What is the safest and most reliable anesthesia technique for globe evisceration, and what alternatives are recommended if general anesthesia is contraindicated?

Anesthesia for Globe Evisceration Surgery

For globe evisceration surgery, retrobulbar or peribulbar anesthesia with monitored sedation is the safest and most reliable technique in adults, providing excellent surgical conditions while avoiding airway manipulation and its associated risks. 1

Primary Anesthetic Approach: Regional Anesthesia

Retrobulbar or peribulbar blocks are the preferred techniques for unilateral globe evisceration, as they provide complete akinesia and anesthesia of the globe while maintaining spontaneous ventilation and avoiding the cardiovascular stress of general anesthesia. 1 These regional techniques are particularly advantageous because:

• Ophthalmic surgery is particularly suited to regional anesthesia, with serious complications (retrobulbar hemorrhage, brainstem anesthesia, globe perforation) being uncommon when performed by skilled practitioners. 2
• The patient remains awake and cooperative, reducing risks of aspiration and postoperative nausea/vomiting. 3
• Cardiovascular stability is maintained without the hemodynamic perturbations of general anesthesia induction and emergence. 2

Technical Execution of Regional Blocks

Calculate a safe dose of local anesthetic before performing the block to minimize the risk of local anesthetic systemic toxicity, which occurs at a rate of 7.5 per 10,000 for peripheral nerve blocks. 1, 2

• Use ultrasound guidance when feasible to reduce the risk of systemic toxicity and improve block success. 1
• Thoroughly test the block for complete success before surgical incision to minimize the risk of emergent conversion to general anesthesia, which carries significant airway management risks. 1
• Allow adequate onset time (typically 10-15 minutes) before proceeding with surgery. 1

When General Anesthesia Is Required

If general anesthesia is necessary due to patient refusal of regional anesthesia, inability to cooperate, or contraindications to regional blocks, general anesthesia with a secure airway via endotracheal intubation is preferable to deep sedation without airway control. 1, 4

Indications for General Anesthesia Over Regional

General anesthesia becomes the safer choice when:

• The patient has significant anxiety or psychiatric conditions preventing cooperation during awake regional anesthesia. 5
• Bilateral procedures or complex, longer surgical procedures are planned, where prolonged immobility under regional anesthesia alone may be poorly tolerated. 1
• Reoperation with significant scarring is anticipated, potentially prolonging surgical time beyond what is comfortable under regional anesthesia. 1

General Anesthesia Technique

Use balanced general anesthesia with endotracheal intubation rather than supraglottic airway devices or deep sedation, as this provides the most secure airway for procedures that may mechanically compromise the airway. 1, 4

• Rapid sequence induction with propofol or etomidate and rocuronium provides optimal intubating conditions while minimizing aspiration risk. 6
• Videolaryngoscopy should be used as first-line technique if available, as it improves first-pass success rates. 6
• Maintain anesthesia with rapidly reversible agents (propofol infusion or sevoflurane) to allow rapid emergence. 6, 7

Combining Regional and General Anesthesia

Consider performing a retrobulbar or peribulbar block even when general anesthesia is used, as this combination reduces total opioid consumption, decreases respiratory depression, and improves recovery quality compared to general anesthesia alone. 4

• This multimodal approach is particularly beneficial for patients with obstructive sleep apnea or other respiratory comorbidities. 1, 4
• The regional block provides extended postoperative analgesia, reducing opioid requirements during the critical recovery period. 4

Contraindications to Regional Anesthesia

Absolute contraindications to retrobulbar/peribulbar blocks include:

• Patient refusal or inability to cooperate. 2
• Coagulopathy or therapeutic anticoagulation (though less stringent than neuraxial requirements). 2
• Active infection at the injection site. 2

In these scenarios, proceed directly to general anesthesia with endotracheal intubation rather than attempting deep sedation without a secure airway. 1

Critical Safety Considerations

Pain on injection or paresthesias during block placement are danger signals of potential neural injury and must not be ignored. 2 If these occur:

• Stop advancing the needle immediately. 2
• Withdraw slightly and redirect. 2
• Consider abandoning the attempt and converting to general anesthesia if repeated attempts are unsuccessful. 2

Have resuscitation equipment immediately available including lipid emulsion for local anesthetic systemic toxicity, as peripheral nerve blocks carry the highest incidence of systemic toxicity among regional techniques. 4, 2

Postoperative Management

Extubation (if general anesthesia was used) should only occur when the patient is fully awake with intact airway reflexes, demonstrating adequate respiratory effort and ability to follow commands. 1, 6

• Extubate in semi-upright position to optimize functional residual capacity. 6
• Full reversal of neuromuscular blockade must be verified before extubation using quantitative neuromuscular monitoring. 1