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Local anesthesia and anxiolytic techniques for

oculoplastic surgery
This article was published in the following Dove Medical Press journal:
Clinical Ophthalmology

Edsel B Ing 1 Abstract: This study discusses local anesthetic agents, administration techniques, ancillary
Justine Philteos 2 considerations, and safety precautions for oculoplastic surgery including eyelid, lacrimal,
Galina Sholohov 3 orbital, and temporal artery biopsy procedures. Methods for reducing patient apprehension and
David Ta Kim 1 discomfort including systemic premedication, topical pre-anesthetic, visual, auditory and tactile
Navdeep Nijhawan 1 distraction techniques, regional blocks, small gauge needles, warmed lidocaine, and buffered
lidocaine are discussed.
Patrick W Mark 4
Keywords: local anesthesia, anxiolytics, oculoplastics, eyelid, orbit, lacrimal, temporal artery
Jaclyn Gilbert 4
biopsy
1
Department of Ophthalmology and
Vision Sciences, University of Toronto,
Toronto, ON, Canada; 2School of Introduction
Medicine, University of Toronto,
Toronto, ON, Canada; 3Barzilai Local anesthesia induces a reversible loss of sensation and loss of muscle contraction,
Medical Center, Ashkelon, Israel; in a limited region of the body without altering the level of consciousness. Local
4
Department of Anesthesia, Michael
Garron Hospital, University of anesthetics are membrane-stabilizing agents that inhibit voltage-gated sodium chan-
Toronto, Toronto, ON Canada nels in the neuronal cell membrane, increasing action potential thresholds, thereby
decreasing the perception of pain and inhibiting muscular contraction.8 The majority
of oculoplastic procedures including eyelid surgery and temporal artery biopsy are rou-
tinely performed in adults with local anesthetic to avoid the increased time and expense
of general anesthesia and the potential side effects of cardiorespiratory compromise,
post-operative nausea and vomiting, and rarely malignant hyperthermia.66 The optimal
administration of local anesthetic is critical to the success of awake procedures as it
ensures patient cooperation, aids hemostasis, facilitates intraoperative adjustments if
needed, and enhances the patient’s surgical experience and perception of good care.

Pre-operative considerations
Most eyelid procedures can be performed in a minor surgery setting under local
anesthesia, but pre-operative medical clearance may still be required. The eyelids
are quite vascular, and as such a thorough medication history should be obtained
with special attention to anticoagulants, especially the newer anticoagulants such as
dabigatran, apixaban, and rivaroxaban.31 Pre-operative dialog including explanations
of the procedure, cosmetic concerns,32 and the provision of treatment options such
as the type, dose, and timing of sedation may help decrease patient’s anxiety during
Correspondence: Edsel B Ing awake procedures.63
Department of Ophthalmology and
Vision Sciences, Michael Garron Hospital,
650 Sammon Avenue, K306, Toronto, Local anesthetic agents
ON M4C 5M5, Canada
Fax +1 416 385 3880
The incongruity of injectable local anesthetics is that although they provide anesthesia,
Email edinglidstrab@gmail.com the injection itself initially causes pain due to the needle puncture, the pressure of the

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solution entering the injection site, and the acidic pH of the properties. Its administration is sublingual or oral, and the
anesthetic solution. We review the local anesthetic agents and usual adult dose is 1–2 mg. Given orally, lorazepam reaches
different techniques to decrease patient’s pain and anxiety its peak concentration in approximately 2 hours. Side effects
during the local anesthetic injection and periocular injections. of lorazepam include dizziness, weakness, unsteadiness,
The mechanism of action of local anesthetics is the inter- hypotension, cognitive impairment, behavioral disinhibition,
ruption of axon depolarization, by preventing the influx of and respiratory depression.3 In some cases, there can be
sodium through the nerve cell membranes. Local anesthetics paradoxical effects with benzodiazepines, such as increased
can be either ester or amide based. Ester local anesthetics hostility, aggression, angry outbursts, and psychomotor
used in ophthalmology are predominantly topical prepara- agitation.43 Surgeons should be cognizant that sedatives
tions including tetracaine, proparacaine, and cocaine. Topical may affect intraoperative upper eyelid margin position.
anesthetic eye drops are instilled at the start of most oculo- Propofol and benzodiazepines such as midazolam
plastic procedures to minimize the stinging from antiseptics (Versed®, Hoffman-La Roche Limited, Missisauga, ON,
and to facilitate fitting of cornea protectors. Upon initial Canada) are commonly used intravenous sedatives that can be
instillation, tetracaine 0.5% eye drops are more uncomfort- administered prior to local anesthetic injection. Midazolam
able than proparacaine 0.5% eye drops.6 and propofol do not have analgesic properties but provide
Most of the injectable local anesthetics are amide local comfort to the patient via their anxiolytic properties.9 Intra-
anesthetics, eg, lidocaine, prilocaine, mepivacaine, bupiva- venous opioid analgesics including short-acting agents such
caine, levobupivacaine, and ropivacaine. as alfentanil25 and remifentanil, and longer-acting agents such
Lidocaine hydrochloride 1%–2% without and with epi- as morphine can provide conscious sedation prior to local
nephrine (1:100,000 or 1:200,000) is the most commonly anesthetic injection. Remifentanil without muscle relaxants
used injectable agent for local anesthesia. The onset of has also been used for total intravenous anesthesia in a patient
action is within 1 minute and can last 1–3 hours depend- with myasthenia gravis undergoing a prolonged oculoplastic
ing on the strength of the preparation, and the duration of procedure.38 The intravenous agents for procedural sedation
action is longer if epinephrine is added to the solution. The and analgesia have the potential for respiratory and/or cardio-
maximum safe dose of tumescent lidocaine is 5 mg/kg and vascular compromise and should only be used by physicians
with epinephrine 7 mg/kg. One milliliter of 1% lidocaine trained in their safe application, who are prepared to manage
contains 10 mg of lidocaine. the potential complications such as airway compromise.35
Bupivacaine hydrochloride 0.50%–0.75% is a longer- Ketamine is a dissociative anesthetic which makes the
acting agent than lidocaine with a duration of 6–8 hours. patients remain conscious but seem “disconnected” from
In comparison to lidocaine, bupivacaine has a slower onset their environment.15 It can be administered intravenously,
of action at 10 minutes, but can be used in combination with intramuscularly, or orally. Since ketamine produces anal-
the former. The maximum safe dose of bupivacaine without gesia and sedation with relatively minimal effect on central
epinephrine is 2.5 mg/kg and with epinephrine is 3.5 mg/kg.56 respiratory drive, it is often used for office-based cosmetic
Ropivacaine hydrochloride 0.75%–1% (Naropin ®, procedures.69 However, ketamine can cause psychological
AstraZeneca, Missisauga, ON, Canada) has less potential disturbances on emergence with agitation, disorientation,
for cardiotoxicity and central nervous system (CNS) toxic- hallucinations, and vivid dreams.
ity than bupivacaine.59 Ropivacaine has similar duration of Inhalational agents such as nitrous oxide or sevoflurane
action to bupivacaine. can also be used for sedation in oculoplastic surgeries. This
An epinephrine concentration of 10 µg/mL (1:100,000) requires the presence of an anesthesiologist for their adminis-
in the local anesthetic is thought to provide adequate vaso- tration and monitoring and a scavenging system. In one study,
constriction for eyelid surgery, with adequate hemostatic sevoflurane was found to have comparable efficacy to pro-
effect within 1 minute.61 pofol for sedation during periocular anesthetic injection, but
caused post-operative nausea and vomiting and disinhibition.65
Systemic anxiolytics and analgesics
Systemic anxiolytics and analgesics can be administered Topical pre-anesthetic
prior to local anesthetic injection. Lorazepam (Ativan®, gels and drops
Pfizer Canada, North York, ON, Canada) is a commonly Many delivery vehicles exist for topical anesthesia including
used benzodiazepine with anxiolytic, sedative, and hypnotic gels, aerosol sprays, creams, ointments, drops, and patches.

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Dovepress Local anesthesia and anxiolytics for oculoplastic surgery

Pre-treatment with topical anesthetics may decrease the pain gentler terminology prior to local anesthetic injection resulted
of local anesthetic injection required for oculoplastic proce- in a better subjective experience during local anesthesia
dures in children and needle phobic patients, regional local compared to harsher words such as “bee sting!” “big ouch!,”
anesthetic blocks, botulinum toxin injection, and procedures “lots of burning!,” or “worst part!” Notwithstanding, patients
such as temporal artery biopsy. Topical anesthesia has the receiving facial and periocular injections must be reminded not
advantages of less distortion of wound margins compared to move their head or bring up their hands during periocular
to infiltrative injections and less risk of needle-stick injury injections. In patients with needle phobia, a three-step behav-
to the patient and physician. ioral approach involving recognition and relaxation, control
A eutectic mixture of the local anesthetics containing and preparation, and graded exposure has been described.70
2.5% each of lidocaine and prilocaine (EMLA) is an example Music relaxation prior to the administration of local
of a topical anesthetic emulsion, which is applied under an anesthesia is well described. Many randomized control
occlusive dressing, and requires about 60 minutes to work. trials on the effects of music intervention in pre-operative
EMLA cream should not be applied to the eye, but has been settings found that music decreased patient’s anxiety and
applied on periocular skin prior to botulinum toxin injection.18 pain. The optimal type of music was non-lyrical, with low
Although EMLA is not approved for use over non-intact skin, tones, mostly strings with rare bass or percussion, and with
it has been described for pre-treatment of facial lacerations.53 a volume of ,60 dB.50
Prilocaine is contraindicated in methemoglobinemia. In a retrospective study investigating the effect of music
Liposome encapsulation extends the action of a topical during ophthalmic surgery, it was demonstrated that mean
anesthetic.10 Topical liposomal lidocaine cream has a more blood pressure, heart rate, and respiratory rate of patients
rapid onset of action and is a less expensive alternative to exposed to piano music were all decreased compared to the
EMLA.17 Lidocaine cream is available as an over-the-counter vital signs taken in a non-music control group. Furthermore,
liposomal formulation in 4% or 5% concentrations, under the vitals of the patients exposed to music were lower in the
the trade names of Maxilene (RGR Pharma, LaSalle, ON, operating room than in the pre-operative holding area where
Canada) and LMX (Ferndale Pharma Group, Ferndale, MI, they were not listening to music.52
USA). Liposomal lidocaine cream has an onset of action of Vibration may ease pain during local anesthetic injection
about 30 minutes and unlike EMLA, an occlusive dressing and botulinum toxin injection.60 The proposed mechanism of
is not mandatory for liposomal lidocaine.71 vibration anesthesia is related to the “gate control” theory of
When local anesthetic must be injected into the poste- pain.41 The brain perceives less pain when the sensorial inputs
rior lamella of the lower lid, the inferior fornix can be first to the nociceptors (pain) and mechanoreceptors (vibration)
anesthetized with proparacaine or tetracaine-soaked cotton are simultaneous. One study described the use of a vibration
tip applicators.47 device applied to the forehead in a circular fashion during
eyelid injections, with favorable results.19
Distraction techniques A tablet computer (eg, Apple iPad) has been described
There are many “distraction” techniques that can be as a distraction technique to relieve anxiety during painful
employed prior to local anesthetic injection to ease the pain pediatric medical procedures.45 This may be potentially use-
and anxiety associated with injection including breathing ful in oculoplastic procedures where one or both eyes can
exercises, audiovisual, and tactile techniques. remain open for the patient to view the computer during local
Breathing exercises have been shown to reduce the pain anesthetic injection.
of injections. Children who were told to repeatedly take deep Visualization techniques often with a highly geographical
breaths during an injection were observed to express less pain emphasis may help patients with needle phobia.4 Prior to
than those in the control group.54 anesthetic injection, the patients are asked to imagine that
An obstetrics study on verbal anesthesia68 found that prior they are in a pleasant environment such as a tropical paradise
to local anesthetic injection, using gentle reassuring words on a sunny day.
such as “We are going to give you a local anesthetic that Stress balls, holding hands with a caregiver, or hand
will numb the area and you will be comfortable during the massage51 may increase the tolerability of local anesthetic
procedure” were preferable to the traditional pre-injection injection. When extra personnel are not available, an inflated
warning, “You are going to feel a big bee sting; this is the rubber glove can be used to simulate hand holding, allowing
worst part of the procedure”. The authors suggested that the medical care team to continue working.

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Preparation and administration of difference in the pain perceived11,20 and that the addition of
local anesthetic bicarbonate to local anesthetic may have a greater overall
The temperature, pH, rate of administration of the local effect than needle size in decreasing the pain associated with
anesthetic, and needle size may affect the patient’s percep- the intradermal injection of lidocaine.52 One small random-
tion of pain during injection. ized control study found that botulinum toxin injection with
Warming the local anesthetic to body temperature can a 32-gauge needle was less painful than a 30-gauge needle,2
reduce the discomfort during local infiltration, compared to but another split-face study did not support this.72
local anesthetic at room temperature.7,29 Applying ice to the Needle-free jet injections deliver drugs percutaneously
skin or skin cooling may also decrease injection-induced pain without a conventional needle and have been described for
of local anesthetics26 and periocular botulinum injections.18,57 decades.42 Liquid medication is forced under high pressure
Local anesthetic solutions are acidic and may cause a through a very small orifice through the skin. However, the
burning sensation upon injection. Buffering lidocaine to eye can be injured from high-pressure jet injections. Cho-
a more physiologic pH with sodium bicarbonate or dilute roidal rupture with vision loss has been described after local
isotonic sodium chloride may decrease pain on injection. anesthesia via jet injection.40 At the present time, needleless
Furthermore, alkalizing the pH increases the portion of jet injection is not suggested for oculoplastic procedures.
non-ionized lidocaine in a given solution, thus potentially
enhancing penetration through the hydrophobic cell mem- Precautions
brane. Lidocaine is marketed in an acidic solution to pro- The administration of local anesthetics may have potential
long shelf-life and should only be buffered shortly prior to iatrogenic complications.
administration. To buffer lidocaine, typically 1 part of 8.4% First, patients may report an allergy to local anesthetics.
sodium bicarbonate is added to 10 parts of lidocaine 1% with True allergic reactions to amide local anesthetics such as
1:100,000 epinephrine.21 Studies have not consistently dem- lidocaine are rare. More commonly, patients claiming allergy
onstrated a significant decrease in pain;16,24,44,46 the favorable to amide local anesthetics are sensitive to the metabisulfite
2010 Cochrane Systematic Review was withdrawn in 2015 (antioxidant) or methylparaben (preservative) contained in
due to conflicts in commercial sponsorship.13 Alkalinization the local anesthetic solution.12 Allergy to amide anesthetics
of the local anesthetic did not affect the duration of anesthesia does not cause cross-allergy to ester anesthetics. Allergies
or hemostasis. Buffered lidocaine does not appear to produce to the ester topical anesthetics are usually due to sensitivity
more short-term complications such as post-operative bleed- to the metabolite para-aminobenzoic acid (PABA). If there
ing, swelling, or pain than its unbuffered counterpart.46,49 are concerns regarding a history of allergic reaction to local
Therefore, the use of buffered lidocaine is as safe as its anesthetics, a referral can be made for allergy testing prior
unbuffered counterpart. to the procedure. Allergic sensitization and possible cross-
It is widely recommended that anesthetic injections reaction to topical anesthetics are a potential occupational
should be administered slowly in the eyelid to decrease hazard for ophthalmologists, especially in providers with
discomfort.27 The slow administration of lidocaine may chronic eczema.14
have a greater impact on decreasing perceived pain than Second, patients’ comorbidities must be considered
buffered lidocaine.58 The use of a microprocessor controlled prior to local anesthetic injection. Local anesthetic injec-
delivery system to administer a constant slow rate of local tion may cause pupillary dilation, and periocular injections
anesthetic has been reported to cause less discomfort than the with epinephrine are a relative contraindication in patients
manual syringe technique.39 However, the speed of anesthetic with untreated narrow angles. Retrobulbar and parabulbar
delivery during retrobulbar and parabulbar injection did not anesthetic injections should not be used for enucleation of
significantly affect pain scores in one study.36 patients with suspected intraocular tumor.
Smaller gauge needles may cause less pain during Third, periocular injections can cause injury to the globe.
cutaneous insertion than larger needles,5 and local anesthetic Several cases of globe perforation during local anesthetic
injection with a 30-gauge needle may be less painful than injection for oculoplastic procedures have been described.62,67
with 27 or 25-gauge needles.55 The authors currently use a To decrease this risk, a cornea protector can be placed with
30-gauge needle for local anesthetic injection in patients sterile gloves prior to injection. Appropriately tightened Luer
undergoing eyelid procedures. However, a dental study lock syringes prevent inadvertent needle expulsion during
suggested that 25, 27, and 30-guage needles caused no local anesthetic administration; Luer slip syringes are not

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Dovepress Local anesthesia and anxiolytics for oculoplastic surgery

recommended. Bending the needle at an acute angle, keeping supraorbital nerve blocks deserve mention. Most oculoplastic
the needle bevel up during injection, and needle trajectories surgeons are familiar with the extraoral infraorbital nerve
almost parallel to the tarsal plate may decrease the risk of block that can potentially anesthetize the large area between
globe injury. In anticipation of patient movement, the syringe the lower eyelid and the upper lip, including the side of the
can be nestled in a “snooker” grip, with the non-injection nose. The infraorbital nerve foramen is 5–8 mm below the
hand resting on the patient’s forehead or cheek. Stimulation inferior orbital rim, in a sagittal line drawn through the medial
of the afferent arm of the sternutatory (sneeze) reflex by limbus.73 The extraoral injection can be administered at a
botulinum toxin injection,37 periocular local anesthetic, or point between the upper nasolabial fold and the alar base of
with propofol may occur in 5%–46% of the patients,1,48,64 the nose with a 25–30-gauge needle and 2 cc of lidocaine 2%
and the surgeon should be prepared for any associated head with epinephrine. As with all local anesthetic injections, the
movements, to avert eye injury. It is speculated that propofol anesthetic is delivered after a negative aspiration for blood.
may suppress sneeze inhibitory neurons. Administration of Patients may feel an “electric shock” during the injection,
an opioid prior to propofol and the local anesthetic injection and if the superior alveolar branch of the infraorbital nerve
may decrease the sternutatory reflex. is anesthetized, the ipsilateral front teeth may feel numb.
Finally, cross-contamination, retrobulbar hemorrhage, A supraorbital nerve block with 1 cc or less of lidocaine
and intrathecal spread are potential concerns during local 2% with epinephrine has been suggested for upper eyelid
anesthetic injection. Labeling the syringe with the patient’s surgery and may not compromise levator function, although
identification sticker helps prevent cross-contamination if hematomas may occasionally occur.34 The supraorbital notch
repeat injection is required. Blunt tipped retrobulbar needles is palpated near the nasal third of the superior orbital rim, and
(eg, Atkinson) decrease the risk of retrobulbar hemorrhage. the injection is placed just lateral to the notch with a 25–30-
If retrobulbar hemorrhage occurs during local anesthetic injec- gauge needle, avoiding the supraorbital vessels. “The needle
tion, procedures other than eye removal should be aborted. is directed posteriorly and superiorly following the curve of
The patient’s acuity, intraocular pressure (IOP), and swinging the orbital roof and advanced until it touches the roof” and
flashlight test should be carefully monitored. If IOP is elevated then withdrawn slightly during anesthetic injection.34
and there is a new onset of relative afferent pupillary defect,
lateral canthotomy and cantholysis should be performed.
Intrathecal spread of local anesthetic is a potential com- Considerations for specific
plication of retrobulbar injections. The incidence of CNS procedures
depression from intrathecal anesthetic injection has been Temporal artery biopsy
reported to be between 1 in 350 and 1 in 500 when sharp nee- Oculoplastic surgeons are frequently called upon to perform
dles are used to administer anesthesia for ocular procedures.28 temporal artery biopsy.33 It is essential to accurately mark the
location of the artery with a marking pen prior to any local
Regional nerve blocks anesthetic administration. In patients with a readily visible
Regional nerve blocks have several advantages over local or palpable artery, epinephrine can be incorporated with the
tissue infiltration. A nerve block may achieve anesthesia initial local anesthetic injection. In patients with limited sur-
with a smaller volume of injection than is required for local face vessel markings and poor arterial pulsation, epinephrine
infiltration. Unlike local tissue infiltration, nerve blocks can is usually not administered with the local anesthetic until
provide anesthesia without causing tissue distortion. This can after the vessel is visualized subcutaneously.
be beneficial in situations such as severe facial lacerations Local anesthetic is administered ~1 cm from either
or canalicular injury, in which tissue distortion may make side of the vessel but not into the vessel. If there is concern
reconstruction more difficult. that the vessel markings will be obscured by the prep
Regional anesthesia is ideal when the area of interest is solution, the vessel location can be scratched with a needle
innervated by a single superficial nerve. Regional blocks tip prior to the antiseptic scrub.
may be particularly advantageous in less cooperative trauma
patients, so that direct infiltration does not have to be admin- Eye removal and post-operative pain
istered close to the eye. Following eye removal, patients may experience considerable
A full discussion of the different periorbital nerve blocks post-operative discomfort. If a porous implant is used, the
is beyond the scope of this review, but the infraorbital and implant can be soaked in local anesthetic prior to placement.

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At the conclusion of the procedure, supplemental long-acting Disclosure

retrobulbar anesthetic is usually administered. Several tem- The authors report no conflicts of interest in this work.
porary post-operative retrobulbar pain catheters have been
described allowing patients to self-administer local anesthetic References
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