The Advantages of Combined Regional and General Anesthesia in Ophthalmic Surgery in Children




Ophthalmic Anesthesia, Peribulbar block, Oculocardiac Reflex, Regional Anesthesia, General Anesthesia


Background: Regional anesthesia is a common procedure in an adult patient undergoing ophthalmic surgery, but it cannot be done alone in the pediatric age group. General anesthesia is accompanied by complications intra- and post-operatively.

Objectives: to determine whether or not using regional anesthesia in combination with general anesthesia in pediatric eye procedures improves patient outcomes.

Methods: Forty children, with an age range of 6 - 12 years were included in the study that was conducted at Ghazi Al-Hariri Hospital / Department of Ophthalmology and Ibn Al-Haytham (Ophthalmology Hospital), both teaching hospitals, from December 2018 to October 2019. These children were allocated into one of two groups: GA (general anesthesia) and GA-R (general anesthesia-regional anesthesia). Heart rates, mean arterial blood pressure, oculo-cardiac reaction, and postoperative nausea and vomiting were measured. All required approvals were obtained from the scientific committee of the Iraqi Board for Medical Specializations. Statistical analysis was done using SPSS V26, with a P value of <0.05 considered significant.

Results: None of the patients developed oculo-cardiac reactions or needed additives to the anesthesia given during surgery in the GA-R compared to the GA group. Intra-operative measurements of heart rates and mean arterial blood pressure were lower in the GA group than in the GA-R group (p<0.05). Compared to the GA group, the GA-R group had a lower incidence of postoperative nausea and vomiting (p<0.05). More patients in the GA group needed analgesia than in the GA-R group.

Conclusion: Using regional anesthesia as a peribulbar block with general anesthesia is a safe and successful procedure in pediatric ocular surgeries.


Received:Feb. 2023

Accepted: Sept. 2023

Published: Oct. 2023


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Deb K, Subramaniam R, Dehran M, Tandon R, Shende D. Safety and efficacy of peribulbar block as adjuvant to general anaesthesia for paediatric ophthalmic surgery. Paediatric Anaesthesia 2001; 11:161–7. DOI: 10.1046/j.1460-9592.2001.00623.x

Kumar C, ‎Dodds C, ‎Gayer S. Oxford Specialist Handbooks in Anaesthesia Ophthalmic Anaesthesia 2012, p. 189–224. 8_Oxford_Handbook_of_Ophthalmic_Anaesthesia

Subramaniam R, Subbarayudu S, Rewari V, Singh R, Madan R. Usefulness of pre-emptive peribulbar block in pediatric viteroretinal surgery: a prospective study. Regional Anesthesia and Pain Medicine 2003; 28:437. DOI: 10.1053/rapm.2003.50032

Breijo Marquez FR. Abnormal Heart Rhythms. 2015;97:105. DOI: 10.5772/59212

Hahnenkamp K, Honemann CW, Fischer LG, Durieux ME, Muehlendyck H, Braun et al. Effect of different anaesthetic regimes on the oculo-cardiac reflex during paediatric strabismus surgery. Paediatr Anaesth. 2000; 10:601–8.

DOI: 10.1111/j.1460-9592.2000.00588.x

Gilani MT, Sharifi M, Najafi MN, Mashhadi MGE. Oculo-cardiac reflex during strabismus surgery. Reviews in. Clinical Medicine. 2016; 3:4–7.

Bietti OB. Problems of anesthesia in strabismus surgery. Int Ophthalmol Clin. 1966; 6:727–37. ophthalmology/Citation/1966/00630/

Chowdhury T, ‎Schaller B, Koerbe A. Functional Consequences of the Trigemino-cardiac Reflex 2015; 14:169:213. DOI: 10.1097/ANA.0000000000000065

Smith RB, Douglas H, Petruscak J. The oculo-cardiac reflex and sino-atrial arrest. Can Anaesth Soc J. 2002; 19:138–42.

Sadhasivam S, Shende D, Madan R. Prophylactic ondansetron in prevention of postoperative nausea and vomiting following pediatric strabismus surgery: a dose response study. Anesthesiology 2000; 92:1035–42.

DOI: 10.1097/00000542-200004000-00021

Watcha MF. The cost/effective management of postoperative nausea and vomiting. Anesthesiology 2000; 92:931–3.

DOI: 10.1097/00000542-200004000-00007

Wolf R, Morinello E, Kestler G, Käsmann-Kellner B, Bischoff M, Hager T, et al. PONV after strabismus surgery: Risk adapted prophylaxis,2016 Jul;65(7):507-13. DOI: 10.1007/s00101-016-0183-2

Kristin N, Schonfeld CL, Bechmann M, Bengisu M, Ludwig k, Scheider A, et al. Vitreoretinal surgery: pre-emptive analgesia. Br J Ophthamol 2001; 85:1328–31 DOI: 10.1136/bjo.85.11.1328

Chhabra A, Pandey R, Khandelwal M, Subramaniam R, Gupta S. Anesthetic techniques and postoperative emesis in pediatric strabismus surgery. Reg Anesthesia Pain Med 2005; 30(1):43–7. DOI: 10.1016/j.rapm.2004.08.023

Coté CJ, Lerman J, and Anderson BJ. A Practice of Anesthesia for Infants and Children 2018; 34:790:810.

Ghali B, Ram J, Makkar JK, Wig J, Kaushik S. Subtenon block compared to intravenous fentanyl for perioperative analgesia in pediatric cataract surgery 2009; 108 (4):1132–8.

DOI: 10.1213/ane.0b013e318198a3fd

Parulekar MV, Berg S, Elston JS. Adjunctive peribulbar anesthesia for paediatric ophthalmic surgery: are the risks justified? Paediatric Anaesth 2002; 12:85–6.

DOI: 10.1046/j.1460-9592.2002.0787a.x

Forrester JV, Dick AD, McMenamin PG, Roberts F, Pearlman E. The Eye: Basic Sciences in Practice Fourth Edition2016; 1:1:60.

Jennings D, Chernega J. Emergency Guide for Dental Auxiliaries 2012; 2:23-233.

Geyer H, Kaufman DM, Milstein MJ, Kaufman's Clinical Neurology for Psychiatrists 2016; 315:688.

Bissonnette B, Lockman JL and Easley RB. Pediatric Anesthesia Basic Principles-State of the Art-Future, Emergence and Postoperative Care 2011; 58:924:939

Gupta N, Kumar R, Kumar S, Sehgal R, Sharma KR. Prospective randomized double-blind study to evaluate the effect of peribulbar block or topical application of local anaesthesia combined with general anaesthesia on intra-operative and postoperative complication during pediatric strabismus surgery. Anaesthesia 2007; 62:1110–3.

DOI: 10.1111/j.1365-2044.2007.05220.x

Ripart J, Lefrant JY, L’Hermite JI, Borzli F, Nouvellon E, Fabbro-Peray P, et al. Caruncle single injection episcleral (sub-tenon) anesthesia for cataract surgery: mepivacaine versus a lidocaine-bupivacaine mixture. Anesth Analg 2000; 91:107–9. DOI: 10.1097/00000539-200007000-00020

Shende D, Sadhasivam S, Madan R. Effect of peribulbar bupivacaine as an adjuvant to general anesthesia on postoperative outcome following retinal detachment surgery. Anesthesia 2000; 55:970–5.

DOI: 10.1046/j.1365-2044.2000.01535.x

Dehghani A, Montazeri K, Masjedi A, Karbasi N, Ashrafi L, Saeedian et al. Adjunctive Local Application of Lidocaine during Scleral Buckling under General Anesthesia 2011;177:181.

Shalini G, Chakrapani K, Harsha N, Karanam S, Nambula S. Occurrence of Oculo-cardiac Reflex During Strabismus SurgeryVol. 30, No. 1, July-September 2019; 28:31.

Gilani MT, Sharifi M, Najafi MN, Mashhadi MGE. Oculo-cardiac reflex during strabismus surgery. Reviews in. Clinical Medicine. 2016; 3:4–7.

Ha SG, Huh J, Lee BR, Kim SH. Surgical factors affecting oculo-cardiac reflex during strabismus surgery, 2018; 18:103:1-5.

Chhabra A, Sinha R, Subramaniam R, Chandra P, Narang D, Garg SP, et al. Comparison of sub-Tenon’s block with i.v. fentanyl for paediatric vitreoretinal surgery. Br J Anesthesia 2009; 103(5):739–43. DOI: 10.1093/bja/aep230

Ghali AM, Hafez A. Single-injection percutaneous peribulbar anaesthesia with a short needle as an alternative to the double injection technique for cataract extraction. Anesth Analg 2010; 110(1):245–7.

DOI: 10.1213/ANE.0b013e3181c293bd

Elgohary MM, Sherif H. Single-injection peribulbar block combined with general anesthesia in children undergoing ophthalmic surgery. Egyptain J Anaesthesia 2011; 77-82.

Morel J, Pascal J, Charier D, De Pasquale V, Gain P, Auboyer C, et al. Preoperative peribulbar block in patients undergoing retinal detachment surgery under general anesthesia: a randomized double-blind study. Anesthesia Analgesia 2006; 102:1082–7.


Moghaddam AAS. Assessment of the Rate of Nausea, Vomiting, and Pain in Patients with Strabismus Anaesthetised with Propofol.Volume 7, Number 2, 2005; 30:32. 4_Assessment_of_the_Rate_of_Nausea_Vomiting_and_Pain_in_Patients_with_Strabismus_Anaesthetised_with_Propofol

Ghali AM, El Btarny AM. The effect on outcome of peribulbar anaesthesia in conjunction with general anesthesia for vitreoretinal surgery. Anaesthesia 2010; 65:249–53.

DOI: 10.1111/j.1365-2044.2009.06191.x

Salman IA. Effects of halothane and isoflurane on uterine muscle relaxation during caesarian section. JFacMedBagdad [Internet]. 2013 Jan. 2 [cited 2023 Jan. 23]; 54(4):314-6.

Salman IA, Kanaan SA. Comparison between the effect of propofol (TIVA) and inhalational anesthesia (halothane)on early postoperative nausea and vomiting. JFacMedBagdad [Internet]. 2013 Jul. 1 [cited 2023 Jan. 23]; 55(2):111-4. DOI:




How to Cite

Abdul-Sattar RS, Al-Maini AH. The Advantages of Combined Regional and General Anesthesia in Ophthalmic Surgery in Children. JFacMedBagdad [Internet]. 2023 Oct. 1 [cited 2023 Dec. 11];65(3):173-8. Available from: