Ropivacaine: Less Pain, Hemorrhage Risk During Vitrectomy

Tara Haelle

February 09, 2017

The best intraoperative peribulbar anesthetic during vitrectomy is ropivacaine (1%) compared with bupivacaine, lidocaine, and a solution of bupivacaine and lidocaine, according to a randomized, double-blinded trial published online February 7 in the British Journal of Ophthalmology.

Ropivacaine showed a lower risk for postoperative pain and hemorrhage and equal effectiveness as other analgesics. In addition, the average time to analgesia and to akinesia for ropivacaine was similar to that of the other analgesics tested.

Despite the short duration of the surgeries in this study (mean, 80 minutes), Ya-li Zhou, from the Department of Ophthalmology, Ninth People's Hospital, and the Department of Ophthalmology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China, and colleagues write that they "firmly believe that ropivacaine is able to sustain analgesia during a longer operation time in peribulbar block. Moreover, ropivacaine has less severe neurotoxicity and cardiotoxicity than bupivacaine. Long duration and less toxicity of ropivacaine make it a better choice than bupivacaine in retina surgery."

The researchers randomly assigned 140 patients undergoing first-time undergoing pars plana vitrectomy with peribulbar anesthesia to receive one of four analgesics: 1% ropivacaine, 0.75% bupivacaine, 2% lidocaine, or a mixture of 0.75% bupivacaine and 2% lidocaine (lido+bupi). Indications for the surgery included proliferative diabetic retinopathy, vitreous hemorrhage, retinal detachment, retinal vein occlusion, macular degeneration, idiopathic macular hole, macular pucker, and high myopic maculopathy.

Exclusion criteria included "[c]ommunication problems, allergy to amide-type local anaesthetic agents, history of vitreoretinal surgery or orbital surgery, orbital deformity, with episcleral adjunct surgery, trauma, keratitis, conjunctivitis and uveitis."

There were no significant differences among the four groups (35 patients each) in terms of patient characteristics, disease types, surgery duration, or patients with high myopia or receiving a phaco-pars plana vitrectomy. Patients reported pain on a scale of 0 (no pain) to 4 (unbearable pain) on the first postoperative day.

The average time to analgesia onset was 90.46 seconds for ropivacaine, 94.83 seconds for bupivacaine, 78.31 seconds for lidocaine, and 101.51 seconds for lido+bupi (P = .087). The average time to akinesia was 138.89 seconds for ropivacaine, 151.86 seconds for bupivacaine, 122.66 seconds for lidocaine, and 141.54 seconds for lido+bupi (P = .323).

The four groups lacked any significant differences in reaching grade 5 anesthesia, and no one experienced unbearable postoperative pain. Moreover, none of the patients in the ropivacaine group reported pain during the surgery compared with 11.4% in the bupivacaine group and 14.3% each in both the lidocaine and lido+bupi groups (P = .931).

Patients receiving 1% ropivacaine reported significantly less postoperative pain than those receiving the other three analgesics, which showed differences in postoperative pain reporting among them. Younger patients were more likely to experience postoperative pain than older patients, making the wide age range of the study (18 - 80 years) a limitation. No other factors emerged as significantly associated with pain.

Patients who received ropivacaine also experienced a lower rate of postoperative subconjunctival hemorrhage than those in the other groups (P = .001). No other differences existed among the groups in adverse events, which included nausea, vomiting, headache, dizziness, and scalp anesthesia.

"[T]his study suggests that 1% ropivacaine alone is a suitable choice when administering peribulbar anaesthesia for patients undergoing pars plana vitrectomy because it produces an adequate quality of intraoperative anaesthesia and better postoperative anaesthesia and also improves patient comfort" compared with the other agents tested, the authors conclude.

The research was funded by the Project of the National Natural Science Funds of China and the Shanghai Pujiang Program. The authors have disclosed no relevant financial relationships.

Br J Ophthalmol. Published online February 7, 2017. Full text

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