Common Pharmocologics

Versed and Fentanyl + intracameral preservative-free Lidocaine.

Benefits

Patient is able to control eye movements intra-operatively.
Faster cognitive recovery compared to general anesthesia.
Low risk of anesthetic related complications.
Faster OR turnover time.

Appropriate patient population

MAC is best suited for most patients.

Contraindications

Recent myocardial infarction (≤6 months ago).

Contraindication for cataract surgery, in general.

Avoid MAC in the following conditions

Associated with greater risk

Intellectual disabilities.
Uncontrolled, severe psychiatric disorders.
Severe respiratory conditions.
Nystagmus.
Complex cataracts with:

High risk of conversion to secondary IOL.
Need for anterior vitrectomy.

Common pharmocologics

Lidocaine 2% with Bupivocaine (or Marcaine) 0.75% + Hyaluronase

Hyaluronase helps block spread between connective tissue.

Retrobulbar Block

Peribulbar/Subtenon's Block

- Performed in the inferonasal quadrant of the globe.

- Lower risk of globe penetration and retrobulbar hemorrhage.

Still provides similar benefit as retrobulbar block.

Benefits

Ocular akinesia and anesthesia.

Risks

Retrobulbar hemorrhage.

- Lower risk with peribulbar/subtenon's.

Globe penetration.

- Lower risk with peribulbar/subtenon's.

Optic nerve trauma.
Extra-ocular muscle toxicity.
Inadvertent injection:

Intravenous → cardiac arrhythmias
Intradural → seizures, respiratory arrest, brainstem anesthesia

Benefits

Concerns for patient cooperation is eliminated.
Ensures airway patency in patients with breathing difficulties

Appropriate patient population

Severe apnea or coughing.
Head tremor.
Neck or back problems resulting in supine discomfort.
Restless leg sydnrome.
Inability to follow verbal commands.
Claustrophobia.

Contraindicated populations

Recent myocardial infarction (≤6 months ago).

Contraindication for cataract surgery, in general.

Risks

Hypotension.
Malignant hyperthermia.
Respiratory paralysis.
Delayed emergence.