Anesthesia for ophthalmic surgery and complications Q & A

1. S
ANESTHESIA FOR
OPHTHALMIC SURGERY
AND COMPLICATIONS
DR AFTAB

2. What are your concerns as an
anaesthesiologist in ophthalmic
surgery?

3. Concerns in Ophthalmic
Surgery
S Akinesia
S Analgesia
S Minimal Bleeding
S Awareness of drug interactions
S Regulation of intraocular pressure
S Prevention of oculocardiac reflex
S Management of oculocardiac reflex
S Control of intraocular gas expansion
S Smooth emergence

4. What are the challenges in this
particular patient?

5. Concerns in Ophthalmic Surgery (RD)
S Extremes of age and associated co-morbidities
are particular concerns especially in geriatric
patients.
S Any drug or manoeuvre that raises intra-
ocular pressure ( lOP ) can cause extrusion of
the vitreous humor and loss of vision.

6. Concerns in Ophthalmic Surgery (RD)
S Retina surgeries are often prolonged. Involve
combination of procedure including scleral
buckle, vitrectomy, laser, cryotherapy and
injection of intravitreal gas.
S Requires extensive manipulation of eye.
S Concerns regarding use of perflourcarbons.

7. S
Open eye surgical procedures ?

8. S Cataract extraction
S Corneal laceration repair
S Corneal transplant ( Penetrating
keratoplasty )
S Peripheral iridectomy
S Foreign body removal
S Ruptured globe repair
S Secondary IOL implantation
S Trabeculectomy
S Vitrectomy

9. S
What is normal IntraocuIar
Pressure?

10. Physiology of IntraocuIar
Pressure
S The eye is hollow
sphere with a rigid
wall.
S Intraocular pressure
12—20 mm Hg
S If the contents of the
sphere increases, the
intraocular pressure
rises.

11. S
Relation between IOP and
anatomy of eye ?

12. S The eye can be considered a hollow sphere
with a rigid wall.
S The intraocular pressure helps to
maintain the shape and therefore optical
properties of eye

13. S
What happens to IOP during
open eye surgery??

14. S When globe is open during open eye
surgery or after traumatic
perforation, intraocular pressure
approaches atmospheric pressure.
S Any factor that increases IOP will
tend to decrease intraocular volume
by causing drainage of aqueous or
extrusion of vitrous humor.

15. What are the effects of cardiac
and respiratory variables on
intraocular pressure?

16. Physiology of IntraocuIar Pressure

17. What are the anaesthetic events
that can affect intraocular
pressure?

18. S Face Mask Ventilation
S Laryngoscopy
S Intubation
S Airway obstruction
S Coughing
S Trendelenburg position
S Drugs
S Hypoxia
S Hypercapnia

19. S
What are the effect of anaesthetic
Drugs on intraocuIar Pressure?

20. Effect of anesthetic agents on
Intraocular Pressure (lOP)

21. Most anaesthetic drugs either lower or
have no effect on intraocular pressure

22. What is the effect of
succinylcholine on IOP ?

23. Muscle relaxants
S Succinylcholine increases intraocular pressure by
5—10 mm Hg for 5—10 minutes principally
through prolonged contracture of extraocular
muscles
S Non-depolarizing muscle relaxants do not increase
intraocular pressure

24. S
Systemic Effect Of
Ophthalmic Drugs ?

25. SYSTEMIC EFFECT OF
OPHTHALMIC DRUGS
S Topical ophthalmic drugs can be
absorbed through conjunctiva, or they
drain through nasolacrimal duct and be
absorbed through nasal mucosa.
S Usage of topical medications can have
implications for anesthesiologist.

26. SYSTEMIC EFFECTS OF
OPHTHALMIC DRUGS
Atropine:
S Used to produce mydriasis and
cycloplegia.
S The 1% solution contains 0.2 to 0.5 mg of
atropine per drop.
S Systemic reactions include tachycardia,
flushing, thirst, dry skin, and agitation
S Contraindicated in closed-angle glaucoma

28. S
What are the different techniques of
anaesthesia for Ophthalmic Surgery?

29. TECHNIQUES OF
ANAESTHESIA
S Regional anesthesia
S Local anesthesia (+/- MAC )
S General anesthesia

30. S
Types of regional anesthesia
for ophthalmic surgery?

31. S Retrobulbar block
S Peribulbar block
S Sub Tenon block
S Facial nerve block

32. What are the indications and benefits of
General, Regional, Local anaesthesia?

33. General
Anaesthesia
Patient
refusal
Children /
movement
disorders
Major / lengthy
procedure
Inability to lie
still / flat
Local
Anaesthesia
No Physiological
disturbance , PONV
Economic, Day care
No risk of
hemorrhage,
brainstem anesthesia,
optic nerve damage or
globe perforation
Regional
Anaesthesia
Good
akinesia and
anaesthesia
Minimal
effect on
IOP
Minimal
equipment
required

34. What are the limitations of general,
regional and local anaesthesia?

35. General Anaesthesia
Eye surgery necessitates
positioning the
anesthesiologist away from
the patient’s airway (Shared
Airway)
Extremes of age
Pediatric patients :
associated congenital
disorders (eg: rubella
syndrome, Down
syndrome)
Co-morbidity in elderly:
esp. Diabetes, hypertension
and coronary artery
disease
Ophthalmic drugs
Local Anaesthesia
Complications, Allergy
to drug
Skill of anaesthetist
Shortness of breath
on lying down,
chronic cough
Parkinson’s disease
Eye Trauma
Topical Anaesthesia
Lack of eye
akinesis
Treatment of
uncomplicated
cataracts only

36. S
How will you decide the type
of anesthesia to be given?

37. Choice of anesthesia depends on
SURGICAL CHOICE:
- Need of complete akinesis
- Duration and type of surgery
- Extent of surgery
PATIENT FACTOR:
-Age and patients cooperation for procedure
- Associated medical conditions

38. What are our main concern about
preop evaluation and history
regarding ophthalmic surgery?

39. PREOPERATIVE
EVALUATION
S Extremes of Age
S Associated medical conditions: diabetes,
hypertension, and atherosclerosis
S Associated congenital disorders
S The anesthesiologists goal is to prepare the
patient to present an acceptable risk at surgery.
S Acceptable risk is determined by the medical care
team with the informed consent of the patient.

40. HISTORY
S Previous hospitalizations and surgical
procedures
S Allergies and drug sensitivities
S Current list of medications
S Other medical conditions that could influence
anaesthetic management include dementia,
deafness, language difficulty, restless legs
syndrome, obstructive sleep apnoea, tremors,
dizziness, and claustrophobia

41. What are the different investigations
required for ophthalmic surgery?

42. INVESTIGATIONS
S Urea nitrogen: Signs or symptoms of renal
decompensation.
S Serum glucose: Polydipsia, polyuria, or weight
loss.
S Hematocrit/hemoglobin: History of bleeding, poor
oral intake, fatigue, decreased exercise tolerance, or
tachycardia.
S TLC & DLC: infection, h/O fever.

43. INVESTIGATIONS
S Electrocardiogram: New chest pain, decreased
exercise tolerance, palpitations, near-syncope,
fatigue, or dyspnea. Tachycardia, bradycardia, or
irregular pulse on examination.
S Serum electrolytes: History of severe vomiting or
diarrhea, poor oral intake, changes in diuretic
management, or arrhythmia.

44. How you will premedicate these
patient for general anaesthesia?

45. GENERAL
ANAESTHESIA
PREMEDICATION
S An effective antiemetic should be used to decrease
PONV.
S Opioids or NSAIDs can be used for effective
analgesia.
S Benzodiazepines are given.

46. Pretreatment regimens to control
the sympathetic response to
tracheal intubation:
S I.V. Lidocaine (1.5 mg/kg)
S I.V. Remifentanil(0.5 to 1 µg/kg)
S I.V. Fentanyl (1 to 3 µg/kg) 3 to 5 minutes
before induction.
S I.V. Alfentanil (20 µg/kg)
S Oral Clonidine (5 µg/kg) 2 hours before
induction

47. How you will induce these patient?

48. GENERALANESTHESIA
INDUCTION
S The choice of induction technique for eye surgery
usually depends more on
S the patient’s medical problems
S the patient’s eye disease
S the type of surgery contemplated.

49. GENERALANESTHESIA
S Intravenous agents: Propofol , Thiopental and
Etomidate
S Volatile Agents: can be used, minimal PONV
S Coughing during intubation: avoided by a deep
level of anesthesia and profound paralysis
S The IOP response to laryngoscopy and
endotracheal intubation can be blunted
S LMA: Less changes in IOP

50. S
How will you manage
airway in these patients?

51. AIRWAY MANAGEMENT
S Shared airway
S For measurement of IOP- maintenance of spontaneous
respiration via a facemask as intubation will raise the
intraocular pressure.
S Examination under anaesthesia (EUA)-spontaneous
respiration through a reinforced laryngeal mask airway
(LMA)
S It has the advantages of reduced coughing at the end of
the surgery and controlled ventilation with the use of
muscle relaxants is possible.

52. AIRWAY MANAGEMENT
S Intraocular surgery requires a still eye with
low IOP and the airway is best managed by
intubation with paralysis and controlled
ventilation.

53. S
Types of airway devices
?

54. S Supraglottic Airway Device
S RAE
S Reinforced metallic PVC tube
S Armored tube

55. S
Maintenance ?

56. MAINTENANCE
S Isoflurane or sevoflurane may be preferable.
S Total intravenous anaesthesia (TIVA) with propofol
has advantages in reducing the risk of postoperative
nausea and vomiting (PONV) since propofol has
anti-emetic effects.
S Remifentanil can reduce volatile requirements

57. What are the harmful effect of use of
nitrous oxide ?

58. S Increase the risk of PONV
S If nitrous oxide is used for a patient who has had recent
vitreoretinal surgery, or if it is commenced mid procedure,
it can cause a significant rise in IOP with resultant
ischaemic damage.
S Alternatively, if nitrous oxide was used from the start of the
anaesthetic, prior to placement of the gas bubble, it will
diffuse out of the bubble on completion of the anaesthetic,
and the bubble will shrink and risk re-detachment.

59. S
How will you prevent
intraocular gas expansion?

60. Intraocular gas expansion
Prevention:
S Discontinue nitrous 15-20 mins prior to
injection.
S Avoid nitrous oxide 5 days after air and 10 days
after sulfur hexachloride injection.
S In case of perfluoropropane avoid nitrous for
at least a month, or until the bubble is resorbed.

61. S
MONITORING?

62. MONITORING
S Eye surgery necessitates positioning the anesthesiologist
away from the patient’s airway, making pulse oximetry
mandatory for all ophthalmologic procedures.
S Continuous monitoring for breathing-circuit disconnections
or unintentional extubation is also crucial.
S The possibility of kinking and obstruction of the
endotracheal tube can be minimised by using a reinforced
or preformed right-angle endotracheal tube.

63. S The possibility of dysrhythmias caused by
the oculocardiac reflex increases the
importance of constantly scrutinizing the
electrocardiograph.
S Most pediatric surgery, infant body
temperature often rises during ophthalmic
surgeon because of head- to-toe draping and
insignificant body-surface exposure.
S End-tidal CO2 analysis helps differentiate
this from malignant hyperthermia.

64. S
Strategy to prevent
increase in IOP ?

66. S
What are your concerns
while
extubating this patient?

67. GENERALANESTHESIA
EXTUBATION & EMERGENCE
S A smooth emergence from general
anesthesia
S Extubation awake
S Intravenous lidocaine (1.5 mg/kg) prior
to extubation.
S Postoperative pain control
S PONV Control

68. What is oculocardiac reflex?

69. OCULOCARDIAC REFLEX
Caused By:
S Traction on the extraocular muscles (medial rectus)
S Ocular manipulation
S Manual pressure on the globe
The OCR is seen during:
S Eye muscle surgery
S Detached retina repair, Enucleation

70. OCULOCARDIAC REFLEX
The Oculocardiac Reflex(OCR) is manifested by
S Bradycardia
S Bigeminy
S Ectopics
S Nodal rhythm
S Atrioventricular block
S Cardiac arrest

71. S
Pathway of OCR?

72. Oculo-cardiac reflexAfferent pathway Efferent pathway
 
Short & long ciliary nerves Nucleus of vagus
 
Ciliary ganglion Vagus nerve from medulla to
via  ophthalmic heart(S.A NODE)
division of trigeminal nerve
Bradycardia

Trigeminal sensory nucleus 72

73. S
Risk /triggering event of
OCR?

74. OCULOCARDIAC REFLEX
S Preoperative anxiety
S Squint surgery
S Acidosis
S Hypoxia
S Hypercarbia
S Increased vagal tone owing to age

75. S
Management of
OCR?

76. OCULOCARDIAC REFLEX
Management
S Stop stimulation by the surgeon.
S Adequate ventilation & oxygenation
S Atropine (0.02 mg/kg IV)
S Local injection of lidocaine near the eye muscle
S Retrobulbar block
Ensure
S Depth of general anesthesia
S Normocapnia, Surgical manipulation is gentle.

77. What is oculo-respiratory reflex?

78. OCULORESPIRATORY REFLEX
S May cause shallow breathing, reduced respiratory rate
and even full respiratory arrest.
S Trigemino-vagal reflex- connection exists between the
trigeminal sensory nucleus and the pneumotactic
centre in the pons and medullary respiratory centre.
S Commonly seen in strabismus surgery
S Atropine has no effect.

79. What is oculoemetic reflex?

80. OCULOEMETIC
REFLEX
S It is likely responsible for the high incidence of
vomiting after squint surgery (60-90%).
S Trigemino-vagal reflex with traction on the
extraocular muscles stimulating the afferent arc.
S Antiemetics may reduce the incidence, a regional
block technique provides the best prophylaxis

81. S
Measures to prevent
PONV?

82. S PONV management (multimodal approach)
S Adequate hydration
S Total intravenous anesthesia (TIVA)
S Avoidance of nitrous oxide are effective in
prevention of PONV.

83. S
What are the complications of
Regional anaesthesia?

84. COMPLICATIONS OF
REGIONALANAESTHESIA
S Retrobulbar hemorrhage
S Stimulation of OC reflex
S Puncture of posterior globe
S IV injection of LA
S Brainstem anesthesia - (delayed onset LOC and
resp. depression)
S Optic nerve trauma

85. What is brainstem anaesthesia?

86. BRAINSTEM ANAESTHESIA
S Brain stem injection of local
anesthetics during
retrobulbar block
S Respiratory failure
S Hypotension and tachycardia
S Hypertension and
tachycardia depending on
whether the parasympathetic
or sympathetic nerves are
blocked,

87. BRAINSTEM ANAESTHESIA
S The onset of symptoms -delayed 2 to 40
minutes after injection.
Management:
S Early and prompt treatment
S 100% oxygen
S maintenance of vital signs
S tracheal intubation and controlled ventilation

88. What are the concerns
related to geriatric patients?

89. Concerns in geriatric age.
S Wide disparity between physiologic and chronologic age.
S Pre operative organ function reserve is unknown.
S Multiple acute and chronic co-morbid condition are typical.
S Emergency procedures are associated with increased
morbidity and mortality.
S Complex medication regimes.
S Advanced age related pharmacodynamics and
pharmacokinetics.

90. Take Home message
S Ophthalmic surgery are associated with
unique range of complications viz
occulocardiac reflex, brainstem anesthesia,
loss of occular contents etc.
S These surgeries are common among elderly
patients and this age group is likely to be
associated with co-morbidities.
S Proper pre-op evaluation should be carried as
per ASA guidelines.

91. S Fast track anaesthesia should be safe choice
for ophthalmic surgery in elderly patients.
S Prevention of coughing and bucking during
ophthalmic procedure is of utmost importance.
S Prevention of PONV is also significant part of
ophthlamic anaesthesia.

92. THANK YOU