Anaesthesia for Eye-surgery <ul><li>Dr.Shailendra.V.L. </li></ul><ul><li>Specialist in Anaesthesia </li></ul><ul><li>Al Bu...
Introduction <ul><li>Technological improvements  </li></ul><ul><li>Improved surgical techniques </li></ul><ul><li>Improved...
Ophthalmic Surgery <ul><li>Extra ocular surgery- strabismus correction </li></ul><ul><li>Intra ocular surgery- cataract wi...
Anaesthesia requirements for ophthalmic surgery <ul><li>Immobile eye </li></ul><ul><li>Uncongested eye </li></ul><ul><li>...
Physiology of intra ocular pressure <ul><li>INTRA-OCULAR PRESSURE  DETERMINANTS: </li></ul><ul><li>Factors exerting outwar...
Intra-ocular pressure <ul><li>Aqueous humour </li></ul><ul><li>Vitreous humour </li></ul><ul><li>Blood within the eye </li...
Aqueous humour dynamics <ul><li>  Ultrafiltration of plasma by ciliary epithelium </li></ul><ul><li> </li></ul><ul><li>  ...
Drugs acting on AH mechanics <ul><li>   production: </li></ul><ul><ul><li>Acetozolamide (carbonic anhydrase inhibitor) </...
Choroidal blood volume effecting AH mechanics <ul><li>Systemic blood pressure: </li></ul><ul><ul><li>Choroidal capillaries...
Vitreous Humour <ul><li>Fine unstable gel consisting of water & fine supporting structure </li></ul><ul><li>Volume & press...
Extra-ocular muscle tone <ul><li>Tone controlled by the mid-brain </li></ul><ul><li>GA  ↓ muscle tone & there by ↓ IOP </l...
Pharmacological modifications of IOP <ul><li>Pre anaesthetic Medication: </li></ul><ul><ul><li>IV diazepam & midazolam  ↓ ...
Pharmacological modifications of IOP <ul><li>Inhalational agents effect IOP by: </li></ul><ul><ul><li>Central action on mi...
Pharmacological modifications of IOP <ul><li>Neuro-muscular blockers: </li></ul><ul><ul><li>Succinylcholine-  ↑ IOP by 10 ...
Oculo-cardiac reflex <ul><li>Trigemino-vagal reflex </li></ul><ul><li>Bradycardia, nodal rhythm, ectopic beats, ventricula...
Oculo cardiac reflex <ul><li>Afferent pathway Efferent pathway </li></ul><ul><li>      </li></ul><ul><li>Short & long ci...
Treatment of OCR <ul><li>Ask surgeon to stop all the manipulations </li></ul><ul><li>Intravenous Atropine 15 micro grams /...
Systemic effects of ophthalmic medications <ul><li>Eye drops are readily absorbed through hyperemic, incised conjunctiva c...
Anaesthetic management of elective intra ocular surgery <ul><li>Goals of general anaesthesia: </li></ul><ul><ul><li>Immobi...
Common Ocular surgeries <ul><li>Cataract  surgeries </li></ul><ul><li>Lid surgeries </li></ul><ul><li>Conjuctival surgerie...
Anaesthetic management of elective intra-ocular surgery <ul><li>Pre-medication:  use of anxiolytics </li></ul><ul><li>Indu...
Anaesthesia for perforating eye injury <ul><li>Problems:  Full stomach patient    Perforated eye  </li></ul><ul><li>Plan: ...
Anaesthesia for special ocular surgeries <ul><li>Glaucoma: </li></ul><ul><ul><li>Anti-cholinesterase eye drops used in  tr...
Anaesthesia for special ocular procedures <ul><li>Retinal detachment surgery: </li></ul><ul><ul><li>Oculo-cardiac reflex c...
Anaesthesia for special ocular surgeries <ul><li>Intra-vitreous gas injection: </li></ul><ul><ul><li>Intra-vitreous inject...
Anaesthesia for special ocular procedures <ul><li>Vitrectomy: </li></ul><ul><ul><li>Closed intra-ocular procedure </li></u...
Ophthalmic procedures in children  <ul><li>Naso-lacrimal duct probing / syringing </li></ul><ul><li>Examination under anae...
Naso-lacrimal duct probing <ul><li>Done to open up the duct </li></ul><ul><li>Trachea to be intubated & throat packed to p...
Examination under GA <ul><li>Very common procedure </li></ul><ul><li>Done to examine in detail the eyes </li></ul><ul><li>...
IOP measurement in children <ul><li>General anaesthesia with ketamine must be avoided as IOP will be raised with ketamine ...
Strabismus surgery <ul><li>Incidence of OCR very high </li></ul><ul><li>Careful monitoring  </li></ul><ul><li>Should be an...
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Anaesthesia For Eye Surgery

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Anesthesia for Eye surgeries

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  1. 1. Anaesthesia for Eye-surgery <ul><li>Dr.Shailendra.V.L. </li></ul><ul><li>Specialist in Anaesthesia </li></ul><ul><li>Al Bukariya general hospital </li></ul><ul><li>Saudi Arabia. </li></ul>
  2. 2. Introduction <ul><li>Technological improvements </li></ul><ul><li>Improved surgical techniques </li></ul><ul><li>Improved techniques in anaesthesia </li></ul><ul><li>Better understanding of the physiology </li></ul>
  3. 3. Ophthalmic Surgery <ul><li>Extra ocular surgery- strabismus correction </li></ul><ul><li>Intra ocular surgery- cataract with IOL </li></ul><ul><li>Mixed - drainage operations for glaucoma </li></ul>
  4. 4. Anaesthesia requirements for ophthalmic surgery <ul><li>Immobile eye </li></ul><ul><li>Uncongested eye </li></ul><ul><li> Intra ocular pressure: </li></ul><ul><ul><li>to minimize the danger of expulsion of intra ocular contents </li></ul></ul><ul><li>Smooth recovery </li></ul><ul><li>Avoidance of PONV </li></ul>
  5. 5. Physiology of intra ocular pressure <ul><li>INTRA-OCULAR PRESSURE DETERMINANTS: </li></ul><ul><li>Factors exerting outward pressure </li></ul><ul><li>Factors exerting inward pressure </li></ul>
  6. 6. Intra-ocular pressure <ul><li>Aqueous humour </li></ul><ul><li>Vitreous humour </li></ul><ul><li>Blood within the eye </li></ul><ul><li>Scleral compliance </li></ul><ul><li>Extra-ocular muscle tone </li></ul>
  7. 7. Aqueous humour dynamics <ul><li> Ultrafiltration of plasma by ciliary epithelium </li></ul><ul><li> </li></ul><ul><li> Formation of A H in ciliary process </li></ul><ul><li> </li></ul><ul><li> A H circulate around Iris </li></ul><ul><li> via pupil </li></ul><ul><li> Anterior chamber </li></ul><ul><li> </li></ul><ul><li> Canal of Schelmn </li></ul><ul><li> </li></ul><ul><li> Trabecular spaces of Fontana </li></ul><ul><li> drains through </li></ul><ul><li>Episleral venous system </li></ul>
  8. 8. Drugs acting on AH mechanics <ul><li> production: </li></ul><ul><ul><li>Acetozolamide (carbonic anhydrase inhibitor) </li></ul></ul><ul><ul><li>Beta blockers </li></ul></ul><ul><li>Improve drainage: </li></ul><ul><ul><li>Miotics (by contracting ciliary muscle) </li></ul></ul><ul><ul><li>Mydriatics affects drainage </li></ul></ul>
  9. 9. Choroidal blood volume effecting AH mechanics <ul><li>Systemic blood pressure: </li></ul><ul><ul><li>Choroidal capillaries auto-regulatory function </li></ul></ul><ul><ul><li>↑ in Blood pressure causes transient ↑in IOP </li></ul></ul><ul><li>Venous pressure: </li></ul><ul><ul><li>↑ in CVP causes acute ↑in IOP </li></ul></ul><ul><ul><li>Coughing/ vomiting/ valsalva/ straining on tube all ↑ IOP </li></ul></ul><ul><ul><li>↑ PaCO2 causes ↑ IOP by choroidal vasodilatation </li></ul></ul>
  10. 10. Vitreous Humour <ul><li>Fine unstable gel consisting of water & fine supporting structure </li></ul><ul><li>Volume & pressure reduced by Mannitol which is a dehydrating agent & there by ↓ IOP </li></ul>
  11. 11. Extra-ocular muscle tone <ul><li>Tone controlled by the mid-brain </li></ul><ul><li>GA ↓ muscle tone & there by ↓ IOP </li></ul><ul><li>Gentle, constant pressure on the eye promotes aqueous humour flow & ↓ IOP </li></ul>
  12. 12. Pharmacological modifications of IOP <ul><li>Pre anaesthetic Medication: </li></ul><ul><ul><li>IV diazepam & midazolam ↓ IOP </li></ul></ul><ul><ul><li>Parental atropine has no effect on IOP </li></ul></ul><ul><li>Intravenous anaesthetics: </li></ul><ul><ul><li>Only ketamine ↑ IOP </li></ul></ul><ul><ul><li>All other agents ↓ IOP </li></ul></ul>
  13. 13. Pharmacological modifications of IOP <ul><li>Inhalational agents effect IOP by: </li></ul><ul><ul><li>Central action on mid-brain </li></ul></ul><ul><ul><li>Alteration of aqueous humour </li></ul></ul><ul><ul><li>↓ extra-ocular muscle tone </li></ul></ul><ul><li>Dose dependent reduction in IOP </li></ul>
  14. 14. Pharmacological modifications of IOP <ul><li>Neuro-muscular blockers: </li></ul><ul><ul><li>Succinylcholine- ↑ IOP by 10 mmHg by 1 minute & lasts for 10 minutes </li></ul></ul><ul><ul><li>↑ IOP due to tonic action of drug on Felderstruktur striated extra0ocular muscle </li></ul></ul><ul><li>Laryngoscopy & Intubation: </li></ul><ul><ul><li>↑ IOP </li></ul></ul>
  15. 15. Oculo-cardiac reflex <ul><li>Trigemino-vagal reflex </li></ul><ul><li>Bradycardia, nodal rhythm, ectopic beats, ventricular fibrillation, asystole </li></ul><ul><li>Eyeball pressure, traction of extra-ocular muscles, orbital haematoma, ocular trauma & eye pain, eyelid traction </li></ul><ul><li>Can occur even from enucleated orbit </li></ul>
  16. 16. Oculo cardiac reflex <ul><li>Afferent pathway Efferent pathway </li></ul><ul><li>   </li></ul><ul><li>Short & long ciliary nerves Nucleus of vagus </li></ul><ul><li>   </li></ul><ul><li>Ciliary ganglion Cardiac branches </li></ul><ul><li>via  ophthalmic  </li></ul><ul><li>division of trigeminal nerve Bradycardia </li></ul><ul><li>  </li></ul><ul><li>Trigeminal sensory nucleus </li></ul>
  17. 17. Treatment of OCR <ul><li>Ask surgeon to stop all the manipulations </li></ul><ul><li>Intravenous Atropine 15 micro grams / Kg or intravenous Glycopyrrolate 7.5 micro grams / Kg </li></ul>
  18. 18. Systemic effects of ophthalmic medications <ul><li>Eye drops are readily absorbed through hyperemic, incised conjunctiva causing systemic effects </li></ul><ul><li>Phenyleohrine(2.5%) cause hypertension, arrhythmia and headache </li></ul><ul><li>Adrenaline(2%) cause hypertension & arrhythmias </li></ul><ul><li>Timolol (B-blocker) causes bradycardia, hypotension & exacerbation of asthma </li></ul><ul><li>Phospoline iodide is a lone acting anti-cholinesterase used in glaucoma prolongs suxamethonium induced muscle relaxation </li></ul>
  19. 19. Anaesthetic management of elective intra ocular surgery <ul><li>Goals of general anaesthesia: </li></ul><ul><ul><li>Immobile eye </li></ul></ul><ul><ul><li>Stable IOP </li></ul></ul><ul><ul><li>Minimize bleeding </li></ul></ul><ul><ul><li>Avoidance of Oculo-cardiac reflex </li></ul></ul><ul><ul><li>Smooth induction </li></ul></ul><ul><ul><li>Smooth emergence </li></ul></ul><ul><ul><li>Minimal post-operative nausea & vomiting </li></ul></ul>
  20. 20. Common Ocular surgeries <ul><li>Cataract surgeries </li></ul><ul><li>Lid surgeries </li></ul><ul><li>Conjuctival surgeries </li></ul><ul><li>Strabismus surgeries </li></ul><ul><li>Penetrating eye injuries </li></ul><ul><li>Vitreous surgeries </li></ul><ul><li>Retinal surgeries </li></ul><ul><li>Laser surgeries </li></ul>
  21. 21. Anaesthetic management of elective intra-ocular surgery <ul><li>Pre-medication: use of anxiolytics </li></ul><ul><li>Induction: Thiopentone + Suxamethonium </li></ul><ul><li>Intubation: Smooth laryngoscopy & intubation </li></ul><ul><li>Maintenance: O2 + N20 + Isoflurane/Halothane IPPV with Non-depolarizing muscle relaxant </li></ul><ul><li>Reversal: Neostigmine + Atropine , extubate in deeper planes </li></ul><ul><li>Problems encountered: Dark room </li></ul><ul><li> Face inaccessible </li></ul>
  22. 22. Anaesthesia for perforating eye injury <ul><li>Problems: Full stomach patient Perforated eye </li></ul><ul><li>Plan: Preoxygenation </li></ul><ul><li>Induction: Thiopentone + Atracurium </li></ul><ul><li> Sellick’s maneuver </li></ul><ul><li> Smooth laryngoscopy & intubation </li></ul><ul><li>Controlled ventilation </li></ul><ul><li>Smooth extubation </li></ul><ul><li> Use of Ondansetron to prevent PONV </li></ul>
  23. 23. Anaesthesia for special ocular surgeries <ul><li>Glaucoma: </li></ul><ul><ul><li>Anti-cholinesterase eye drops used in treatment can potentiate effects of succinylcholine precipitating bradycardia & arrhythmias </li></ul></ul><ul><ul><li>To ↓ IOP 20% mannitol is used, hence it is better to catheterize these patients </li></ul></ul>
  24. 24. Anaesthesia for special ocular procedures <ul><li>Retinal detachment surgery: </li></ul><ul><ul><li>Oculo-cardiac reflex commonly observed </li></ul></ul><ul><ul><li>Essentially extra-ocular surgery </li></ul></ul><ul><ul><li>Synthetic silicone strap used to produce scleral indentation </li></ul></ul>
  25. 25. Anaesthesia for special ocular surgeries <ul><li>Intra-vitreous gas injection: </li></ul><ul><ul><li>Intra-vitreous injection of inert gas of low diffusibility such as Sulphar hexafluride (SF6) or Carbon octofluride (C3F6) </li></ul></ul><ul><ul><li>Gas is absorbed over 10 days and the bubble keeps the sclera intact </li></ul></ul><ul><ul><li>N20 must be avoided as the bubble size increases upto three times </li></ul></ul>
  26. 26. Anaesthesia for special ocular procedures <ul><li>Vitrectomy: </li></ul><ul><ul><li>Closed intra-ocular procedure </li></ul></ul><ul><ul><li>Surgeon controls IOP manometrically by water tight infusion </li></ul></ul>
  27. 27. Ophthalmic procedures in children <ul><li>Naso-lacrimal duct probing / syringing </li></ul><ul><li>Examination under anaesthesia </li></ul><ul><li>Intra-ocular pressure measurement </li></ul><ul><li>Strabismus correction </li></ul>
  28. 28. Naso-lacrimal duct probing <ul><li>Done to open up the duct </li></ul><ul><li>Trachea to be intubated & throat packed to prevent the fluid entering trachea </li></ul>
  29. 29. Examination under GA <ul><li>Very common procedure </li></ul><ul><li>Done to examine in detail the eyes </li></ul><ul><li>Total intra-venous anaesthesia technique should be used as the procedure is short </li></ul>
  30. 30. IOP measurement in children <ul><li>General anaesthesia with ketamine must be avoided as IOP will be raised with ketamine </li></ul><ul><li>General anaesthesia with non-depolarizing relaxants preferred </li></ul><ul><li>It is advisable to wait for 10 minutes to take measurements after intubation for the IOP to stabilize </li></ul>
  31. 31. Strabismus surgery <ul><li>Incidence of OCR very high </li></ul><ul><li>Careful monitoring </li></ul><ul><li>Should be anticipated and treated with Atropine / Glycopyrrolate </li></ul><ul><li>Avoidance of PONV by the use of Ondansetrone </li></ul>
  32. 32. Thank you
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