Cataract surgery in children requires careful anesthetic management to prevent complications like laryngospasm from excessive secretions, and the oculocardiac reflex which can cause bradycardia. Sedation with midazolam and fentanyl or propofol is suitable, and atropine may be given preventively. Peribulbar block is preferable for young patients who can lie still, and maintaining the shape of the anterior chamber with sodium hyaluronate injection helps control vitreous bulge.

1. นพ. ณัฐพงค์ ฉัตรศรีวงศ์
วิสัญญีแพทย์ รพ.เมตตาประชารักษ์ (วัดไร่ขง)
ิ

2.  Oculoplastic
 Squint
 Cornea
 Lens
 Glaucoma
 Vitreoretinal
 Neuro-
ophthalmology

3.  Local anesthesia
 Topical anesthesia
 Regional anesthesia
 General anesthesia
 Ophthalmic surgery

4. General
anesthesia
VS
Local
anesthesia

5.  Many benefits
  Physiological disturbance
  PONV
 Economic
 Topical / Regional anesthesia

6.  Non-invasive
 Virtually no complications
 Challenging operating conditions
– no akinesia
 Increasingly popular for
phacoemulsification cataract surgery

7.  Careful patient selection
 Co-operative
 Not distressed
 Straightforward surgery
 Must be able to lie supine and still
 Not claustrophobic
 Sedation (Anesthesiologist stand-by)

8.  IV access / supplementary O2
 Which LA?
 Proxymetacaine / amethocaine
 Preservative free preferred
 ± topical NSAID and mydriatic

9.  20-30 min before surgery
 Two to three drops every 5 minutes
 Cornea is avascular – once absorbed LA
remains for about 30 min
 Supplemented by incremental injection

10. What about this choice?

11.  Advantages
 Day cases
 Good akinesia and Anesthesia
 Minimal effect on IOP
 Minimal equipment required

12.  Disadvantages
 Not suitable for all patients
 Complications
 Skill of Surgeons/Anesthesiologists
 Unsuitable for certain types of surgery

13.  Orbit – shape of
irregular pyramid
 Base at front
 Axis points posterio-
medially towards skull
Globe lies in anterior
part of orbit
- sits high and lateral

14.  Four rectus muscles
arise from the back of
orbit
 Insert into the globe
just forward of
equator
 Form a cone
- boundary between
two compartments
CENTRAL PERIPHERAL
(retrobulbar) (peribulbar)

15.  Within the cone
 Optic nerve
 Opthalmic artery & vein
 Ciliary ganglion
 Oculomotor nerves
 Sensory supply to orbit
 from opthalmic division Trigeminal nerve
 enters the orbit through superior orbital fissure

17.  Peribulbar block (Pericone)
 Retrobulbar block (Intracone)
 Sub-Tenon’s block

18.  Comfort
 Assistant providing
reassurance
 O2 saturation, ECG,
BP monitoring
 Right angled screen
providing O2

19.  Intravascular injection
 Anaphylaxis
 Hemorrhage
 Subconjunctival edema
 Penetration / perforation of the globe
 Central spread (sub-arachnoid)
 Optic nerve atrophy

20.  2001Guidelines (RCA & College Of
Ophthalmologists)
 Trained staff
 Surgeons – topical / sub-conjunctival / sub-Tenon
– without Anesthesiologist
 Anesthesiologist & iv access when retrobulbar /
peribulbar
 Anesthesiologist in charge when sedation used

21.  Indications:
 Patient refusal
 Children / learning difficulties / movement
disorders
 Major / lengthy procedures
 Inability to lie still / flat
 Claustrophobic

22.  Patients at extreme age
 Old – medication, confused, deaf, blind, with
co-morbid like DM, CAD, HTN, COPD
 Young – congenital anomalies, temp. & fluid
balance
 Opthalmic drugs
 Timolol – B-Blocker
 Phospholine iodide – anti-cholinesterase

23.  Normally 10-20 mmHg
 Must be controlled when operating within the globe
 IOP impaired op. conditions
expulsion of intra-ocular contents
 Mild IOP  improved op. conditions

24.  Increasing  Decreasing
 External pressure e.g. face   Venous pressure
mask   Arterial pressure
  Venous pressure  Hypocarbia
  Arterial pressure  IV induction agents
 Hypoxia  NDMRD
 Hypercarbia  Aqeous volume
 Succinylcholine, Ketamine (acetazolamide)
 Laryngoscopy  Vitreous volume
 Coughing (mannitol)

25.  Careful with face mask
 No ketamine
 Laryngoscopy after completely paralyzed
 4% Xylocaine topical anesthesia at vocal cord
 Head up tilt
 Monitoring: ECG, oximeter, capnograph and
peripheral nerve stimulator if available

26.  Continue volatile agent until spontaneous
respiration is resumed after reversal
 Anti-emetic may be administered
 No food/drink for 3 hours to reduce the
possibility of aspiration of gastric contents
★
If no muscle relaxants and patient breathes
spontaneously, the depth of anesthesia must
be increased to prevent coughing or straining
against the tube.

28.  Avoid nitrous in vitreoretinal surgery
 Bubbles of sulphurhexafluoride (SF3)
 Emergence without coughing
 Deep extubation
 Lignocaine on cords
 Bolus lignocaine/ propofol beforehand

29. ?
Scoline or not?

32.  Traction on EOM may cause sudden and
profound bradycardia via oculocardiac reflex
mediated by CN X
 Occasionally seen during other forms of eye
surgery e.g. retinal detachment

35.  Prevention
 Moderated by LA (abolish afferent arc)
 Avoid hypoxia/hypercapnia (sensitizes the reflex)
 Prophylactic anticholinergic ★ esp in children
 Management
 STOP stimuli at once
 Ensure adequate ventilation
 Ensure sufficient anesthetic depth
 If needed, atropine 0.02 mg/kg IV

36. Is atropine useful?
 Controversial
 0.4 mg IM as a premedicant has no vagolytic
effect after 60 min and is of no value in
preventing or treating OCR
 0.4 mg IV is effective for 30 minutes in
preventing bradycardia associated with the
OCR
 Doses >0.5 mg IV can cause tachycardia★

37.  Examination in children can often be provided
satisfactorily via a face mask
 If the naso-lacrimal duct is to be irrigated
 Intubation or
 Positioning the patient with a pillow under the
shoulders
 Ketamine can also be used but pre-medication with
atropine is essential to prevent laryngospasm caused
by excessive secretions.

38.  If sedation is required Midazolam (0.5 -1 mg) with
Fentanyl 25 – 50 mg or Propofol 20 mg.
 Peribulbar block is advisable when axial length is
less than 26mm and patient can lie flat & still.
 Haelan (Sodium Hyaluronate) is injected at the time
of incision to maintain the shape of anterior
chamber and controls the vitreous bulge.

39.  Cataract Surgery can be performed under Regional
Anesthesia without discontinuing anticoagulant
therapy (Prothrombin Time 1.5 times control).