August 2009




challenging cataract cases

Various topical anesthesia combinations


Dilation protocol for Topical Anesthesia with lidocaine gel mixture in use at OCLI

In a glass cup, place: One tube of lidocaine 2% (5 ml) Five (5) drops each of: Phenylephrine 10% Tropicamide 1% Cyclopentolate 2% Zymar (gatifloxacin 0.3%), 1 drop every 5 minutes, times 4 Acular (ketorolac tromethamine 0.5%), 1 drop every 5 minutes, times 4 Stir all ingredients with a tongue blade

Draw up dilation in a 30cc syringe with fluid dispenser attached. Next, withdraw 0.5 cc into each tuberculin syringe, placing cap onto tip. Lastly, label each syringe with “Dilation solution with Xylocaine jelly 2%”.

The above mixture should make about five syringes.

Reprinted with permission from Stanley Berke, M.D.

Recipe for “epi-Shugarcaine,” first proposed by the late Joel Shugar, M.D., courtesy of Thomas L. Beardsley, M.D.

The recipe in whole cc quantities is: 9 cc BSS Plus 3 cc 4% preservative-free lidocaine and 4 cc 1:1000 preservative-free, bisulfite free epinephrine. Plain BSS may be safely substituted for the BSS Plus. This ends up as buffered 0.75% lidocaine and 1:4000 epinephrine.

A smaller quantity can be made by drawing up 1 cc of 4% preservative lidocaine into 3 cc of BSS Plus, which makes 4 cc of plain “Shugarcaine.” Discard 1 cc of this mixture and draw up 1 cc of preservative-free epinephrine.

This yields 4 cc of the “epi- Shugarcaine.”


Shugar, JK. Use of epinephrine for IFIS prophylaxis. J Cataract Refract Surg 2006; 32:1074-5.

Shugar, JK. Intracameral Epinephrine for IFIS Prophylaxis. Cat & Refract Surg Today 2006; 6:9: 72-4.

Shugar, JK Prophylaxis for IFIS. J Cataract Refract Surg 2007; 33: 942-3

Anesthesia protocol, courtesy of Lisa B. Arbisser, M.D.

1.All patients have saline lock 2.In O.R., after monitor hookup, majority of patients receive 1mg Versed (midazolam) (range 0.5mg to 2mg) 3.During prep and drape, if patient is tense and squeezes lids then give 125mg Alfenta (alfentanil) and 10mg Diprivan (propofol).

(Alfenta is diluted 8 times so final concentration is 2cc=125mg or else volume is too small to push without having to follow with saline) 4.Intra-op, if patient feels pressure or at surgeon’s request ie. due to high myope or post PPV, give 125mg Alfenta which may be repeated x 1. If patient is still uncomfortable add 10mg Diprivan with the Alfenta in same syringe (“pina colada”)

Dr. Arbisser said this combination was created by her anesthesiologist, Sang Sapthevie, M.D., and she has been using it for more than 20 years.

Various topical anesthesia combinations Various topical anesthesia combinations
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