart following pressure applied to the globe, is com-
block is recommended as it puts less stress on the mon in strabismus surgery. Anesthetic selection has
optic nerve [22]. While topical anesthesia use in tra- influence over OCR severity; a recent study of pediat-
beculectomy and aqueous shunt surgery is associated ric strabismus surgery found that propofol or remifen-
with higher pain and increased need for intraopera- tanil was associated with a higher incidence of OCR
tive IV anesthetic than regional blocks, this must be when compared to sevoflurane and desflurane anes-
weighed against reduced of severe complications such thesia [26]. With other studies demonstrating conflict-
as globe perforation, retrobulbar hemorrhage, optic ing findings, there remains no definitive method to
nerve injury, and central nervous system depression reduce OCR occurrence during surgery on the extra-
[21]. As such, topical anesthesia has emerged as an ocular muscles [27]. Sub-Tenon’s block with general
effective option for trabeculectomy [21]. It is impor- anesthesia has also been found to reduce intraopera-
tant to note that subconjunctival 2% lidocaine may tive OCR and postoperative nausea and vomiting in a
impair trabeculectomy healing; however, there is a

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pediatric population when compared to fentanyl with be preferred as the addition of epinephrine has been
general anesthesia [28]. reported to contribute to a poorer estimation of post-
operative eyelid height in aponeurotic blepharoptosis
Vitreoretinal surgery surgery [36].
Recent reports indicate that local anesthesia com-
Significant advancements in instrumentation and the bined with moderate sedation can be a safe alterna-
growing sophistication of surgical techniques have tive to general anesthesia for certain orbital surgeries
led to shorter and more predictable surgeries, which such as external dacryocystorhinostomy and orbital
in turn have allowed vitreoretinal surgery to transition interventions without bone removal [37, 38]. Gold-
from general anesthetic to regional eye anesthesia berg et al. [39] report removing benign orbital tumors
with the patient awake during surgery [29]. For exam- through minimally invasive, soft-tissue incisions
ple, the introduction of suture-less 23- and 25-gauge under a local block. This approach may be appropri-
vitrectomy using peribulbar block for epiretinal mem- ate if the pathology is consistent with a benign tumor
brane surgery and 25-gauge transconjunctival suture- and imaging delineates a well-defined mass without
less vitrectomy under retrobulbar block for various tethering or infiltration into surrounding tissue into
vitreoretinal procedures were found to be safe, effec- bone or the sinuses, with the major advantage being
tive and reduce surgical time [30]. avoidance of a bony marginotomy [39]. In such cases,
A prospective, randomized clinical trial including patient selection is important as some level of cooper-
23- or 25-gauge vitrectomies compared the safety and ation is necessary. Anxiolytics are helpful in patients
efficacy of topical anesthesia combined with subcon- with moderate anxiety [34, 40].
junctival anesthesia (referred to as “two-step anesthe- Special considerations are required for patients
sia”) to peribulbar and retrobulbar anesthesia, finding with thyroid eye disease undergoing orbital decom-
similar pain scores between the two methods [31]. pression surgery. This patient population often has
An analogous clinical trial comparing topical anes- multiple comorbidities (e.g., autoimmune disorders,
thesia with retrobulbar technique reported similar diabetes, or smoking-related issues) with long-term
results with regard to pain control, safety and efficacy corticosteroid use being common, all factors that
[32]. While topical analgesia does not produce ocu- could affect wound healing. Additional challenges
lar akinesia, with modern small gauge instruments, may arise with airway management in the presence
eye movement can be reduced by the surgeon once of goiter [41]. Enucleation also warrants special
the vitrectomy procedure is started, thus requiring a anesthetic considerations as patients can experience
moderate level of patient cooperation. Ultimately, significant postoperative discomfort; postoperative
this approach can be used in carefully selected cases. retrobulbar pain catheters or parabulbar butterfly
Special consideration should be given for macular catheters can allow patients to self-administer local
surgical cases, as even slight ocular movement could anesthetic postoperatively as needed [34]. Eviscera-
severely impact the success of the surgery [33]. tion with orbital implant placement is often conducted
under general anesthesia due to difficulty achieving
Orbital and oculoplastic surgery sufficient analgesia using local anesthesia [42]. The
addition of local anesthetic to general anesthesia is
Most oculoplastic procedures such as blepharoplast- recognized to improve hemostasis, postoperative
ies and ptosis repairs are performed under local anes- comfort and reduce OCR [43]. Preemptive anesthe-
thesia, while traditionally orbital surgery is performed sia, injection of anesthetic drugs into the orbit, can be
under general anesthesia. In the case of eyelid surger- considered to reduce the occurrence of postoperative
ies, topical pre-anesthetic gels and drops can reduce pain and nausea. A retrospective study of 39 individu-
discomfort of typical injectable local anesthetics such als who underwent enucleation indicated that patients
as lidocaine, prilocaine, mepivacaine, bupivacaine, who received periocular anesthesia with sedation
levobupivacaine, and ropivacaine [34]. Epinephrine required less postoperative analgesic and antiemetic
is typically used to augment the duration of action drugs than those in using general anesthesia.
of agents such as lidocaine and bupivacaine [35]. Local anesthetic options have been explored in
However, local anesthetics without epinephrine may a limited number of studies: combined retro-upper

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peribulbar and subconjunctival anesthesia with intra- Conclusion

venous sedation (i.e., combination of lidocaine with
epinephrine and bupivacaine injection, and sedation Ocular surgery is continuously evolving in the direc-
with midazolam and fentanyl) for evisceration plus tion of improved safety and reduced case times. As
orbital implant placement, and retrobulbar block such, the indications for topical anesthesia continue
with intravenous sedation for enucleations and evis- to expand as the strong efficacy and safety profiles of
cerations (i.e., combined lidocaine with epinephrine topical anesthetics are detailed [2]. However, regional
mixed with bupivacaine with hyaluronidase) [43, 44]. blocks remain a safe and effective option when aki-
Only one of 116 evisceration patients (0.9%) required nesia is required, while general anesthesia is indi-
transition to general anesthesia due to severe anxiety cated when amnesia is preferable or in populations
[44]. Caleda et al. [45] performed eye enucleations less tolerant of surgery [4]. Regardless, anesthetizing
and eviscerations under local anesthetic injected into the eye has rapidly evolved in recent years, support-
the inferior orbital and the supraorbital notch (i.e., ing the safety, efficacy and comfort of ocular surgery
lidocaine with epinephrine and bupivacaine with [2]. Since there are many viable options of anesthet-
epinephrine) for 17 cases, reporting both decreased ics available for ophthalmic surgery, a robust under-
bleeding from the operative area and less need for standing of the patients needs, the skill of the surgical
additional analgesia pre and postoperative analgesia. team, and surgery-specific factors ought to be consid-
ered when creating an anesthetic plan for surgery.
Ocular trauma
Author contributions All authors contributed to the con-
ception, search design, synthesis of the data, and manuscript
The main challenge in anesthetic management of
preparation.
patients with penetrating eye injury is risk of extru-
sion of intraocular contents secondary to raised IOP. Funding This research did not receive any specific grant
The age of patients influences anesthetic choice, as from funding agencies in the public, commercial, or not-for-
profit sectors.
nearly one third of the eye injuries are encountered
in patients less than 18 years of age. Furthermore, Declarations
associated orbital or head traumas are common in this
population. Conflict of interest The authors have conflicts of interest to
disclose. The authors do not have any proprietary interests in the
General anesthesia is typically preferred for repair
materials described in the article.
of open globe injuries due to the complete akine-
sia and anesthesia obtained. It is also the method of
choice for the pediatric or uncooperative patients,
exploratory surgeries, or when the extent of the
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Springer Nature or its licensor (e.g. a society or other partner)
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holds exclusive rights to this article under a publishing
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self-archiving of the accepted manuscript version of this article
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