|Year : 2016 | Volume
| Issue : 2 | Page : 304-308
Articaine versus bupivacaine/lidocaine mixture in episcleral peribulbar anesthesia for cataract surgery: A prospective randomized-controlled study
Mostafa M Houssein Khalil MD , Ibrahim M Ibrahim Mohamed
Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||29-Jan-2015|
|Date of Acceptance||10-Mar-2016|
|Date of Web Publication||11-May-2016|
Mostafa M Houssein Khalil
Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, 5 Abdelazem Salama Street, Nasr city, 11727 Cairo
Source of Support: None, Conflict of Interest: None
Medial episcleral peribulbar anesthesia has been shown to be a valid alternative for ocular regional anesthesia because of the infrequent complications observed. Articaine is a new local anesthetic drug used in eye surgery with dense motor block and fewer complications.
The aim of this study was to compare the efficacy and safety of an episcleral peribulbar block using articaine 2% versus bupivacaine 0.5%/lidocaine 2% mixture in patients undergoing cataract surgery.
Patients and methods
This study was carried out in Ain Shams University Hospital on 60 patients who underwent elective cataract surgery with peribulbar episcleral anesthesia. Patients were allocated randomly to two groups of 30 patients each. Group A included patients who received peribulbar episcleral anesthesia using 2% articaine as a local anesthetic agent. Group B included patients who received peribulbar episcleral anesthesia using a mixture of 0.5% bupivacaine and 2% lidocaine as a local anesthetic agent. The primary outcome measures were the onset of eye globe akinesia and the ocular mobility score. The secondary outcome measures were the need for a supplementary injection and the occurrence of complications.
In terms of eye globe akinesia, there were statistically significant differences between the two groups in the onset of satisfactory globe akinesia. Group A showed rapid onset, whereas group B had delayed onset of action. The onset of satisfactory globe akinesia with an ocular mobility score less than 4 was achieved in 4.44 ± 0.76 min in group A (articaine group) compared with 8 ± 0.85 min in group B (bupivacaine/lidocaine mixture group).
The current study showed that the episcleral peribulbar technique with 2% articaine and epinephrine 5 mg/ml was effective and provided a superior option to a mixture of 0.5% bupivacaine/2% lidocaine.
Keywords: articaine, bupivacaine, cataract, lidocaine, peribulbar, episcleral
|How to cite this article:|
Houssein Khalil MM, Ibrahim Mohamed IM. Articaine versus bupivacaine/lidocaine mixture in episcleral peribulbar anesthesia for cataract surgery: A prospective randomized-controlled study. Ain-Shams J Anaesthesiol 2016;9:304-8
|How to cite this URL:|
Houssein Khalil MM, Ibrahim Mohamed IM. Articaine versus bupivacaine/lidocaine mixture in episcleral peribulbar anesthesia for cataract surgery: A prospective randomized-controlled study. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 May 9];9:304-8. Available from: http://www.asja.eg.net/text.asp?2016/9/2/304/179905
| Introduction|| |
Regular advancements and improvements have occurred in peribulbar anesthesia since it was first described by Davis and Mandel in 1986 not only in the number and methods of injections but also the type of local anesthetic mixture administered and the site of injection .
Medial episcleral peribulbar anesthesia has been shown to be a valid alternative for ocular regional anesthesia because of the infrequent complications observed. The site of injection is relatively avascular, which may decrease the risk of subcutaneous hematoma; it is also far from the ophthalmic artery, optic nerve, and central retinal blood vessels. Remarkably, relatively small volumes of local anesthetic can be used to achieve adequate akinesia and analgesia with this technique .
Articaine is a local anesthetic synthesized in the 1960s and first investigated clinically in 1974. It is an amide that is chemically similar to prilocaine, but it contains a thiophene rather than a benzene ring. Articaine has low toxicity and appears to diffuse through tissues more readily than other local anesthetic agents. Also, it is metabolized by nonspecific plasma esterases in blood and tissues, leading to rapid clearance .
A mixture of 0.5% bupivacaine and 2% lidocaine is the most frequently used local anesthetic in ophthalmic anesthesia. Limited diffusion of local anesthetic is the main drawback of peribulbar anesthesia, leading to failure to achieve eyeball akinesia. This lack of immobility can hinder surgical success and may require repeated injections of the local anesthetic that may, presumably, increase the risk of traumatic complications. A medial episcleral peribulbar injection technique aims at reducing the morbidity from repeated injections .
The aim of this study was to compare the efficacy and safety of an episcleral peribulbar block using articaine 2%, versus bupivacaine 0.5% and lidocaine 2% mixture in patients undergoing cataract surgery.
| Patients and methods|| |
This randomized-controlled study included patients scheduled for cataract surgery in Ain Shams University Hospital during the period from December 2013 to June 2014. After the approval of the ethical committee and informed patients' consent were obtained, 60 patients of both sexes, American Society of Anesthesiologists (ASA) classification I-III, scheduled to undergo an elective cataract surgery under local anesthesia were enrolled in this prospective randomized study. Patients younger than 30 years old, those with a history of succinylcholine apnea (i.e. low plasma choline esterase level because this will interfere with articaine metabolism with plasma esterase), or a history of allergy to amide-type local anesthetics, patients who refused to participate, and patients with communication problems were excluded from the study.
Patients were divided randomly using a computer-generated random number with closed sealed envelopes into two groups:
Group A (n = 30) received 8 ml articaine 2% with 1: 200 000 epinephrine (Ultracaine, Sanofi-Aventis, Germany).
Group B, the control group (n = 30), received a mixture of equal volumes of bupivacaine 0.5%, 4 ml (Marcaine; AstraZeneca AB, Södertälje, Sweden), and lidocaine 2%, 4 ml (Jetocaine amp®; Adeka ilac, Istanbul, Turkey).
Neither group received hyaluronidase as part of their anesthetic solutions.
All patients were examined preoperatively and routine laboratory investigations were performed. Before administration of local anesthetics, routine monitoring of all patients was carried out; this included ECG, noninvasive blood pressure, and pulse oximetry (Cardiocap II; Datex Ohmeda, Helsinki, Finland). Intravenous access was inserted and all patients received sedation in the form of midazolam 0.02 mg/kg intravenous (Dormicum; Roche, Basle, Switzerland) 5 min before the block. Analgesia of the conjunctiva and cornea was achieved by the topical administration of oxybuprocaine 0.4% eye drops.
In both groups, the ocular injection was administered with a 25-G, 25-mm cutting bevel disposable needle (Atkinson needle), followed by external compression with the Honan balloon for 5 min after injection. The injection was stopped if conjunctival chemosis or proptosis developed.
The inferomedial injection point is located at 10 O'clock for the right eye and at 2 O'clock for the left eye. This point is bounded superiorly by the inferior lacrimal canaliculus, medially by the lateral margin of the nose, laterally by an imaginary perpendicular line that joins the inferior lacrimal papilla to the inferior margin of the orbit, and inferiorly by the inferior margin of the orbit. With the eye in a neutral position, the needle was inserted percutaneously in the anteroposterior direction perpendicular to the frontal plane and parallel to the sagittal plane, and then directed obliquely toward the optic foramen with the needle on the same plane of the bony orbital margin. Transient fullness of the superior eyelid is highly predictive of a successful block.
Ocular movement was assessed using the scoring system described by Brahma et al.  at 1, 5, and 10 min after the block. Ocular movement was scored for each direction of gaze in the superior, inferior, medial, and lateral directions, with a maximum score for each direction of 3 points and a possible total maximum score of 12 points.
Scoring system for ocular movement:
Readiness for surgery was considered when the total scoring for ocular movement in four directions was 4 or less. A score of 2 or more in any direction after 15 min required a supplementary injection of 2-4 ml of local anesthetic (articaine 2% with epinephrine 1 : 200 000 in group A or lidocaine 2%/bupivacaine 0.5% mixture in group B) at the medial canthus using the same type of needle as the primary block. Reassessment was then performed 5 min later.
The total volume of local anesthetic required and the need for supplementary local anesthesia were recorded. Immediate complications because of the block (e.g. subconjunctival hemorrhage, ecchymosis, retrobulbar hematoma, vasovagal attack, allergic reaction, proptosis of the eye) were also recorded.
The primary outcome measures were the onset of global akinesia and the ocular mobility score (OMS). The secondary outcome measures were the need for a supplementary injection, the total volume of local anesthetic injected, and the occurrence of complications.
Sample size calculation was carried out using Power Analysis & Sample Size (PASS) 11 software program (NCSS, LLC. Kaysville, Utah, USA). The power analysis was carried out on the basis of the onset of motor block, which was the primary outcome. Group sample sizes of 25 patients per group would achieve an 80% power to detect a difference of 3.6 min in the onset of motor block with estimated means of 5.0 and 9.0 min and with estimated group SDs of 3.0 and 5.3 and with a significance level (a) of 0.05000 using a two-sided two-sample t-test. Thirty patients per group were included to replace any missing data.
The statistical analysis was carried out using a standard Statistical Package for Social Science (SPSS) software package (version 17; SPSS Inc., Chicago, Illinois, USA). Student's t-test was used to analyze parametric data that were expressed as mean ± SD values; discrete (categorical) variables were analyzed using the c2 -test and were expressed as numbers (%). P-value less than 0.05 was considered statistically significant.
| Results|| |
There was no statistically significant difference between the two groups in age, sex, ASA physical status, duration of surgery, or the axial length (P > 0.05) [Table 1].
[Table 2] shows the comparison between the two groups in the onset of motor block. The onset of satisfactory globe akinesia was achieved at 4.44 ± 0.76 min in group A (articaine group) compared with 8.0 ± 0.85 min in group B (bupivacaine/lidocaine mixture). The OMS was 3.02 ± 1.6 at 5 min in group A, whereas it was 5.32 ± 2.5 at 5 min in group B (P < 0.05). The OMS was insignificant between the two groups at 10 min (P > 0.05).
[Table 3] shows a comparison between the two groups in the need for a supplementary injection. In group A (articaine group), only three (10%) patients needed a supplementary injection, whereas in group B (bupivacaine/lidocaine group), 14 (46.6%) patients needed a supplementary injection. Ninety percent of patients in group A required only 8 ml total injection to produce a significant block compared with 53.3% of patients in group B (P < 0.05).
[Table 4] shows a comparison between the two groups in the incidence of complications. There was no statistically significant difference between the two groups in the incidence of complications.
| Discussion|| |
In this randomized study, articaine provided a more complete block with faster onset, no need for a supplementary injection, and shorter recovery time than the bupivacaine/lidocaine mixture. Articaine does not require the addition of epinephrine solution as it is already added in the ampoule, decreasing the risk of errors during preparation. A molecular difference between articaine and other local anesthetics is the extra ester linkage incorporated into the articaine molecule, which results in hydrolysis of articaine by plasma esterases. The result is that articaine has a half-life of only 20 min compared with 90 min for other amides that require hepatic clearance .
In terms of eye globe akinesia, there was a statistically significant difference between the two groups. In group A, the onset was faster than group B, which showed delayed onset of action. Thus, the articaine group showed a shorter time to achieve adequate surgical condition than the lidocaine/bupivacaine group.
This is in agreement with a previous study carried out by Allman and Barker , who compared articaine and bupivacaine/lidocaine for peribulbar anesthesia for cataract surgery. The authors reported a rapid onset of peribulbar block in association with articaine with a mean ± SD time to readiness for surgery of 4.2 ± 4.5 compared with 7.2 ± 5.7 min in the bupivacaine/lidocaine group .
Our study is also in agreement with the study carried out by Gouws et al. , who compared articaine 2% and bupivacaine/lidocaine mixture for sub-Tenon's anesthesia in cataract extraction. They showed that articaine 2% administered by sub-Tenon's injection provided a more rapid onset of akinesia compared with the bupivacaine 0.5%/lidocaine 2% mixture. Time to readiness for surgery was reduced from 5.2 ± 3.4 to 3.5 ± 2.5 min and ocular movement scores were reduced at all time points from injection to the end of surgery in the articaine group . This effect might be attributed to articaine as it has increased tissue diffusion, enabling a wide distribution within the orbital muscle cone . The use of articaine offers obvious advantages over the bupivacaine/lidocaine mixture; increased tissue penetration obviates the need for hyaluronidase, reducing costs and allergic reactions.
In our study, only three (10%) patients needed a supplementary injection in group A compared with 14 (46.6%) patients who needed a supplementary injection in group B. This is in agreement with the study carried out by Allman , who compared articaine and bupivacaine/lidocaine for single medial canthus peribulbar anesthesia; the number of patients in the articaine group requiring a second injection was 24% compared with 51% in the bupivacaine/lidocaine group (P = 0.02). This may reflect better diffusion of articaine from the medial orbital compartment to the eyelids and muscle cone .
Ripart et al.  reported a supplementary injection rate of 9.27% at 15 min using 0.5% bupivacaine alone or with 2% lidocaine. They observed that articaine also had a faster offset than other groups with quicker return of protective reflexes and lower likelihood of inadvertent damage to the anesthetized eye when the patient was discharged after surgery .
In terms of sensory block, sensation was absent in all patients of the articaine group of our study. This is in agreement with the study carried out by Allman et al. , who reported that sensory analgesia was compete in all patients in the articaine group. Nicholson et al.  assumed that when motor block was achieved, adequate sensory block was already present as this usually preceded the motor block.
Gillart et al.  reported that 6% of the patients in the articaine group and 8% of the patients in the lidocaine/bupivacaine group experienced discomfort. Woodward et al.  showed that 25% of patients in the 1% ropivacaine with hyaluronidase 300 IU/ml group and 25% of patients in the 0.5% bupivacaine/2% lidocaine and hyaluronidase 50 IU/ml mixture group reported mild to moderate discomfort. Corke et al.  reported that 6% of patients in the articaine group and 16% of patients in the lidocaine/bupivacaine group complained of pain; the difference was statistically nonsignificant.
The wide variation in the results of different studies in discomfort during surgery can be attributed to many factors, including the different techniques of the block (number and site of injections) and the different concentrations and volumes of local anesthetics injected, which may result in different densities of sensory anesthesia. To eliminate this bias, the present study used the same technique, volume, and type of procedure, which minimized statistical errors.
In terms of side effects and complications, such as chemosis, ecchymosis, subconjunctival hematoma, nausea and vomiting, vasovagal attack, retrobulbar hematoma, allergic reactions, and proptosis of eye, there was no statistically significant difference between the two groups in the incidence of complications, although the articaine group showed fewer incidences of complications.
Chemosis is defined as subconjunctival edema; it develops when the local anesthetic solution spreads to the subconjunctival space. In all cases, chemosis resolved preoperatively following digital compression of the globe or intraoperatively following a surgical incision. There was no statistically significant difference among the two groups in the incidence of chemosis.
Ecchymosis is defined as subcutaneous hemorrhage in the skin of the eyelid. It develops because of injury of blood vessels of the skin of the eyelid by the penetrating needle. There was no statistically significant difference among the two groups in ecchymosis. There was also no statistically significant difference between the two groups in the incidence of subconjunctival hematoma.
The lower incidences of chemosis, ecchymosis, and subconjunctival hematoma in the present study might be because of the use of a single episcleral percutaneous injection technique with short needle insertion, decreased volume of anesthetics and single rather than multiple punctures. Also, puncture was in a relatively avascular area and the needle path was with fewer incidences to misdirection.
In terms of retrobulbar hematoma, proptosis of eye, and neurological manifestations, there was no documented case in the two groups. There were no cases of perforation of the globe, retinal, or optic nerve damage or orbital hematoma or postoperative diplopia. This is in agreement with a study carried out by Leonardo  using a peribulbar percutaneous single injection technique with a small volume of local anesthetics.
Only one (3.3%) patient in group A (articaine group) complained of allergy in the form of rash in the face on the side of the operation. This might be due to sensitivity of patient to amide-type local anesthetics and in patient with allergic-type asthma.
One (3.3%) patient in group B developed vasovagal attack with nausea and vomiting 15 min following the block. The symptoms were relieved after 10 min and the attack did not interfere with the surgical procedure. None of the patients in group A developed this complication. These results are similar to those of the study carried out by Gioia et al. , who reported that the incidence of nausea and vomiting was less than 7% in the lidocaine/bupivacaine group. This might be related to vasovagal attack after a local injection.
| Conclusion|| |
Articaine 2% in adrenaline 1 : 200 000 without hyaluronidase is superior and more advantageous than a mixture of lidocaine 2%/bupivacaine 0.5% for episcleral peribulbar anesthesia for cataract surgery. Articaine has more rapid onset of eye globe akinesia with less need for a supplementary injection.
Mostafa M. Houssein Khalil designed and conducted the study and wrote the manuscript. Ibrahim M. Ibrahim carried out data collection and analysis and statistical analyses.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]