The concept of “open” and “closed” intraocular surgery is discussed particularly with respect to ocular anesthesia. While topical anesthesia is possible for closed surgery of limited duration and manipulation such as phacoemulcification, in cases of open intraocular surgery (nuclear expression cataract surgery, penetrating keratoplasty, trabeculectomy) a good sensory and motor block and control of the orbicularis by block or speculum is very important to avoid positive vitreous pressure and its complications. We highlight the importance of administering additional anesthesia when converting from topical anesthesia phacoemulsification to nuclear expression to try to prevent positive vitreous pressure and vitreous loss.
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