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Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 190-194

Comparison of lignocaine 2% with adrenaline and a mixture of bupivacaine 0.5% plus lignocaine 2% with hyaluronidase for peribulbar block analgesia

Department of Ophthalmology, J.N. Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Ngangom Sangeeta Devi
Thangmeiband Lairenhanjaba Leikai, Imphal West - 795 004, Manipur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jms.jms_63_18

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Purpose: Lignocaine and bupivacaine are the most freely available local anesthetic agents which may be used alone or in combination for peribulbar block analgesia (PBA) with or without hyaluronidase and epinephrine. A prospective comparative study of two solutions was undertaken to rationalize choice of local analgesic agent for PBA.
Materials and Methods: A randomized, prospective study on 100 middle-aged to elderly patients undergoing cataract extraction was undertaken to compare the efficacy of (1) 2% lidocaine plus epinephrine 1:200,000 (Group 1) or (2) a mixture of 2% lidocaine and 0.5% bupivacaine (2:3 volume per volume mix) (Group 2). A standardized deep peribulbar block technique, akinesia scoring system, analgesia scoring system, and supplemental protocol were followed. The onset of block and supplementation rates to achieve akinesia was recorded by a blinded observer. The time from 1st PBA injection to the completion of surgery (the duration of surgical access) was also recorded.
Results: Significantly better results for akinesia were obtained with the combination of 2% lignocaine plus 0.5% bupivacaine mixed with 50 IU/ml of hyaluronidase at 10 min after injection and also at the end of surgery. However, with regard to analgesia, both 2% lignocaine and 2% lignocaine with 0.5% bupivacaine had a similar effect. Furthermore, the patients in Group 2 showed a significantly reduced need for the first supplemental injection and no need for a second supplemental injection. The incidence of complications was very low in this study. No serious local or systemic complication was encountered.
Conclusion: The combination of 2% lignocaine with 0.5% bupivacaine results in a better quality peribulbar block than 2% lignocaine alone, while perioperative analgesia was found to be similar for both combinations. The former also required less frequent supplementary injections.

Keywords: Bupivacaine, hyaluronidase, lidocaine, peribulbar block

How to cite this article:
Devi NS, Singh K N. Comparison of lignocaine 2% with adrenaline and a mixture of bupivacaine 0.5% plus lignocaine 2% with hyaluronidase for peribulbar block analgesia. J Med Soc 2018;32:190-4

How to cite this URL:
Devi NS, Singh K N. Comparison of lignocaine 2% with adrenaline and a mixture of bupivacaine 0.5% plus lignocaine 2% with hyaluronidase for peribulbar block analgesia. J Med Soc [serial online] 2018 [cited 2021 Jun 20];32:190-4. Available from:

  Introduction Top

Regional or local anesthesia is more frequently preferred over general anesthesia in cataract surgery as the patients requiring cataract extraction are usually of geriatric group in whom complications of general anesthesia are more prevalent. It is easy to perform, entails little risk, and is less dependent on the patient's general health. Moreover, in developing countries like India, with a large number of cataract cases, regional or local anesthesia are more economical.

Most ophthalmic surgery requires akinesia of the globe and often, a reduction in intraocular pressure in addition to sensory block. These are rapidly achieved by regional anesthesia. The traditional method for this is retrobulbar block.[1] Originally, the retrobulbar block was combined with a facial nerve block.[2] The peribulbar technique[3],[4] has almost replaced the time-tested combination of retrobulbar and facial blocks for the last two decades. To date, peribulbar anesthesia has been commonly performed with a mixture of local anesthetics.[3],[4],[5] In general, bupivacaine 0.5% is used in association with either lignocaine 2%, etidocaine 1%, or mepivacaine 2%, depending on the availability of drugs in different countries. Hyaluronidase is commonly used as an adjunct to the mixture as it favors the diffusion of the anesthetics.[6],[7] However, with multitude of techniques and varieties of local anesthetic agents available for use in peribulbar block, it is pertinent to evaluate the efficacy and safety of the technique as well as the various anesthetic agents in clinical use.

To rationalize our choice of local anesthetic solution for routine use in peribulbar block analgesia (PBA), a prospective audit of the efficacy of two of the most readily available agents – the shorter acting lignocaine 2% (with added adrenaline 1:200,000 to enhance its duration of action) and the popular mixture of 2% lignocaine/0.5% bupivacaine/hyaluronidase – was undertaken. The audit assessed three aspects that we consider essential in assessing the efficacy of local anesthetic agents used for establishing PBA, namely (1) the orbital akinesia score, (2) the analgesia score, and (3) the requirement for supplementary injections to establish akinesia as a secondary measure of the effectiveness of injectate.

  Materials and Methods Top

After approval of the Institutional Medical Ethics Committee and obtaining informed consent, the study was conducted in 100 patients undergoing cataract surgery at a tertiary teaching hospital in North-east India, under peribulbar anesthesia during a 2-year period. Persons of either sex between the ages of 20 and 90 were included the study. Exclusion criteria include communication problems, refusing consent, taking anticoagulants, and history of allergy to amide-type local anesthetic agents. Preoperatively, the patients were subjected to a routine eye examination including slit-lamp examination of anterior segment, direct ophthalmoscopy, intraocular pressure measurement, keratometry, and A-scan/B-scan ultrasound for axial length calculation.

Patients were allocated randomly in two groups according to the anesthetic agent received:

(a) Group 1 (n = 50) receiving 10 ml of 2% lignocaine hydrochloride with adrenaline 1:200,000 and (b) Group 2 (n = 50), 6 ml of 2% lignocaine hydrochloride with adrenaline 1:200,000 plus 4 ml of 0.5% bupivacaine hydrochloride. Both groups shall also receive 50 IU/ml of hyaluronidase mixed with the lignocaine solution. Simple randomization was done to decide which local anesthetic agent to be given to the first case. Thereafter, the two types of local anesthetic solutions are given alternately until the last case. On arrival in the anesthetic room, topical anesthesia of the conjunctiva and cornea was provided by administering 4% lignocaine drops. Anesthetic solutions were prepared individually immediately before injection.

Peribulbar anesthesia was administered by a two-injection technique using a 24-gauge 25 mm long hypodermic needle. In each case, the first injection was given through the lower lid at the junction of lateral one-third and medial two thirds. The needle was directed first along the floor of orbit and then turned slightly upward. At a depth of approximately 2.5 cm, after aspiration, 4 ml of local anesthetic was injected in the lower peripheral space. The 2nd injection was given through the upper lid at the junction of medial one-third and lateral two-thirds of the superior orbital rim. The needle was directed first along the roof of the orbit and then turned slightly downward. At a depth of approximately 2.5 cm, after aspiration, 4 ml of local anesthetic solution was injected in the upper peripheral space. An additional 1 ml of local anesthetic was deposited in the upper as well as lower orbicularis on withdrawal of the needle. Each injection was followed by a period of firm orbital pressure using super pinky ball for 10 min, which was removed at 2 min interval to assess residual ocular movement.

A pro forma designed for the study was used. In each case, patient data including visual acuity, intraocular pressure before injection of anesthetic solution, technique of peribulbar block, quality of block, degree of analgesia, number of supplemental injection, volume of anesthetic solution required, peroperative pain and medications, duration of surgery, and complications were collected. The quality of the block was assessed using a three-point akinesia scoring system [Table 1],[8] based on the reduction of globe motility in each quadrant (akinesia score). Ocular movements were scored for each direction of gaze in the superior, inferior, medial, and lateral directions. The score for movement in each direction of gaze was thus the sum of scores for the two corresponding quadrants – minimum score possible = 0 and maximum score possible = 3 × 4 = 12. The block was considered inadequate for surgery if eyeball movement score was 4 or more in any direction at 10 min. If these occurred a supplementary injection(s) of 3–5 ml of the same type of anesthetic mixture was performed. The need for supplementary injection(s) and the anesthetic volume required were recorded. The patients were offered for surgery 20 min after the injection. The duration of surgery was recorded, and globe akinesia was again scored at the end of surgery for each patient. The degree of pain was rated using a five-point score [Table 2]. Patients were specifically asked after the surgery to grade separately for pain during administration of anesthesia and pain during surgery.
Table 1: Scoring system for degree of akinesia

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Table 2: Scoring system for degree of analgesia

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All the cases were entered in the pro forma specially designed for the study. Statistical analysis was performed using appropriate statistical software for windows. Statistical significance in respect of the efficacy of each anesthetic mixture was tested using the Chi-square or Fisher's exact test, as appropriate, at P < 0.05.

  Results Top

Patient demographic characteristics, the volumes of local anesthetic injection required, and the duration of surgery in the two groups were similar, and no significant differences were detected [Table 3]. Pain on injection was found significantly more frequent in Group 1 (2% lignocaine) (P < 0.05) [Table 4]. However, perioperative analgesia was satisfactory in both groups with no significant difference [Table 4]. Patients in Group 2 (2% lignocaine + 0.5% bupivacaine) showed a better ocular akinesia at 10 min and at the end of surgery (mean akinesia score of 1.08 and 0.76, respectively) in comparison to that of Group 1 (mean akinesia score of 2.52 and 1.48, respectively) which was found to be statistically significant [Table 4]. Furthermore, the patients in Group 2 showed a significantly reduced need for the first supplemental injection [Table 4]. While there was no need for a second supplemental injection in Group 2, 10% of the patients in Group 1 required a second top-up injection though this difference was statistically not significant. Local complications such as chemosis occurred in 10 patients (20%) in Group 1 and 13 patients (26%) in Group 2; the difference was not significant. No case of proptosis and serious cardiac or central nervous system complications were noted in either group.
Table 3: Demographic data of patients, volumes of local anesthetic agents injected and duration of surgery

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Table 4: Block characteristics

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  Discussion Top

The study has shown that significantly better results for akinesia were obtained with the combination of 2% lignocaine plus 0.5% bupivacaine mixed with 50 IU/ml of hyaluronidase at 10 min after injection and also at the end of surgery. However, with regard to analgesia, both 2% lignocaine and 2% lignocaine with 0.5% bupivacaine had a similar effect. Most of the patients experienced only mild pain at injection while they rarely experienced pain during surgery in both groups.

The proportion of re-injections reported in the literature after supra- and infra-orbital double injection varied between 4%[9] and 50%.[10] However, reinjection percentages vary, depending on the degree of akinesia required by the surgeon. In addition, it is difficult to compare the various studies of peribulbar anesthesia because of the great differences between the substances used and the ways in which local anesthetics are administered. In the present study, the rate of the first supplementary injection was significantly lower in the lignocaine with bupivacaine group at 18% compared to 40% in the lignocaine group. The rate of the second supplementary injection was also lower in the lignocaine plus bupivacaine group, although nonsignificant, at 0% in comparison to 10% in the lignocaine group. In both groups, supplemental injections were required only because of inadequate akinesia. The level of analgesia was almost always satisfactory after the first injection in both groups.

The decision regarding the amount of anesthetic mixture for supplemental injection was made by the practitioner performing the peribulbar anesthesia in our study, to obtain a protocol that would be applicable to all patients and would correspond as closely as possible to normal conditions of practice. The mean volume of anesthetic solution required to achieve block in this study was higher (10.76 ml for lignocaine with bupivacaine group and 11.80 ml in the lignocaine group) than in previous studies.[11] Although the volume required in lignocaine with bupivacaine group was lower than the lignocaine group, the difference was not significant.

The present study did not assess the duration of anesthesia and analgesia of the anesthetic agents used because patients rarely experienced pain or failure of block toward the end of surgery in either group despite delays of up to 1 h in the operating program. It is however found by others that the duration of action of lignocaine was only 45 min while bupivacaine acted for a much longer period.[12]

Hyaluronidase promotes the spread of anesthetic solution within the fat filled spaces of the orbits and lids.[6] In this study, 50 IU/ml of hyaluronidase was added to the anesthetic solution, without pH adjustment, to take advantage of any possible effect promoting spread. However, this study could not prove or disprove the beneficial effect of hyaluronidase in peribulbar block.

In this study, peribulbar anesthesia was administered by a two-injection technique. This technique of peribulbar injection was in frequent use in our department when the study began and also favored by many[11] for their study of comparing two anesthetic solutions, while some favored the use of single-injection technique.[8],[13] It was, however, found that the incidence of complications was not increased in the two-injection technique used for the study.

Peroperative and early postoperative complications were noted in both groups, and most attention was paid to the occurrence of conjunctival chemosis, conjunctival hemorrhage, and proptosis which often occur after local anesthesia, and also on serious systemic and sight-threatening complication if it may occur. The occurrence of conjunctival chemosis in the present study is about 23% with no significant difference between the two groups. There was no case of conjunctival hemorrhage, proptosis or any other sight-threatening complication before, during, or immediately after the operation. A few cases of conjunctival ecchymosis were noted only after 24 h of the surgery. These complications were not recorded as the cause could not be completely attributed to the injection of anesthetic solution. The incidence of complications was very low in this study. No serious local complication was encountered. However, there is an ever-present risk of serious complications such as globe perforation, optic nerve injury, and even brainstem anesthesia.[14] These risks can be avoided by using short needles, not longer than 25 mm length.

Systemic side effects and complications of the local anesthetic agents were not seen in either group. Adverse cardiovascular effects following systemic absorption or inadvertent intravascular injection of local anesthetics are, however, well documented.[15],[16] In this study, we found no cardiovascular complications in either of the groups. However, our results cannot be deemed as conclusive in this regard, and further studies may be necessary.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol 1884;13:402-48.  Back to cited text no. 1
Lint V. Development of ophthalmic anaesthesia. Am J Ophthalmol 1961;51:1-14.  Back to cited text no. 2
Davis DB 2nd, Mandel MR. Posterior peribulbar anesthesia: An alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986;12:182-4.  Back to cited text no. 3
Davis DB 2nd, Mandel MR. Efficacy and complication rate of 16,224 consecutive peribulbar blocks. A prospective multicenter study. J Cataract Refract Surg 1994;20:327-37.  Back to cited text no. 4
Davis PL, O'Connor JP. Peribulbar block for cataract surgery: A prospective double-blind study of two local anesthetics. Can J Ophthalmol 1989;24:155-8.  Back to cited text no. 5
Thomson I. Addition of hyaluronidase to lignocaine with adrenaline for retrobulbar anaesthesia in the surgery of senile cataract. Br J Ophthalmol 1988;72:700-2.  Back to cited text no. 6
Kallio H, Paloheimo M, Maunuksela EL. Hyaluronidase as an adjuvant in bupivacaine-lidocaine mixture for retrobulbar/peribulbar block. Anesth Analg 2000;91:934-7.  Back to cited text no. 7
Brahma AK, Pemberton CJ, Ayeko M, Morgan LH. Single medial injection peribulbar anaesthesia using prilocaine. Anaesthesia 1994;49:1003-5.  Back to cited text no. 8
Ahmad S, Ahmad A, Benzon HT. Clinical experience with the peribulbar block for ophthalmologic surgery. Reg Anesth 1993;18:184-8.  Back to cited text no. 9
Loots JH, Koorts AS, Venter JA. Peribulbar anesthesia. A prospective statistical analysis of the efficacy and predictability of bupivacaine and a lignocaine/bupivacaine mixture. J Cataract Refract Surg 1993;19:72-6.  Back to cited text no. 10
Woodward DK, Leung AT, Tse MW, Law RW, Lam DS, Ngan Kee WD, et al. Peribulbar anaesthesia with 1% ropivacaine and hyaluronidase 300 IU ml-1: Comparison with 0.5% bupivacaine/2% lidocaine and hyaluronidase 50 IU ml-1. Br J Anaesth 2000;85:618-20.  Back to cited text no. 11
Lim AS, Checc CK. Local anaesthesia in ophthalmology. Curr Anaesth Crit Care 1991;2:117-121.  Back to cited text no. 12
Allman KG, Barker LL, Werrett GC, Gouws P, Sturrock GD, Wilson IH, et al. Comparison of articaine and bupivacaine/lidocaine for peribulbar anaesthesia by inferotemporal injection. Br J Anaesth 2002;88:676-8.  Back to cited text no. 13
Hamilton RC. Complications of ophthalmic regional anaesthesia. Ophthalmic Clin North Am 1998;11:99-114.  Back to cited text no. 14
Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology 1979;51:285-7.  Back to cited text no. 15
Reiz S, Nath S. Cardiotoxicity of local anaesthetic agents. Br J Anaesth 1986;58:736-46.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4]


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