What kind of sedation is used for enucleation?

Anesthesia for Eye Enucleation

For eye enucleation, patients should receive either periocular (peribulbar/retrobulbar) anesthesia with monitored intravenous sedation OR general anesthesia, with periocular anesthesia plus sedation being the preferred approach due to superior outcomes including reduced postoperative pain, less nausea/vomiting, and lower costs. 1

Primary Anesthetic Approach: Periocular Anesthesia with IV Sedation

Periocular anesthesia with monitored intravenous sedation is the recommended first-line approach for enucleation in appropriate candidates. 1 This technique provides:

• Complete peroperative analgesia in 95.4% of cases when peribulbar block is properly performed 2
• Postoperative analgesia lasting 4+ hours in 100% of patients, with many patients (35%) requiring no additional pain medication for 24 hours 2
• Dramatically reduced postoperative morbidity: only 52% require postoperative analgesics versus 94% with general anesthesia 1
• Minimal nausea/vomiting: only 5% require antiemetics versus 56% with general anesthesia 1

Periocular Block Technique

The peribulbar block should be performed with: 2

• First needle insertion parallel to the inferior orbital floor
• Second insertion at the level of the supraorbital notch
• Anesthetic mixture: Equal parts lidocaine 2% with epinephrine (0.25 mg/20 ml) and bupivacaine 0.5% with epinephrine (0.10 mg/20 ml)
• Total volume: Approximately 16-17 ml 2

Intravenous Sedation Component

For the sedation component, use midazolam combined with fentanyl as the standard regimen: 3, 4

• Fentanyl: 50-100 μg IV initially, with supplemental 25 μg doses every 2-5 minutes as needed 3
• Midazolam: Titrate in small increments (1-2 mg doses) to achieve conscious sedation 3, 4
• Allow 2-5 minutes between doses to assess maximum effect before administering additional medication 4

Alternative: General Anesthesia

General anesthesia is indicated when: 1

• Patient has cognitive barriers or inability to cooperate
• Patient preference after informed discussion
• Extensive orbital trauma requiring longer operative time
• Failed or inadequate local anesthesia (rare, <5% of cases) 2

When general anesthesia is used, propofol-based induction is appropriate, with standard volatile anesthetic maintenance 5

Critical Monitoring Requirements

Mandatory monitoring must include: 3, 4

• Continuous pulse oximetry
• Blood pressure monitoring
• ECG monitoring
• Respiratory rate assessment
• Level of consciousness evaluation 3

Immediately available equipment: 3

• Age-appropriate bag-valve-mask
• Intubation equipment
• Reversal agents (naloxone for opioids, flumazenil for benzodiazepines)
• Resuscitation medications

A dedicated individual other than the surgeon must monitor the patient throughout the procedure 4

High-Risk Patient Modifications

For elderly patients (>60 years) or those with significant comorbidities: 4

• Reduce initial sedative and analgesic doses by 50%
• Titrate more slowly with smaller increments
• Consider ketamine (50-100 μg IV) instead of midazolam for hemodynamically unstable patients 3

Common Pitfalls to Avoid

Do not proceed with local anesthesia alone without adequate sedation - while technically feasible, patient comfort and cooperation are significantly improved with appropriate IV sedation 6, 1

Avoid oversedation - the goal is conscious sedation where the patient can respond to verbal commands, not deep sedation requiring airway management 5, 4

Do not use general anesthesia as default - periocular anesthesia with sedation has proven superior outcomes and should be offered to all appropriate candidates 1

Postoperative Pain Management

When periocular anesthesia is used, expect: 2

• Complete analgesia for first 4 hours in all patients
• 35% of patients require no additional analgesia for 24 hours
• When pain emerges (typically 4-10 hours postoperatively), paracetamol alone is sufficient in 70% of cases
• Only 25% require addition of nalbuphine to paracetamol

This extended analgesia is a major advantage over general anesthesia alone, which provides no residual postoperative pain control 1