In my practice we do alot of cataracts and other optho cases. Most of the cataracts are done with a retrobulbar block. A few surgeons do them with just topical. I and my partners do most of the retrobulbars. I usually give about 150 to 200 mg of pentothal, or 70-100 mg of propofol and do the block. We have very few complications with the retrobulbars. There have been one or two retrobulbar hemorrhages in the last few years. But that is out of about 1500 cataracts per year. These few hemorrhages have not been a problem b/c we pick up on them quickly and the optho guys take care of them. I have seen the oculocardiac reflex a few times with cataracts, but is usually as the surgeon starts and not with the block. I think the cataracts done with retrobulbars are easier for the surgeon to do because the eye doesn't move and they seem to get better dilation. It seems like the ones done under topical take longer (20-25 min vs 10-15 min with retrobulbar). The patients I don't do retrobulbars in are ones with high INR's ie>3 or plt counts less than 100k. Even with high INR's our optho guys will usually block them. I had a lady with a prosthetic heart valve with an INR of 3.7 and she still got blocked but not by me.
As for surgical complications, rarely the optho guy will rupture the capsule and have to do a vitrectomy. If the cataract is being done under topical the patient is brought back the next day for GA/retrobulbar. Do we really need to be there for topical cataracts? I feel given this patient population we do. Usually we don't do much other than give some versed and fentanly (especially if they have good topicalization). I think the fact that alot of these patients have one foot in the grave already justifies us being there.
