Sir,

We were interested in Goldsmith et al's comments on our recent paper.1 We are aware that subtenons anaesthesia is used for VR surgery;2 however, to achieve a rate of 87%, under local anaesthesia, is certainly impressive. The authors are not clear on their own use of sedation. In some units nearly all patients are sedated, and in others it is rarely used. We have tailored our use to measured patient satisfaction outcomes performed over the last 5 years,3, 4 and clearly have a lower threshold for their use than Goldsmith et al. This may be because we have access to an experienced anaesthetist for our VR lists.

The Royal College of Ophthalmologists 2004 guidelines on cataract surgery do not specify the necessity of anaesthetist presence where blunt needle subtenons anaesthesia is required, such anaesthetic cover is recommended where sharp needle anaesthesia and/or sedation is required.5 Arguably in VR surgery anaesthetic cover is more important given the longer and more unpredictable nature of the surgery.

We note with interest Goldsmith et al's comment that grouping all retinopexy patients may bias the results. However, our previous work showed that the laser and cryopexy were more important determinants of discomfort during vitrectomy than other aspects of the surgery, and so these were analysed as one group.2