Ophthalmic Anaesthesia - Some Current Issues (July 2007)
Over the last year BUPA Insurance has attempted to package ophthalmic surgery in the independent sector into restricted networks. Its particular focus has been on cataract surgery. AXA PPP also appears intent on developing a network for cataract surgery for its subscribers. Both schemes seem to question the need for an anaesthetist’s presence during ophthalmic surgery. Conflicting statements have been made about the proportion of cases attended by anaesthetists, and conclusions are hard to draw from the figures produced. The FIPO cataract audit may provide some answers about what is actually happening in the independent sector, but it may be helpful to review some aspects of this topic and to consider the need for an anaesthetic presence.
In terms of routine practice for cataract surgery, anaesthetists will argue that if in 95% (or thereabouts – precise figure uncertain) of private cataract operations an anaesthetist is present, it is because the surgeon has invited them, presumably because the surgeon thinks it is necessary for the safe and effective care of the patient. No anaesthetist is going to be there just because he or she feels like it! Surgeons have a number of reasons for requesting the presence of an anaesthetist. Most commonly it is to give the local anaesthetic and to provide sedation when required and, of course, to monitor the patient and to manage any problems that occur. Cataract surgery is performed on a mostly elderly population, 80% of patients being over 70 years of age and 57% having concurrent medical problems . Therefore, it is not surprising that systemic reactions and acute medical problems occur quite commonly. Anaesthetists are trained to manage these problems and complications. In one year, 15 cases of “potentially life-threatening” events during cataract surgery were reported in a Royal College of Ophthalmologists survey .
The Joint Colleges’ guidelines are sometimes used as a justification for a lack of anaesthetic presence during eye surgery. These guidelines state that an anaesthetist is not essential if cataract surgery is being performed under topical or sub-Tenon’s block. However, these guidelines were drafted with the NHS only in mind. An anaesthetist is almost always readily available in the event of an emergency in the NHS setting. This is not true in all units in the independent sector, where there may be fewer adequately trained and experienced immediately available to treat a collapse in an elderly patient with multiple medical problems. The Joint Colleges’ guidelines also added that this was a minimum standard and that many units might like to offer a higher standard, i.e. the presence of an anaesthetist. For this reason some private hospitals insist that the surgeon brings an anaesthetist for all ophthalmic procedures as part of their clinical governance arrangements in order to guarantee the safety of the patient.
If an anaesthetist is not present, the choice of technique is obviously very limited; sedation and general anaesthesia are obviously not options. This must signify a lower quality of care. There is a variety of local anaesthetic, sedative and general anaesthetic techniques used for cataract surgery. In a recent large study, anaesthesia for cataract surgery comprised 4.1% general anaesthesia, 92.1% local anaesthesia without sedation and 3.9% local anaesthesia with sedation. Of the estimated 375,000 local anaesthetics given in one year, 30.6% were peribulbar, 3.5% retrobulbar, 42.6% sub-Tenon’s, 1.7% sub-conjunctival, 9.9% topical and 11.0% topical-intracameral . The presence of an anaesthetist allows the optimal technique to be used, taking into account the needs of the patient and of the surgeon. Eyes are not all the same, and different surgical procedures and requirements produce a wide spectrum of difficulty in cataract surgery.
Only the surgeon and the anaesthetist, taking into account the needs of the patient, can decide on these matters - not any outside body. Surgeons must make it clear to their prospective cataract patients that they should get authorisation from their insurance company for the presence of an anaesthetist. This does not present a problem to most insurers, who will readily authorise this. If an anaesthetist is present but only provides standby monitoring, some insurers may suggest a lower level of benefit. If so, this will create problems for anaesthetists, as they will wish to charge for their “professional time”, which is the same whether they are acting as a standby or giving an anaesthetic. The anaesthetist is also involved in the pre-operative assessment as well as close monitoring and any necessary treatment. Under these circumstances the surgeon may still actually give the local anaesthetic and may in theory charge a fee for doing so, although it would seem to be common experience that if an anaesthetist is present there is not usually an extra charge made for the surgical administration of the local anaesthetic. In most instances, if an anaesthetist is involved, he or she will administer the local anaesthetic as well.
Anaesthetists have largely replaced general physicians as the peri-operative physicians to the surgical team, being best equipped to advise on pre-operative assessment and preparation, monitoring and management of the patient during surgery and in the immediate postoperative period. They will not be able to fulfil this role if they are not involved during the period of the surgery. It is also worth noting that insurers have long recognised the standby arrangements made by cardiologists for an anaesthetist and surgeon to be present during coronary artery angioplasty, and they provide the patients with an insurance benefit towards the fees for their professional time. All surgical, anaesthetic, hospital and any other charges should in any event be made perfectly clear to the patient in advance of surgery.
- Desai P et al. Profile of patients presenting for cataract surgery: National Data Collection. Br J Ophthalmol 1999; 83: 893-896.
- Eke T & Thomson JR. Serious complications of local anaesthesia for cataract surgery: a one year national survey in the United Kingdom Brit J Ophthalmol 2007; 91: 470-475.
Dr David Whitaker
President of the Association of Anaesthetists of Great Britain and Ireland Professor
President of the British Ophthalmic Anaesthesia Society
Dr Anthony Rubin
British Ophthalmic Anaesthesia Society