British Ophthalmic Anaesthesia Society

BOAS is not a society for anaesthetists alone: it’s objectives can only be met if its membership includes representation from all groups involved with ophthalmic anaesthesia, the membership of Council reflects this harmonisation. Also, although there is a growing trend towards greater use of local anaesthetic techniques, general anaesthesia still has an important place and should not be ignored.

The 1993 Colleges’ report on local anaesthesia was much needed and made proposals for improved standards of safety. There is a similar need for high standards of efficacy and of efficiency. All this requires knowledge achieved from observation, research and audit. It also requires a formal training syllabus with the availability of literature, videos, simulators, courses and table-side teaching necessary to impart the knowledge and to develop skills in a safe environment. The 1996 audit of local anaesthetic practice in the United Kingdom shows the extent to which Colleges’ guidance was heeded and suggests that there was still a long way to go. Also, the passage of time and developments in knowledge and techniques suggest that the 1993 guidance needs fine tuning and a new working group is meeting at this time.

The American Society (OAS) is a few years older than BOAS and its officers and members have been very generous with their advice and help with our conception, pregnancy and parturition. A number of its members will be speaking at our inaugural meeting in Middlesbrough and others will be present as delegates. If our meetings are as stimulating and exciting as the OAS meetings that I have had the honour and pleasure to attend, we will be going a long way towards attaining our goals.

A specialist professional society thrives if it achieves not only its more medical and scientific goals but promotes friendship and collaboration between its members. I think we are very fortunate that the relationships between ophthalmic surgeons, anaesthetists and nurses are second to none and we have the common goals of providing a safe, effective and efficient service for our patients in the most pleasant way possible.

I am very honoured to have been asked to be the first President of BOAS and take my responsibility seriously. Without Chandra Kumar’s foresight, enthusiasm and energy BOAS would not be with us. A number of our surgical and anaesthesia colleagues have given much time and enormous support. Once again I would like to thank our American friends for their advice: in particular, Dr Gary Fanning who has given us so much of his time and responds so promptly to e-mails requesting urgent help.

Finally, I would like to invite BOAS to Bristol next year for a meeting that will attempt to utilise some of our local specialities such as our strong paediatric interest and our Medical Simulation Centre. We also believe that we can cater for the all important friendship functions of our Society. Like Seattle, it never rains in Bristol – so bring an umbrella.

It was my honor to attend the British Ophthalmic Anaesthesia Society Council meeting in Middlesbrough in November, and I am very much looking forward to attending and participating in the inaugural annual meeting of your Society in June. Chandra Kumar has put together an exciting program, and he and all the other members who have helped to organize this gathering are to be congratulated for their prodigious efforts.

Having been actively associated with the OAS in America for a number of years now, I can affirm how rewarding it is to gather with one's peers annually to talk shop. Many of us over here practice by ourselves or, at best, in very small groups. Sharing our triumphs, disasters, frustrations, and discoveries doesn't happen on a daily basis for those of us who practice alone. The OAS has given us a forum wherein we have colleagues from border to border and even across the seas with whom we can share information and from whom we can seek advice. Through newsletters, the Internet, and even that old-fashioned instrument, the telephone, we keep in touch with one another throughout the year. Our annual meeting, then, becomes as much a family reunion as it is a mechanism for disseminating new information and reviewing old.

I wish you great success and hope that your Society will continue to grow and thrive into the new century. Those of us who have a special interest in safe and effective anaesthesia for patients undergoing surgery of the eye are a small but ardent cadre. It is my further hope, therefore, that members of both the BOAS and OAS will develop a strong fellowship so that the sharing of information and experiences becomes a very decidedly Trans-Atlantic phenomenon.

I send my very best wishes to you all while eagerly anticipating our meeting in June in Middlesbrough.

Gary L. Fanning, M.D.
Program Director
Ophthalmic Anesthesia Society
Sycamore, Illinois

The creation of an organisation focused on the provision of safe anaesthesia for ophthalmic procedures provides many opportunities. The development of clear evidence-based and practical guidelines, the detailing of appropriately timed training schemes for anaesthetists and surgeons, and the establishment of ‘best practice’ are all such potential goals. The links with an elder sister organisation will undoubtedly help in these endeavours. The BOAS will move into Europe and offer to organise ‘satellite meetings’ at such major events as the ESRA and ESA meetings. Many of the members have close links with these organisations, and our sights are set high.

However, while waking from such fancies does not detract from their potential value, caution is a very useful daytime vice. What will our training schemes and best practice be used for? Will we provide clinical governance with unachievable targets? Will our trainees accuse us of breach of contract if we do not deliver teaching on sub-tenon’s by their second month as an SHO? Where will the place of general anaesthesia be in the next 10 years – will it be unacceptable?

Some of these questions or worries are being addressed at this moment – exemplar sites have been chosen for cataract surgery for instance, equally there is a remise of the original joint college guidelines – but are we the appropriate body to define clinical governance or the syllabus for training?

I think so, but do you? If you feel threatened by the risk of yet another set of clinical guidelines tell us. After all, doesn’t silence equal consent?

As an ophthalmologist, I have always had a rather jaundiced view of local anaesthetic techniques for cataract surgery and would welcome cases under general anaesthetic. LA cases seemed rather hit-and-miss (sic) as far as the degree of anaesthesia was concerned. To me, it always seemed unprofessional, to say the least, to perform painful surgery if there was a more reliable alternative. General anaesthesia has its disadvantages, but the absence of pain is assured, or the anaesthetist is sued! With the introduction of the peribulbar technique and the involvement of anaesthetists in the administration of eye blocks, the situation changed, but there were still problems. The variable onset of a true peribulbar, along with the variable pain relief (bipolar cautery and subconjunctival injections were still painful enough to require top-up anaesthesia on occasions) and the occasional orbital haemorrhage made these techniques less than perfect. Even in the best hands, needle techniques occasionally lead to surgery being cancelled in the anaesthetic room. I recently performed an audit of cancellations in theatre over the year 1995-1996. There was approximately the same number of GA and LA cases in that year. There were 2 GA and 24 LA cancellations.

We all associate GA cases with late cancellations, but these occur before the patient gets to theatre, whereas LA cancellations occur after the administration of the anaesthetic. In the two years since changing to subtenons anaesthesia, there has not been a single cancellation in theatre.

Those of us with exceptional general anaesthesia support wondered why ophthalmologists were rushing headlong for techniques which, rather unpredictably, produced sub-optimal operating conditions.

Those of you who attended the Video workshop in Middlesbrough two years ago when Mags Dyan first demonstrated subtenons block will remember two things. Firstly there was the gasp of horror from the audience when the four millilitres suddenly disappeared behind the eye. Secondly there was disbelief at the rapid onset of akinesia and claims of instant and total anaesthesia. My team immediately shifted to subtenons anaesthesia for all locals. With the exception of one list (covered by Chandra Kumar who is a devoted P/RBA expert, when I could not bring myself to insist on subtenons in the face of such expertise), my team has not performed a needle local since.

But there has been a bigger change. The degree of anaesthesia is so reliable, never needing a top-up for residual sensation, that my GA preference has gone. We now perform well over 95% of cases under STLA. What is more, top-up anaesthesia is never required (I did top-up one case with full anaesthesia but quite excessive eye movement – another 2ml stopped that). I feel happy, the anaesthetist feels happy (once they get over the shock of being handed surgical instruments) and most important of all, the patient is happy.

The final measure of a technique is whether we would accept it on us. In a recent conversation with Helen Seward, she said that she would have to have a general anaesthetic (mainly to eliminate the panic that would ensue when the surgeons said "Oh **!#!"). In the past I would not have accepted a needle local and (forgive me, Chandra) still wouldn’t, and although I would still accept a GA if I could chose my anaesthetist, I’d have a subtenons!

This is the first edition of our BOAS Newsletter. It is hoped that it will be published twice annually and that it will reflect the work of the BOAS and the practice of Ophthalmic Anaesthesia in the United Kingdom. The Newsletter will publish views, news, case reports, interesting ideas, concerns, opinion, current literature on ophthalmic anaesthesia, list meetings relevant to ophthalmic anaesthesia, minutes of BOAS, membership list etc. We hope to elect an editorial board for the Newsletter at the next BOAS Council meeting. We welcome your comments on issues related to ophthalmic anaesthesia and how we can further improve things, either write to us or email me at secretary@boas.org Please continue to visit our web site at www.boas.org and in future issues we hope to provide more information. We have started a message / bulletin board at our web site to discuss on-line views on matters related to ophthalmic anaesthesia.

Dr Chandra M Kumar
Secretary, BOAS
Department of Anaesthesia
South Cleveland Hospital
Middlesbrough TS4 3BW
Tel 01642 854601
Fax 01642 854246

BOAS was formed in 1998 to provide a forum for anaesthetists, ophthalmologists and other professionals with an interest in ophthalmic anaesthesia to facilitate co-operation on all matters concerned with the safety, efficacy and efficiency of anaesthesia for ophthalmic surgery. It is concerned with education, achievement of high standards, audit and research. BOAS will organise annual scientific meetings, produce a newsletter and maintain a web page.

Members of BOAS include anaesthetists, ophthalmologists and other professionals with an interest in ophthalmic anaesthesia.

Membership runs from January each year. The current subscription is Ł25.00 payable by banker’s standing order.

With the Royal College of Anaesthetists, the Association of Anaesthetists of Great Britain and Ireland and the Ophthalmic Anesthesia Society of the USA.

Dr Chandra M. Kumar Tel 01642 854601
Secretary, BOAS Fax 01642 854246
South Cleveland Hospital Email secretary@boas.org
Middlesbrough Web Site http://www.boas.org
TS4 3BW UK

Council Members
Mr. Ken Barber (Worcester)
Dr. Caroline Carr (London)
Mr. Louis Clearkin (Wirral)
Mr. Stuart Cook (Bristol)
Dr. David Greaves (Newcastle)
Dr. Monica Hardwick (Worcester)
Dr. Anthony P Rubin (London)
Mr. David Smerdon (Middlesbrough)
Dr. Sean Tighe (Chester)

The working party (The Royal College of Anaesthetists and the Royal College of Ophthalmologists) has been set up to review the document "Joint College Guidelines on Ophthalmic Anaesthesia" published in 1993. We are proud to say that 3 members of BOAS (Dr Robert Johnson, Dr A P Rubin and Dr Monica Hardwick) are representing the Royal College of Anaesthetists. If you had any concerns or would like to pass your opinion or views you can write directly to the working party members or send them to BOAS secretary.

The Society has its own Web Site http://www.boas.org. You can visit this site for more information regarding the Society, pages of interest, relevant links and search engines. We have also started an interactive BOAS Message Board. Once you log on to BOAS Homepage you can navigate to the pages of your interest including the Message Board page. Once you are in the Message Board page, you can leave your message by filling appropriate boxes. Your message will appear immediately and the visitors can reply to your message. Your message and replies will remain there for 90 days.

MINUTES OF THE BRITISH OPHTHALMIC ANAESTHESIA SOCIETY COUNCIL MEETING HELD ON 26^th NOVEMBER 98 AT POSTHOUSE HOTEL, MIDDLESBROUGH

Mr Ken Barber
Dr Caroline Carr
Dr Chris Dodds
Dr J David Greaves
Dr Monica Hardwick
Dr Robert Johnson (Chairman)
Dr Chandra Kumar
Mr David Smerdon
Dr Sean Tighe

Mr John Clarke
Mr T Dowd
Mr M H R El-Naggar
Miss Chris Ellerton
Dr Gary Fanning
Dr Manmohan Singh Kokri
Dr Mani Mehta
Dr David Ryall

The minutes of the previous meeting held on 28^th May 98 were agreed as a correct record.

Rules of the association: Members discussed the rules of the association and no changes were suggested. However, Dr Robert Johnson pointed out that he, Dr Anthony Rubin and some others were not happy with the name of the organisation because it appeared to be similar to Obstetric Anaesthetists Association in short form. Discussion took place and it was resolved unanimously to change the name of the organisation to avoid confusion. The organisation from now on will be called British Ophthalmic Anaesthesia Society (BOAS). Dr Kumar was asked to execute this change and inform relevant people and organisations accordingly.

Members database: Discussions took place on this subject and Mr Smerdon agreed to help build the database.

Funds and accounts: Currently there is a positive balance of Ł500. This amount has been given as a loan to the Society by Chandra Kumar to start the business. Although at present there is no treasurer, Chandra Kumar and Chris Dodds will continue to look after the treasurer’s activities until a treasurer is appointed.

The President has written to the President of the Royal College of Anaesthetists informing him of the existence and aims of our organisation. A reply has been received from the College President suggesting that the organisation will be discussed at the next Council meeting.

Chandra Kumar reported that an account with Midland Bank has been opened and Ł500 has been transferred as a loan to the organisation by the Amenity Fund of South Cleveland Hospital, Middlesbrough. Robert Johnson, Chris Dodds, David Smerdon and Chandra Kumar were kindly invited by the Ophthalmic Anaesthesia Society of USA to their meeting in Chicago. Attending guests received a warm welcome from all the members of the OAS. David Smerdon gave a presentation on the plans for the inaugural meeting of the organisation and the prospect of joint meetings. The presentation was well received and the majority of the OAS members agreed to share speakers but continue separate meetings. Many delegates expressed their wish to attend the BOAS meeting in June 99.

Chandra Kumar agreed to host the Inaugural Annual Conference on 17, 18 and 19^th June ‘99 in Middlesbrough. Several possible venues were discussed. It was unanimously agreed that the Tall Trees Hotel would be the best choice. An Organising faculty was formed. Caroline Carr, Chris Dodds, Gary Fanning, Robert Johnson, Chandra Kumar, Anthony Rubin and David Smerdon were asked to serve. The format of the scientific meeting was discussed but it was resolved that the organising faculty should discuss this matter in a separate meeting. The subscription (Registration?) charges should also be discussed by the organising faculty. The organising faculty agreed to meet in the first week of December.

It was unanimously agreed that US and Canadian speakers would be offered Ł500=00 towards their travelling and accommodation will be provided for the duration of the meeting. British speakers will be offered Ł300=00 toward travelling expenses and hotel accommodation will be provided for the duration of the meeting. It was also agreed that Council members of BOAS might be requested to chair or speak at the meeting, but no expenses would be reimbursed. Therefore, those Council members who will be a part of the organising or guest faculty will register for the meeting at the reduced subscription charge like other Society members and arrange their own accommodation. This decision recognised that the Society is newly established and has no funds to support expenses of the council members.

All officers of the Society were requested to support an initiative to raise funds for the Society and the forthcoming inaugural annual conference in June 99.

The next meeting of the BOAS would be held on Thursday 17^th June ‘99 at 1pm in Tall Trees Hotel, Middlesbrough.

Dr Zia Arfeen, Consultant Anaesthetist, Sunderland District General Hospital, SUNDERLAND
Mr K. Barber, Worcester Royal Infirmary, Newtown Hospital, Newtown Road, WORCESTER
Dr. Joy Beamer, 4 Nova Lodge, Emerson Valley, MILTON KEYNES
Mr Michael Andrew Bearn, Consultant Ophthalmologist, Cumberland Infirmary, CARLISLE
Dr. Alison Budd, Dept. of Anaesthesia, Moorfields Eye Hospital, City Road, LONDON
Dr Caroline Carr, Consultant anaesthetist, Moorfields Eye Hospital, City Road, LONDON
Dr. Donald Child, Dept. of Anaesthesia, York General Hospital, Wigginton Road, YORK
Mr Louis Clearkin, Consultant Ophthalmologist, arrow Park Hospital, WIRRAL
Dr. John H. Cook, Dept. of Anaesthesia, District General Hospital, Kings Drive, EASTBOURNE
Dr. David Cranston, 10 West Common Way, Harpenden, HERTS
Dr. Damien Cremin, Dept. of Anaesthesia, East Glamorgan General Hospital, Church Village, NR PONTYPRIDD
Dr Steven Cruickshank, Dept. of Anaesthesia, Newcastle General Hospital, Westgate Road, NEWCASTLE
Dr. Narinder Dhariwal, Consultant Anaesthetist, Sunderland Royal Infirmary, Kayll Road, SUNDERLAND
Dr Christopher Dodds, Consultant Anaesthetist, South Cleveland Hospital, Marton Road, MIDDLESBROUGH
Mr Tim C Dowd, Consultant Ophthalmologist, North Riding Infirmary, MIDDLESBROUGH
Mr. Mamdouh El-Naggar, North Riding Infirmary, Newport Road, MIDDLESBROUGH
Miss Christine Ellerton, Consultant Ophthalmologist, North Riding Infirmary, Newport Road, MIDDLESBROUGH
Dr Kevin Evans, Dept of Anaesthesia, Walsgrave NHS Trust, 78 Chanty Heath Cres, Solihull, WESTMIDLAND
Dr David Greaves, Consultant Anaesthetist, Royal Victoria Infirmary, NEWCASTLE UPON TYNE
Dr John Halshaw, Department of Anaesthesia, Royal Victoria Infirmary, Queen Victoria Road, NEWCASTLE
Dr. Monica Hardwick, Worcester Royal Infirmary, Newtown Road, WORCESTER
Dr. Michael Hargrave, 39a Broomfield Avenue, Palmers Green, LONDON N13 4JJ
Dr R.B.S. Hudson, Consultant Anaesthetist, 3 Burnulf Court, Burnaston, DERBY
Dr. Peter James, Dept. of Anaesthesia, North Hampshire Hospital, Aldermaston Road, BASINGSTOKE, HANTS
Dr. Shankaranand Jha, Scunthorpe General Hospital SCUNTHORPE
Dr. Robert W. Johnson, Consultant Anaesthetist, Bristol Royal Infirmary, BRISTOL
Dr Ruth M. Jones, Dept. of Anaesthesia, Addenbrookes Hospital, PO Box 93, Addenbrookes Hospital, CAMBRIDGE
Dr. Gareth Kessell, Dept. of Anaesthesia, South Cleveland Hospital, Marton Road, MIDDLESBROUGH
Dr Manmohan Singh Kokri, Consultant Anaesthetist, South Cleveland Hospital, Middlesbrough
Dr. Chandra M. Kumar, Consultant Anaesthetist, South Cleveland Hospital, Marton Road, MIDDLESBROUGH
Dr Eva Marie Lang, Dept. of Anaesthesia, Luton & Dunstable Hospital, Lewsey Road, LUTON
Dr. Morag Lauckner, Consultant Anaesthetist, North Staffs Hospital Trust, 41 Sneyd Avenue, NEWCASTLE UNDER LYME
Dr. Jonathan Lord, Dept. of Anaesthesia, Moorfields Eye Hospital, City Road, LONDON
Dr. Anne Marczak, Hollybush Cottage, Hollybush Lane, Oaken, WOLVERHAMPTON
Dr Stephen J. Mather, Sir Humphry Davy Dept. of Anaesthesia, Bristol Royal Infirmary, Marlborough Street, BRISTOL
Dr. Elamma Mathew, Dept. of Anaesthesia, Pinderfields Hospital, Aberford Road, WAKEFIELD, WEST YORKS
Mr Bartley J McNeela, Consultant Ophthalmologist, North Riding Infirmary, MIDDLESBROUGH
Dr. Mani Mehta, Dept. of Anaesthesia, South Cleveland Hospital, Marton Road, MIDDLESBROUGH
Dr. Brian Milne, Consultant Anaesthetist, Doncaster Royal Infirmary, Armthorpe Road, DONCASTER
Dr Georgios Moutsianos, 2 New Heath close, Wolverhampton, WV11 1XX
Dr Tom Neal, Consultant Anaesthetist, Royal orthopaedic Hospital, 15 Greenhill Road, Moseley, BIRMINGHAM
Dr. Pinakin Patel, Dept. of Anaesthesia, Royal National Orthopaedic Hospital, STANMORE, MIDDLESEX
Dr. Virginia Penning Rowsell, Bristol Royal Infirmary, BRISTOL
Dr. John Prosser, 32 Albany Terrace, WORCESTER
Dr. Anthony P. Rubin, 126 Harley Street, LONDON
Dr. John Sale, Dept. of Anaesthesia, Stoke mandeville Hospital, One Acre, Peters Lane, Princes Risborough, BUCKS
Dr. S.J. Seddon, Dept. of Anaesthesia, City General Hospital, Newcastle Road, STOKE ON TRENT
Dr. R. Sharawi, Dept. of Anaesthesia, Scunthorpe General Hospital, The Generals,, Vicarage Lane, GRASBY
Dr. Zahid Sheikh, 2 Doe Park, Cliffton Moor, YORK
Mr David Smerdon, Consultant Ophthalmologist, North Riding Infirmary, Newport Road, MIDDLESBROUGH
De Sean Tighe, Consultant Anaesthetists, Countess of Chester Hospital, Liverpool Road, CHESTER
Dr Anthony Christopher Wainwright, Consultant Anaesthetist, Ashton Cottage, Kewlake Lane, Cadnam,, SOUTHAMPTON
Dr. L.M. Walton, Dept. of Anaesthesia, Ninewells Hospital, DUNDEE
Dr. A.O.B. Williamson, Dept. of Anaesthesia, Walsgrave Hospital, 9 Clarence Road, Four Oaks, SUTTONCOLDFIELD
Dr Sean Williamson, consultant Anaesthetist, South Cleveland Hospital, MIDDLESBROUGH TS4 3BW

Moorfields Eye Hospital

Sub-Tenon-The ophthalmic local anaesthetic for the new millennium

Friday 9 July 1999

This one day course will be held in the Clinical Tutorial Complex at Moorfields Eye Hospital.

The course is suitable for anaesthetists and ophthalmologists interested in learning about sub-tenon local anaesthesia and will cover:

Applied anatomy, Equipment, Technique, Recognition and management of complications, Live video demonstrations of the technique

Course organiser: Dr Jonathan Lord FRCA, Consultant Anaesthetist

Course fee: Ł155 (to include lunch and refreshments)

To obtain an application form please contact:

Postgraduate Medical Education Centre

Moorfields Eye Hospital,

City Road,

London EC1V 2PD

Telephone:0171-566 2222 (direct line) or 0171-253 3411 ext 2248, Fax: 0171-566 2223

E-mail: courses@moorfields.org.uk

Rather than use the traditional two-thirds/one-third entry location on the inferior orbit rim ("T", Figure 1), I now routinely inject transcutaneously much further to the temporal side, at the junction of the lateral and inferior orbit rims and close to the bony orbit rim as palpated through the skin prior to injection ("M", Figure 1). The rationale for going transcutaneously is to get around the tense orbicularis tone often present in the inferior eyelid, or the problems created when there is a narrow palpebral fissure and wide lateral canthal fold.

I do a preblock transconjunctival injection of local anesthetic diluted ten times with sterile balanced salt solution which renders the transcutaneous injection to follow, totally painless (Figure 2).

It is imperative that the globe be in primary position at the time of the retro/peri-bulbar block; maximum depth of penetration from the orbit rim should never exceed 31 mm (l 1/4 inches). Fine sharp disposable needles provide the best tactile discrimination and potential for total patient comfort during the block procedure. In all cases the axial length measurement of the globe is carefully noted; in the presence of high myopia periconal block may be more prudent than intraconal, or general anaesthesia may be the method of choice.

Having chosen the exact point of injection on the skin surface, the needle is advanced in a sagittal plane with ten degree upward inflection from the transverse plane. The needle at first invaginates the skin while being directed safely between the globe and lateral orbit wall, very soon penetrates the skin and can then be advanced to the depth of the globe equator before being redirected according to whether one is doing an intracone (Figure 3), or pericone block.

This modified entry position provides safer access to the Orbit as there is more physical space here compared with the traditional entry point (Figure 1). In addition the modified technique avoids possible needle damage to the inferior rectus and inferior oblique muscles and to the motor nerve supply to the inferior oblique (Figure 4).

The forthcoming Inaugural BOAS Conference has attracted many international and national speakers (see advert below). Prof. L Strunin, President of the Royal College of Anaesthetists and Prof. J Jay, President of the Royal College of Ophthalmologists have kindly agreed to inaugurate the BOAS conference. The other notable surprise for the attending delegates would be Dr Robert Hustead of USA. We are eagerly looking forward to his participation in the conference.