Anaesthesia for Eye
Surgery
Overview
• Goals of Anaesthetic Care
• IOP
• GA
• Regional Anaesthesia
• Oculomedullary reflexes
• Types of Surgeries: Strabismus, Glaucoma, Cataract,
Enucleation and evisceration, Penetrating Eye Injury
• Summary
• The goals of anesthetic care during elective eye
surgery:
• pain-free surgery
• facilitation of the surgical procedure
• rapid recovery
• minimization of risks associated with surgery and
anesthesia.
Intraocular pressure – IOP
• Definition: Tension exerted by the contents of the globe on the surrounding
corneo-scleral envelope.
• Ranges: 10-20 mmHg.
• Increases with age.
• Normal diurnal variation of 2-3 mmHg with higher pressures in the morning.
• IOP may differ by up to 5 mmHg between eyes.
• IOP changes from sitting to supine position from between 0.3-6 mmHg.
• Transient rises in IOP are seen with coughing, straining and vomiting, but are of
no consequence to the intact eye. Prolonged rises in IOP however, may cause
progressive loss of vision.
• The control of IOP is therefore a function of:
• production of aqueous humour
• resistance to aqueous outflow
• episcleral venous outflow
• Aqueous humour :This is a clear fluid that fills the anterior
and posterior chambers of the eye. Its volume is about 250 μL
and is produced at a rate of 2.5μL/min.
Mode of anesthesia
• General anaesthesia
• Local anaesthesia
• Regional anaesthesia
GA
• Induction
• Intubation – Should be smooth
• No coughing- deep anaesthesia and profound
paralysis
• The Intraoccular pressure is affected by
laryngoscopy and endotracheal intubation
Reduced by admistration of IV lidocaine 1.5mg/kg) +
opioids like remifentanyl
Monitoring and maintenance
• Patient’s airway is away from anaesthetist
• ETT kinking, breathing circuit disconnection and
unintentional extubation may occur
• Avoid by using RAE tube
• ECG and pulse tones
• Infants body temperature – draping
• Medication for PONV
Extubation and emergence
• A smooth extubation
• Moderate deep level of anaesthesia – to avoid
coughing and gagging
• IV lidocaine (1.5mg/kg) admistration before
extubate(1-2min)
• Adequate pain relieve is necessary – scleral
buckling, enucleation and ruptured globe repair
• GA and the physical intervention by the
anaesthetist affects IOP.
• Laryngoscopy and intubation causes a rise in IOP
and to a lesser degree the insertion of a laryngeal
mask airway.
• Any coughing or gagging during extubation also
causes a rise in IOP.
Factors that increase IOP
Laryngoscopy – pressor
response, orstraining in Scoline –contract
the extraocular PONV
an inadequately relaxed
pt muscles
Large volume of LA External compression of
placed in th orbit. globe by tightly applied Steroid
This effect is FM
transient
Factors that decrease IOP
Non- depolarization
Induction agent –by
muscle relaxant by Head up tilt at 15^,
decrease arterial and
reduction in tone of assist venous drainage
venous pressure
extraocular muscle
Moderate hypocapnoea
(26 to 39mmhg) reduce Mannitol -by removing Acetazolamide –reduce
choroidal blood volume fluid from the vitreous aqueus production by
by vasocontriction of ciliary body
choroidal vessels
• Anaesthetic drugs may act via a number of ways to
reduce IOP :
• a direct effect on the central diencephalic control
centre
• reduction of aqueous humour production
• facilitation of aqueous drainage
• relaxation of extraocular muscle tone
Factors that affect IOP
Arterial blood pressure Venous
Drugs
pressur
e– Partial pressures
of oxygen (pO2)
and carbon
blood flow in
dioxide (pCO2)
the human eye
remains Reduce in IOP Increase in
Head up tilt Metabolic IOP
constant over a decreases
range of acidosis mannitol
venous decreases
perfusion congestion (0.5mg/kg
pressures due IOP and iv) which
reducing IOP metabolic
to and vice versa. works by
autoregulation alkalosis removing
of retinal and increases fluid from
choroidal IOP. the
coughing,
circulations. A straining, vitreous Depolarisin
. A rise in
decrease in vomiting and and g muscle
pCO2
choroidal blood Valsalva relaxants
secondary to acetazola
volume is manoeuvre will cause a
any cause of mide
thought to cause venous small,
hypoventilatio (500mg
cause the congestion transient
n and hypoxia iv) which
reduction in thereby results in acts to
IOP.
. A fall in systemic increasing dilation of the decrease
blood will reduce IOP, intraocular choroidal aqueous
but only becomes vessel volume vessels and a humour ine
significant at pressures and reducing rise in IOP, productio ketam
below 90 mmHg. episcleral n by the
venous ciliary
drainage body.
causing a rise
in IOP.
Regional
• Retrobulbar block
• Peribulbar block
• subtenon’s block (episcleral block)
• Facial nerve block
Insertion point
-1st:junction of medial 2/3rd and
lateral 1/3rd of lower lid adjacent
and parelal to orbital floor
-2nd –just infero-medial to supra
orbital notch or just medial to
medial canthus
• Injection of LA following a peribulbar or
retrobulbar block will cause a rise in IOP: transient
and depends on the rate and volume of injection.
OCULOMEDULLARY
REFLEXES
Oculocardiac Oculoemetic
Oculorespiratory
Oculocardiac reflex
• causes bradycardia, nodal rhythms, ectopic beats or sinus
arrest due to pressure, torsion or traction on the
extraocluar muscles
• It is a trigemino-vagal reflex – the afferent arc is via long
and short ciliary nerves to the ciliary ganglion and the
ophthalmic division of the trigeminal nerve with the
efferent impulses conveyed by the vagus.
• most commonly occurs in paediatric squint patients.
• Hypercarbia sensitizes the reflex and should be avoided.
Triggers : compression/ traction to extraocular muscle
↓
Stimulation of short ciliary nerve
↓
Ciliary ganglion Oculocardiac reflex
↓
(Aschner reflex)
Gasserion ganglion
↓
CVS centre at medulla
↓
Send stimulation via CN 10 :vagus
↓
Increase parasympathetic tone Reduce SA output Bradycardia, hypotension
How can we prevent it?
• Avoid compression or traction of the eye
• Retrobulbar blockade or deep inhalational
anesthesia
• Anticholinergics - Atropine or glycopyrrolate
Management during occulocardiac reflex?
• Notify surgeon and temporary cessation of surgical
stimulus until heart rate increases
• Confirm adequate ventilation, oxygenation, depth
of anaesthesia
• Administer atropine 10mcg/kg
• If recalcitrant, infiltrate rectus of muscles with LA
• The reflex eventually fatigues with repeated
traction
Oculorespiratory reflex
• may cause shallow breathing, reduced respiratory rate and
even full respiratory arrest.
• The afferent pathways are similar oculocardiac reflex and it
is thought that a connection exists between the trigeminal
sensory nucleus and the pneumotactic centre in the pons and
medullary respiratory centre.
• Again this reflex is commonly seen in strabismus surgery
and atropine has no effect.
• If controlled ventilation is not routinely employed then extra
attention is needed.
Oculoemetic reflex
• is likely responsible for the high incidence of
vomiting after squint surgery (60- 90%).
• A trigemino-vagal reflex with traction on the
extraocular muscles stimulating the afferent arc.
• Whilst antiemetics may reduce the incidence, a
regional block technique provides the best
prophylaxis.
Strabismus surgery
• Affects 3 – 5% of the population, esp. paediatric eye
surgery.
• Squint correction is achieved by lengthening
(recession), shortening or tightening (resection) or
transposition of any of the four rectus and two
oblique extra-ocular muscles, or combinations of
any of the above.
Strabismus surgery
• Induction technique, method of airway control and choice of
ventilation according to the preference of the anaesthetist.
• Maintenance of anaesthesia is usually achieved with a
volatile anaesthetic agent and air; the use of total intravenous
anaesthesia (TIVA) has been shown to reduce PONV.
• Consider atropine 20mcg/kg IV or glycopyrolate 10mcg/kg
IV as high incidence of oculocardiac reflex.
Strabismus surgery
• PONV is common, up to 50 – 75%. Giving two
anti-emetic agents such as ondansetron 0.1
mg/kg IV and dexamethasone 0.1-0.2 mg/kg IV
can reduce this to 10%. (20,21,22).
• Ideally extubate the child deeply.
• Analgesia should include topical LA, NSAIDS
such as ibuprofen or diclofenac and
paracetamol, unless contraindicated.
Strabismus surgery
• Intraoperative opioids should be avoided due to the
high incidence of PONV, but where necessary,
consider the use of fentanyl.
• A peribulbar block is effective for analgesic
requirements and reduces PONV
• A sub-Tenon block performed intraoperatively by
the surgeon can be very effective for analgesia.
Glaucoma
• The pressure within the eye is maintained through a
balance between the production of aqueous humor by the
ciliary body in the posterior chamber, and drainage via
the trabecular network to the canal of Schlem in the
anterior chamber.
• In glaucoma the normal IOP of 10 – 20 mmHg becomes
elevated such that capillary blood flow to the optic nerve
becomes reduced, compromising the function of the optic
nerve.
Glaucoma
• Avoid raising the IOP by ensuring a smooth induction
and deep emergence without coughing.
• Maintain a motionless eye; consider paralysis and
controlled ventilation to avoid hypercapnia.
• Analgesia with paracetamol and NSAIDS is usually
adequate, however when cyclocryotherapy is used
opioids may be necessary.
• High incidence of PONV – routine anti-emetics.
Cataract extraction
Anaesthetic considerations:
• Aim for a motionless eye either with deep
anaesthesia or a paralysed patient.
• Avoid high IOP with a smooth induction and
emergence.
• Consider controlled ventilation to avoid
hypercapnia.
• Give anti-emetics.
Enucleation and evisceration
• Enucleation is the removal of the whole eye.
• Surgical treatment of a retinoblastoma, significant eye trauma or
for cosmetic reasons where an eye is blind.
• It involves the dissection of the extra-ocular muscles off the
globe.
• Similar risk here for the oculocardiac reflex, although less risk of
PONV, and should manage the case as for strabismus surgery.
• Evisceration involves the removal of the contents of the globe,
but retention of the sclera. This procedure is often painful and
opioid use should be considered .
Penetrating eye surgery
• Common injury in children
• Primarily boys between 3 and 9 years, and requires
surgery to close the defect or remove a foreign body.
• Surgery is urgent as anything that raises IOP (coughing,
straining) may cause the globe to extrude its contents
Penetrating eye surgery
• Two conflicting anaesthetic problems:
• Full stomach so a RSI with suxamethonium is
indicated in order to prevent aspiration.
• Protect the globe from a rise in IOP that could
result in extrusion of the structures of the anterior
chamber or the vitreous humor. The transient rise
in intraocular pressure produced by the use of
suxamethonium could theoretically cause this.
Penetrating eye surgery
• One approach recommends the use of a large dose of
non-depolarising muscle relaxant (NDMR) and
ventilation with cricoid pressure until intubating
condition is achieved, providing the child has a normal
airway
• The advent of suggamadex a drug that can rapidly
reverse rocuronium (rapid onset, long acting muscle
relaxant) may allow rapid sequence induction using
rocuronium to be used as an alternative technique in the
presence of a more challenging airway.
Penetrating eye surgery
Other considerations include:
• Crying, coughing and straining should be avoided; consider light
oral sedation and analgesia preoperatively.
• Direct larygnoscopy of a poorly paralysed airway can cause
coughing and bucking, whichever technique is used.
• Consider blunting the intubation response prior to laryngoscopy.
Administer lidocaine 1 -2 mg/kg IV given 3 minutes prior to
rapid sequence intubation during preoxygenation
• Consider monitoring the child with a nerve stimulator after
adminstration of the muscle relaxant.
Vitreoretinal surgery
• Repair of a detached retina
Anaesthetic considerations:
• Avoid nitrous oxide if an intraocular gas bubble is used.
• Controlled ventilation and paralysis should be
considered for maintaining a still eye and avoiding
raised IOP during the procedure.
• This procedure is painful and analgesia including
opioids should be considered.
• Anti-emesis should be used routinely
• Avoid raised IOP during extubation
Questions
1. The following drugs decrease intraocular pressure:
• Enflurane
• Nitrous oxide
• Etomidate
• Ketamine
• Suxamethonium
2. The oculocardiac reflex
• Occurs on traction of the medial rectus
• Does not occur with retrobulbar block
• May be obtunded by local anaesthetic infiltration
of ocular muscles
• Is most active in the elderly
• Precipitates non-sinus dysrhythmias
3. The following will raise the intraocular pressure in
the normal eye:
• Hypercarbia
• Acetazolomide
• Atropine
• Hypotension
• Respiratory obstruction
4. Contraindications to local anaesthesia for eye
surgery include:
• Glaucoma
• Inability to lie flat
• Procedures that last more than 90 minutes
• Penetrating eye injury
• Retinal detachment
References
• Morgan and Mikhail’s clinical anesthesiology
• [Link]
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