Once a rarely used subset of medical treatments, protein therapeutics have increased dramatically in number and frequency of use since the introduction of the first recombinant protein therapeutic--human insulin--25 years ago. Protein therapeutics already have a significant role in almost every field of medicine, but this role is still only in its infancy. This article overviews some of the key characteristics of protein therapeutics, summarizes the more than 130 protein therapeutics used currently and suggests a new classification of these proteins according to their pharmacological action.

Protein therapeutics: a summary and pharmacological classification

BACKGROUND:Melatonin has anxiolytic and potential analgesic effects. In this study, we assessed the effects of melatonin premedication on pain, anxiety, intraocular pressure (IOP), and operative conditions during cataract surgery under topical analgesia.METHODS:Forty patients undergoing cataract sur

Melatonin provides anxiolysis, enhances analgesia, decreases intraocular pressure, and promotes better operating conditions during cataract surgery under topical anesthesia.

A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine

Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery.

Objectives To evaluate and compare levels of patient discomfort and perioperative complications during phacoemulsification and implantation of a foldable intraocular lens under topical lidocaine hydrochloride and retrobulbar anesthesia in patients with cataract who also had exfoliation syndrome, uveitis, posterior synechia, phacodonesis, or previous intraocular surgery. Design A prospective, randomized, controlled trial was carried out at 2 institutions. Participants A total of 476 eyes of 476 patients with various well-established risk factors fulfilled the inclusion criteria. In 238 eyes, phacoemulsification was performed under retrobulbar anesthesia, while the other 238 eyes received topical anesthesia. Interventions All patients underwent temporal clear corneal phacoemulsification and implantation of a foldable intraocular lens. Patients under retrobulbar anesthesia received a single injection (3.5-5.5 mL) of a combination of 0.75% bupivacaine hydrochloride, 2% lidocaine, and hyaluronidase into the retrobulbar space. Patients in the topical anesthesia group received a minimum of 5 doses (approximately 40 µL per dose) of 2% topical lidocaine. No intracameral injection of any anesthetic was given. Main Outcome Measures The number of complications and adverse events. The intraoperative conditions were judged by the surgeon (P.C.J. or F.K.J.), and a 10-point visual analog scale was used immediately after surgery to assess each patient's overall severity of intraoperative pain. Results The overall intraoperative complication rate was 1.9% for capsular tear, 3.8% for zonular tear, 1.5% for vitreous loss, and 1.0% for iris prolapse. Apart from the incidence of vitreous loss, which was significantly ( P = .041) lower in the topical anesthesia group, no statistically significant differences in intraoperative and early postoperative complications were found between the groups. A supplemental posterior sub-Tenon space injection was required in 1.3% of the topical anesthesia group and in 0.8% of the retrobulbar anesthesia group. Chemosis (2.5%), subconjunctival hemorrhage (1.7%), and periorbital hematoma (0.8%) were seen only in the retrobulbar anesthesia group. The mean + SE pain scores estimated by the patients were 0.84 + 1.30 in the topical anesthesia group and 0.73 + 1.50 in the retrobulbar anesthesia group ( P = .41). Patient preference for topical anesthesia (91%) appeared to be significantly ( P = .01) higher than for retrobulbar anesthesia (62%). The surgeons found anesthesia-related intraoperative difficulty to be slightly lower in the retrobulbar anesthesia group (8%) than in the topical anesthesia group (14%). Conclusions Surgery-related complications and patient discomfort were similar for the 2 methods of anesthesia. Topical anesthesia is justified as a means of improving safety without causing discomfort to the patient even in complicated cases of cataract surgery.

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A comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery.

A comparison of topical and retrobulbar anesthesia for cataract surgery.

Purpose: To evaluate and compare the efficacy of topical versus retrobulbar anesthesia for cataract surgery performed by a surgeon newly converting to the topical technique. Setting: Department of Ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Methods: Ninety patients were prospectively assigned by permuted block restricted randomization to receive topical (Group 1; n=45) or retrobulbar (Group 2; n=45) anesthesia. Group 1 received topical bupivacaine 0.75% and intravenous midazolam and fentanyl for anesthesia. Group 2 received intravenous methohexital followed by retrobulbar block with an equal mixture of lidocaine 2% and bupivacaine 0.75% plus hyaluronidase 150 units. A visual pain analog scale was used to assess the degree of pain during anesthesia administration and surgery and postoperatively. The degree to which eye movement, touch, and light caused patient discomfort was assessed. Intraoperative conditions and complications were recorded. Results: Intraoperative operating conditions were significantly better in Group 2 ( P P Conclusion: Cataract surgery was safely performed by a surgeon converting to topical anesthesia. After a distinct learning curve, the procedure was performed with minimal patient discomfort. Surgical training and patient preparation are the key to safe use of topical anesthesia.

Samuel T. Shomaker

Papers

A comparison of topical and retrobulbar anesthesia for cataract surgery.

Prospective evaluation of topical versus retrobulbar anesthesia: A converting surgeon's experience