*Co esponding au ho : Vic o Imanuel Si aniapessy
Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion Liscense 4.0.
Pe ibulba ne e block using opi acaine in pa ien wi h se e e co ona y a e ial
disease unde going pa s plana i ec omy p ocedu e: A case epo
Vic o Imanuel Si aniapessy 1, *, Adinda Pu a P adhana 2 and IGP. Suk ana Sidemen 2
1 Depa men o Anes hesiology and In ensi e Ca e, P o . D . d . IGNG Ngoe ah Gene al Hospi al/, Denpasa , Bali, Indonesia.
2 Depa men o Anes hesiology and In ensi e Ca e, Udayana Uni e si y Gene al Hospi al, Denpasa , Bali, Indonesia.
GSC Biological and Pha maceu ical Sciences, 2025, 32(03), 281-285
Publica ion his o y: Recei ed on 27 July 2025; e ised on 19 Sep embe 2025; accep ed on 22 Sep embe 2025
A icle DOI: h ps://doi.o g/10.30574/gscbps.2025.32.3.0349
Abs ac
Pa ien s unde going oph halmic su ge y may ep esen ex emes o age. Many o hem may ha e coexis ing diseases
(e.g., diabe es melli us, co ona y a e y disease, essen ial hype ension, ch onic lung disease, enal
insu iciency/ ailu e). The p ima y goal o any success ul ca diac anes he ic is p e en ion o myoca dial ischemia and
p omp iden i ica ion and ea men o new ischemic episodes.
Case : A 51 h-yea -old male was diagnosed wi h complica ed ca a ac and was planned o unde go VPP (Pa s Plana
Vi ec omy) and Phaco. The pa ien has uncon olled diabe es melli us since 10 yea s, had used OADs and insulin bu
was sel -discon inued, cu en ly using insulin gla gin 8 uni s a nigh since he i s igh eye su ge y. The pa ien also
has a his o y o hype ension and se e e co ona y a e ial disease (CAD) known since July 2024. The choice is
Pe ibulba ne e block wi h mild seda ion i needed o gua an ee pain ee and no anxious du ing he su ge y so as no
o wo sen his CAD p oblems. Pos ne e block e alua e akinesia and analgesia o he eye achie ed be o e su ge y.
Discussion : Ad an ages o he pe ibulba echnique include less isk o pene a ion o he globe, op ic ne e, and a e y
and less pain on injec ion. The pe ibulba ha has been done in his case showed ha pe iphe al ne e block wi h
opi acaine can mimimalize ca diac e en and a oid gene al anes hesia in pa ien wi h se e e CAD.
Conclussion : This case demons a es ha he adminis a ion o opi acaine in pe ibulba ne e block is bene icial in
oph halmic su gical p ocedu es wi h pa ien s who ha e se e e CAD
Keywo ds: Anes hesia; Pe ibulba Ne e block; Ropi acaine; Vi ec omy; Co ona y a e y diseases
1. In oduc ion
Subs an ial p opo ion o pa ien s unde going oph halmic su ge y a e o en elde ly wi h signi ican como bidi ies,
including diabe es melli us, co ona y a e y disease, essen ial hype ension, ch onic lung disease, and enal
insu iciency o ailu e. This g oup is pa icula ly ulne able due o educed unc ional ese e and he p e alence o
mul iple age- ela ed diseases. Pa ien wi h signi ican ca diac como bidi ies may es ic he use o some anaes hesia
echniques and agen s. They may ha e e y na ow window o ca diac unc ion, unable o be on a lying la posi ion,
sensi i e o oculoca diac e lex and he use o an i-pla ele /an i h ombo ic agen .
The use o a pe ibulba ne e block wi h opi acaine o e s signi ican bene i s o pa ien s wi h ca diac diseases
unde going oph halmic su ge y. This echnique a oids he sys emic hemodynamic al e a ions associa ed wi h gene al
anes hesia, he eby minimizing he isk o myoca dial ischemia, a hy hmias, and o he pe iope a i e ca diac
GSC Biological and Pha maceu ical Sciences, 2025, 32(03), 281-285
282
complica ions. Ropi acaine, a long-ac ing local anes he ic wi h a a o able sa e y p o ile, is pa icula ly ad an ageous
in his con ex due o i s lowe ca dio oxici y compa ed o bupi acaine. By p o iding e ec i e analgesia and akinesia,
opi acaine ensu es op imal su gical condi ions while educing he need o supplemen al opioids o seda i es, which
can exace ba e ca diac s ain. Addi ionally, he educed eliance on sys emic anes he ic agen s p omo es as e
pos ope a i e eco e y, acili a es ea ly mobiliza ion, and may sho en hospi al s ays. These bene i s make he
pe ibulba block wi h opi acaine a aluable anes he ic s a egy o high- isk ca diac pa ien s, combining e icacy,
sa e y, and imp o ed pe iope a i e ou comes.
In he con ex o ca diac anes hesia, he p ima y objec i e is main aining he hemodynamic s abili y and op imaliza ion
o oxygen supply and demand. This necessi a es igilan moni o ing o ischemic episodes and p omp in e en ion.
E ec i e managemen in ol es educing myoca dial oxygen demand (MVO2) by con olling key de e minan s such as
hea a e, con ac ili y, and wall ension, while simul aneously op imizing co ona y blood low h ough he
main enance o co ona y pe usion p essu e and p olonga ion o dias olic ime.
2. Case epo
A 51-yea -old male p esen ed wi h a p ima y complain o g adual ision loss in he le eye o e he pas wo yea s.
The pa ien denied addi ional symp oms such as eye edness, discha ge, pain, o a his o y o ocula auma. He was
diagnosed wi h complica ed ca a ac and was planned o unde go VPP (Pa s Plana Vi ec omy) and Phaco. He has a 10-
yea his o y o uncon olled diabe es melli us, p e iously managed wi h o al an idiabe ic d ugs (OADs) and insulin,
which we e discon inued by he pa ien . Cu en ly, he is on insulin gla gine 8 uni s nigh ly, ini ia ed ollowing he i s
su ge y on he igh eye.
The pa ien has a documen ed his o y o hype ension and se e e co ona y a e y disease diagnosed in July 2024. His
cu en medica ions include amlodipine 5 mg once daily (PO), ca edilol 3.125 mg wice daily (PO), and amip il 2.5 mg
once daily (PO). An ipla ele he apy wi h ace ylsalicylic acid was discon inued one week p io o p esen a ion. He
epo s exe ional dyspnea, pa icula ly when walking dis ances exceeding 1 kilome e .
The pa ien denies a his o y o e e , cough, cold, o sho ness o b ea h in he p eceding wo weeks. He also denies any
known d ug alle gies. Despi e his como bidi ies, he pa ien wo ks as a p i a e employee and emains capable o
pe o ming ligh physical ac i i ies wi hou expe iencing ches pain o sho ness o b ea h. He epo s being able o
sleep com o ably wi h one pillow and has no expe ienced noc u nal dyspnea o o hopnea.
2.1. P eope a i e Examina ion
P eope a i e e alua ion included a comp ehensi e assessmen , wi h pa icula emphasis on he pa ien ’s
ca dio ascula s a us. Physical examina ion e ealed a blood p essu e o 140/80 mmHg, a egula hea a e o 75 bea s
pe minu e, and no mal hea sounds (S1 and S2) wi hou mu mu s o gallop. Labo a o y in es iga ions we e wi hin
no mal limi s. Elec oca diog aphy (ECG) demons a ed sinus hy hm a a a e o 78 bea s pe minu e, a no mal axis,
and T-wa e in e sion in leads aVL and V5-V6, sugges i e o la e al ischemia.
Ca diology consul a ion included a ull echoca diog aphic s udy, which e ealed he ollowing indings:
• Ca diac chambe dimensions: Dila a ion o all chambe s
• Le en icula hype ophy: P esen
• Le en icula sys olic unc ion: Se e ely dec eased, wi h an ejec ion ac ion o 25.72%
• Le en icula dias olic unc ion: G ade III dias olic dys unc ion
• Righ en icula sys olic unc ion: No mal, wi h TAPSE o 29 mm
• Le en icula wall mo ion: Regional wall mo ion abno mali ies no ed
• Val ula indings: Seconda y mild mi al egu gi a ion
Based on hese indings, he pa ien was classi ied as ASA Physical S a us IV due o signi ican sys emic disease posing
a cons an h ea o li e. In o med consen was ob ained ollowing de ailed educa ion on he anes he ic p ocedu e,
po en ial complica ions, and he possibili y o ne e block ailu e. The anes he ic plan p io i ized s a egies o minimize
pe iope a i e pain and mi iga e ca diac complica ions, pa icula ly gi en he p esence o se e e co ona y a e y
disease.
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2.2. Anes hesia Managemen
The anes hesia plan was ca e ully ailo ed o minimize pe iope a i e complica ions, wi h pa icula a en ion o he
pa ien ’s ca diac unc ional s a us and he associa ed isks o se e e co ona y a e y disease (CAD). Gi en he pa ien 's
comp omised ca diac ese e, he chosen anes hesia echnique was a pe ibulba ne e block, which p o ides e ec i e
egional anes hesia while a oiding he hemodynamic pe u ba ions associa ed wi h gene al anes hesia. Mild seda ion
was included as an op ional adjunc o manage anxie y and ensu e pa ien com o , ecognizing he impo ance o
main aining hemodynamic s abili y.
E ec i e pain managemen and anxie y con ol we e p io i ized, as bo h ac o s can exace ba e myoca dial oxygen
demand and po en ially p ecipi a e ischemic e en s in pa ien s wi h CAD. Excessi e sympa he ic s imula ion om pain
o anxie y could lead o inc eased hea a e, blood p essu e, and myoca dial wo kload, u he comp omising an
al eady impai ed ca dio ascula sys em. Thus, me iculous in aope a i e moni o ing is essen ial. We use in aa e ial
line, pulse oxime y and 5 leads-ECG.
2.3. Pe ibulba Ne e Block
The p ocedu e begins wi h wo d ops o 0.5% pan ocaine o opical anes hesia. In a enous adminis a ion o
midazolam (1.5 mg) was used o mild seda ion and as an anxioly ic agen , accompanied by en anyl (25 µg) o
addi ional analgesia. In aocula p essu e was assessed p io o ini ia ing he block, and a s e ile block se was p epa ed.
A local anes he ic injec ion consis ing o 4 mL o 0.375% plain opi acaine was adminis e ed in o he le in e o empo al
egion o he eye, ollowed by an addi ional 4 mL injec ed in o he medial can hus o he le eye and o acili a e he
sp ead o he anes he ic and educe in aocula p essu e, a Honan balloon was applied wi h a p essu e o 30 mmHg o
5–10 minu es. Pa ien was calm du ing he block and had no complain o he p ocedu e. Pos -ne e block, he adequacy
o akinesia and analgesia was ca e ully e alua ed o ensu e op imal condi ions be o e su ge y. Pa ien was ask o mo e
his eyeball in o se e al di ec ion o see i he akinesia is achie ed and he co nea was ouch using issue o e alua e he
numbness.
Du ing he su gical p ocedu e, anes hesia was main ained wi h oxygen deli e ed a 3 L/min ia nasal cannula. No
addi ional opioids o seda i es we e adminis e ed o minimize po en ial espi a o y and ca dio ascula complica ions,
aligning wi h he anes he ic s a egy o a high- isk ca diac pa ien . Pa ien showed a g ea coope a ion and was calm
du ing he 80 minu es su ge y.
Figu e 1 In aope a i e Hemodynamic moni o ing show ha pa ien a e s able wi hou any ca diac e en
2.4. Pos ope a i e Ca e
Following he comple ion o he su gical p ocedu e, he pa ien was ans e ed o he pos -anes hesia ca e uni (PACU)
o close moni o ing o ensu e he absence o immedia e pos ope a i e complica ions. Pa icula a en ion was gi en o
de ec ing any signs o ca dio ascula ins abili y, such as a hy hmias o ischemic symp oms, as well as local
complica ions such as e obulba hemo hage, excessi e swelling, p osis o inadequa e e u n o ocula unc ion.
GSC Biological and Pha maceu ical Sciences, 2025, 32(03), 281-285
284
Once he pa ien was deemed s able and ee o acu e complica ions, hey we e ans e ed back o he egula wa d o
u he eco e y. Analgesic managemen included o al pa ace amol and ibup o en, and du ing he ollow up 12 and 24
hou s a e su ge y show VAS sco e o 1/10. The pa ien was moni o ed o e nigh , wi h no ad e se e en s no ed, and
discha ged he ollowing day wi h ins uc ions o con inued ca e and ollow-up o moni o su gical ou comes and
ensu e eco e y was p og essing app op ia ely.
3. Discussion
The pe ibulba anes hesia echnique o e s dis inc ad an ages o e e obulba block, pa icula ly o high- isk
pa ien s. I minimizes he isks o globe pene a ion, op ic ne e o a e y inju y, and injec ion-associa ed pain.
Howe e , i s slowe onse ime and inc eased likelihood o ecchymosis a e no able d awbacks. Bo h echniques,
none heless, achie e compa able le els o ocula akinesia.
Local anes he ics exe hei e ec s by blocking pe iphe al ne es, p ima ily h ough in e e ence wi h he ansmission
o ac ion po en ials along ne e ibe s. This blockade is media ed by he inhibi ion o ol age-ga ed sodium channels, a
p ocess ha equi es he local anes he ic o di use h ough su ounding issue o each he ne e memb ane. Despi e
p ecise injec ion nea he a ge ne e, only 1–2% o he adminis e ed local anes he ic pene a es he ne e o exe i s
e ec . The deg ee o blockade is de e mined by he concen a ion and olume o he local anes he ic, as hese ac o s
go e n he es ablishmen o an e ec i e concen a ion g adien .
Among he local anes he ics, he pipecoloxylidide g oup (e.g., mepi acaine, bupi acaine, opi acaine, and
le obupi acaine) consis s o chi al compounds wi h molecules ha possess an asymme ic ca bon a om. Many such
anes he ics a e a ailable as acemic mix u es con aining equal p opo ions o le -handed (S) and igh -handed (R)
enan iome s. Pha macological and oxicological p o iles di e be ween enan iome s due o s e eoselec i e binding o
chi al ecep o s o enzymes. S-enan iome s, such as hose in opi acaine and le obupi acaine, demons a e educed
neu o oxici y and ca dio oxici y compa ed o hei acemic o R-enan iome coun e pa s. This cha ac e is ic is
pa icula ly ad an ageous in high- isk pa ien s, such as hose wi h se e e co ona y a e y disease (CAD).
The pe ibulba echnique in ol es he adminis a ion o a la ge olume (6–12 mL) o local anes he ic in o he
ex aconal space, allowing ex ensi e sp ead wi hin he o bi al adipose issue and in o he in aconal space o e ec i ely
block he ele an ne es. Addi ionally, he an e io sp ead o he anes he ic in o he eyelids p o ides a block o he
o bicula is muscle, elimina ing he need o sepa a e eyelid ne e blocks. The classic app oach employs wo injec ions:
one in he in e o empo al egion and he o he in he medial can hus, wi h p ecise placemen acili a ed by aspi a ion
o a oid in a ascula injec ion.
In his case, opi acaine was selec ed due o i s po en analgesic p ope ies and lowe isk o ca dio oxici y compa ed
o al e na i es like bupi acaine. A combina ion o opi acaine 0.75% (2 mL) and lidocaine 2% (2 mL) was adminis e ed
using a 25-gauge needle in o he in e o empo al and medial can hus egions o he le eye, ensu ing no in a ascula
injec ion h ough aspi a ion.
The sa e y and e icacy o opi acaine in high- isk pa ien s a e suppo ed by clinical e idence. Choi e al. epo ed he
success ul use o opi acaine o pe iphe al ne e block in a pa ien wi h B ugada synd ome unde going lowe -limb
su ge y, highligh ing i s sa e y in a hy hmia-p one pa ien s. Simila ly, Ma inez e al. desc ibed he e ec i e use o
opi acaine ia in e cos al ca he e in usion in a pa ien wi h se e e mul i essel CAD unde going li e ansplan a ion,
demons a ing excellen analgesia and acili a ing ea ly eco e y. Senapa hi e al. u he alida ed he use o
opi acaine 0.75% combined wi h lidocaine 2% o pe ibulba block du ing i ec omy, achie ing su icien analgesia
and akinesia.
In his case, he pe ibulba block wi h opi acaine p o ided e ec i e analgesia and ocula akinesia while minimizing
he isk o ca diac e en s associa ed wi h gene al anes hesia in a pa ien wi h se e e CAD. This app oach unde sco es
he alue o egional anes hesia in op imizing ou comes o high- isk pa ien s, o e ing bo h sa e y and e icacy in he
pe iope a i e se ing.
4. Conclusion
This case highligh s he e icacy o opi acaine in pe ibulba ne e block as a aluable anes he ic echnique o
oph halmic su gical p ocedu es in pa ien s wi h se e e co ona y a e y disease (CAD). The use o opi acaine no only
minimizes he equi emen o opioids and sys emic anes he ic agen s, he eby educing associa ed side e ec s, bu also
GSC Biological and Pha maceu ical Sciences, 2025, 32(03), 281-285
285
acili a es imp o ed pos ope a i e eco e y and mobiliza ion. These bene i s con ibu e o a sho e hospi al leng h o
s ay, which is pa icula ly ad an ageous o high- isk ca diac pa ien s.
Compliance wi h e hical s anda ds
Acknowledgmen s
The au ho s would like o acknowledge ha he e a e no con ibu ions o suppo o decla e o his case epo .
Disclosu e o con lic o in e es
The au ho s decla e ha he e is no po en ial con lic o in e es ela ed o his case epo .
S a emen o in o med consen
In o med consen was ob ained om all indi idual pa icipan s included in he s udy.
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