Ophthalmol Clin N Am 19 (2006) 193 – 202
Sedation Techniques in Ophthalmic Anesthesia
Shireen Ahmad, MD
Northwestern University, Feinberg School of Medicine, Department of Anesthesiology, 251 East Huron Street, F5-704,
Chicago, IL 60611, USA
The majority of ophthalmologic surgeries are
performed with regional nerve block anesthesia.
Preoperatively, sedation may be required during the
placement of the nerve block to decrease the dis-
comfort of the injection, limit patient motion, relieve
anxiety, and produce amnesia about the procedure.
Intraoperatively, sedatives may also be administered
to relieve anxiety and prevent uncontrolled and
unexpected movement. However, it is also important
during surgery for the patient be calm, cooperative,
and aware; reflexes should not be obtunded; and the
airway should not be obstructed. Ideal sedation levels
can be achieved by careful intravenous titration of
suitable agents while monitoring the effect of the
sedative and analgesic agents.
Evidence-based medicine
Sedation practices for ophthalmologic surgery
range from none to multiple drug combinations that
result in a level of sedation that borders on general
anesthesia. There are limited data regarding the
question of whether there is a sedation strategy that
is safer and more effective, with most studies, despite
being randomized and placebo controlled, not having
a large enough sample size to detect any adverse
medical event with a low incidence. One study of
90 subjects who underwent cataract surgery follow-
ing intramuscular analgesic agents found that intra-
muscular sedation was associated with a higher
incidence of bradycardia compared with no sedation
[1], and another found an increased need for sup-
plemental oxygen when intramuscular sedative use
E-mail address: sah704@northwestern.edu
0896-1549/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.ohc.2006.02.004
was compared with placebo [2]. Oral sedatives were
not associated with any adverse events in two studies
[3,4], neither was intravenous propofol [5,6]. Barbi-
turates have been evaluated also and revealed no
hemodynamic complications [7,8]. A large cohort
study of 19,354 patients reported a 1.95% and 1.23%
incidence of intraoperative and postoperative adverse
events, respectively [9]. There was a strong associa-
tion between the use of intravenous agents in con-
junction with topical or nerve block anesthesia and
intraoperative adverse medical events after adjusting
for age, gender, length of surgery, and American
Society of Anesthesiologists Physical Status classi-
fication [10]. Use of more than one agent also was
associated with an increased risk of adverse events,
suggesting that use of multiple agents may not be
advisable. Most of the events were bradyarrhythmias
and hypertension.
Levels of sedation
The American Society of Anesthesiologists has
defined the levels of sedation [11,12] that are
commonly used to monitor patients perioperatively
and have also been used by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO)
to establish standards and guidelines on sedation.
These levels of sedation are as follows.
Minimal sedation (anxiolysis)
Minimal sedation (anxiolysis) produces a drug-
induced state during which patients respond normally
to verbal commands. Although cognitive function
and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected.
ophthalmology.theclinics.com
194
Moderate sedation or analgesia (‘‘conscious
sedation’’)
Moderate sedation or analgesia (‘‘conscious seda-
tion’’) is a drug-induced depression of conscious-
ness during which patients respond purposefully to
verbal commands, either alone or accompanied by
light tactile stimulation. No interventions are required
to maintain a patent airway, and spontaneous venti-
lation is adequate. Cardiovascular function is usu-
ally maintained.
Deep sedation and analgesia
Deep sedation and analgesia is a drug-induced
depression of consciousness during which patients
cannot be easily aroused but respond purposefully
following repeated or painful stimulation. The ability
to independently maintain ventilatory function may
be impaired. Patients may require assistance in main-
taining a patent airway and spontaneous ventilation
may be inadequate. Cardiovascular function is usu-
ally maintained.
Anesthesia
General anesthesia is a drug-induced loss of con-
sciousness during which patients are not arousable,
even by painful stimulation. The ability to indepen-
dently maintain ventilatory function is often impaired.
Patients often require assistance maintaining a patent
airway, and positive-pressure ventilation may be re-
quired because of depressed spontaneous ventilation
or drug-induced depression of neuromuscular func-
tion. Cardiovascular function may be impaired.
The JCAHO standards require that moderate or
deep sedation be administered by a practioner with
‘‘appropriate credentials’’ who can ‘‘rescue’’ the pa-
tients from deep sedation and general anesthesia.
Monitoring level of sedation
Patients undergoing surgery may become sedated
as a result of the effects of regional blockade. Spinal
anesthesia is known to be accompanied by significant
sedation [13] and both spinal and epidural anesthesia
reduce hypnotic requirements for midazolam [14,15]
and thiopental [16]. Patients undergoing ophthal-
mologic surgery under regional block may also fall
asleep during the procedure. The mechanism for this
effect is not completely understood, but it has been
demonstrated that temporary peripheral denervation
ahmad
decreases the excitability of the cuneate nucleus in the
brainstem [17] and acute block of retinal discharges
results in synchronization of cortical electroencepha-
logram (EEG), which is normally desynchronized
[18]. More recently it has been suggested that de-
crease in ascending somatosensory transmission can
modulate the activity of the reticulo-thalamo-cortical
mechanisms that regulate arousal [19,20] and thus
neuraxial blockade could result in a reduced level
of consciousness.
Ongoing assessment of the level of conscious-
ness throughout the surgical procedure is essential
to prevent the patient from progressing into deep
sedation with loss of protective airway reflexes. The
accurate assessment of the depth of sedation re-
quires a tool that is reliable and valid, and at the same
time is easy to use in the clinical arena. Various such
tools have been developed [21 – 29]. The Ramsay
sedation scale is a commonly used subjective assess-
ment of level of consciousness that uses an ordinal
scaling system to describe the level of conscious-
ness [21]:
 Level 1: Patient awake, anxious/restless, or both
 Level 2: Patient awake, cooperative, oriented
and tranquil
 Level 3: Patient awake responds to
commands only
 Level 4: Patient asleep, brisk response to light
glabellar tap or loud auditory stimulus
 Level 5: Patient asleep, sluggish response to
light glabellar tap/loud auditory stimulus
 Level 6: Patient asleep, no response to light
glabellar tap or loud auditory stimulus
The Observer’s Assessment of Alertness/Sedation
Scale (OAA/S) was designed to measure changes
in the level of consciousness during procedures,
but it is limited with deeper levels of sedation
(Table 1) [22].
The Neurobehavioral Assessment Scale [23] and
the Vancouver Sedative Recovery Scale (VSRS) [30]
are better at assessing the patient at the two extreme
ends of the scale. Children may progress rapidly from
light to deeper levels of sedation and greater vigilance
is necessary. The University of Michigan Sedation
Scale (UMSS) [31] is a validated scoring system that
has been used in children undergoing nonpainful
procedures and may be useful in the child undergoing
minor ophthalmologic surgery:
 0, Awake and alert
 1, Minimally sedated: tired/sleepy, appropriate
response to verbal conversation and/ or sound
 sedation techniques in ophthalmic anesthesia
 2, Moderately sedated: somnolent/sleeping,
easily aroused with light tactile stimulation or a
simple verbal command
 3, Deeply sedated: deep sleep, arousable only
with significant physical stimulation
 4, Unarousable
Conscious sedation versus sedation/analgesia
The term conscious sedation was coined by
the American Dental Association to describe the
practice of using sedatives and analgesics to alleviate
the fear, anxiety, and pain of dental surgery. Deeper
levels of sedation induced by an anesthesiologist are
referred to as sedation/analgesia or ‘‘monitored
anesthesia care.’’
Route of administration
The intravenous route is the preferred method of
administration, however in some very young chil-
dren, oral and inhalation agents may be necessary.
The enteral, subcutaneous, or intramuscular routes
are best avoided whenever possible because of unpre-
dictability of absorption and distribution of the drugs.
Choice of drugs
The drugs commonly used fall into two main
categories, namely sedatives and analgesics. When
Table 1
Observer’s Assessment of Alertness/Sedation Scale
(OAA/S) [22]
Subscore Responsiveness Speech
5 Responds readily to Normal
name in normal tone
4 Lethargic response to Mild slowing
name spoken loudly or thickening
repeatedly
3 Responds only after Slurring or slowing
name spoken loudly
or repeatedly
2 Responds after mild Few recognized
prodding or shaking words
1 Does not respond to
mild prodding or shaking
195
used in combination these drugs have a synergistic
effect and need to be titrated carefully [32 – 34].
Additionally, it is important to differentiate between
patient movement as a result of anxiety and that as a
result of pain. Administration of additional sedatives
in the presence of pain resulting from inadequate
regional block will only worsen the situation and
result in a deeply sedated, uncooperative patient with
uncontrolled movement.
Sedative agents
Benzodiazepines
Benzodiazepines are the most commonly used
drugs for peri-operative sedation. They act by binding
to the g-aminobutyric acid (GABA) complex and in-
hibit neuronal transmission. These drugs exhibit hyp-
notic, anxiolytic, and amnestic properties and lower
intraocular pressure. Cardiovascular and respiratory
depression is seen with excessive doses. Diazepam
has a long half-life, which is further prolonged in the
elderly. Its original formulation (Valium; Roche
Laboratories, Nutley, NJ), which contained propylene
glycol, was associated with venous irritation and phle-
bitis [35]. The newer lipid-based formulation (Dizac;
Ohmeda, Liberty Corner, NJ) is less irritating [36].
Midazolam is a water-soluble imidazo-benzodia-
zepine, with a rapid onset and short duration of effect.
The half-life of midazolam is 1.7 to 2.6 hours,
whereas that of diazepam is 20 to 50 hours [37].
Midazolam is metabolized in the liver by hydrox-
ylation to 1-hydroxy-midazolam, which has 20% to
30% the activity of midazolam and a shorter dura-
tion of action. It is excreted by the kidneys and could
have a prolonged effect in patients with renal failure
[38]. Respiratory depression and apnea occurs with
all benzodiazepines and is more likely to occur in the
presence of opioids, old age, and debilitating dis-
ease. Low doses of midazolam (0.075 mg/kg) do not
affect the ventilatory response to carbon dioxide,
suggesting that clinically significant respiratory
depression is unlikely at that dose range [39]. In a
study of midazolam in male volunteers, the elimi-
nation half-life was prolonged more than twofold in
the elderly group as compared with the young males
[40]. This study also revealed that the volume of
distribution was increased in the elderly, the obese,
and in women. Used alone, the benzodiazepines have
modest hemodynamic effects. The predominant
hemodynamic change is a slight reduction in arterial
blood pressure that results from a decrease in sys-
temic vascular resistance. The hemodynamic effects
of midazolam are dose related: the higher the plasma
level, the greater the decrease in systemic blood
196
pressure [41]. The amnesic effect of midazolam has
been compared with diazepam and it was found to
produce better antegrade amnesia and faster recovery,
making it a more suitable drug for the elderly patient
having outpatient surgery than diazepam [42]. Mid-
azolam has been administered in small doses in the
range of 0.015 mg/kg, before administration of local
anesthetic in patients undergoing phacoemulsification
and lens implant surgery [43 – 45] and resulted in
high patient satisfaction scores and low levels of in-
traoperative anxiety.
In children ranging from 2 to 10 years of age,
midazolam has been administered orally (0.5 mg/kg)
before diagnostic and minor ophthalmologic surgical
procedures [46]. Administration of intranasal midazo-
lam has been reported in pediatric patients aged
3.5 months to 10 years for sedation before ocular
examination. This method of administration was as-
sociated with a rapid onset and was preferable to the
rectal route [47].
Lorazepam has twice the sedative potency of
midazolam, a slower onset of action, and longer du-
ration of action. A prospective randomized placebo-
controlled study of sublingual lorazepam 1 mg
administered an hour before peribulbar block for
cataract or glaucoma surgery resulted in good patient
comfort and amnesia related to the injection [48].
Propofol
Propofol (2, 6-di-isopropylphenol) is an alkylphe-
nol nonbarbiturate sedative-hypnotic that modulates
the GABAA receptor. It is rapidly metabolized in
the liver by conjugation to glucuronide and sulfate to
produce water-soluble compounds, which are ex-
creted by the kidneys [49]. The elimination half-life
of propofol is 4 to 23.5 hours [50,51]. Propofol phar-
macokinetics are affected by age, with elderly hav-
ing decreased clearance rates [52] and children a
more rapid clearance [53]. The degree of sedation and
reliable amnesia, as well as preservation of respira-
tory and hemodynamic function, are better overall
with benzodiazepines than with other sedative-
hypnotic drugs used for conscious sedation. When
midazolam is compared with propofol for sedation,
the two are generally similar except that emergence
or wake-up is more rapid with propofol. Because of
the potential for significant respiratory depression it
is recommended that propofol be administered under
close medical supervision by physicians with airway
management skills [54].
Propofol in small incremental intravenous doses
(20 mg) has been used to achieve amnesia for re-
gional eye blocks [55]; however, propofol provides
no analgesia for insertion of the block needle and
ahmad
therefore semiconscious patients may have a startle
response to needle insertion. A single dose of pro-
pofol (0.98 mg/kg) has been shown to reduce intra-
ocular pressure (IOP) by 17% to 27%, which is
also beneficial during ophthalmologic surgery [56].
This change occurs immediately following injec-
tion and may be related to relaxation of the ex-
traocular muscles. Continuous infusion of propofol
(1.5 mg/kg/hour) has been found to be effective
during cataract surgery under topical anesthesia
but does require close monitoring for signs of respi-
ratory depression [57]. Patient-controlled sedation
using propofol (0.3 mg/kg, lockout interval of
3 minutes) in 55 elderly patients undergoing cataract
surgery has been reported [58]. Patients used less
than 1 mg/kg and reported a high degree of satis-
faction. One patient developed excessive sedation and
transient respiratory depression, which responded to
patient stimulation.
Ketamine
Ketamine is a phenylcyclidine derivative and dif-
fers from other sedative-hypnotic agents in that it also
has significant analgesic effects. It is metabolized by
hepatic microsomal enzymes to form norketamine
(metabolite I), which has been shown to have sig-
nificantly less (between 20% and 30%) activity than
the parent compound [59]. Ketamine produces a dis-
sociative state in which patients have profound anal-
gesia but keep their eyes open and maintain their
corneal, cough, and swallow reflexes. Ketamine ad-
ministration results in pupillary dilation, nystagmus,
lacrimation, salivation, and increased skeletal muscle
tone, often with coordinated but seemingly purpose-
less movement of the arms, legs, trunk, and head.
Ketamine is associated with psychic emergence reac-
tions, including excitement, confusion, euphoria, and
fear, which usually abate within 1 to several hours
[60]. The incidence of emergence reactions is higher
in adults [61], women [62], and with larger doses [63]
and can be reduced by concomitant use of benzodiaze-
pines [64].
Ketamine has minimal effect on the central respi-
ratory drive [65] and does not usually depress the
cardiovascular system [63]. Early studies reported an
increase in IOP after intramuscular or intravenous
administration of ketamine. However, subsequent
studies of ketamine given with diazepam and meper-
idine showed no affect on IOP, and intramuscularly
administered ketamine may even lower IOP in chil-
dren [66]. The use of ketamine in conjunction with
droperidol and diazepam has been reported to be a
useful adjunct in patients undergoing cataract surgery
with regional block [67].
 sedation techniques in ophthalmic anesthesia
Barbiturates
Barbiturate compounds such as methohexital and
thiopental have been used for sedation in ophthalmo-
logic surgery in the past, but have been replaced by
newer agents such as propofol and midazolam, which
have better pharmacologic profiles and fewer side
effects. Methohexital is administered in incremental
doses of 10 to 20 mg [68]. Residual sedation is
greater with methohexital than with propofol [69].
Chloral hydrate
Chloral hydrate has been used in children under-
going diagnostic procedures in offices and outpatient
clinics [70] and in elderly patients before cataract
surgery [71]; however, midazolam was found to be
preferable for the amnesic properties.
Dexmedetomidine
Dexmedetomidine is an a2-adrenergic agonist and
produces a sedative-hypnotic effect by an action on
a2-receptors in the locus ceruleus and an analgesic
effect by its action on a2-receptors within the locus
ceruleus and the spinal cord [72]. In volunteers, dex-
medetomidine sedation reduced minute ventilation
but did not alter the slope of the ventilatory response
to increasing CO2 [73]. The effects on the cardiovas-
cular system are a decreased heart rate; decreased
systemic vascular resistance; and indirectly decreased
myocardial contractility, cardiac output, and systemic
blood pressure [74]. Used as a premedicant at intra-
venous doses of 0.33 to 0.67 mg/kg given 15 minutes
before surgery, dexmedetomidine appears to be effi-
cacious with minimal cardiovascular side effects [75].
When used for intraoperative sedation, dexmedeto-
midine (0.7 mg/kg/hr) had a slower onset than pro-
pofol but had similar cardiorespiratory effects. With
continuous infusion sedation after termination of the
infusion was more prolonged, as was recovery of
blood pressure; however, lower doses of opioid were
needed in the first hour postoperatively [76]. A
double-blind placebo-controlled comparative study of
intramuscular dexmedetomidine (1 mg/kg) and mid-
azolam (20 mg/kg) before peribulbar block for cata-
ract surgery revealed comparable sedation in both
groups, but dexmedetomidine was more effective at
lowering IOP [77].
Opioid Analgesic Agents
Analgesic agents may be administered before
performing regional nerve block to decrease the pain
associated with the injection. Additionally, pain may
occur intraoperatively as a result of the light from the
197
operating microscope, iris manipulation, irrigation-
aspiration, and intraocular lens manipulation [78,79]
necessitating intraoperative analgesics.
Fentanyl
Fentanyl is the opioid analgesic most commonly
used to supplement regional blockade. It is usually
administered intravenously, in small doses in the
range of 50 to 100 mg. Onset of action is within 3 to
5 minutes but fentanyl has a relatively long half-life,
in large part because of this widespread distribution
in body tissues. The elimination half-life is 2 to
3 hours. Fentanyl is primarily metabolized in the liver
by N-dealkylation and hydroxylation to norfentanyl,
which is detectable in the urine for up to 48 hours
after intravenous administration [80]. Elderly pa-
tients are more sensitive to fentanyl and lower doses
(0.7 mg/kg) have been recommended in this age
group [81,82].
Fentanyl is available for oral transmucosal admin-
istration and results in reasonably rapid absorption,
with peak blood levels achieved within 15 to 30 min-
utes [83]. A recent study found that the liquid
intravenous formulation administered orally was rap-
idly absorbed and may be a reasonable substitute for
intramuscular opioid administration in children who
do not have intravenous access. An advantage of this
method may be the shorter and less variable con-
sumption time and greater versatility in dosing in
comparison to the Fentanyl Oralet [84].
Alfentanil
Alfentanil is a more rapid and shorter-acting
analog of fentanyl [85].The main metabolic pathways
of alfentanil include oxidative N-dealkylation and
O-demethylation, aromatic hydroxylation, and ether
glucuronide formation. The degradation products of
alfentanil have little, if any, opioid activity. Human
alfentanil metabolism may be predominantly, if not
exclusively, by cytochrome P-450 3A4 /5. Alfentanil
has been reported to have fewer side effects and simi-
lar or shorter recovery times than fentanyl [86,87].
Onset of action is in 1 to 3 minutes and the elimi-
nation is 1 to 2 hours [80]. The elderly exhibit an
increased sensitivity to the opioids and the dose of
alfentanil should be reduced by half [88].
Remifentanil
Remifentanil is chemically related to the fentanyl
congeners, but it is structurally unique because of
its ester linkages that render it susceptible to hydroly-
sis—primarily by enzymes within the erythrocytes—
resulting in its rapid metabolism. Remifentanil has a
30- to 60-second onset time and a 5- to 10-minute
198 ahmad
duration. The primary metabolic pathway of remifen-
tanil is de-esterification to form a carboxylic acid
metabolite, GI90291, which is 0.001 to 0.003 times as
potent as remifentanil. Excretion of GI90291 is
dependent on renal clearance mechanisms [89]. Its
pharmacokinetics are not appreciably influenced by
renal or hepatic failure [90,91]. Remifentanil (0.3 to
0.6 mg/kg IV) has been used to prevent the pain
associated with placement of the peribulbar block
[92]. A double-blind, randomized study of remi-
fentanil (remifentanil 1 mg/kg, remifentanil 1 mg/kg +
infusion of 0.2 mg/kg/min) administered before per-
forming peribulbar block found it to be more effective
than alfentanil (0.7 mg/kg) [93]. It was noted that the
patients were calm and cooperative, although aware
during the eye block and did not move or startle. In
this study the group that had the bolus dose followed
by an infusion had a higher incidence of respiratory
depression; however, in clinical situations the bolus
dose alone would be adequate.
Combinations of sedatives and analgesics
It is a common practice to combine sedatives and
analgesics in an attempt to minimize the side effects
of the individual agents by using smaller doses than
would be necessary if they were used alone. In most
situations the drugs have synergistic effects and may
result in significant hemodynamic and respiratory
depression, especially in the elderly patient. Propofol
has been used in combination with alfentanil [94] and
a combination of midazolam, propofol, and alfentanil
revealed the increased risk of apnea with multiple
drug combinations [95]. A combination of propofol
and ketamine provided better analgesia and sedation
than propofol alone and was not associated with an
increase in IOP [96].
Patient-controlled sedation and analgesia
The level of stimulation and discomfort may vary
during the peri-operative period and the need for
sedation/analgesia varies considerably among pa-
tients, making the patient-controlled administration a
useful alternative [97,98]. Successful use of the tech-
nique in patients undergoing ophthalmologic surgery
has been reported [99 – 101]. The main advantage with
this technique is the increased patient satisfaction;
however, it is important that patients be appropriately
monitored to prevent excessive sedation.
Nonpharmacologic measures
It has been suggested that music may be able to
modulate the human stress response [102] and studies
have suggested that music may be used as an adjunct
to sedatives. It has also been shown that music can
reduce pain reported by patients [103] and may
decrease analgesic requirements. The music selected
needs to have specific characteristics, namely, the
music needs to be of the patients choice, tracks need
to be mixed to convey homogeneous ambience, and
the playing device needs to be of good quality to
avoid auditory fatigue [104 – 106].
Type of surgery
Besides cataract surgery, regional anesthesia and
sedation has been used for trabeculectomy [107],
keratoplasty [108], vitreoretinal surgery [109], open
globe injuries [110], and enucleations and eviscera-
tions [111].
Summary
Sedation/analgesia for ophthalmologic surgery is
safe and effective [9]. The choice of sedation/an-
algesia strategy should be based on patient preference
and the assessment of risk for adverse events. Pre-
operative screening and preparation of the patient
is most important in obtaining cooperation and pa-
tient acceptance.
Despite the obvious effectiveness of the various
strategies, there is a small group of patients who are
not suitable for regional anesthesia with sedation.
Patients with chronic spontaneous cough, shortness
of breath while lying flat, parkinsonian head tremor,
Alzheimer’s disease, or claustrophobia may be very
difficult to manage with regional anesthesia and light
sedation. These patients may best be managed with a
general anesthetic.
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