Preliminary Report on Anæsthesia and Akinesia in Intra-ocular Operations

WHEN a patient expresses sufficient confidence in a surgeon to allow him to perform an intra-ocular operation upon his eye, it is up to the surgeon to make this ordeal as easy and as safe as it is possible for him to do. All our patients are admitted to hospital two days before operation, so that they may get to know the nursing staff and their surroundings. They are told what will happen to them in the operating theatre and how they will be bandaged, and every effort is made to gain their confidence. In spite of this, it is human to have a certain fear and apprehension, and so some mild sedation on the pre-operation night and again before operation is desirable. As well as removing all painful stimuli, the ideal is to have complete mental and muscular relaxation. But no mental relaxation will be complete without good muscular relaxation, which is obtained by good analgesia and akinesia. It is interesting to note that it has been stated that good voluntary muscular relaxation alone will produce mental calm. If pushed too far, however, the reverse is the case as, if breathing is affected, the patient will become distressed. Now, as far as the eye is concerned, muscular relaxation can be produced locally by means of a facial nerve block and a retrobulbar block of the extra-ocular muscles, or it may be produced generally by means of curare or allied drugs. When using curare it is fortunate, from our point of view, that the extra-ocular muscles are the first to be affected and the last to regain tone. Therefore, only a comparatively small and safe dose need be given. In 1939, I read a paper at the meeting of the Ophthalmological Society of the United Kingdom, pointing out the effect that curare and retrobulbar anaesthesia had in reducing intra-ocular tension, and therefore intra-vitreous pressure, by removing the abnormal tonus of the intra-ocular muscles. That is, muscular relaxation will produce what Barraquer Moner terms "a sleeping vitreous body." Kirby's paper to the last International Ophthalmological Congress in London in 1950, on "Three Years Experience with General Akinesia in Cataract Surgery," is no doubt well known to all of you, but my interest in the subject was further stimulated by a visit to the Barraquer Clinic in Barcelona last spring.