I would like to make several comments regarding the excellent article by Vann et al.  1First, I would encourage anesthesiologists to resist the use of topical anesthesia for ophthalmologic surgery except when the most competent surgeons are doing straightforward procedures in healthy patients. I have been caught several times when cataract surgery went awry and a retinal surgeon had to be called in urgently to perform surgery that could not be tolerated using topical anesthesia alone. The alternatives are to stop the procedure and induce emergent general anesthesia or to induce very deep sedation without control of the airway. A sub-Tenon, peribulbar, or retrobulbar block would have prevented the added risks of either of the above alternatives.

Second, I have performed several hundred retrobulbar blocks without using any premedication or sedation. In addition, I have been the anesthesiologist during many other retrobulbar or peribulbar blocks performed by the surgeon without any premedication or sedation. In the vast majority of cases, all that is required is a little hand-holding, encouragement, and empathy. Occasionally, for patients with high anxiety or a low pain threshold, a transcutaneous electrical nerve stimulation unit with the electrodes placed on the temple and forehead virtually eliminates any discomfort. It is the rare patient who must have something like propofol for the block.

With a little preparation by the surgeon and anesthesiologist, it is seldom that any medication at all is required for ophthalmologic surgery. The less medication is used, the more alert and cooperative the patient will be and the less likely the patient will be to fall asleep, suddenly awaken, and move during surgery. To me, the risk–benefit ratio clearly favors the major block without sedation.

Johns Hopkins School of Medicine, Baltimore, Maryland. BourkedenisL@aol.com

Vann MA, Babatunde OO, Joshi GP: Sedation and anesthesia care for ophthalmologic surgery during local/regional anesthesia. Anesthesiology 2007; 107:502–8