O A S I S

The 21st Annual Scientific Meeting of the Ophthalmic Anesthesia Society

 

The 2007 national meeting of the Ophthalmic Anesthesia Society was held at The Conrad Chicago Hotel in Chicago September 28-30. The event was jointly sponsored by the Cleveland Clinic Foundation Center for Continuing Education and OAS. Co-chairs Scott Greenbaum and Gary Cass arranged a bullpen-full of speakers and activities and even managed to have the Cubs make the playoffs while the OAS was in town!

Following a warm introduction from current OAS president, Scott Greenbaum, the first session began with discussion of the team concept for successful ophthalmic surgery centers. Don Hirschman reviewed a number of important factors, including wrong-side errors, record-keeping that facilitates flow, and perioperative anticoagulation. He stressed the need to balance the timing of patient arrivals with the facility’s desire to keep the OR’s running nonstop. Patient satisfaction improves with short wait times, but centers save money and increase revenue by increasing throughput and keeping the OR’s in continuous use.

I presented the following lecture, introducing the concept of using portable bedside ultrasound with needle-based ophthalmic regional anesthesia. A hearty discussion followed.

Next up, Dr. Mary Keyes, a pediatric-anesthesiologist from UCLA’s Jules Stein Institute, detailed novel methods for sedating ophthalmic surgery patients. This included an interesting technique using pump delivery of a narcotic-propofol-lidocaine cocktail. Their preferred narcotics in that mixture are alfentanil or remifentanil. Dexmedetomidine and benzodiazepines were discussed (and debated during Q&A.). She stressed that the ideal formula for sedation of eye patients is elusive, as many variables need to be considered.

After the break, Dr. Howard Amiel, an Ophthalmologist at Brown University’s Medical School elucidated the audience regarding the use of high-viscosity local anesthetics for topical anesthesia. He reviewed the literature on anesthetic drops, gels, and intracameral injection anesthesia. He compared and contrasted lidocaine gel versus tetravisc solution, noting that the former is less expensive, but the latter has preservatives and is easier to dispense. A vigorous discussion ensued after the talk, including reference to a recent paper that found increased incidence of endophthalmitis after topical anesthesia. Various etiologies were postulated including the potential barrier-effect of gels to antiseptics and the notion that infection may be more likely if the eye is not patched after surgery, as is frequently the case when cataract surgery is accomplished via topical anesthesia.

Next at bat, David Markoff, our newly-elected Vice President. His mission: Determining the ideal volume of local anesthetic for sub-Tenon’s anesthesia. A review of the literature revealed that as little as one half cc to as much as 11 ccs of local has been used to attain good operative conditions. Dr. Markoff noted an increase of light sensitivity, eyelid squeezing, and diminished akinesia with lower volumes, while more generous dosing instigated chemosis, globe tension and may be associated with rare CRAO. He concluded with prudent advice- use the minimum volume of anesthetic needed to achieve the best result for the particular patient.

David gave a second, fascinating discussion describing medical missions he has conducted to developing-world countries. He presented photographs from La Paz and other areas to a rapt audience.

Friday concluded with Mayo Clinic’s Dr. Rick Bendel. He tackled the problematic Intraoperative Floppy Iris Syndrome, increasingly encountered with men who have been prescribed alpha-1a-receptor antagonists such as Tamulosin for management of BPH (nearly one in three men over 50 years of age). Various strategies, including preoperative atropine, intracameral epinephrine, viscoadaptive viscoelastics and pupil expanders were considered. He advocated use of atropine preoperatively. After further Q&A, we adjourned to a delightful reception.

The meeting resumed on Saturday, with a lecture by Dr. John Ng, an Oculoplastic Surgeon from Casey Eye Institute in Portland Oregon. He examined the literature on the use of indwelling catheters after orbital surgery; most commonly enucleation. Ophthalmologists seem to prefer intraoperative placement, while others perform indirect percutaneous placement. Complications range in severity and frequency: Inadequate pain control and infections as well as migration of the catheter out (minor problem) or in through the superior ophthalmic fissure (major problem).

Chandra Kumar, good friend of OAS and Founder of our sister organization, BOAS and organizer of the World Congress of Ophthalmic Anesthesia, then took the floor with the intriguing question, “Are ultra-short sub-Tenon’s cannulae safer?” He stressed that complications of this modality of anesthesia are usually due to inadequate technique. Use of excessive force with long, rigid cannulae can result in perforation of the globe or other injuries. A spirited Q&A ensued on the relative merits and safety of topical, intracameral, needle-based and cannula-based ophthalmic anesthetic techniques. The cordial consensus opinion was that all techniques have application depending on the situation.

After the break, we reconvened to hear Dr. David Guyton from Johns Hopkins Wilmer Eye Institute outline in detail the pathogenesis of restrictive muscle disorders after local anesthetic. Marc Feldman took the opportunity to demonstrate his keen mathematical skills.

Two talks on hyaluronidase followed. Scott Greenbaum looked at his experience with the recombinant Hylenex-brand agent and parabulbar anesthesia, while our second international guest, Dr. George Martin Hall provided a comprehensive dissection of the still-evolving literature. To this point five of our speakers had dissertated on the action and risks/benefits of ophthalmic anesthesia with/without hyaluronidase. Such an important drug, who knew its proper name is hyaluronoglucosamidinase?

After lunch (Chicago’s famed deep-dish pizza stuffed with onions, peppers, mushrooms), I found myself in need of more light-hearted fare (and an H-2 Blocker). My needs were met by a short video presentation, entitled “Our Work” by Drs. Rylov and Idov. This was a high-speed movie of a typical day in their Russian eye surgery center. We appreciated and were honored by their presence at our national meeting.

Dr. Pierre Pang also came from considerable distance. He practices at the Pacific Eye Surgery Center in Honolulu Hawaii. He subjected the database on intracameral injection to rigorous interrogation and quoted from two papers that found the addition of intracameral lidocaine to topical anesthesia did not significantly reduce intraoperative pain or photophobia.

Saturday concluded with a series of interactive workshops that provided opportunity for new members to learn ophthalmic block techniques and long-term members to refresh their skills. Once again we had the honor of hearing Gary Fanning’s discourse on needle-based ophthalmic anesthesia with emphasis on using knowledge of orbital anatomy as a basis for determining optimal placement of needles. Gary Cass’ sessions on complications also generated a good deal of positive buzz. Scott Greenbaum, Chandra Kumar, and I conducted a sub-tenon’s web lab using cadaveric porcine eyes.

Sunday began with a good cup of hot coffee and the annual meeting of the membership, hosted by incoming president Gary Cass. I wish I could comment, but the caffeine did not take effect until Daniel Moss CRNA began his talk on obstructive sleep apnea in the ambulatory surgical center. This is an increasingly important issue as obesity becomes more prevalent. Howard Palte’s lecture on the subject at OAS a few years ago is available from AudioDigest.

Dr. David Friedman, also from Johns Hopkins, has a significant body of work on patient preference in local anesthetic technique for eye surgery that he shared with us. One of his studies uncovered that, when given a choice of multiple anesthesia management strategies, over 70% preferred block to topical anesthesia.

The penultimate lecture was given by UC Davis’ Dr.Vahid Feiz who revealed the results of a retrospective multicenter case study of the incidence of post cataract surgery endophthalmitis with use of 4th generation fluoroquinolones. No statistically significant decrement of endophthalmitis was noted when these antibiotics were used with uneventful cataract surgery. Povidone-Iodine is still the only scientifically proven agent that decreases the incidence of this dreaded complication.

Last at bat, Marc Feldman concluded our meeting with a discussion of cases derived from a typical, hectic day in his OR suite. This was a hysterical way to conclude a successful meeting. Kudos to Scott and Gary and all who participated.

Next year, the twenty-second annual national meeting of the Ophthalmic Anesthesia Society will be held once again at the Conrad Hotel on Rush Street on the Magnificent Mile just off of Michigan Avenue. Hope to see all of you there!!

Steven D. Gayer MD MBA

 

Member Spotlight

 

Associated Eye Surgery Center
Wichita, Kansas
Don R. Hirschman CRNA MHA ND

Don Hirschman became a Charter Member of the Ophthalmic Anesthesia Society when it was first organized in 1986. Don has had three terms of service on the OAS Scientific Advisory Board and has been OAS Secretary and Treasurer during those terms. In addition, he has made presentations at five Annual Meetings, including our recent meeting this September.

Hirschman also serves on the Board of Directors of the Kansas Association of Nurse Anesthetists, and has served on the Board of the California Association of Nurse Anesthetists. He has also been a member of and spoken at the annual meetings of AAASC (SOBS) and OOSS and is a frequent presenter at the Royal Hawaiian Eye Meeting.

After earning a Bachelor's in history, Don went to nursing school in California, followed by an anesthesia program at the University of Pennsylvania. His MHA thesis was "A Management Guide and Strategic Plan for the Eye Surgery Center."

He then noticed a lack of consistency in anticoagulation therapy protocols for cataract surgery patients. A literature review revealed small studies on anticoagulation therapy—all recommending continuation. Only the McMahan 1988 study was larger. Don and OAS Member, Lesa Morby, presented a plan to Rush University for a prospective study collecting data from six ASCs to determine any statistical difference in patients with continued therapy vs. those with anticoagulants halted pre-surgery. The study of <2200 patients showed no difference. Rush University accepted the study, and awarded a Doctorate in Nursing to Don and Lesa. The study was published in Nursing Forum (Jan 2006) and has been presented to several meetings, including family practice, nurse practitioner and anesthesia groups. Don is thankful to his colleagues in OAS for their assistance in data collection and notes that without OAS this study would not have been completed.

Don is Administrator of the Associated Eye Surgery Center in Wichita, Kansas. The center's two Medical Directors are Bruce Ochsner MD and David Kingrey MD. The Associated Eye Surgery Center was built in 1984 to resemble neighboring Victorian homes. The facility has two operating rooms and it is licensed by the State of Kansas and certified by the Accreditation Association for Ambulatory Health Care. The building features beautiful stained glass windows and in every way feels like a comfortable home; patients and staff all enjoy being there! Doctors and staff also participate in charitable medical missions outside the United States, including Panama and India. Don has participated with Surgical Eye Expeditions (SEE) on trips to Mexico, Malaysia, and Romania. He has also traveled to Bolivia with the Flying Eye Hospital, and states these trips can make a big difference for the patients who receive care.

Don states that meeting OAS Founder, Dr. Robert Hustead, in 1985 changed his practice. Since that time, Don has incorporated Dr. Hustead's "painless" technique into his own patient care. Don is a familiar face at the OAS annual meetings: he has attended every one. The Annual Meeting attracts Don because he says they are a great source of technical and clinical information as well as providing a much-needed opportunity for networking and camaraderie. Don reflects on the old advertisement, "I got my job through the New York Times", and says "I got my job through OAS and Bob Hustead."

Don finds the greatest challenge to his practice now is to become more efficient while increasing his case load and still keep each patient's care individualized. The Associated Eye Surgery Center practice includes cataract extraction with IOL implantation, ophthalmic plastic surgery, and refractive surgery. Two nurse anesthetists have provided all anesthesia services since the 1997 retirement of Dr. Hustead and his wife, Joy, a CRNA.

Don had been living in California for many years when Dr. Hustead contacted him and invited him to come to Kansas to take over the practice. At the outset, it did not seem like an attractive relocation, but Don says now "Kansas is a wonderful place to live—but I wouldn't want to vacation here." Don and his wife, Jana, have a home on fifteen acres that include a fishing pond, abundant wildlife, chickens, two cats, and Maestro (a border collie) who keeps everything under control. All that, and less than fifteen minutes to work with no traffic!

At the conclusion of the OAS Annual Meeting on Sunday afternoon, you may see Don click his heels together three times: he's on his way home.

 

MEEI Meeting Details

The Anesthesia Department of the Massachusetts Eye & Ear Infirmary (MEEI) is sponsoring it's 3rd biannual conference titled; Introduction to Regional Anesthesia for Ophthalmic Surgery. The conference will be held on Saturday June 14, 2008 at MEEI in Boston, MA. The conference is geared towards anesthesiologists and CRNAs who want to learn, or increase their knowledge of block technique(s), and tips for reducing risks of complications.

The morning sessions will include lectures on orbital anatomy, peribulbar and retrobulbar block technique, alternative and supplementary block techniques, and complications of blocks. The afternoon sessions will include hands on practice using peribulbar and intraconal blocks on human cadavers, and a seperate lab practicing sub-Tenon's blocks on animal eyes led by Dr. Steve Gayer.

The cost of the conference is $250 for anesthesiologists and $200 for CRNAs. For more information or to register, please click on the link for the MEEI conference on this (web based) issue of OASIS, go to http://www.meei.harvard.edu/edu/anesthconf.php, or call 617 573 3378. Please register early as seating is limited.