Ophthalmic Regional Blocks

[doctor712]

Hey All,

Eye blocks. I'm working on two papers and am learning about a whole new area of regional: the eye block. RBB, PBB, STB...
A couple questions as I'm curious:

- Are these blocks common? That is, are they in the regional docs repertoire much the same way a CSE or cervical epidural or femoral block is?

- This paper is on U/S guided for ophthalmic blocks. Is it typical to still do these blocks "blind" (where you are)? Or are you doing these with U/S?

- are these blocks regularly taught during residency? fellowship? both? is it institution dependent? some places give amazing case counts, and at others...2 during 3 years??? This feels like one of those moments I'd want my eyes in the hands of someone who did tons of these as a trainee...

- Lastly, I understand the complication rates (read a bunch on this, this Dr. Hamilton in Alberta has the market cornered on papers here - sheesh!) of bad things happening is exceedingly small - Miller says 1 in 500 of something like globe penetration, hemorrhage or brain stem anesthesia. So, I'm curious, and I know this is coming from a pre-med but please hear me out: i love all the procedures of anesthesia, all these blocks and cases are fascinating, top to bottom. But the face, especially the eyes, are hard for me to want to F @$K around with. Even with .2% complication rate. Ya know? I feel as if I can't wait to do a spinal or epidural or any other block, I love the cath lab too and all that they do inside a beating heart. But eyes, I dunno. Maybe it's because I never had good ones and appreciate...vision. Especially after I had mine fixed. But I feel it's more the anatomy and the proximity to the "mind", strange, I'll get over it in med school I think, just sharing.

ANYHOO, question, why even mess with these blocks that are mm away from the globe, where you are so close to causing blindness, when an option may seem to be general anesthesia? Is this just regional docs being curious and seeing how many cool things they can do? Which is fine. How else do we expand...

I asked one of the ophth anesthesiologists this and he said, it's safer. But, then I feel all I read about lately are the papers about the growing safety stats with general anesthesia. So, is this a question of...who I am asking? Or, in cases where you prefer to do an awake regional eye block, it's simply more dangerous to do as general?? Insane co-morbidities aside, what about the average, otherwise healthy patient in for eye surgery... is IOP the answer as to why no/less GA for eyes?

Thanks!!!!

D712

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[Mman]

The opthamologists do the blocks where I trained and where I work. I'm sure anesthesiologists do them in some places, but I'd venture a guess that >95% of places they are not done by anesthesiologists.

Also, I'd imagine that it is not very conducive to ultrasound based on the relatively small area you are working in and the shallow depth to the skull. You'd need a very high frequency probe and a very small probe to have any sort of utility. But that's just a guess.

 

[jwk]

I've never seen an ultrasound guided eye block.

We abandoned doing eye blocks years ago. We were doing them solely for the convenience of the surgeon, but the liability potential really outweighed the benefits of us doing them. Remember, you can't charge extra for doing the eye block, so reimbursement is the same topical/MAC or block/MAC.

Most of our cataract work is done with topicals and has been for many years. The few holdouts that want a block do their own with propofol sedation provided by us in the pre-op area. Our vitreo-retinal work is a split between block and GA, but again, all the blocks are done by the eye doc. Those types of patients have enough problems already.

 

[Dogdaze]

I was never taught one in residency, and never intend on doing one. Agree with JWK that the opthamologists do them all, also agree that the risk/benny balance make it not worth learning at this point. We do a lot of eye cases though, and therefore, still have to deal with the effects of potential complications.

 

[pgg]

I've witnessed a couple of retrobulbar blocks done by ophthalmologists. I've never done one, and it's not on my agenda to start. I was interested in doing some as a resident, but I was interested in all kinds of neat stuff when it wasn't my own ass on the line. There's just no up side for doing one now.

Given a patient with comorbidities that would make a regional technique attractive, the ophthalmologist can drive the needle. Otherwise, goodnight.

 

[Idiopathic]

the only modern utility in the retrobulbar block is as material for a board exam

 

[doctor712]

the only modern utility in the retrobulbar block is as material for a board exam

Here's another modern utility of the RBB: keeping me up late at night writing about it.

Well, a handful of anesthesiologists (2 that I work with) are doing them, though they prefer the PBB as it's a bit safer from the literature. I asked one about it last night and they said that indeed they don't know any other anesthesiologists doing RBBs. The manuscript is about the use of U/S for guidance and in fact it is very promising with the right transducer/probe, and there are a bunch of papers out there about it. The chapter is basically for the benefit of ophthalmologists doing ophthalmic anesthesia. Which, when I get to training, deferring to ophthalmology to do these - I think I wouldn't necessarily mind too much. Sounds like I'm not outside the norm there...

Thanks for replies!
D712

 

[Southpaw]

ophtho guys do them regularly where i train...esp at the outpatient center. i have no interest in learning these blocks.

 

[pd4emergence]

Hey All,

Eye blocks. I'm working on two papers and am learning about a whole new area of regional: the eye block. RBB, PBB, STB...
A couple questions as I'm curious:

- Are these blocks common? That is, are they in the regional docs repertoire much the same way a CSE or cervical epidural or femoral block is?

- This paper is on U/S guided for ophthalmic blocks. Is it typical to still do these blocks "blind" (where you are)? Or are you doing these with U/S?

- are these blocks regularly taught during residency? fellowship? both? is it institution dependent? some places give amazing case counts, and at others...2 during 3 years??? This feels like one of those moments I'd want my eyes in the hands of someone who did tons of these as a trainee...

- Lastly, I understand the complication rates (read a bunch on this, this Dr. Hamilton in Alberta has the market cornered on papers here - sheesh!) of bad things happening is exceedingly small - Miller says 1 in 500 of something like globe penetration, hemorrhage or brain stem anesthesia. So, I'm curious, and I know this is coming from a pre-med but please hear me out: i love all the procedures of anesthesia, all these blocks and cases are fascinating, top to bottom. But the face, especially the eyes, are hard for me to want to F @$K around with. Even with .2% complication rate. Ya know? I feel as if I can't wait to do a spinal or epidural or any other block, I love the cath lab too and all that they do inside a beating heart. But eyes, I dunno. Maybe it's because I never had good ones and appreciate...vision. Especially after I had mine fixed. But I feel it's more the anatomy and the proximity to the "mind", strange, I'll get over it in med school I think, just sharing.

ANYHOO, question, why even mess with these blocks that are mm away from the globe, where you are so close to causing blindness, when an option may seem to be general anesthesia? Is this just regional docs being curious and seeing how many cool things they can do? Which is fine. How else do we expand...

I asked one of the ophth anesthesiologists this and he said, it's safer. But, then I feel all I read about lately are the papers about the growing safety stats with general anesthesia. So, is this a question of...who I am asking? Or, in cases where you prefer to do an awake regional eye block, it's simply more dangerous to do as general?? Insane co-morbidities aside, what about the average, otherwise healthy patient in for eye surgery... is IOP the answer as to why no/less GA for eyes?

Thanks!!!!

D712

We do lots of eye blocks in my practice mosty for cataracts. I don't think it is a common thing for anesthesiology practices to do. I did a few RBB/PBB's in residency but really learned when I got out into pp. My record day for RBB's is 51. We have a 3 or 4 cataract guys in town that can do one in less than 5 minutes. I think alot of places are going more towards topical/mac anesthesia for cataracts. Some of our surgeons are in the process of changing and doing some with topical. The problem with topical for them is that it slows them down significantly. There is no way they could do 25 cats by lunch if they were doing them all with just topical. Good or bad that's the way it is.

Other cases we do blocks for are glaucoma shunts, pterygiums, and certian retina cases. As far as the complication rate, as a group we are much less than the quoted study rates. At the eye place we cover we have done 30-50 cats (and some other cases) every day for years and only very rarely have a complication that involves vision loss (maybe once every 2 or 3 years). I think 15 or 20 years ago one of my older partners had a central/subarachnoid injection (the pt did fine). We do occassionally get a retrobulbar hemorrhage (2 or 3 a year) but these are not really a big deal as long as they are recognized and treated.

From a safety standpoint, ga vs. block vs. topical, if you saw some of the patients I block, there would be no way you would want to put them to sleep for anything much less a minor procedure that really could be done topically. Eye patients are a difficult patient population to deal with. Where I live they are old, fat, diabetic, hypertensive, have CAD, CHF, and CRF, and would not be in the building if the nursing home had not have transported them there.

I don't think doing these blocks is unreasonable from a safety standpoint. Should the opthmologist be doing his own blocks? I think its a valid question, but when it takes almost as long for him to block a patient as it does for him to do a cataract its hard for him to be cranking out the cases. In private practice, when the surgeon is not cranking out the cases, you as the anesthesiologist are not making any money.

 

[jwk]

We do lots of eye blocks in my practice mosty for cataracts. I don't think it is a common thing for anesthesiology practices to do. I did a few RBB/PBB's in residency but really learned when I got out into pp. My record day for RBB's is 51. We have a 3 or 4 cataract guys in town that can do one in less than 5 minutes. I think alot of places are going more towards topical/mac anesthesia for cataracts. Some of our surgeons are in the process of changing and doing some with topical. The problem with topical for them is that it slows them down significantly. There is no way they could do 25 cats by lunch if they were doing them all with just topical. Good or bad that's the way it is.

Other cases we do blocks for are glaucoma shunts, pterygiums, and certian retina cases. As far as the complication rate, as a group we are much less than the quoted study rates. At the eye place we cover we have done 30-50 cats (and some other cases) every day for years and only very rarely have a complication that involves vision loss (maybe once every 2 or 3 years). I think 15 or 20 years ago one of my older partners had a central/subarachnoid injection (the pt did fine). We do occassionally get a retrobulbar hemorrhage (2 or 3 a year) but these are not really a big deal as long as they are recognized and treated.

From a safety standpoint, ga vs. block vs. topical, if you saw some of the patients I block, there would be no way you would want to put them to sleep for anything much less a minor procedure that really could be done topically. Eye patients are a difficult patient population to deal with. Where I live they are old, fat, diabetic, hypertensive, have CAD, CHF, and CRF, and would not be in the building if the nursing home had not have transported them there.

I don't think doing these blocks is unreasonable from a safety standpoint. Should the opthmologist be doing his own blocks? I think its a valid question, but when it takes almost as long for him to block a patient as it does for him to do a cataract its hard for him to be cranking out the cases. In private practice, when the surgeon is not cranking out the cases, you as the anesthesiologist are not making any money.

I'm not sure why they can't do a topical case in 5 minutes as well. They start getting drops in pre-op, get a few more as they're prepping and draping, and away we go.

 

[ASA6]

I'm not sure why they can't do a topical case in 5 minutes as well. They start getting drops in pre-op, get a few more as they're prepping and draping, and away we go.

I Kind of agree with this. Where I am training there is an outpatient eye center, and they crank through the cataracts. The opthamologists do the blocks. About half of them do it topical, half the surgeons do blocks. To be honest its quicker topical, because there is no waiting for the sedation to kick in and actually do the block, and the occasional jaw thrust or chin lift when I over do it. As far as U/S goes, Ive never seen it used.

 

[Mman]

In private practice, when the surgeon is not cranking out the cases, you as the anesthesiologist are not making any money.

In PP if you are doing cataracts, you are not making money because the patients are almost all medicare/caid.

 

[pd4emergence]

I Kind of agree with this. Where I am training there is an outpatient eye center, and they crank through the cataracts. The opthamologists do the blocks. About half of them do it topical, half the surgeons do blocks. To be honest its quicker topical, because there is no waiting for the sedation to kick in and actually do the block, and the occasional jaw thrust or chin lift when I over do it. As far as U/S goes, Ive never seen it used.

I think part of the reason for the time difference is that with the blocks the pt's eye is akinetic. This is what they are used to working with. We block the pt's before they get to the OR so by the time they get there their sedation for the block is gone. I keep three or four blocked for each surgeon and it is a regular factory. I agree with you that if they wanted to change their system they probably could and have the same numbers. They would just have to get used to working on pt's whose eye's can move. These guys have done it for years this way, there is one or two of them that are coming around to doing them topically but they are still taking 8-10 min instead of 5.

 

[pd4emergence]

In PP if you are doing cataracts, you are not making money because the patients are almost all medicare/caid.

True, they don't pay much but at some point volume overcomes shi#ty pay.

 

[Mman]

True, they don't pay much but at some point volume overcomes shi#ty pay.

We found it more economical to convince (most) of the surgeons to do them under topical without us involved.

 

[cchoukal]

We're a small shop and an academic place to boot, but our ophthalmologists do a sub-tenon block (it appears to just be a depot of local under the sclera) after topical drops. They need the patient to cooperate w/ eye mvmt for the block, so no extra sedation required. Of course, door to door, the cases are more like an hour...

 

[Frank Rizzo]

From a safety standpoint, ga vs. block vs. topical, if you saw some of the patients I block, there would be no way you would want to put them to sleep for anything much less a minor procedure that really could be done topically. Eye patients are a difficult patient population to deal with. Where I live they are old, fat, diabetic, hypertensive, have CAD, CHF, and CRF, and would not be in the building if the nursing home had not have transported them there.

I do PLENTY of these blocks, both peri's and retro's, and this is the main reason why.

 

[Frank Rizzo]

True, they don't pay much but at some point volume overcomes shi#ty pay.

exactly, throw in a decent payer mix, and it can be well worth it.

 

[Mman]

exactly, throw in a decent payer mix, and it can be well worth it.

But how good can the payer mix get? The median age nationwide for cataract surgery patients is around 75 years old. I'm not sure what the standard deviation on that is, but at least 80% of patients have to be Medicare. Even if you have 100% private insurance, that's still not a good deal.

I mean you make money, but if you have the choice of doing something better it isn't worth it financially. In other words, the opportunity cost makes it a relative loser for a profitable group.

 

[pd4emergence]

But how good can the payer mix get? The median age nationwide for cataract surgery patients is around 75 years old. I'm not sure what the standard deviation on that is, but at least 80% of patients have to be Medicare. Even if you have 100% private insurance, that's still not a good deal.

I mean you make money, but if you have the choice of doing something better it isn't worth it financially. In other words, the opportunity cost makes it a relative loser for a profitable group.

We make 1.5 to 2 FTE's off of the ASC that we staff that does mostly cataracts, that's with just having to put one MD there (rarely 2). Fast surgeons and lots of patients, it doesn't really matter that they are all medicare. For us it's about 85% medicare and 15% private. I even live in a state that has terrible reimbursement rates (one of the lowest). I would go into the numbers but I have been chastised here before for giving ballpark real numbers. Redo your numbers with 8 cataracts an hour and getting the full anesthesia fee (we employ the CRNA's at our ASC's). It works out ok as long as the surgeons are fast, the volume is there, and you are not having to split the anesthesia fee with some other entity.

 

[Frank Rizzo]

We make 1.5 to 2 FTE's off of the ASC that we staff that does mostly cataracts, that's with just having to put one MD there (rarely 2). Fast surgeons and lots of patients, it doesn't really matter that they are all medicare. For us it's about 85% medicare and 15% private. I even live in a state that has terrible reimbursement rates (one of the lowest). I would go into the numbers but I have been chastised here before for giving ballpark real numbers. Redo your numbers with 8 cataracts an hour and getting the full anesthesia fee (we employ the CRNA's at our ASC's). It works out ok as long as the surgeons are fast, the volume is there, and you are not having to split the anesthesia fee with some other entity.

Are you one of my partners? Ha!

 

[Mman]

We make 1.5 to 2 FTE's off of the ASC that we staff that does mostly cataracts, that's with just having to put one MD there (rarely 2). Fast surgeons and lots of patients, it doesn't really matter that they are all medicare. For us it's about 85% medicare and 15% private. I even live in a state that has terrible reimbursement rates (one of the lowest). I would go into the numbers but I have been chastised here before for giving ballpark real numbers. Redo your numbers with 8 cataracts an hour and getting the full anesthesia fee (we employ the CRNA's at our ASC's). It works out ok as long as the surgeons are fast, the volume is there, and you are not having to split the anesthesia fee with some other entity.

We have a similar set up (including employing the CRNAs) and it is a relative money loser compared to everything else we do. I guess the surgeons are slightly slower as we only get about 6 per hour per surgeon when it's all said and done.

I mean we don't lose money, but the opportunity cost of having to pay someone to be there when it generates less revenue than other areas is still not good.