At the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024), Dr. Rosario Gómez de Liaño (Spain) took the stage for the Leonard Apt Lecture on Pediatric Ophthalmology Subspecialty Day. With a wealth of experience and a flair for the practical, she dove into the world of topical anesthesia (TA) for strabismus surgery, offering up pro tips that had the audience scribbling notes faster than you can say “no more needles.”
When you hear the name Leonard Apt—the annual lecture series namesake—it’s more than just a nod to ophthalmology history, it’s a reminder of one of the true trailblazers in the field. Apt wasn’t just your average doctor; “he was the first full-time academic pediatric ophthalmologist practitioner in North America and probably worldwide,” noted Dr. Gómez de Liaño during her lecture.
Leonard Apt’s legacy is as vast as it is influential. From pioneering povidone-iodine as a topical antimicrobial for the eyes—a method still in use today—to devising clever diagnostic tools like the Apt test, which helps determine the origin of blood in a newborn’s stool, he left an indelible mark on both pediatrics and ophthalmology. “He was a pioneer, an innovator, and he was a big philanthropist for pediatric ophthalmology,” highlighted Dr. Gómez de Liaño.
This year’s Leonard Apt awardee is no stranger to making waves in the world of pediatric ophthalmology. Dr. Gómez de Liaño, a powerhouse in her field, has earned the honor. But let’s be real—her accomplishments read like a highlight reel of excellence. Not only is she the current president of both the European Strabismological Association and the International Strabismological Association, she has also published 128 articles and 40 book chapters, and has traveled to 11 countries as a keynote lecturer.
In today’s session, Dr. Gómez de Liaño took a deep dive into her vast expertise in TA for strabismus surgery. She shared her hard-earned insights in the field, bringing a powerful mix of precision and innovation to the table.
Topical anesthesia 101
After paying tribute to Leonard Apt, Dr. Gómez de Liaño began by clearing the air on TA, saying, “I would like to clarify the meaning of topical anesthesia,” before diving into the specifics. So here’s the deal: TA is simple, surface-level stuff—think drops, not needles.
But then there’s assisted topical anesthesia, which sounds fancy, but it’s just when an anesthetist steps in to add a little sedation. It’s controlled and participatory sedation administered preoperatively via IV or oral medication. The patient is still conscious, though relaxed, similar to what happens during cataract surgery.
And finally, let’s bust a common misconception—subtenon anesthesia. It’s a learning curve savior, and great for rescuing tricky cases when things get a bit more painful than expected. But as Dr. Gómez de Liaño reminded us, that’s not topical anesthesia.
The case for topical anesthesia
When it comes to strabismus surgery, the debate between topical and general anesthesia (GA) is a tale of two very different approaches. GA has long been the go-to, and for good reason—after all, when you’re working with little kids (or squirmy adults), it’s easier to keep everyone calm and still. Plus, as Dr. Gómez de Liaño pointed out, “Certain steps of the surgery could be painful,” so being knocked out makes things simpler for both patient and surgeon.
But here’s the twist—times are changing. “In my hospital, three out of four of my surgical patients today are adults,” Dr. Gómez de Liaño explained. “And not only that, the average age of our adult clinic is increasing.” The average age of her adult clinic patients has jumped from 41 in 2000 to 62 currently. With an aging population comes the question: Is general anesthesia really necessary for everyone?
Enter topical anesthesia. This approach, according to Dr. Gómez de Liaño, is well-tolerated, reduces pre-op anxiety (especially in elderly patients), and comes with some serious perks. It allows for intraoperative adjustments and cuts down on recovery time and costs.
Topical anesthesia pearls
When it comes to mastering TA for strabismus surgery, Dr. Gómez de Liaño is all about precision—and a bit of a perfectionist when it comes to those all-important anesthetic drops. The magic starts with a cocktail of eye drops. “One drop of tetracaine…then you put in the betadine, and then the brimonidine,” she instructed. “Then use a sponge of lidocaine because we don’t want too much anesthesia on the cornea.”
What about anesthetic gels? Dr. Gómez de Liaño is not a fan because although gels may penetrate deeper, they’re also more toxic. She prefers to keep the anesthesia focused only on the surgical area.
Her final pearls of wisdom? Make sure you’re collaborating with someone experienced in topical anesthesia before going all in. Start small—just a muscle or two—and slowly work your way up. Have the patient seated during surgery and postsurgery recovery. Use adjustable sutures as they’re easier, less painful and have greater capacity for modification. And remember that you can convert to subtenon anesthesia, should the occasion arise.
As Dr. Gómez de Liaño wrapped up her lecture, she couldn’t resist a little detour into some Madrid nostalgia. Flashing an image on the screen, she proudly pointed out a statue in front of her beloved Universidad Complutense de Madrid. “It’s called the Torch Carrier,” she said, clearly fond of the monument. The statue shows a dying man passing a torch—the symbol of knowledge—to a young rider on horseback, representing the transmission of wisdom through generations.
With a grin, Dr. Gómez de Liaño added, “Although, the torch was stolen in this case.” And with that, she tied it all back to her concluding message. “I hope I could transmit today, at least for the younger ones, some of my message, and that you can follow and transmit it to the next generation.” Just like the Torch Carrier—minus the stolen flame, of course.
Editor’s Note: Reporting for this story took place during the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024) from 18-21 October in Chicago, Illinois, USA.
