Eye blocks

[coffeebythelake]

Did you learn to do them during residency?
Comfortable performing them?
Doing them now as an attending?

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[GassYous]

no
no
no

 

[thinkorswim]

I would say I’m pretty good at taping the eyes. Never tried it with a needle though.

 

[kidthor]

Absolutely not. Nor will I ever.

 

[aneftp]

I did a couple of them during residency. But it’s been so long.

Some of the docs at my place can do it.

But honestly. It’s all risk. No reward if you are on salary like me.

It’s like asking an OB to do the epidural for u. (A couple of Deep South old school Ob do epidurals!!). God honest truth. Lol. My friend worked with one in the south. But that’s rare.

 

[TheLoneWolf]

Nope
Not interested
Never

 

[TheLoneWolf]

Anesthesiologist linked to West Springfield blindings loses medical license

An anesthesiologist linked to West Springfield eye surgeries that caused five patients to lose vision has resigned his medical license.

www.masslive.com

5 patients blinded in a single day. No thanks.

Was at a talk at Cleveland Clinic shortly after this happened and it's really indefensible. Same as routinely doing bier blocks and someone has LAST or a seizure...cool to know but not super applicable to routine practice.

 

[DocVapor]

no
no
no

My response before seeing other responses:

No
H*** No
F*** No

 

[Gasmd98]

Learned after residency. Probably the scariest thing I have ever done as an anesthesiologist. Got pretty slick and did a couple hundred. Great for long retina cases in sick diabetics. No longer do them and glad to avoid the risk.

 

[crash2500]

Coffee, don't you do these fancy blocks in academics? Us private guys do spinal with LMA generals.

 

[JoelJoel84]

Same responses as above, but for a Bier block, which a much older surgeon asked me to do yesterday at an ASC.

Never seen one, learned one, or performed one.

I’m <10 years out of training, but I can’t imagine anyone is using them with the advent of ultrasound PNBs.

 

[bourg]

Yes, yes, yes. So I'm surprised by the answers here, practices vary wildly across different countries. Where I trained in Brazil, a big part of CA1 is spent doing ophthalmic surgeries. In fact, traditionally, in my residency, it's usually the first anesthesia you do in you life (a peribulbar block). What do you do for these retina/cataract cases? To be fair, cataracts can be done with topical anesthesia, but the retina ones? LMA? GETA?

 

[Drwine]

Some anesthetic techniques belong on the scrap heap. It has been over 25 years since I have done a Bier Block or caudal anesthesia. Anywhere I ever worked the surgeon did their own peribulbar or retrobulbar blocks just like podiatrists do their own Mayo blocks. So no way to all of the above.

 

[wysdoc]

Did you learn to do them during residency?
Comfortable performing them?
Doing them now as an attending?

@coffeebythelake are you being asked to do retrobulbar blocks by ophthalmologists?
It is an antiquated custom as cataract surgery is now mainly done with topical anesthetic.

 

[coffeebythelake]

@coffeebythelake are you being asked to do retrobulbar blocks by ophthalmologists?
It is an antiquated custom as cataract surgery is now mainly done with topical anesthetic.

Nah.. Just curious what others experience is like. We do topical lidocaine jelly like everyone else. The long, tough ones get a block by the surgeon.

There was a place out in the community many years ago when I was interviewing of new attending job where the anesthesiologists did them regularly. They told me they would "train me" to do em. Didn't think it was a good idea then. Don't think it is a good idea now..

 

[GassYous]

I guess I'm the only one that likes bier blocks
There's something about watching the veins plump up...

 

[coffeebythelake]

Coffee, don't you do these fancy blocks in academics? Us private guys do spinal with LMA generals.

@crash2500 You have to say light GA. 🤪

And good for you doing spinal with a SGA for an eye case. I wouldn't think that was a solution but you surprise me constantly.

 

[coffeebythelake]

Yes, yes, yes. So I'm surprised by the answers here, practices vary wildly across different countries. Where I trained in Brazil, a big part of CA1 is spent doing ophthalmic surgeries. In fact, traditionally, in my residency, it's usually the first anesthesia you do in you life (a peribulbar block). What do you do for these retina/cataract cases? To be fair, cataracts can be done with topical anesthesia, but the retina ones? LMA? GETA?

Surgeon preference for the more complicated ophtho cases. Some of them do blocks with moderate sedation. Others ask for GA.

 

[ethernet]

Sort of. I did a couple with one of the surgeons on my outpatient rotation in residency.
Yes, I was trained in by a colleague.
Yes, some surgeons will do their own, some will request our services for room efficiency (or to defer liability)

 

[coffeebythelake]

Sort of. I did a couple with one of the surgeons on my outpatient rotation in residency.
Yes, I was trained in by a colleague.
Yes, some surgeons will do their own, some will request our services for room efficiency (or to defer liability)

i don't know how much efficiency you can squeeze by doing the block outside the OR. save maybe 2 minutes.
i agree this is probably used by some ophthalmologists to defer liability if there is a complication

 

[DocMcCoy]

Did peribulbars with option to do some retrobulbars with attendings that were comfortable with them in residency. Can’t ever see myself stabbing around an eye now. Our retinal guy does his own blocks which should be how it is since he can fix his own complications if they were to arise. Cataracts get drops and a wiff of versed.

 

[IMGASMD]

No, no, and no.
My last job covered an eye place, and was going to train me, then dropped the contract within a year, because the surgeon was too slow, and we were constantly there after 5, on what supposedly be “easy outpatient eye days”.

I was told when it worked as designed, then it should be very efficient. You’d do the block, as the surgeon works on the eye, you leave to do the next one. Never seen it in action, probably for the best with what everyone says above.

One of my co-resident told me she was trained on the job.

 

[pocafx]

No no no. Optho blocks any cases they want to
Same answer for bier block. Never seen one

 

[Shimmy8]

Yes
No
No


Not a chance in hell I’d do them now.

 

[Gasworks]

I don’t do them nor do I want to learn. I do work with several crnas that are proficient at them and they do solo days at retina centers. Is this another example of a mid level stepping up to provide a service Im “too good” to do? Maybe, but I’m just too old to be bothered.

I also know several docs that trained in Miami, they rotate through the eye hospital and leave the program very proficient in eye blocks. They tell me it’s easy and low risk but I’m still too old to be bothered.

 

[Angus Avagadro]

Got named in a lawsuit, then eventually dropped when my Crna assisted an opthomologist in the holding area doing a retrobulnar block. The holding area nurse handed him a syringe filled with formalin rather than bupivacaine. The patient was blinded. I was never trained in performing those blocks, and had little interest in learning them.

 

[coffeebythelake]

Got named in a lawsuit, then eventually dropped when my Crna assisted an opthomologist in the holding area doing a retrobulnar block. The holding area nurse handed him a syringe filled with formalin rather than bupivacaine. The patient was blinded. I was never trained in performing those blocks, and had little interest in learning them.

Wow that sucks. But I don't think this could be truly labeled as a block complication. This was a medication error. A horrifying one.

 

[coffeebythelake]

Same answer for bier block. Never seen one

We occasionally perform bier blocks at my shop on surgeon request. I'm not a fan of them and approach them with high vigilance. Stories abound of wrong medication injected (e.g. bupivicaine or even 8.4% sodium bicarbonate!), LAST and other serious complications.

Many cases could be done just as well with local anesthetic infiltration by the surgeon, or a short acting nerve block.

 

[DrAmir0078]

I know only two residents had done them during the board because their graduation research. Otherwise, all Opthalmologists do them by their own, and only request simple sedation only.
By the way, I agree someone here who said "very good at taping the eyes - lol, same here"

 

[GassYous]

This is why I draw up all of my own meds!

 

[woopedazz]

Yes, yes, yes.

We get a load of training in them. As an equivalent to your CA-2 we would routinely do a 12 patient morning phaeco list which were all blocked.

Revolving door with attending/trainee taking turns with each patient assessing, consenting, blocking, handing off to theatre.

I will never do a retrobulbar ever. That's risky.

 

[dabears505]

@crash2500 You have to say light GA. 🤪

And good for you doing spinal with a SGA for an eye case. I wouldn't think that was a solution but you surprise me constantly.

Yes super high spinal then lma with volume control ventilation with super high volumes at that.

 

[coffeebythelake]

Yes super high spinal then lma with volume control ventilation with super high volumes at that.

Oh damn.. we would normally avoid high spinals but this must be one of those instances where it is done purposefully.

 

[IMGASMD]

Oh damn.. we would normally avoid high spinals but this must be one of those instances where it is done purposefully.

High spinal technique?

I didn’t go to an ivory tower program, is that the special technique that you all learned?

Is there a paper to support this?

/s

 

[coffeebythelake]

High spinal technique?

I didn’t go to an ivory tower program, is that the special technique that you all learned?

Is there a paper to support this?

/s

I dont know. This isnt a technique we use in academics. Ask @crash2500. He will fill you in all the details. I think he is about to publish a case series on it.

 

[Maz777]

Unfortunately yes
No
Thankfully never

Another nugget:

Eye Surgery Mistake - $1.29 Million Verdict - Eye & Lasik Center

Eye Surgery Medical Malpractice Trial ends in $1.29M verdict for plaintiff - 50 year old man blind in one eye when doctor injects anesthesia behind eye - Ben Novotny Attorney for plaintiff, Lubin & Meyer representing medical malpractice victims in MA, NH, RI.

www.lubinandmeyer.com

No thanks. Would never join a practice in which this was expected.

I'm fine with Bier blocks if some 80-year-old surgeon forces me to, but an LMA is equally efficacious and a fraction of the effort. Most patients do not want two PIVs for ditzel hand surgeries.

 

[dabears505]

Yea its not that complicated. I've noticed that the spinal kit comes with two clear vials. For the eye surgeries I draw up all of both, then do a spinal as normal. After a few minutes they go apnic. Then I put in the lma. I usually don't need propofol.

 

[Realgassy]

No
No
No.

I do bier block’s occasionally - always double check dosages. Safest if I can convince them to go with the forearm tourniquet. Had a wonderful experience where the tourniquet machine started beeping right after injecting the local and the or tech unplugged the machine to “help.”

Lots of old school surgeons. I request the resident/surgeon do the esmarch arm wrap for me.

 

[pgg]

Some obnoxious clown of an ophthalmologist at a surgicenter where I once did some moonlighting kept nagging me to do his retrobulbar blocks. I said no and quit that job after 4 ridiculous days because of him (and some other reasons involving safety at that place).

 

[Ashers]

Residency, no. Fellowship, yes a couple, until I started refusing to do them because I was never going to do them in practice, and I almost passed out doing it.

When asked by my fellowship director what I'd do if the surgeon asked me for one, I said I'd tell the surgeon to block the eye. I've never been asked to do one by a surgeon, I had a locums gig ask if I did them, so they could put me with a surgeon who wanted the anesthesiologist to do them, I said no.

 

[narcotics999]

Residency, no. Fellowship, yes a couple, until I started refusing to do them because I was never going to do them in practice, and I almost passed out doing it.

When asked by my fellowship director what I'd do if the surgeon asked me for one, I said I'd tell the surgeon to block the eye. I've never been asked to do one by a surgeon, I had a locums gig ask if I did them, so they could put me with a surgeon who wanted the anesthesiologist to do them, I said no.

Next time I will ask ENT and Maxillofacial surgeons to do the intubations for me, lol.

 

[anesthesiadoc]

Next time I will ask ENT and Maxillofacial surgeons to do the intubations for me, lol.

Not really a fair comparison there.

 

[GassYous]

Next time I will ask ENT and Maxillofacial surgeons to do the intubations for me, lol.

I've had an ent do an awake for me before
Nasty anatomy wide awake

 

[fadedrebel]

We took over a surgery center where the prev group did eye blocks. So we learned and started doing them as well. I did probably close to 500 of them while I worked there. Never did one in residency - essentially learned on the job.

And while we called them peribulbar... it was mostly retrobulbar we were doing based on angle and depth. I never had a complication (that i was aware of). Haven't done them in years since we stopped staffing that place .

 

[jwk]

Our big group stopped doing them years ago. All the risk, zero reward. You can't bill separately for the block, just for the MAC anesthesia time while you're actually doing the case, so what's the point? Topical +/- sedation is more than adequate for 99.9% of cataracts, including the ones we do at the hospital that don't meet criteria for having them done at the outpatient centers.