Anesthesiologist role in eye surgery care

Anesthesiologists role in ophtalmic
surgery with special emphasis on
day/office surgery
Il ruolo dell’anestesista nella chirurgia oftalmologica
con speciale riguardo alla day surgery
Dott.Claudio Melloni
Libero professionista
Spec.in Anestesia e Rianimazione

Anesthesiologist role and services :
• Safety:
– screening of patients
– Administration of anesthesia
– Monitoring of vital signs
– Prevention of complications
– Treatment of complications
– Safe discharge
• Cooperation
• Administrative
• Financial
• helping to develop and review policies
• equipment-purchasing
• drug formulary advice.

Value added services
• helping to develop and review policies
• ensuring earlier discharges
• offering equipment-purchasing
• drug formulary advice

For O.R.:
• performing
anesthesia/analgesia/resusci
tation...............

Anesthesiologist added value....
• make sure the surgery schedule starts on time;
• decrease turnover time;
• decrease cancellations by using pre-op phone calls
and questionnaires;
• spearhead proper anti-PONV efforts, including pre-op
risk assessments and interventions;
• use such PONV-sparing anesthesia techniques
• provide pain prophylaxis,
• administer antibiotics in a timely manner
• employ anti-venous embolism strategies.

Beyond O.R.
• Equipment purchases,evaluation,maintenance :a separate contribution?
• •Drug formulary:streamline the number of medication choices in a common
sense and cost-effective manner. For example, is there really a need for 5
different non-depolarizing muscle relaxants and 5 different narcotics?
• Agree on practices /surgical load
• Participating in lectures and seminars in the surgeons' offices takes some of
the fear out of scheduling surgery and can put patients and families at ease
when they see another familiar face on the day of surgery. It's a great
educational and PR opportunity.
• Sit on committees. Your anesthesia team should be eager participants on
your committees, even if they are not owners or partners. This promotes a
collaborative team feeling, and their input will be clinically vital and
important to the overall health and strategic planning for the facility.
• Help formulate policies. Review and revision of policies and procedures is a
critical area that necessitates anesthesia department participation,
particularly when there is an impending certification inspection.
• Explain anesthesia billing. Your anesthesia team should designate someone
— beyond billing personnel — who is adept and comfortable handling
potentially tricky discussions about the bill for anesthesia services. This
person must understand the subtleties and unique qualities of anesthesia
billing, and be flexible and patient when trying to explain and resolve billing
issues.

Anaesthetic Requirement
• Safety
• Akinesia
• Analgesia
• Minimal bleeding
• Avoidance or obtundation of oculocardiac reflex
• Prevention of rise in I.O.P
• Awareness of drug interaction
• Smooth emergence (no vomiting, coughing, retching)
• Pupil should be dilated for IO surgery (except
• glaucoma)
• Anaesthesia for Eye Surgery

TOPICs:discussion
• Preop testing
• Monitoring
• Arrythmias detection
• Accessories
• Discharge
• Some cases...
• Patient evaluation:
– Fitness ....Anticoag...........
• phenylephrine

Preop .Lab?
• Most cataracts are performed on older
individuals with correspondingly high systemic
and ocular comorbidities.
• routine preoperative medical testing will detect
medical conditions?
• it is questionable whether these conditions
should preclude individuals from cataract surgery
or change their perioperative management.

Br J Anaesth. 2013 Jun;110(6):926-39. Effectiveness of non-cardiac preoperative
testing in non-cardiac elective surgery: a systematic review.
Johansson T, Fritsch G, Flamm M, Hansbauer B, Bachofner N, Mann E, Bock M,
Sönnichsen AC.
• Elective surgery is usually preceded by preoperative diagnostics to minimize risk.
• The results are assumed to elicit preventive measures or even cancellation of surgery.
• Moreover, physicians perform preoperative tests as a baseline to detect subsequent changes.
• This systematic review aims to explore whether preoperative testing leads to changes in management or reduces
perioperative mortality or morbidity in unselected patients undergoing elective, non-cardiac surgery.
• We systematically seardatabases from January 2001 to February 2011 for studies investigating the relationship
between preoperative diagnostics and perioperative outcome.
• methodology was based on the manual of the Ludwig Boltzmann Institute for Health Technology Assessment, the
Scottish Intercollegiate Guidelines Network (SIGN) handbook, and the PRISMA statement for reporting systematic
reviews.
• 101/25 281 publications retrieved met our inclusion criteria. Three test grid studies used a randomized controlled
design and 98 studies used an observational design.
• The test grid studies show that in cataract surgery and ambulatory
surgery, there are no significant differences between
patients with indicated preoperative testing and no
testing regarding perioperative outcome. The observational studies do not
provide valid evidence that preoperative testing is beneficial in healthy adults undergoing non-cardiac surgery.
There is no evidence derived from high-quality studies that supports routine preoperative testing in healthy adults
undergoing non-cardiac surgery. Testing according to pathological findings in a patient's medical history or physical
examination seems justified, although the evidence is scarce. High-quality studies, especially large randomized
controlled trials, are needed to explore the effectiveness of indicated preoperative testin

Am Fam Physician. 2013 Mar 15;87(6):414-8.
Preoperative testing before noncardiac surgery: guidelines and
recommendations.
Feely MA, Collins CS, Daniels PR, Kebede EB, Jatoi A, Mauck KF.
• Preoperative testing (e.g., chest radiography, electrocardiography, laboratory testing, urinalysis) is often performed
before surgical procedures. These investigations can be helpful to stratify risk, direct anesthetic choices, and guide
postoperative management, but often are obtained because of protocol rather than medical necessity. The decision to
order preoperative tests should be guided by the patient's clinical history, comorbidities, and physical examination
findings. Patients with signs or symptoms of active cardiovascular disease should be evaluated with appropriate testing,
regardless of their preoperative status. Electrocardiography is recommended for patients undergoing high-risk surgery
and those undergoing intermediate-risk surgery who have additional risk factors. Patients undergoing low-risk surgery
do not require electrocardiography. Chest radiography is reasonable for patients at risk of postoperative pulmonary
complications if the results would change perioperative management. Preoperative urinalysis is recommended for
patients undergoing invasive urologic procedures and those undergoing implantation of foreign material. Electrolyte and
creatinine testing should be performed in patients with underlying chronic disease and those taking medications that
predispose them to electrolyte abnormalities or renal failure. Random glucose testing should be performed in patients
at high risk of undiagnosed diabetes mellitus. In patients with diagnosed diabetes, A1C testing is recommended only if
the result would change perioperative management. A complete blood count is indicated for patients with diseases that
increase the risk of anemia or patients in whom significant perioperative blood loss is anticipated. Coagulation studies
are reserved for patients with a history of bleeding or medical conditions that predispose them to bleeding, and for
those taking anticoagulants. Patients in their usual state of health who
are undergoing cataract surgery do not require
preoperative testing.

Anesthesiology. 2013 May;118(5):1038-45. Global health
implications of preanesthesia medical examination for
ophthalmic surgery.
Phillips MB, Bendel RE, Crook JE, Diehl NN.
• Author information
• Abstract
• BACKGROUND:
• Preanesthesia medical examination is a common procedure performed before ophthalmic surgery. The frequency and characteristics of new medical issues and unstable medical
conditions revealed by ophthalmic preanesthesia medical examination are unknown. We conducted a prospective observational study to estimate the proportion of patients with new
medical issues and unstable medical conditions discovered during ophthalmic preanesthesia medical examination. Secondary aims were to characterize abnormal findings and assess
surgical delay and adverse perioperative events, in relation to findings.
• METHODS:
• Patients having preanesthesia medical examination, before ophthalmic surgery, were enrolled over a period of 2 years. A review was conducted of historical, physical examination, and
test findings from the preanesthesia medical examination.
• RESULTS:
• From review of medical records of 530 patients, 100 patients (19%; 95% CI, 16-23%) were reported by providers to have abnormal conditions requiring further medical evaluation. Of
these, 12 (12%) had surgery delayed. Retrospective review of examination results identified an additional 114 patients with abnormal findings for a total of 214 (40%; 95% CI, 36-45%)
patients. Among the 214 patients, primary findings were cardiovascular (139, 26%), endocrine (26, 5%), and renal (24, 5%). Complications occurred in 49 (9%; 95% CI, 7-12%) patients
within 1 month of surgery.
• CONCLUSIONS:
• Ophthalmic preanesthesia medical examination frequently detects
new medical issues or unstable existing conditions, which do not
typically alter conduct of perioperative procedures or outcomes.
However, these conditions are relevant to long-term patient health
and should be conveyed to primary care physicians for further
evaluation

Cochrane Database Syst Rev. 2009.
Routine preoperative medical testing for cataract surgery.
Keay L, Lindsley K, Tielsch J, Katz J, Schein O.
OBJECTIVES:
• (1) To investigate the evidence for reductions in adverse events through preoperative medical testing,
and (2) to estimate the average cost of performing routine medical testing.
• SEARCH STRATEGY:
• We searched CENTRAL, MEDLINE, EMBASE and LILACS using no date or language restrictions. We used
reference lists and the Science Citation Index to search for additional studies.
• SELECTION CRITERIA:
• We included randomized clinical trials in which routine preoperative medical testing was compared to
no preoperative or selective preoperative testing prior to age-related cataract surgery.
• DATA COLLECTION AND ANALYSIS:
• Two review authors independently assessed abstracts to identify possible trials for inclusion. For each
included study, two review authors independently documented study characteristics, extracted data,
and assessed methodological quality.
• MAIN RESULTS:
• The three randomized clinical trials included in this review reported results for 21,531 total cataract
surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and
three deaths. Of the 707 medical adverse events reported, 353 occurred in the pretesting group and
354 occurred in the no testing group. Most events were cardiovascular and occurred during the
intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative
(OR 1.02, 95% CI 0.85 to 1.22) or postoperative medical adverse events (OR 0.96, 95% CI 0.74 to 1.24)
when compared to selective or no testing. Cost savings were evaluated in one study which estimated
the costs to be 2.55 times higher in those with preoperative medical testing compared to those
without preoperative medical testing. There was no difference in cancellation of surgery between
those with preoperative medical testing and those with no or limited preoperative testing, reported by
two studies.

AUTHORS' CONCLUSIONS
This review has shown that routine pre-operative
testing does not increase the safety of
cataract surgery.
Alternatives to routine preoperative medical testing have been proposed,
including self-administered health questionnaires, which could substitute for
health provider histories and physical examinations. Such avenues may lead to
cost-effective means of identifying those at increased risk of medical adverse
events due to cataract surgery. However, despite the rare occurrence, adverse
medical events precipitated by cataract surgery remain a concern because of
the large number of elderly patients with multiple medical comorbidities who
have cataract surgery in various settings. The studies summarized in this review
should assist recommendations for the standard of care of cataract surgery, at
least in developed settings. Unfortunately, in developing country settings,
medical history questionnaires would be useless to screen for risk since few
people have ever been to a physician, let alone been diagnosed with any
chronic disease

Patient selection and assessment

Back up monitors ;minilab?Hemocue
glucose

Competitive edge
• In an economy that continues to bring decreased caseloads and the
potential for reimbursement uncertainty and upheaval, anesthesia groups
that can provide value-added staffing flexibility could make or break your
bottom line.
• This means more than just avoiding a revolving door of unfamiliar
providers that make your surgeons anxious. Your providers must share
your strategic goals and understand your corporate and community
culture. They must provide anesthesia delivery models that strive to put
the right patients in the right facilities at the right time, in order to provide
the safest and best outcomes in the most cost-effective manner. If a
subsidy or stipend is requested or contracted, then it should be done
transparently and properly incentivized.
• It's a scary environment out there for anesthesia professionals and
facilities. An attitude of collaboration and cooperation designed to add
value to all we do is a recipe for success for ourselves and the patients and
communities we serve.
•

standards
•Same standards as
per O.R
•Continuous
anesthetic
surveillance.

Requisites
• Any unit providing sedation techniques should have the
following
• readily available :
• Suitably trained individual to monitor the patient
– • ECG
• • Non-invasive blood pressure monitoring
• • Pulse oximetry
• etCO2 …..
• Further requirements include:
• • The patient should be sedated on a trolley or operating table that can
be tipped head-down
• • Oxygen should be readily available
• • Full resuscitation equipment should be available
– Laryngoscope,LMA’s,suction,ventilator,defibrillator etc:drugs(lipids?)…………..
• • The staff looking after the patient should be trained and regularly
updated in resuscitation techniques.

Training in CPR/ALS
• Certificates for the anesthesiologist(s) and
surgeons!
• Certificates for BLS(D) for nurses
• ricertifications needed…………

Oxygen application by a nasal probe prevents hypoxia but not
rebreathing of carbon dioxide in patients undergoing eye surgery under
local anaesthesia.Schlager A, Luger TJ. : Br J Ophthalmol. 2000
Apr;84(4):399-402

New equipment to prevent carbon dioxide rebreathing during eye
surgery under retrobulbar anaesthesia.Schlager A, Staud H
Br J Ophthalmol. 1999 Oct;83(10):1131-4

EtCO2 Divided Sampling Cannula with
Simultaneous Oxygen Delivery
•Features
•Design incorporates a permanent barrier in
the facepiece and a dual tubing set.
•Benefits
•Allows End Tidal sampling from one nare and
oxygen or gaseous analgesia delivery to the
other. Delivers accurate, quantitative reading.
Eliminates dilution of gases
•Unique, innovative configuration, no
modification required. Integrity of the
procedure is certain
•Same quantitative readings seen during
general anesthesia. Safe, simple, cost-effective
monitoring of EtCO2
•Curved, tapered nasal prongs. Facepiece
anatomically curved to fit upper lip
•Better anatomical fit for long term use. No
irritating flap or ridge
•Soft, lightweight clear material •Does not interfere with patient observation
•Full range of sizes available •Versatile. Compatible with all systems and
modalities prescribed
•Dual Port Salter Eyes® •Safety apertures to reduce possible
occlusions
•22 mm I.D. X 6 mm O.D. anesthesia circuit
oxygen adapter
•Allows easy connection to anesthesia “Y”
fitting or other large bore oxygen source

EtCO2 Divided Sampling Cannula with
Simultaneous Oxygen Delivery

Oral-Trac® Oral/Nasal EtCO2 Divided
Sampling Cannula with Oxygen
Delivery
With Unique Oral Sampling TRUNK
Accurate End Tidal Sampling with Simultaneous Oxygen
Delivery. The Salter Oral-Trac® oral/nasal cannula features
dual EtCO2 sampling through both nasal prong and a unique
oral sampling trunk. This allows accurate patient monitoring
even during spontaneous breathing or with mouth
breathers. Simultaneously oxygen can be delivered through
a separate tube and nasal prong. A permanent barrier in the
facepiece separates the oxygen delivery and EtCO2 sampling
pathways to permit an undiluted gas sample. Salter-Eyes®,
safety apertures (a Salter exclusive) are incorporated

Cannula brevettata a 2 vie per somministrazione di
ossigeno e campionamento della CO2 espirata
setto che separa
le due vie
Curva della CO2 espirata(etCO2)

Oral-Trac® Oral/Nasal EtCO2 Divided Sampling Cannula
with Oxygen Delivery
Features
•Oral/Nasal End Tidal CO2 sampling
•Benefits
Delivers accurate, quantitative waveforms
•Additional oral sampling through TRUNK •Provides more accurate EtCO2 sampling during
spontaneous nose or mouth breathing
•Design incorporates a permanent barrier in the
facepiece and a dual tubing set
•Allows End Tidal sampling from one naris and
TRUNK while oxygen or gaseous analgesia is
delivered to the other naris
•Oral sampling TRUNK is adjustable to fit
individual patient’s facial contours
•Ensures optimal placement for maximum
sampling efficiency
•A malleable, semi-rigid wire is encased in the
body of the Oral-Trac®TRUNK
•The TRUNK can be easily hand contoured in
front of the oral cavity to provide accurate
readings
•Malleable, semi-rigid wire is non-ferrous •Permits use in MRI suite
•Dual port Salter Eyes® in nasal prongs •Safety apertures help to reduce possible
occlusions
•Facepiece anatomically curved to fit upper lip •Comfortable, secure fit. No irritating flaps or
ridges

Accessories
• For the comfort of patients:
• Mattresses for the operating table
• Leg rest…
• Head rest..
• Warming blankets
• Forced air warming blankets..

Evaluation of recovery after
sedation(+/-analgesia):1
• “Street fitness”=home discharge
• Blood pressure stable :± 20% basal
• Oxygen saturation:± 20% basal
• Pulse:± 20% basal
• Mental state; ±20% (attention,concentration test,etc..)
• Equilibrium;walking unassisted
• Ability to dress
• Ability to tolerate oral fluids
• Absence of bleeding ,nausea(significant)
• Voiding?(mannitol…..)
• Scores:Aldrete…..

Evaluation of recovery after
sedation(+/-analgesia):2
• Easy arousability, full orientation ,
• Ability to maintain and protect the
• airway,
• Stable vital signs for at least one hour,
• The ability to call for help if necessary,
• Ability to unassisted ambulation,
• Ability to tolerate oral fluids,
• Ability to void,
• Absence of significant pain or bleeding
• Adult companion

SOME PARADIGMATIC CASES
….IMPORTANCE OF A LITTLE EXTRA
TIME…………

200
180
160
140
120
100
80
60
40
20
0
RB,72,kg 75,cm 176,ASA
3(hypert,reumat,light diab)
5 15 25 35
PAS
PAD
Fc
SaO2
Clonid 150 microgr+
Diaz 5 mg p.os
Desat!!!vasoconstricti
on.

MLR,87a,85kg,170 cm,Asa 3(IPERTENS,PROT.AORT,bav1)
200
180
160
140
120
100
80
60
40
20
0
bas
10
20
30
40
50
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
Pas
Pad
FC
etCO2
DIAZ 5+2
CLONID 150
MIDAZ 2 FENT25 MIDAZ 0,5
FENT 25
SEDUTA
ATTESA
Csi Danmeter

M.S,53 y,85 kg,180 cm,ASA 1(24/3/11)
180
160
140
120
100
80
60
40
20
0
bas 5 10 15 20 25 30
PAS
PAD
FC
Clonidine 150 mcg+diaz 5 mg

C.O.,60 yr,66 kg,163 cm,ASA 3(Rh arthrt,ipertens,ipoacus)
200
180
160
140
120
100
80
60
40
20
0
bas 5 10 15 20
PAS
PAD
FC

DeG. L.,71,77,160,Asa 2(ipertens)
200
180
160
140
120
100
80
60
40
20
0
bas 5 10 15 20 25 30 35 40
PAS
PAD
FC

Sergio A.l 62 a,107 kg,199
cm,muratore!,ASA 1.
160
140
120
100
80
60
40
20
0
bas 5 10 15 20 25 30
PAS
PAD
FC
Diaz 8
mg

300
250
200
150
100
50
0
Mannitol 18% 250
MIDAZ 2 mg
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
PAS
PAD
FC
clonid 150 microg
diaz 5 mg
clonid 150 microgr
Urapidil 100
NTG 5/ mg250 ml
sitting
supine
saline 250 ml
sitting,ok
V. M.80 yr,70 kg,164 cm ,ASA1(13/4/11)

PP,F,56 a,kg50,cm 160,ASA 1
140
120
100
80
60
40
20
0
Dorme:Ramsey 4 Sveglia!
Atropa 0,5
bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100105110115120125130135140145150155160165170
PAS
Pad
FC
SaO2
etCO2
15.55
15.55 ini op.
Midaz 0,5
Fent 25 +fent 25
Midaz 0,5
+fent 25 +fent 25 Midaz 0,5+midaz 0,5
14.50;clonid 150+diaz
5:si addomenta sulla
popltrona della presala!
Midaz 0,5+fent 12,5
Perfalgan 1000

ZC,87a,kg80,cm 160,ASA3(BPCO asmatif,ipert)
250
200
150
100
50
0
Lidocaine slow infus *cough control
0 5 0 15 20 25 30
PAS
PAD
Fc
SaO2
diaz 5 mg 30 min before.
Clonid 90
microgr
Atropa o,5 mg

PL,83a,44 kg,150 cm,ASA 1,diaz 4 mg premed
20 min before
250
200
150
100
50
0
0 5 10 15 20 25 30 35
PAS
PAD
Fc
SaO2
Midaz 1 mg
Clonidine 90 mg

PREVENTION OF OTHER
COMPLICATIONS

Ko:personal statistics
• Excimer laser:
• 3 vasovagal reactions,1 severe and long lasting:incidence 8-10%
• FAG;
– 1 vasovagal reaction,severe:;phedrine,atropine,fluids,supine 30’,Oxygen:incidence
10%
– 1 allergic reaction;hypotension ,erythema;incidence 5% .
• Avastin;
– Severe hypertension common ;generally no treatment or raraely anxiolysis
– Other
• 1 haemorhage during cheek pithelioma dissection:fluids++
Cataract;
– Arrival hypertension common ----clonidine 150 microgr in premed ,for all(sometime)s
75
– 1 severe pre/ and intraop hypertension:NTG;incidence 0.3%
– 4 arrythmias atropine,lidocaine;sotalol incidence;1%,
– Intraop bardycardia:6 cases :atropine;incidence 2%
– 1 PONV
– 2 postop syncopal reaction:,1 during discharge:fluids,ephedrine;incidence 0.5%
– Need for deep sedation:2 cases 1 during IFIS.

Conclusions:
which are the benefits having an anesthesiologist during the
case?
• Benefits of an expert;
– sedation,analgesia,general anesthesia just in case,
– perioperative medicine(“the internist of the O:R”
• However ... sedation/anakgesia mya increase
complications(nausea,PONV;discharge delay...)
• Treating patient discomfort
• Preventing ortreating complications;pain,arrhytmias,blood
pressure elevations,anxiety....
• Liability of MD vs CRNA,reason to prefer an anesthesiologist
• Weeding out risky patients
• Surgeon only focus is surgery?

conclusion
• Anesthesiologst useful,probably
necessary.........

Key Components of Risk Associated
with Ophthalmic
Anesthesia
Anesthesiology 2006; 105:859

Sedation risk
• Disorientation—head movement
• Restlessness
• If a patient is unable to tolerate a
block…..would he feel better with sedation?

Risk of eye injury during anesthesia
for eye surgery
• Regional anesthesia technique(US??,blunt
cannulas??)
• Education,experience
• Movements,coughing during surgery

Ngozi Imasogie FRCA, David T. Wong MD, Ken Luk BSc, Frances Chung
FRCPC.Elimination of routine testing in patients undergoing
cataract surgery allows substantial savings in laboratory costs. A brief report. CAN J
ANESTH 2003 / 50: 3 / pp 246–248

• Editor:—I read with interest the closed claims analysis “Injury and
• Liability Associated with Monitored Anesthesia Care” by Bhananker et al.1
• and the accompanying editorial opinion by Hug.2 The study indicated that
• more than one in five monitored anesthesia care claims in the database
• occurred with patients undergoing elective eye surgery. It also reiterated
• that the most common causes of patient eye injury and anesthesiologist
• liability linked to ophthalmic anesthesia consisted of complications related
• to the eye block and perioperative patient movement. More than four
• fifths (83%) of ophthalmic anesthesia monitored anesthesia care cases
• associated with inadequate anesthesia and/or patient movement, either
• during the block or intraoperatively, resulted in ocular injury and, presumably,
• poor visual outcome. A previous American Society of Anesthesiologists
• Closed Claims Project, “Eye Injuries Associated with Anesthesia”
• by Gild et al.3 published in the Journal identified 21 cases of blindness
• allegedly the result of intraoperative movement during ophthalmic surgery.
• Movement was the foremost mechanism of injury cited. Five of
• those claims occurred during regional anesthesia and were attributed to
• “restlessness” or coughing during the procedure.
• Regional anesthesia is a vital part of the scope of anesthesia practice.
• Because of its safety and efficacy, it is a preferred option for many
• ophthalmic surgical procedures.4 Aside from intraoperative analgesia and
• akinesia, advantages of conduction anesthesia for ophthalmic surgery
• patients include suppression of the oculocardiac reflex and provision of

• References
• 1. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB:
• Injury and liability associated with monitored anesthesia care: A closed claims
• analysis. ANESTHESIOLOGY 2006; 104:228–34
• 2. Hug CC: MAC should stand for maximum anesthesia caution, not minimal
• anesthesiology care. ANESTHESIOLOGY 2006; 104:221–3
• 3. Gild WM, Posner KL, Caplan RA, Cheney FW: Eye injuries associated with
• anaesthesia: A closed claims analysis. ANESTHESIOLOGY 1992; 76:204–8
• 4. Eke T, Thompson JR: The National Survey of Local Anaesthesia for Ocular
• Surgery: II. Safety profiles of local anaesthesia techniques. Eye 1999; 13:196–204
• 5. Scott IU, McCabe CM, Flynn HW Jr, Lemus DR, SchiffmanMS, Gayer S: Local
• anaesthesia with intravenous sedation for surgical repair of selected open globe
• injuries. Am J Ophthalmol 2002; 134:707–11
• 6. Scott IU, Gayer S, Voo I, Flynn HW Jr, Diniz JR, Venkatraman A: Regional
• anaesthesia with monitored anaesthesia care for surgical repair of selected open
• globe injuries. Ophthalmic Surg Lasers Imaging 2005; 36:122–8
• 7. Grizzard WS, Kirk NM, Pavan PR, AntworthMV, Hammer ME, Roseman RL:
• Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991;
• 98:1011–6
• 8. Hay A, Flynn HW Jr, Hoffman JI, Rivera AH: Needle penetration of the globe
• during retrobulbar and peribulbar injections. Ophthalmology 1991; 98:1017–24
• 9. Duker JS, Belmont JB, Benson WE, Brooks HLJr, Brown GC, Federman JL,
• Fisher DH, Tasman WS: Inadvertent globe perforation during retrobulbar and
• peribulbar anesthesia: Patient characteristics, surgical management, and visual
• outcome. Ophthalmology 1991; 98:519–26
• 10. Gayer S, Cass G: Sub-Tenon techniques should be one option among many
• (letter). ANESTHESIOLOGY 2004; 100:196
• 11. Miller-Meeks MJ, Bergstrom T, Karp KO: Prevalent attitudes regarding
• residency training in ocular anesthesia. Ophthalmology 1994; 101:1353–6

Cataract Patient Whose Eyeball "Exploded" Wins $925K Settlement
Botched anesthesia injection left man with right-eye blindness and pain.
Published:June 30, 2011.Outpatient surgery dec 2012.
• AnesthesiaOphthalmologySafetyNews
• A cataract surgery patient's eyeball exploded when a resident physician mistakenly injected local anesthetic
directly into the man's right eye rather than behind it, according to the patient's lawyer.
•
• The alleged incident, which left the man with permanent damage to his right eye, happened at a West Haven,
Conn., Veterans Affairs hospital in 2007. Earlier this week, the U.S. Department of Veterans Affairs agreed to pay
nearly $1 million to settle a malpractice lawsuit brought by the patient, 60-year-old Army veteran Jose
Goncalves.
•
• According to Mr. Goncalves' lawsuit, the injury occurred when a third-year resident at the hospital incorrectly
administered local anesthesia directly into the patient's eye. She first placed the needle in the wrong spot and
then, failing to realize her mistake, "proceeded to inject so much anesthetic, so quickly, that Jose's eye literally
exploded," Christopher Bernard, attorney for Mr. Goncalves, tells the Connecticut Post. The lawsuit blames the
incident on poor training of the resident.
•
• In addition to losing sight out of his right eye, Mr. Goncalves also suffered "excrutiating pain" after the botched
procedure and "continued to have severe pain for months afterward," says Mr. Bernard. Because of his loss of
vision and depth perception, he is no longer able to continue his previous career as a roofer; he now works in the
maintenance department at a state university.
•
• The VA settled the case just as it was being prepared for trial, agreeing to pay Mr. Goncalves $925,000. The U.S.
attorney's office has declined to comment.
•
• Irene Tsikitas

Risk of eye injury during anesthesia for eye surgery ;data:
• ASA Closed claim .Cheney FW. High-severity injuries associated with regional
anesthesia in the 1990s. American Society of Anesthesiologists Newsletter
2001;65:6– 8.
– 71 permanent disabling injuries among the 308 claims.
– The most common of these (23%) was associated with
nerve blocks of the eye (13 retrobulbar, 3 peribulbar),and
typically the injury entailed loss of vision.
– Second in frequency (21%) were pain-management related claims
involving, for example, neuraxial opiates or neurolytic blocks.
– Third in frequency (20%) were nerve injuries ssociated with neuraxial
and peripheral blocks followed by epidural hematomas (13%).

• In 3 claims, patients were left
unmonitored after retrobulbar
blocks with sedation and developed
respiratory and/or cardiovascular
collapse.

Fatal Cataract Sedation Results in $2.1M Settlement
Patient "inexplicably left alone" and unmonitored before surgery.
• Published: January 24, 2014
• The estate of a cataract patient whose routine sedation was fatally complicated by negligent
monitoring has agreed to a $2.1 million settlement, according to court records.
• Marie Golubski, then 68, was scheduled to undergo cataract surgery on her right eye at the
Pittsburgh-area Associates Surgery Center in June 2010. She was prepped and intravenously
sedated before being "inexplicably left alone."
• During this time her breathing slowed significantly and the medical staff, having neglected to monitor
her vital signs, failed to notice that she had fallen into respiratory and cardiac arrest. Twenty-three
minutes after the IV sedation had been administered, she was
discovered unresponsive and suffering anoxic brain injury, according to court
records. She was transferred to a nearby hospital for resuscitative efforts, but
died 6 days later.
• Ms. Golubski's husband filed suit, citing negligence in failing to monitor her, failing to provide
continuous care and leaving her unattended after sedation. The defendants denied negligence.
According to a case summary, ophthalmic surgeon Daniel Zimmer, MD, and anesthesia provider Brian
Cross, CRNA, each argued that monitoring was the other's responsibility.
• In the August 2013 settlement, however, Dr. Zimmer, Mr. Cross, the surgery center and Dr. Zimmer's
practice settled the case for a total of $2,125,000 in damages.
• Attorneys for Ms. Golubski's estate and the defendants did not immediately return calls seeking
comment.

Anesthesiology 2004; 101:143–52.Injuries Associated with Regional Anesthesia in
the 1980s and 1990s.A Closed Claims Analysis.Lorri A. Lee, Karen L. Posner, Karen B.
Domino, M.P.H.,Robert A. Caplan,Frederick W. Cheney.

Contraindications of local/regional
anesthesia
• Pts unable to cooperate(mental
impairment,dementia,Alzheimer’s)
• Difficult communication(inability to speak the
language,deafness)
• Involuntary movements:Parkinson’s disease..
• Unable to lie flat or still:(CHF,COPD chest up,pillows….)
• Uncontrolled coughing or sneezing:chronic bronchitis…
• Fentanyl
• Severely anxious or claustrophobic: diazepam,midazolam…
• Bilateral surgery
• Prolonged or difficult surgery anticipated
• Preference for GA,wether by the patient or surgeon or the
anesthetist…

Intraocular use of large doses of
phenylephrine
• has been reported to cause severe cardiovascular
compromise and possibly death.
– [2. Van der Spek AF: Cyanosis and cardiovascular depression in a
neonate: Complications of halothane anesthesia or phenylephrine
eyedrops? Can J Ophthalmol 1987; 22: 37-9 Abstract
3. Greher M, Harmann T, Winkler M, Zimpfer M, Crabnor CM:
Hypertension and pulmonary edema associated with subconjunctival
phenylephrine in a 2-month-old child during cataract extraction.
ANESTHESIOLOGY 1998; 88: 1394-6 Full Text
4. Fraunfelder FT, Scafidi AF: Possible adverse effects from topical
ocular 10% phenylephrine. Am J Ophthalmol 1978; 85: 447-
53 Citation
2] [3] [4]

• New York State Guidelines on the Topical Use
of Phenylephrine in the Operating Room
• Anesthesiology - Volume 92, Issue 3 (March
2000) -
• Scott B. Groudine M.D.*, Ingrid Hollinger M.D.
, Jacqueline Jones M.D. , Barbara A. DeBouno
M.D., M.P.H.§

The following is a summary of the guidelines circulated to NYS
hospitals:1)
• 1. The initial dose of phenylephrine for adults should not exceed 0.5 mg
(four drops of a 0.25% solution). This dosage is based on the product insert
(Neo-Synephrine Sanofi, New York, NY) for the intravenous administration of phenylephrine for the
treatment of mild/moderate hypotension. This dosage assumes 100% absorption of the administered
phenylephrine. In children (up to 25 kg), the initial dose should not exceed 20 mug/kg. [25]
2. The minimal amount of phenylephrine needed to achieve vasoconstriction should be administered.
BP and pulse should be closely monitored after phenylephrine is given.
3. The dose of phenylephrine should be administered in a calibrated syringe and should be verified by
a physician.
4. The anesthesiologist should be aware of all medications that are administered to the patient
perioperatively.
5. Mild-to-moderate hypertension resulting from phenylephrine use, in a healthy individual, should be
closely monitored for 10-15 min before antihypertensive medications are given. Severe hypertension,
as well as its adverse effects such as electrocardiographic changes or pulmonary edema, must be
treated immediately. Antihypertensive agents that are direct vasodilators or alpha-receptor
antagonists are appropriate treatments.

Visumidriatic fenilefrina
• Flacone da 10 ml con 50 mg di tropicamide e
1 gr di fenilefrina:1000 mg di fenilefrina ,100
mg /ml se 1 gt è 1/10 di ml,1 gt contiene 10
mg!!!!
• Il prodotto contiene sodio metabisolfito; tale sostanza può
provocare in soggetti sensibili e particolarmente negli
asmatici reazioni di tipo allergico ed attacchi asmatici gravi.
• Questa specialità medicinale contiene sodio etilmercurio
tiosalicilato ( un composto organomercuriale) come
conservante e, quindi, possono verificarsi reazioni di
sensibilizzazione (vedi paragrafo 4.8).

Fenilefrina cloridrato in commercio in
Italia
22 results found for FENILEFRINA-CLORIDRATO (303001)
AIC/EMEA Name Brand
030969012 FENILEFRINA CLOR.*OFT 5ML0,25% ALFA INTES (IND.TER.SPLENDORE)
030969024 FENILEFRINA CLOR.*OFT 10ML0,25 ALFA INTES (IND.TER.SPLENDORE)
030969036 FENILEFRINA CLOR.*OFT 5ML 1% ALFA INTES (IND.TER.SPLENDORE)
030969048 FENILEFRINA CLOR.*OFT 10ML 1% ALFA INTES (IND.TER.SPLENDORE)
030969051 FENILEFRINA CLOR.*OFT 5ML0,25% ALFA INTES (IND.TER.SPLENDORE)
030969063 FENILEFRINA CLOR.*OFT 10ML0,25 ALFA INTES (IND.TER.SPLENDORE)
038070013 NASOMIXIN CM*GTT 15ML 2,5MG/ML TEOFARMA Srl
016308025 RIBEX NASALE*SPRAY 15ML JOHNSON & JOHNSON SpA
011621012 ISONEFRINE*COLL 5ML 10% TUBILUX PHARMA SpA
011621024 ISONEFRINE*POM OFT 5G 10% TUBILUX PHARMA SpA
021953017 OPTISTIN*COLL 10ML 0,12% TUBILUX PHARMA SpA

Fenilefrina bassa concentrazione
0.12% OPTISTIN*COLL 10ML 0,12% TUBILUX PHARMA SpA
=1,2 mg/ml Visadron 0,125% BOEHRINGER INGELHEIM IT.
0,25% FENILEFRINA CLOR.*OFT 5ML0,25% ALFA INTES (IND.TER.SPLENDORE)
=2,5 mg/ml FENILEFRINA CLOR.*OFT 10ML0,25 ALFA INTES (IND.TER.SPLENDORE)
FENILEFRINA CLORID.*0,25% 10ML DYNACREN Lab.Farmaceutico Srl
FENILEFRINA CLOR.*OFT 10ML0,25 C.O.C. FARMACEUTICI Srl
FENILEFRINA CLORID.*0,25% 10ML OGNA GIOVANNI & FIGLI SpA
FENILEFRINA*0,25% 10ML C/NEBUL OGNA GIOVANNI & FIGLI SpA
FENILEFRINA CLORID.*0,25% 10ML A.F.O.M. MEDICAL SpA
NEOSYNEPHRINE*SOLUZ 10ML
0,25%
TEOFARMA Srl
NEOSYNEPHRINE*GTT 15ML 2,5MG/M TEOFARMA Srl

Fenilefrina ad alta concentrazione
1% FENILEFRINA CLOR.*OFT 5ML 1% ALFA INTES (IND.TER.SPLENDORE)
=10 mg/ml FENILEFRINA CLOR.*OFT 10ML 1% ALFA INTES (IND.TER.SPLENDORE)
10% ISONEFRINE*COLL 5ML 10% TUBILUX PHARMA SpA
=100 mg/ml ISONEFRINE*POM OFT 5G 10% TUBILUX PHARMA SpA
MINIMS FENILEFRINA*GTT OFT 10% SMITH & NEPHEW Srl(DIV.SANIT.)

FENILEFRINA:
assumendo che 15 gtt = 1 ml,
Concentrazione % Mg/ml Mg/goccia Microgr/gtt
0.12 1.2 0.08 80
0.25 2,5 0,166 166,66
0.5 5 0,333 333
1 10 0,666 666
10 100 6,66 6660

Phenylephrine usage in hypotension
following spinal anesthesia for C/S
• intermittent bolus (120 μg) or a fixed-rate infusion (120
μg/min) regimen of phenylephrine:total infusion
group received .(1740 (613) versus 964 (454) μg):
– Anesth Analg. 2012 Dec;115(6):1343-50. Phenylephrine infusion versus
bolus regimens during cesarean delivery under spinal anesthesia: a
double-blind randomized clinical trial to assess hemodynamic
changes.Doherty A, Ohashi Y, Downey K, Carvalho JC
• Boletti di 50 microgr alla volta per ipotensione durante
C/s in spinale:
– Anaesthesia. 2012 Dec;67(12):1348-55. Closed-loop double-vasopressor
automated system to treat hypotension during spinal anaesthesia for
caesarean section: a preliminary study.Sia AT, Tan HS, Sng BL.

Dosaggi di fenilefrina
(e.v.)somministrata per ipotensione:
• In un trial clinico recente in pazienti sottoposti a endoarterectomia carotidea il
farmaco sarebbe stato impiegato in boletti da 50 o 100 microgrammi per
ristorare la PA in caso di ipotensione
– Trials. 2013 Feb 14;14:43. Phenylephrine versus ephedrine on cerebral perfusion during
carotid endarterectomy (PEPPER): study protocol for a randomized controlled
trial.Pennekamp CW, Immink RV, Buhre WF, Moll FL, de Borst GJ. ;
dosaggio di 100 microgr è stato scelto per contrastare la sindrome di ipotensione
postperfusione nei trapiantati di fegato (Liver Transpl. 2012 Dec;18(12):1430-9. Epinephrine and
phenylephrine pretreatments for preventing postreperfusion syndrome during adult liver
transplantationRyu HG, Jung CW, Lee HC, Cho YJ.)
• Una recentissima review della fenilefrina nel trattamento e prevenzione della
ipotensione materna e benessere neonatale in ostetricia ha suggerito come
ottimali infusioni tra 25 e 50 microgr/min
– (Anesth Analg. 2012 Feb;114(2):377-90. A review of the impact of phenylephrine
administration on maternal hemodynamics and maternal and neonatal outcomes in women
undergoing cesarean delivery under spinal anesthesia.Habib,AS.

summary of the guidelines circulated to NYS hospitals:2)
• 6. The use of beta blockers and calcium-channel blockers should be
avoided when vasoconstrictive agents such as phenylephrine are used in
the operating room. Case reviews, as well as a review of the medical
literature, suggest that the use of beta blockers, and potentially calcium-channel
blockers, as treatment of hypertension secondary to a
vasoconstrictor may worsen cardiac output and result in pulmonary edema.
• Unfortunately the specific alpha blocking drug phentolamine
is not readily available…………….
7. If a beta blocker is used for the treatment of resulting hypertension,
glucagon may be considered to counteract the loss of cardiac contractility as
well as other standard therapies.
•
• In conclusion, it is hoped that these guidelines will result in more cautious
use of phenylephrine in ENT surgery and alert the anesthesia community to
the potentially lethal dangers of treating alpha-agonist-induced
hypertension with cardiac-depressant therapies.

Haloperidol+dexamethasone
• Eur J Anaesthesiol. 2010 Feb;27(2):192-5.
• Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for
postoperative nausea and vomiting in high-risk day surgery patients: a randomized blinded trial.
• Chaparro LE, Gallo T, Gonzalez NJ, Rivera MF, Peng PW.
– 160 high-risk patients undergoing ambulatory
surgery.(nonsmoking,women ,18 -50 ), cosmetic or
ENT surgery,
– 1.5 mg of haloperidol 30’ before end of surgery + 8
mg of dexamethasone preop reduces the cumulative
incidence of postoperative vomiting at 6 and 24 h
postoperatively

Combination antiemetic therapy in paediatric strabismus
surgery :ondansetron and dexamethasone
author Drugs(microgr/kg) POV incidence %
Splinter ,Anesthesiology 1998 Ondansetron 150 28
Ondansetron 50 +dexamethasone 150 9
Splinter ,Paediatr
Anaesth.2001
Dexamethasone 150 23
Dexamethasone 150+ondansetron 50 5
Bhardway J.Pediatr Ophtalmol
Strabismus 2004
Placebo 64,5
Ondansetron 150 33,3
Ondansetron 150+dexamethasone 200 10

Anaesthesia
To be read in conjunction with The Royal College of
Ophthalmologists/Royal College of Anaesthetists guidelines
‘Local anaesthesia for intraocular surgery’
6.1 Background
• There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade. The
• use of local anaesthesia (LA) has risen from around 20% in 19911 to over 75% in 19962a and 86% in 19973
• and the use of sedation with LA has fallen from 45% in 1991 to around 6% in 1996.2a
• Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques.5,6,7
• Most patients presenting for cataract surgery are elderly and have pre-existing medical problems. A local
• anaesthetic is preferable, particularly for small incision surgery, as it will usually be associated with lower
• morbidity and it causes least disruption to daily routine.
• The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that serious systemic adverse
• events may occur with all types of LA, but are rare (3.4 per 10,000), although a degree of under-reporting was
• suspected.2b These events are not reduced by routine pre-operative investigations.8,9
• No LA technique is totally free of the risk of a serious systemic adverse event. This is not necessarily a
• consequence of a particular local anaesthetic technique. Other factors include pre-existing medical conditions,
• anxiety, pain or stress reaction to the operation.
• 6.2 Organisation of ophthalmic anaesthetic services
• • Multi-professional teamwork is the key to day case cataract surgery and is essential at every stage of the
• process
• • Every unit should identify an anaesthetist with overall responsibility for ophthalmic services
• • Meticulous recording of important data is a necessary prerequisite for good communication, safe practice,
• clinical governance and audit
• 6.3 Recommending the type of anaesthesia
• The surgical assessment should include recommendations on the type of anaesthetic indicated for the
• individual patient. This will depend on psychological aspects, the particular features of the globe and orbit, and
• the anticipated difficulty of the surgery.
• 6.3.1 Pre-operative investigations
• In a randomised survey of over 19,000 cataract operations, routine pre-operative medical
• investigations did not reduce the incidence of peri-and post-operative morbidity.8
• A previous study in a large teaching hospital showed that even when routine investigations were performed,
• the results were rarely taken into account.9
• A
• 19
• To quote from the ‘Local Anaesthesia for Intraocular Surgery Guidelines’,
• “Tests should only be considered when the history or a finding on physical examination would have indicated
• the need for an investigation even if surgery had not been planned…….Most abnormalities that would be
• detected on special testing (e.g. ECG, CXR, FBC, clotting studies, urea and electrolytes) can be predicted from
• taking a careful history and performing a physical examination. Special tests do not reduce morbidity in this
• context and are not required unless specifically indicated…For the patient with no history of significant systemic
• disease and no abnormal findings on examination at the nurse-led assessment, no special investigations are
• indicated. Any patient requiring special tests may need a medical opinion.”
• • Hypertension should be controlled well before the patient is scheduled for surgery and not lowered
• immediately prior to surgery.
• • Angina should be controlled by a patient’s usual angina medication which should be available in theatre.
• Every effort should be made to make the experience as stress-free as possible. Generally patients should
• not have surgery within three months of a myocardial infarct.

SCREENING PREOP/PATIENT
EVALUATION

Anticoagulants and platelet inhibitors.
• A a study of 19,283 cataract surgeries, 13.8% of the 4588 aspirin users and 10.5% of the
752 warfarin users were advised to stop their aspirin or warfarin before surgery. The
authors concluded that “There was no evidence to suggest that patients who continued
use were at increased risk of ocular hemorrhagic events,nor that those who discontinued
use were at increased risk of medical events for which these medications were routinely
prescribed.”
– Katz J, Feldman MA, Bass EB, et al; for the Study of Medical Testing for Cataract Surgery Study Team. Risks and benefits of
anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology 2003;110:1784–8.
• A recent multicentre audit of 55,567 cataract operations on patients taking antiplatelet and
anticoagulant medications concluded that “Clopidrogrel or warfarin use was associated
with a significant increase in minor complications of sharp needle and sub-Tenon’s
cannula local anesthesia, but was not associated with a significant increase in potentially
sight-threatening local anesthetic or operative hemorrhagic complications.”
– Benzimra JD, Johnson RL, Jaycock P, et al. The Cataract National Dataset electronic multicentre audit of 55,567
operations:antiplatelet and anticoagulant medications. Eye 2008 Feb 8 (Epub ahead of print).
• It has been estimated that a randomized clinical trial would require 20,000 patients on
anticoagulants to definitively determine if the medical risks of discontinuing therapy
outweigh the surgical risks of continuing therapy. Often patients are concomitantly taking
Chinese herbal medicine and other supplements that may have anticoagulant properties or
alter blood levels of anticoagulant medications. An International Normalized Ratio (INR)

Jamula E, Anderson J, Douketis JD.
Safety of continuing warfarin therapy during cataract
surgery: a systematic review and meta-analysis.
Thromb Res. 2009 Jul;124(3):292-9. Epub 2009 Feb 23.
• Department of Medicine, McMaster University and St Joseph's Healthcare, Hamilton, ON, Canada.
• Abstract
• BACKGROUND: In patients who are receiving warfarin therapy and require cataract surgery, it may be
possible to continue warfarin in the perioperative period but the safety of this management strategy
has not been systematically evaluated.
• METHODS: We performed a systematic review of the literature to assess the safety (bleeding events)
of continuing warfarin before and after cataract surgery. We included studies that enrolled patients
undergoing cataract surgery who were anticoagulated with warfarin alone and that reported bleeding
events as an outcome. Study quality was assessed using a validated form. Odds ratios and bleeding
rates were pooled to give summary estimates of bleeding risk.
• RESULTS: We identified 11 studies (5 cohort and 6 case series) assessing bleeding risk associated with
warfarin continuation during cataract surgery. Patients who continued warfarin had an increased risk
for bleeding (odds ratio; 3.26; 95% confidence interval [CI]: 1.73-6.16). The overall incidence of
bleeding (95% CI) was 10% (5-19). Almost all bleeding events were self-limiting and not
significant, consisting of dot hyphemae or subconjunctival hemorrhages. No patient had
compromised visual acuity related to a bleeding event.
• CONCLUSION: Patients who are receiving warfarin therapy and undergo
cataract surgery without warfarin interruption have an increased risk for
bleeding but such bleeds are not clinically significant. The low quality of
studies assessed, however, precludes definitive conclusions as to the risk
for bleeding in patients who continue warfarin around the time of cataract
surgery

Katz J, Feldman MA, Bass EB, Lubomski LH, Tielsch JM, Petty BG, Fleisher LA,
Schein OD; Study of Medical Testing for Cataract SurgeryTeam.
Risks and benefits of anticoagulant and antiplatelet medication use before
cataract surgery.Ophthalmology. 2003 Dec;110(12):2309. Sep;110(9):1784-8
• Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore,
Maryland 21205-2103, USA. jkatz@jhsph.edu
• OBJECTIVE: To estimate the risks and benefits associated with continuation of anticoagulants or
antiplatelet medication use before cataract surgery.
• DESIGN: Prospective cohort study.
• PARTICIPANTS: Patients 50 and older scheduled for 19,283 cataract surgeries at nine
centers in the United States and Canada between June 1995 and June 1997.
• MAIN OUTCOME MEASURES: Intraoperative and postoperative (within 7 days) retrobulbar
hemorrhage, vitreous or choroidal hemorrhage, hyphema, transient ischemic attack (TIA), stroke,
deep vein thrombosis, myocardial ischemia, and myocardial infarction.
• RESULTS: Before cataract surgery 24.2% and 4.0% of patients routinely used aspirin and warfarin,
respectively. Among routine users, 22.5% of aspirin users and 28.3% of warfarin users discontinued
these medications before surgery. The rates of stroke, TIA, or deep vein thrombosis were 1.5/1000
among those who did not use aspirin or warfarin and 3.8/1000 surgeries among routine users of
aspirin and warfarin who continued their medication before surgery. The rate was 1 event per 1000
surgeries among those who discontinued aspirin use (relative risk = 0.7, 95% confidence interval = 0.1-
5.9). There were no events among warfarin users who discontinued use. The rates of myocardial
infarction or ischemia were 5.1/1000 surgeries (aspirin) and 7.6/1000 surgeries (warfarin) among
routine continuous users and no different from those of routine users who discontinued use.
• CONCLUSIONS: The risks of medical and ophthalmic events surrounding cataract
surgery were so low that absolute differences in risk associated with changes in
routine anticoagulant or antiplatelet use were minimal

J Cataract Refract Surg. 2009 Oct;35(10):1815-20.
Perioperative management of anticoagulated patients having
cataract surgery: National audit of current practice of members of
the Royal College of Ophthalmologists. Batra R, Maino A, Ch'ng SW,
Marsh IB.
• Department of Ophthalmology, University Hospital Aintree, Liverpool, United
Kingdom. RuchikaBatra@aol.com
• Comment in:
• J Cataract Refract Surg. 2010 Apr;36(4):701; author reply 701-2.
• Abstract
• An 11-item questionnaire was mailed to 891 consultant members of the Royal
College of Ophthalmologists (RCOphth) to audit compliance with RCOphth
guidelines for perioperative management of anticoagulated patients having cataract
surgery. Four hundred ninety-nine questionnaires were analyzed.(56%) The results
showed that 29.5% of respondents adhered to all aspects of RCOphth guidelines;
that is, they checked the international normalized ratio (INR)
preoperatively, continued warfarin, operated within the
desired therapeutic INR range for the condition that warfarin
was being used to treat (as set by the treating physician), and
considered sub-Tenon or topical anesthesia in anticoagulated
patients.

Thromboembolic events according to
management strategy Arch. Intern.Med.2003
Continuation of
OAC
Discontinuation
of AOC
Discontinuation
of therapy with
administration of
i.v.heparin
Discontinuation
of therapy with
administration
Of LMWH
Discontinuation
of therapy with
administration of
unclear therapy
1/237
(0,4%)
6/996
(0,6%)
0/166
(0%)
1/180
(0,6%)
21/263
(8%)
Overall 29 thromboembolic events /1868 patients:7 strokes

Major bleeding events while receiving
therapeutic OAC.(Arch Intern.Med 2003)
dental arthrocentesis Cataract
surgery
upper
endoscopy or
colonoscopy
with or
without
biopsy
4/2014
(0.2%)
0/32
(0%)
0/203
(0%)
0/111
(0%)

Arch Intern Med. 2003 Apr 28;163(8):901-8.
Perioperative management of patients receiving oral
anticoagulants: a systematic review.
Dunn AS, Turpie AG.
Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA. andrew.dunn@mountsinai.org
.safety and efficacy of various management strategies for patients receiving
oral anticoagulants (OACs) who need to undergo surgery or invasive
procedures .
. systematic review and synthesis of the English-language literature examining
the perioperative management and outcomes of patients receiving long-term
OAC therapy.
. 31 reports identified.
. quality of the identified reports was generally poor;
. no randomized controlled trials have been performed and duration of
follow-up was typically not stated.

Arch Intern Med. 2003 Apr 28;163(8):901-8.
Perioperative management of patients receiving oral
anticoagulants: a systematic review.Dunn AS, Turpie AG
.
• CONCLUSIONS:
• Most patients can undergo dental procedures, arthrocentesis, cataract
surgery, and diagnostic endoscopy without alteration of their regimen.
• For other invasive and surgical procedures, oral anticoagulation needs to be
withheld, and the decision whether to pursue an aggressive strategy of
perioperative administration of intravenous heparin or subcutaneous low-molecular-
weight heparin should be individualized.
• The current literature is substantially limited in its ability to help choose an
optimal strategy. Further and more rigorous studies are needed to better
inform this decision.
• Comment in
• Dental procedures can be undertaken without alteration of oral anticoagulant regimen.
[Evid Based Dent. 2005]
• Oral anticoagulant and dental procedures. [Arch Intern Med. 2003]
• Perioperative management of patients receiving oral anticoagulants. [Arch Intern Med.
2003]
• The perioperative management of warfarin therapy. [Arch Intern Med. 2003]

The Cataract National Dataset electronic multicentre audit
of 55,567 operations: antiplatelet and anticoagulant
medications:
% complications
clopidogrel warfarin control
needle haematoma 8 6,2 4,3
subjunctival
haemorrhage 4,4 3,2 1,7
any op.complication 7,3 ?? 4,4
post.capsular rupture 3,2 ?? 1,7

The Cataract National Dataset electronic multicentre audit of
55,567 operations: antiplatelet and anticoagulant medications:
% complications
8
7
6
5
4
3
2
1
0
needle haematoma subjunctival
haemorrhage
any
op.complication
post.capsular
rupture
clopidogrel
warfarin
control
aspirin only

The Royal College of Ophthalmologists of the United
Kingdom (RCOphth) guidelines on the
perioperative management of the anticoagulated patient.2007
• (1) Warfarin is effective at reducing health and life-threatening
thrombotic events.
• (2) To stop warfarin risks stroke and death. The risk
for stroke increases to 1:100.
• (3)The INR should be checked to ensure that a
patient is within the desired therapeutic range (set
by the treating physician)
• (4) If needle local anesthesia is performed,the risk
for orbital hemorrhage is increased by 0.2% to
1.0%.
• (5) Consideration should be given to using sub-
Tenon or topical anesthesia.

Chest. 2008 Jun;133(6 Suppl):299S-339S.
The perioperative management of antithrombotic therapy: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J;
American College of Chest Physicians.
• McMaster University, Hamilton, Ontario, Canada.
• Abstract
• This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of
patients who are receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other
invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or
unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The
recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S-131S).
Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade
2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices. The key
recommendations in this article include the following: in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE)
at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging
during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for
thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no
bridging during temporary interruption of VKA therapy (Grade 2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for
thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C). In patients with
a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the
perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we
recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C). In patients who are
undergoing minor dental procedures and are receiving VKAs, we
recommend continuing VKAs around the time of the procedure and co-administering
an oral prohemostatic agent (Grade 1B); in patients who are
undergoing minor dermatologic procedures and are receiving VKAs, we
recommend continuing VKAs around the time of the procedure (Grade
1C); in patients who are undergoing cataract removal and are receiving
VKAs, we recommend continuing VKAs around the time of the procedure
(Grade 1C).

The perioperative management of antithrombotic therapy: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
5.3.1 Patients Who Are Receiving VKAs
• 5.3.1 Patients Who Are Receiving VKAs
• Six prospective cohort studies assessed bleeding in patients who continued VKA therapy during
ophthalmologic surgery and in a control group of patients who were either not receiving VKA
therapy or who interrupted VKA therapy before surgery. [219] , [220] , [221] , [222] , [223] , [224] Two other
prospective cohort studies assessed bleeding in patients who continued VKA therapy during
ophthalmologic surgery but did not have a control group. [225] , [226] In one prospective cohort
study assessing patients who had cataract surgery, there was no apparent increase in arterial
thromboembolic events in 208 patients who discontinued VKAs compared to 526 patients who
continued VKAs and the incidence of such events appeared higher in patients who continued
VKAs (1.14% vs 0.48%).[221] In these patients, there were no major or clinically relevant
nonmajor bleeds. In another cohort study involving 639 patients who continued VKAs and
1,203 controls who were not taking VKAs around the time of cataract surgery, there were no
arterial thromboembolic events.[219] There appeared to be a higher incidence of clinically
relevant nonmajor bleeding (0.16% vs 0.08%) and minor bleeding (1.41% vs 0.67%) in patients
who continued VKAs although there were no major bleeds reported. While other smaller
cohort studies demonstrated similar results, [225] , [226] one cohort study involving 125 patients
who had cataract surgery reported a high rate of major bleeding (8.7%).[224]

Perioperative Management of Antithrombotic Therapy Patients Who
Require Urgent Surgical or Other Invasive Procedures (American
College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition). 2008 )
• 6.1 Patients Who Are Receiving VKAs
• In the nonbleeding patient who requires rapid (within 12 h) reversal of the anticoagulant effect of VKAs because of an urgent surgical or
other invasive procedure, treatment options that have been assessed in observational studies include fresh-frozen plasma, prothrombin
concentrates, and recombinant factor VIIa.[229] No randomized trials, to date and to our knowledge, have compared these treatments in
patients who require urgent reversal of anticoagulation.[230] In addition to these treatment options, all patients should receive vitamin
K, at a dose of 2.5 to 5.0 mg po or by slow IV infusion.[231] Administering fresh-frozen plasma, prothrombin concentrates, or
recombinant factor VIIa alone will temporarily override but will not eliminate the anticoagulant effect of VKAs, which persist until VKAs
are endogenously metabolized or neutralized by vitamin K. For example, as fresh-frozen plasma has an elimination half-life of 4 to 6 h,
not administering vitamin K will lead to reemergence of a VKA-associated anticoagulant effect within 12 to 24 h. If surgery is urgent but
can be delayed for 18 to 24 h, the anticoagulant effect of VKAs is likely to be neutralized by IV vitamin K, at a dose of 2.5 to 5.0 mg
without the need for blood product or recombinant factor VII administration.[230] , [232]
• Recommendation
• 6.1. In patients who are receiving VKAs and require reversal of the anticoagulant effect for an urgent surgical or other invasive
procedure, we suggest treatment with low-dose (2.5 to 5.0 mg) IV or oral vitamin K (Grade 1C). For more immediate reversal of the
anticoagulant effect, we suggest treatment with fresh-frozen plasma or another prothrombin concentrate in addition to low-dose IV
or oral vitamin K (Grade 2C).
• 6.2 Patients Who Are Receiving Antiplatelet Drugs
• There is no pharmacologic agent that can reverse the antithrombotic effect of aspirin, clopidogrel, or ticlopidine, which irreversibly
inhibit platelet function. Consequently, patients who require an urgent surgical or other invasive procedure that requires normalized
platelet function may receive transfused platelets, which would not be affected by prior administration of antiplatelet drugs.[233]
However, the efficacy and safety of platelet transfusion in patients who are not thrombocytopenic and who require an urgent surgical
or other invasive procedure are not known. One randomized trial in 11 healthy volunteers who received aspirin (325 mg loadingdose,
81 mg maintenance dose) and clopidogrel (300-mg or 600-mg loading dose, 75-mg maintenance dose) found that subsequent
transfusion of 12.5 U platelets led to normalized platelet function as determined by platelet function assays.[234] However, studies to
assess the efficacy and safety of a platelet transfusion to neutralize the antiplatelet effects of aspirin or clopidogrel in the perioperative
setting are lacking. Until such studies are done, it is reasonable to limit platelet transfusion to those patients who have excessive or life-threatening
bleeding in the perioperative period.
• Potential alternatives to platelet transfusion in patients who have been exposed to antiplatelet drugs are prohemostatic agents. These
include ɛ-aminocaproic acid and tranexamic acid, which are antifibrinolytic agents, and 1-deamino-8-D-arginine vasopressin, which
increases plasma levels of von Willebrand factor and associated coagulation factor VIII. These agents may improve platelet function in
patients who have been exposed to antiplatelet drugs.[235] However, outside of the setting of cardiac surgery, these drugs have not
been widely studied[113] , [236] and should be limited to patients who have excessive or life-threatening perioperative bleeding because of
potential prothrombotic effects.
• Recommendation
• 6.2. For patients receiving aspirin, clopidogrel, or both, are undergoing surgery and have excessive or life-threatening perioperative
bleeding, we suggest transfusion of platelets or administration of other prohemostatic agents (Grade 2C).

The perioperative management of antithrombotic therapy: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
5.3.2 Patients Who Are Receiving Antiplatelet Drugs
• 5.3.2 Patients Who Are Receiving Antiplatelet Drugs
• A prospective cohort study assessing patients who underwent cataract surgery found no
important increase in arterial thromboembolic events in 977 patients who interrupted aspirin
compared to 3,363 patients who continued aspirin (0.20% vs 0.65%).[221] In these patients,
there were no major or clinically relevant nonmajor bleeds and marginally higher clinically
relevant nonmajor bleeds in patients who continued aspirin (0.06% vs 0%). Other studies
reported similar results in patients undergoing cataract or vitreoretinal surgery. [222] , [223]
• There are few data in regard to the safety of continuing clopidogrel in patients undergoing
ophthalmologic surgery. One study of patients undergoing cataract surgery found that
although subconjunctival hemorrhage was more common in patients who were receiving
either clopidogrel or warfarin than aspirin or no antithrombotic drugs, there were no sight-threatening
bleeding complications.[227] One study described a patient who was receiving
aspirin and clopidogrel and underwent an intracapsular extraction and anterior vitrectomy in
whom the postoperative course was complicated by extensive hyphema and vitreous
hemorrhage that cleared within 3 months.[228] As with other minor procedures, perioperative
management will be driven by thromboembolic risk.

Recommendations of American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines (8th Edition). 2008
• 5.3. In patients who are undergoing cataract removal
and are receiving VKAs, we recommend continuing
VKAs around the time of the procedure (Grade 1C).
• In patients who are undergoing cataract removal and
are receiving aspirin, we recommend continuing
aspirin around the time of the procedure (Grade 1C).
• In patients who are undergoing cataract removal and
are receiving clopidogrel, please refer to the
recommendations outlined in Section 4.5 and Section
4.6.

Ann Fr Anesth Reanim. 2010 Dec;29(12):878-83. Epub 2010 Nov
26.[Safety of "needle" regional anaesthesia for anterior segment surgery under
antiplatelet agents and anticoagulants therapies].
Saumier N, Lorne E, Dermigny F, Walkzak K, Daelman F, Jezraoui P, Mahjoub Y,
Milazzo S, Dupont H.
• Pôle d'anesthésie-réanimation, centre hospitalier universitaire d'Amiens, université Jules-Verne-de-Picardie,
avenue René-Laennec, 80054 Amiens cedex, France.
• Abstract
• INTRODUCTION: cataracts preferentially affect the elderly. More than 560,000 procedures are performed annually
in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet and/or
anticoagulants. Haemorrhagic complications resulting from cataract surgery and/or eye regional anaesthesia are
rare but can lead to serious damage to eye function.
• PATIENTS AND METHODS: in this study, we compared the management care of two types of antiplatelet and/or
anticoagulants successively utilizing the following procedure: first, the cessation of antiplatelet agents and
anticoagulants were relayed with rapid elimination agents (constituting our reference "before" cohort [November
2004-May 2005]), then the antiplatelet or anticoagulant management was continued without stint according to
recent data from literature (constituting our "after" cohort (April 2007-March 2008)).
• RESULTS: a reference population, consisting of 229 patients, was operated on exclusively with "surgical" sub-
Tenon's anaesthesia. A second group, consisting of 178 patients, was operated on using "needle" regional
anaesthesia. In both populations, nearly 33% of patients received antiplatelet or anticoagulant treatment. The
incidence of subconjonctival haemorrhage occurred more frequently when anticoagulants agents were relayed
(33% vs 0%; P<0,05), but there was no significant difference with antiplatelet agents (23% vs 8%; NS). The most
common non-bleeding event was Chemosis and related to the type of anaesthetic technique utilized, although not
serious it tended to jeopardize surgical comfort (anticoagulants: 35% vs 36% (NS), antiplatelet agents: 38% vs 40%;
NS).
• CONCLUSION: the technical changes do not explain fully that occurrence of the HSC, in patients under
anticoagulant treatment, decreased in the second period. The achievement of "needle" regional anaesthesia in
the anterior segment eye surgery is a safe technique that does not require stopping antiplatelet treatment or
anticoagulation

Kobayashi. H.Evaluation of the need to discontinue
antiplatelet and anticoagulant medications before
cataract surgery. J Cataract Refract Surg. 2010
Jul;36(7):1115-9.
• Department of Ophthalmology, Kanmon Medical Center, Shimonoseki, Japan. kobi@earth.ocn.ne.jp
• Abstract
• PURPOSE: To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet
and/or anticoagulant treatment in patients having uneventful phacoemulsification.
• SETTING: Kokura Memorial Hospital, Kitakyusyu, Japan.
• METHODS: In a nonrandomized case series, consecutive patients had phacoemulsification and intraocular
lens implantation under sub-Tenon anesthesia. All patients were on warfarin, acetylsalicylic acid (aspirin)
therapy, or both. Patients discontinued therapy 1 week before surgery (discontinuation group) or continued
the therapeutic regimen until the time of surgery (maintenance group).
• RESULTS: The discontinuation group comprised 182 patients and the maintenance group, 173 patients.
There was no significant difference between the 2 groups in the mean prothrombin time-international
normalized ratio in patients taking warfarin (P = .6). Although there was no significant intraoperative
bleeding in any case, 47 eyes (16.5%) in the maintenance group and 31 eyes (10.8%) in the discontinuation
group had a subconjunctival hemorrhage postoperatively (P = .0309). Minor postoperative ocular bleeding
occurred in 11 eyes (4.0%) in the maintenance group and 7 eyes (2.5%) in the discontinuation group (P = .4).
During the 1-month postoperative period, the mean change in corrected distance visual acuity was -0.462
logMAR +/- 0.331 (SD) in the maintenance group and -0.434 +/- 0.318 logMAR in the discontinuation group
(P = .3).
• CONCLUSIONS: Patients taking warfarin, aspirin, or both up to the time of phacoemulsification had a
significantly higher incidence of subconjunctival hemorrhage than those who discontinued therapy.
There was no significant difference between the 2 groups in the incidence of intraoperative and
postoperative complications or in visual improvement

J Cataract Refract Surg. 2011 Aug;37(8):1434-8.
Risk assessment of simple phacoemulsification in patients on combined
anticoagulant and antiplatelet therapy.Barequet IS, Sachs D, Shenkman
B, Priel A, Wasserzug Y, Budnik I, Moisseiev J, Salomon O.
Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel
Hashomer, Israel. ibarequet@hotmail.com
To assess the safety of phacoemulsification cataract extraction in patients on combined
anticoagulant and antiplatelet treatment.
Prospective interventional case series.:
Consecutive patients with simple cataract on combined anticoagulant (warfarin) and
antiplatelet (aspirin or clopidogrel) treatment who were unable to discontinue the treatment
because of a high risk for thromboembolic events were included. Patients had cataract
extraction under topical anesthesia with a clear corneal incision (CCI), phacoemulsification,
and implantation of a foldable posterior chamber intraocular lens. Prothrombin time-international
normalized ratio and platelet functions were evaluated immediately before
surgery. Patients were also examined 1 day and 7 days postoperatively. Intraoperative and
postoperative ocular bleeding and other related complications were assessed.
RESULTS:
40 patients (51 eyes) with a mean age of 72 years (range 51 to 90 years) had
phacoemulsification. Hemorrhagic complications were not observed at surgery or during the
1-week follow-up. Surgical complications included 1 rupture of the capsulorhexis and 1
implantation of a capsular tension ring due to partial zonulysis. No patient had a
thromboembolic event.
• CONCLUSIONS: In patients with uncomplicated cataract at high risk for
thromboembolic events, phacoemulsification cataract surgery using a CCI under
topical needle-free anesthesia was safely performed without discontinuing
systemic anticoagulant and antiplatelet treatment

Eur J Anaesthesiol. 2013 Aug;30(8):449-54. Management of
antithrombotic therapies in patients scheduled for eye
surgery.Bonhomme F, Hafezi F, Boehlen F, Habre W.
• The large majority of patients undergoing ophthalmic surgery are elderly and take systemic
medications on a regular basis, including antiplatelet and anticoagulant treatments. It is current
practice for many physicians to discontinue antithrombotic treatment prior to surgery to reduce
bleeding complications that may lead to retrobulbar haemorrhage and, ultimately, to loss of vision.
However, discontinuation of antithrombotic treatment in such patients may lead to
thromboembolic events with serious consequences. The present narrative review highlights the risk
of thrombosis when discontinuing antithrombotic drugs and the risk of bleeding when continuing
them. The published literature on this topic shows that discontinuation of antiplatelet or
anticoagulant treatment leads to a substantially increased risk of arterial or venous
thromboembolic events and related complications, especially in patients with atrial fibrillation,
prosthetic heart valves or recent coronary stenting. This risk is distinctly higher than the risk of
significant local haemorrhage. Ophthalmic bleeding events reported in the literature are usually
minor, without serious consequences, even if antiplatelet or anticoagulant treatments are
continued, provided that the anticoagulation level is within the therapeutic range. Thus, the
current data are in favour of maintaining antiplatelet and anticoagulant
drugs for most ophthalmic procedures, regardless of the anaesthetic
techniques.

Risks and benefits of anticoagulant and antiplatelet
medication use before cataract surgery
Study Operations number Aspirin warfari
n
Conclusion
Katz 2003 19,283 4588 752 No dif cont vs noncont.
Benzimra
2008
55,567 9101 1525 Clopidogrel (524 pts)more
local risk
Kobayashi 182+173 Subconjunct haemorr
higher in the maintenance
group
Saumier 229 vs 178 33% /// + Subconjunct haemorr
(poor stat!!)
Barequet 40 all all 2 minor Ko
Hall* 49 no all Hyphema 3(6%)
Gainey * 9 no all 2 KO,1 rehospitalization
Roberts * 35 si si 1 retrobulbar hemorrhage

Unstable coronary artery disease (CAD) or uncontrolled
hypertension.
• In general, surgery should be delayed in these circumstances
until a cardiologist and (or) an anesthesiologist has determined
that the risk profile has returned to normal. If surgery cannot be
delayed (e.g., for sight-threatening phakolytic glaucoma in a
monocular patient), monitoring of oxygen saturation, blood
pressure, heart rate, and electrocardiogram by dedicated
operating room personnel with IV access, advanced cardiac life
support certification, IV medication injection ability, and with
access to an anesthesiologist are needed.

COPD.
• • Oxygen dependency must be maintained
intraoperatively.
• CO2-dependent breathers may do better with
room air and drapes off the face.
• When cautery is used, the oxygen-enriched
tmosphere beneath a closed, nonscavenged
drape is a potential fire hazard. Lifting the
edge of the drape or using a scavenger system
is recommended if cautery is to be used.

Tamsulosin HCl, alfuzosin HCl, and other alpha1-
adrenergic blocking agents may lead to IFIS
• • Once the patient has been identified as a user,
special surgical measures might be taken. Stopping
these medications does not seem to reduce the risk of
IFIS and may aggravate urinary obstructive problems.
• Farmaci in Italia:
alfuzosina,doxazosin,indoramina,prazosin,tamsulosina,
terazosina(nomi commerciali:
Mittoval,Xatral,Benur,Omnic,Pradif,Prostatil,Terafluss,Te
raprost,Unoprost,Urodie,Lura,Botam,Tamlic,ecc
Tamsulosin:Botam;Lura,Omnic,Pradif,Tamlic,
Tamsulosin,Tamsulosina
– Alfuzosin:Mittoval,Xatral

• “Caine” allergies.
• Local anesthetics are either esters of benzoic and
aminobenzoic derivatives (e.g., cocaine,
benzocaine, procaine, tetracaine, butacaine) or
amidederivatives of xylidine and toluidine groups (e.g.,
lidocaine, mepivicaine, prilocaine).
• Skin testing for amide and ester local anesthetics can
include preservative-free
lidocaine, which may identify patients allergic to the
preservatives in amide anesthetics.( Methylparaben)
•

Street clothes
• Many facilities allow patients to wear select items of
personal clothing to preserve their dignity. No research
has been published comparing field contamination or
infection rates with and without personal clothing. The
Operating Room Nurses Association of Canada
recommends that “for outpatient surgery, patients may
wear some of their own clothing, especially if the
clothing does not interfere with the procedure and the
procedure is short (e.g.,cataract surgery). However,
patients should still have their hair covered and be
covered with clean linens.”

Footwear practices and operating room
contamination
• Nurs Res. 1987 Nov-Dec;36(6):366-9.
• Footwear practices and operating room contamination.
• Copp G1, Slezak L, Dudley N, Mailhot CB.
• Abstract
• The extent of bacterial transfer into the clean confines of the operating room (OR) was studied by
comparing the use of protective footwear (i.e., polypropylene shoe covers and OR restricted shoes)
with unprotected street shoes over a 5-week period. The study was divided into two experimental
times: (a) early morning (disinfected floor) and (b) midmorning (dirty floor). Data obtained from the
early morning experiment showed that OR restricted shoes and shoe covers transferred fewer
bacteria onto the disinfected study area than unprotected street shoes; similar findings were
obtained from the midmorning experiment for shoe covers, but not for OR restricted shoes. A
comparison of changes in bacterial counts obtained from OR restricted shoes and shoe covers worn
from the changing room through a common corridor to the disinfected study area did not differ
significantly from OR restricted shoes and shoe covers that were put on immediately before walking
through the study area at both experimental times. Overall results indicated that protective
footwear may act to reduce bacterial contamination on OR floors

Supporting the clothes change....
• Ugeskr Laeger. 2009 Feb 2;171(6):420-3.
• [Dispersal of Staphylococcus aureus from nasal carriers].
• [Article in Danish]
• Iskandar A1, Nguyen N, Kolmos HJ.
• Abstract
• INTRODUCTION:
• Staphylococcus aureus (Sa) is an important cause of hospital-acquired infections, and nasal carriage of Sa is common among health care workers. This
study was designed to measure the airborne dispersal of Sa and other bacteria from such carriers and to investigate whether the use of cap, gown,
gloves, and mask could reduce this dispersal.
• MATERIAL AND METHODS:
• A total of 13 nasal Sa carriers were identified among 63 persons screened for Sa nasal carriage. The volunteers were studied for airborne dispersal of
Sa in four different situations: quiet breathing, movements of the arms, whispering and loud talking. These activities were performed with and
without gown, gloves, mask and cap upon street clothes.
• RESULTS:
• The study showed that the highest number of Sa and bacteria in total was dispersed into the air when the volunteers were moving and wearing only
their street clothes. The dispersal of Sa into the air was reduced into a minimum by wearing cap, gown and gloves, and no further significant
decrease was achieved by wearing a mask. This applied for all volunteers except for one, who had to wear a mask in order to reduce his dispersal of
Sa to a minimum. The total dispersal of bacteria was significantly reduced by wearing cap, gown and gloves; however, to reduce this dispersal to a
minimum, volunteers also had to wear a mask.
• CONCLUSION:
• Our study supports the rational basis that gown, cap, gloves and mask should be used not only in the operating theatre, but also while e.g. inserting
central venous catheters.

Patients opinion about surgical attire:
• Am J Surg. 2012 Nov;204(5):663-5. doi: 10.1016/j.amjsurg.2009.09.001. Epub 2010 Jun 29.
• Patient attitudes to surgeons' attire in an outpatient clinic setting: substance over style.
• Edwards RD1, Saladyga AT, Schriver JP, Davis KG.
• Abstract
• BACKGROUND:
• It is believed that patients prefer that surgeons convey a professional appearance with traditional business attire
and white laboratory coat. We performed a prospective study to assess patient opinions regarding traditional
attire versus the wearing surgical scrubs in the outpatient setting.
• METHODS:
• During a 5-month period, surgeons alternated wearing traditional clothing and surgical scrubs. Adult patients were
given a questionnaire assessing their preferences regarding surgeons' clothing.
• RESULTS:
• Six hundred twelve patients returned the questionnaire. The majority felt that scrubs were appropriate attire for
physicians. Half of the patients felt that wearing white laboratory coats is necessary. A minority felt that their
surgeon's dress affects their opinion regarding the care they received. There was no difference between responses
regardless of the attire actually worn.
• CONCLUSIONS:
• Surgeon's clothing choice does not significantly influence patient's opinion of the care they receive. Patients do
not have strong preferences for white coats or more traditional surgical attire

Recentemente(genn 2014) sulla rivistina “Outpatient
surgery”....un sondaggio di opinioni :8:1 per i mantenimento
vestiario,ma copertura con gown ,cappello,telo..
• We are a newly opened ASC doing ophthalmology procedures. The patients remain in street clothes that are
covered with a hospital gown, shoe covers and bouffant cap for transport into the OR. I have been told that we
do much more than other ASCs by using the gown and shoe covers and have been asked to stop this practice. I
would like to hear what other ASCs require?
• Cathy Summers (Administrator/Director/Manager/Owner/Executive Officer) at January 10, 2014 (3:57 pm)
• We are a four OR ophthalmology ambulatory facility. Our patients are provided a bouffant cap, shoe covers, a
paper "johnny coat" to place over their clothes, and shoe covers.
• Mary Craddock (Administrator/Director/Manager/Owner/Exec. Officer) at January 13, 2014 (2:44 pm)
• We have a cataract/eye procedure specific O.R., where no other procedures are performed. Our cataract/eye
patients are brought from the pre-op holding area to the cataract room on a gurney, fully clothed -- no shoe
covers, no hats, and covered in a warmed blanket (for their comfort, not for infection control). Also, the room
does not enter/exit into a sub-sterile room like our other O.R.'s, and does not have luminar air flow. We have
little to no infections.
• Terrolynn G. (Other) at January 13, 2014 (2:12 pm)
• We are a multi-specialty clinic and we allow the patient to leave on their pants (jeans,etc). Woman are allowed
to also leave on their bras and we give each patient a gown, cap and shoes covers. Shoes are removed and
placed in bags with all other belongings. Patient is allowed to leave on their socks. Each patient gets a blanket
and placed on a gurney. We have had no issues of infection.
• Linda Lewis (Director, Surgical Services/Director of Nursing) at January 13, 2014 (1:52 pm)
• Our patients remove their top, wear shoe covers and a bouffant cap. Andrea Hyatt
• Andrea Hyatt (Administrator/Director/Manager/Owner/Executive Officer) at January 13, 2014 (1:15 pm)
• Our patients leave on their clothing. We have them wear a bouffant cap, shoe covers, and they are covered with
a blanket. We do almost all ophthalmology procedures and this seems to work well for us.
• Heather Barbish (Other) at January 13, 2014 (1:11 pm)

Patient allergic to Xr contrast media
• “Little evidence exists that elemental iodine is responsible for
idiosyncratic contrast reactions or povidone-iodine dermatitis
and no evidence exists that it is involved in seafood allergy.
The notion that iodine confers specific cross-reactivity
between these agents is unfounded.”82 In patients with
povidone-iodine dermatitis, an alternative skin preparation
solution with a nonalcohol, aqueous-based chlorhexidine skin
preparation and conjunctival antibiotic prophylaxis should be
considered. In patients with iodine, IVP dye, or seafood
allergies, the evidence supports the use of povidone-iodine
for skin preparation. The use of sterile 5% povidone-iodine in
the conjunctival sac is also supported for patients reporting
these allergies. There is no reported safety profile for its use
in the conjunctival sac in the presence of skin allergy to
povidone-iodine.

["Iodine allergy": point of view].
[Dewachter P, Tréchot P, Mouton-Faivre C. Ann Fr Anesth
Reanim. 2005 Jan;24(1):40-52
• Source
• Service d'anesthésie-réanimation chirurgicale, CHU, hôpital central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy cedex, France. pascale.dewachter@wanadoo.fr
• Abstract
• OBJECTIVE:
• The aim of this literature review is to suggest a diagnostic and a preventive attitude in patients having presented an immediate hypersensitivity reaction due to an iodinated drug.
• DATA SOURCES:
• Literature review. Data were searched in the Medline database from 1967 to 2004 in English and French language. Complementary references were selected from the bibliography of
selected references or from authors' personal databases. The following key-words were used separately or combined: Hypersensitivity, Immediate; Allergy; Contrast Media; Povidone-
Iodine; Iodine; Iodine Compounds; Iodides; Amiodarone; Seafood, Parvalbumins; Tropomyosin.
• STUDY SELECTION:
• Randomized studies, epidemiological studies, original articles, clinical cases, and letters to the editor were selected.
• DATA SYNTHESIS:
• The implication of iodine has never been demonstrated during allergic hypersensitivity reactions due to iodinated drugs. However, IgE-mediated allergic hypersensitivity reactions have
been published with contrast media or iodinated antiseptics and will be described in this development. In a wider sense, allergic hypersensitivity reactions due to seafood are evoked
because often improperly considered as a risk factor of allergic reaction to iodinated drugs. The allergenic determinant responsible of patient sensitization is not known for iodinated
contrast media, but is probably due to povidone in case of iodine povidone. In fish, the allergen is described as the protein M. There has also been strong immunological evidence that
tropomyosin is a cross-reactive allergen among crustaceans and molluscs (shellfishs). In case of hypersensitivity reaction occurring with iodinated drug, an allergological assessment is
required to confirm the immune mechanism, to identify the culprit drug or substance and to identify cross-reactivity especially with iodinated contrast media.
• CONCLUSION:
• Asking a patient if he/she is "allergic to iodine" is a question that should be avoided because its significance is null. A diagnosis of drug allergy, essentially relying on clinical symptoms,
biological tests and cutaneous tests, is required to take adequate preventive measures

Dewachter, Pascale a; Mouton-Faivre, Claudie b; Castells, Mariana C c;
Hepner, David L d
Anesthesia in the patient with multiple drug allergies: are all allergies the
same?Current Opinion in Anaesthesiology. 24(3):320-325, June 2011.
• Povidone iodine
• Povidone iodine is a stable iodophor solution containing a
water-soluble complex of iodine and polyvinylpyrrolidone (PVP).
PVP is a water-soluble polymer made from the monomer N-vinylpyrrolidone,
which has been identified as the allergenic
determinant by skin testing and immunoassays [31]. Less than
10 documented IgEmediated allergic reactions have been
reported following povidone iodine. Clinical features of these
reactions are moderate and observed following topical, vaginal
or rectal applications. The allergenic determinant of povidone
iodine in cases of immediate hypersensitivity is povidone. There
are no data to support potential cross-reactivity between
shellfish and povidone iodine. Therefore, the only
contraindication to povidone iodine is a previous documented
hypersensitivity reaction to this antiseptic.
• .

Iodinated contrast agents
• All the currently available iodinated contrast media (ICM) are
chemical modifications of a 2,4,6-tri-iodinated benzene ring [32].
Although the allergenic determinant remains unknown, it is not
the iodine atom. Crossreactivity among the different ICM
seems to be low despite their closely related molecular structures,
but should be assessed through skin tests in order to identify safe
alternative regimens [32]. Patients with a previous documented IgE-mediated
hypersensitivity to an ICM
• have been safely injected during subsequent radiological
procedures with another ICM that was negative by skin
• testing [33]. In addition, there is no role to
contraindicate the use of povidone iodine in
patients allergic to ICM

BMJ. 2006 Sep 30;333(7570):675. Pharmacological prevention of
serious anaphylactic reactions due to iodinated contrast media:
systematic review.Tramèr MR, von Elm E, Loubeyre P, Hauser C.
• Systematic search (multiple databases, bibliographies, all languages, to October 2005) for randomised
comparisons of pretreatment with placebo or no treatment (control) in patients receiving iodinated contrast
media. Review methods Trial quality was assessed by all investigators. Information on trial design, population,
interventions, and outcomes was abstracted by one investigator and cross checked by the others. Data were
combined by using Peto odds ratios with 95% confidence intervals.
• RESULTS:
• Nine trials (1975-96, 10 011 adults) tested H1 antihistamines, corticosteroids, and an H1-H2 combination. No trial
included exclusively patients with a history of allergic reactions. Many outcomes were not allergy related, and only
a few were potentially life threatening. No reports on death, cardiopulmonary resuscitation, irreversible
neurological deficit, or prolonged hospital stays were found. In two trials, 3/778 (0.4%) patients who received oral
methylprednisolone 2x32 mg or intravenous prednisolone 250 mg had laryngeal oedema compared with 11/769
(1.4%) controls (odds ratio 0.31, 95% confidence interval 0.11 to 0.88). In two trials, 7/3093 (0.2%) patients who
received oral methylprednisolone 2x32 mg had a composite outcome (including shock, bronchospasm, and
laryngospasm) compared with 20/2178 (0.9%) controls (odds ratio 0.28, 0.13 to 0.60). In one trial, 1/196 (0.5%)
patients who received intravenous clemastine 0.03 mg/kg and cimetidine 2-5 mg/kg had angio-oedema compared
with 8/194 (4.1%) controls (odds ratio 0.20, 0.05 to 0.76).
• CONCLUSIONS:
• Life threatening anaphylactic reactions due to iodinated contrast media are rare. In
unselected patients, the usefulness of premedication is doubtful, as a large number of
patients need to receive premedication to prevent one potentially serious reaction. Data
supporting the use of premedication in patients with a history of allergic reactions are
lacking. Physicians who are dealing with these patients should not rely on the efficacy of
premedication

Factors Lowering IOP
• Drop in B.P, reduces choroidal volume.
• Relaxation of extraocular muscles lowers
wall
• tension.
• Pupillary constriction facilitates aqueous
• outflow.
• Mild hypocapnia (26 – 30 mmHg) reduces
• choroidal blood volume

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