Anesth Analg 2001;93:518
© 2001 International Anesthesia Research Society
LETTERS TO THE EDITOR
Myocardial Ischemia in Cataract Surgery Patients
Narendra Dhingra, FRCS(Ed)
Glan Clwyd Hospital, Denbighshire, UK
To the Editor: I read with interest the paper by Glantz et al. (1) on perioperative myocardial ischemia in cataract surgery patients. They have made some important observations that, as ophthalmologists, we tend to overlook while operating on elderly patients with cardiovascular risks. In their study, the incidence of ischemic events was similar in local and general anesthesia patients (nearly 31%). According to them, the ischemic events occurred mainly in the postoperative period in the local anesthesia group. The authors have failed to mention whether the irrigating solution used during cataract surgery contained adrenaline. Studies in the past have shown that adrenaline in the irrigating solution does not change the heart rate or the blood pressure regardless of whether the surgery is performed under general or local anesthesia (2,3); however, those studies did not measure the ischemic events, as was done in this study. As this is the first prospective trial looking at the perioperative and postoperative ischemic events, the role of adrenaline in irrigating solutions to induce ischemic events in the elderly population needs to be eliminated. More ophthalmologists are now performing phacoemulsification with intraocular lens implantation using topical anesthesia. Suzuki et al. (4) found that the postoperative decrease in arterial blood pressure was greater in patients undergoing cataract surgery with retrobulbar anesthesia than in those receiving topical anesthesia. Jolliffe et al. (5) found the mean cardiovascular stress comparable between patients receiving topical and retro bulbar block, but this incorporated giving a facial block as well, which in itself can trigger a stress-related response. More prospective studies like that of Glantz et al. (1) are needed to find if surgery under topical anesthesia also reduces catecholamine release and thereby the ischemic event as done by retrobulbar anesthesia (5,6) in the elderly population undergoing cataract surgery.
References
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Glantz L, Drenger B, Gozal Y. Perioperative myocardial ischemia in cataract surgery patients: general versus local anesthesia. Anesth Analg 2000; 91: 1415–9.[Abstract/Free Full Text]
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Fiore PM, Cinotti AA. Systemic effects of intraocular epinephrine during cataract surgery. Ann Ophthalmol 1988; 20: 23–5.[Medline]
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Corbett MC, Richards AB. Intraocular adrenaline maintains mydriasis during cataract surgery. Br J Ophthalmol 1994; 78: 95–8.[Abstract/Free Full Text]
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Suzuki R, Kurori S, Fujiwara. A comparison of blood pressure changes in phacoemulsification cataract surgery with topical and retrobulbar block local anaesthesia. Graefes Arch Exp Ophthalmol 1997;235:277–82.
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Jolliffe DM, Abdel-Khalek MN, Norton AC. A comparison of topical anaesthesia and retrobulbar block for cataract surgery. Eye 1997; 11 (Pt 6):858–62.
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Barker JP, Vafidis GC, Robinson PN, Hall GM. Plasma catecholeamine response to cataract surgery: a comparison between general and local anaesthesia. Anaesthesia 1991; 46: 642–5.[Web of Science][Medline]
Yaacov Gozal, MD,
Benjamin Drenger, MD, and
Lucio Glantz, MD
Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, Jerusalem, Israel
Department of Anesthesiology, Rabin Medical Center, Tel Aviv, Israel
In Response: We thank the authors of the letter for addressing our article. We agree that most of ophthalmologists consider cataract surgery a low risk.
Indeed, the irrigating solution used during surgery included adrenaline. However, we do not think that adrenaline is the origin of the ischemic events. This irrigating solution was used in both groups (General and Local Anesthesia). The ischemic events in the Local Anesthesia group occurred almost exclusively in the postoperative period. Thus they cannot be attributed to a solution used during surgery. In our discussion, we suggest some of the explanations for postoperative ischemia: pain after fading of the block, increase in catecholamine levels, and platelet aggregation. We are confident that our article will promote further studies in this field.
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