Anesthesia Management of Ophthalmic Surgery in Geriatric Patients
Zhuang T. Fang, M.D., MSPH
Clinical Professor
Associate Director, the Jules Stein Eye Institute Operating Rooms
Department of Anesthesiology and Perioperative Medicine
David Geffen School of Medicine at UCLA
1. Overview of Ophthalmic Surgery and Anesthesia
Ophthalmic surgery is currently the most common procedure among the elderly population in
the United States, primarily performed in ambulatory surgical centers. The outcome of
ophthalmic surgery is usually good because the eye disorders requiring surgery are generally
not life threatening. In fact, cataract surgery can improve an elderly patient’s vision
dramatically leading to improvement in their quality of life and prevention of injury due to falls.
There have been significant changes in many of the ophthalmic procedures, especially cataract
and retinal procedures. Revolutionary improvements of the technology making these
procedures easier and taking less time to perform have rendered them safer with fewer
complications from the anesthesiology standpoint.
Ophthalmic surgery consists of cataract, glaucoma, and retinal surgery, including vitrectomy
(20, 23, 25, or 27 gauge) and scleral buckle for not only retinal detachment, but also for diabetic
retinopathy, epiretinal membrane and macular hole surgery, and radioactive plaque
implantation for choroidal melanoma. Other procedures include strabismus repair, corneal
transplantation, and plastic surgery, including blepharoplasty (ptosis repair),
dacryocystorhinostomy (DCR) for obstruction of the tear ducts, orbitotomy for orbital tumor or
exophthalmos secondary to hyperthyroidism, and trauma to repair a ruptured globe or orbital
fracture.
In general, ophthalmic surgical procedures are considered low risk because of the low incidence
of large volume blood loss (although DCR and orbitotomy can potentially lose up to several
hundred milliliters of blood), and lack of major fluid shifts or prolonged duration (except for
some complex procedures such as complicated corneal or combined retinal surgery and corneal
transplantation, which can be last up to 4 to 5 hours). However, ophthalmic procedures are
associated with unique complications, such as:
1) oculocardiac reflex (a trigemino-vagal reflex leading to variety of arrhythmias including
cardiac arrest),
2) brain stem injection of local anesthetics during retrobulbar block which can cause not only
respiratory failure requiring intubation, but also either profound hypotension and
tachycardia or profound hypertension and tachycardia depending on whether the
parasympathetic or sympathetic nerves are blocked,
3) loss of ocular contents due to patient movement or coughing during corneal or retina
surgery,
4) increased intraocular pressure (IOP) and/or bleeding during extubation and emergence
from anesthesia due to patient coughing and bucking,
5) anxiety or panic attack because of the surgical drape that covers patient's face,
6) postoperative impairment of vision from the eye patch or surgery itself (which raises
concern for the risk of falling at home, especially if patients also have poor vision for their
nonsurgical eye and live alone),
7) pain after enucleation and more complex procedures.
In addition, elderly patients undergoing general anesthesia face the same stress response from
intubation, extubation and surgical stimulation, and the side effects of volatile and or
intravenous anesthetics as any younger patient having any other surgery. More importantly,
the underlying comorbidities place the geriatric patient at higher risk for anesthetic or medical
complications. Their high prevalence of risk factors, such as hypertension, diabetic mellitus,
renal insufficiency, chronic heart failure (CHF), and chronic obstructive lung disease (COPD)
increase the incidence of perioperative myocardial ischemia to as high as 31 %. The mortality
rate within 90 days of cataract surgery is 7.1 per 1,000 patients. In addition, surgical or
anesthetic complications can also occur due to mishaps in the management of this high risk
patient population. Poor outcomes are less likely to be accepted by patients, their family
members, and health care providers because of the misperception of the "low surgical risk" of
ophthalmic surgery in the general population. Anxiety is very common among elderly patients
undergo ophthalmic surgery. Even in patients whose hypertension is reasonably well
controlled at home, it is not uncommon that these patients become severely hypertensive on
the day of surgery. Similar phenomenon can also occur in patients with diabetes, especially in
insulin-dependent patients. It is a challenge for health care providers to take care of the
geriatric patient undergoing ophthalmic procedure safely and efficiently for all of these
reasons. It requires all medical subspecialists to understand the details of the ophthalmic
procedure, and recognize the additional burden on the patient’s underlying comorbidity from
the physiological changes caused by mental stress, surgery and anesthesia.
2. Anesthesia Management
The challenges of anesthesia management of geriatric patients undergoing ophthalmic surgery
are numerous. The volume of procedures is high; the demand for high efficiency and quick
turnover in the operating rooms is high; there is a variety of comorbidities in this population;
there is high expectation of surgery and anesthesia outcomes. From a business standpoint, if
you consider ophthalmic procedures as an "assembly line" operation, any variation along the
"assembly line", including preoperative evaluation and optimization, patient arrival time on the
day of surgery, anesthesia induction time and emergence time, and postoperative recovery and
post anesthesia care unit (PACU) turnover, and the skill and comfort level of the anesthesia
providers can become potential "bottlenecks" of the process. The best strategy to deal with
the challenge is to have a realistically workable system in place in order to tightly control the
variables and provide the highest possible care to our geriatric patients.
1) Preoperative evaluation. Adequate preoperative evaluation is part of the standard of care
according to the American Society of Anesthesiologists (ASA). Ophthalmic surgery patients are a
high-risk population due to the advanced age and associated comorbidities such as
hypertension, diabetes mellitus, coronary artery disease, peripheral vascular disease, chronic
obstructive pulmonary disease (COPD), renal deficiency, obesity, stroke, and chronic heart
failure. A patient’s primary care physician (PCP) plays an important role in the process to
provide adequate information regarding comorbidities (history and physical examination, H/P),
necessary laboratory tests, electrocardiogram, and more advanced testing if medically
indicated. Ideally, every patient should be screened either in person or by telephone by an
anesthesia provider or an advanced nurse practitioner in addition to the PCP.
The goal of the preoperative evaluation is not only to discover underlying medical conditions of
the geriatric patient, but more importantly to make sure those conditions are optimized and
clinically stable in order to handle the stress associated with surgery and anesthesia. It is an
over simplification to characterize all ophthalmic surgeries as low risk procedures. For example,
the stress that a patient undergoes for a 10-minute cataract surgery under monitored
anesthesia care (MAC) will be much less than a three to four hour combined corneal
transplantation and retinal surgery under general endotracheal anesthesia. Without adequate
preoperative evaluation, it is a guessing game for anesthesiologists to determine which patients
will be able to tolerate the stress of surgery and anesthesia, which patients will most likely be
able to go home without complications, and which patients will require hospital admission.
Most ophthalmic surgeries are performed at free-standing ambulatory surgical centers, in
which invasive hemodynamic monitoring, echocardiogram capability, and cardiology
consultation are not readily available. Because of these limitations, some patients will be
determined not to be candidates for ambulatory surgery; they include patients with ASA
physical status 4 (refer to a patient with severe systemic disease that is a constant threat to
life), morbid obesity (BMI > 40), and those likely to require hospitalization postoperatively.
Although preoperative laboratory testing has not been shown to improve perioperative and
postoperative outcome in cataract surgery, specific tests guided by a patient’s medical
problems are helpful to access the severity of organ dysfunction and are valuable in
perioperative anesthesia management.
In general, an electrocardiogram (ECG) is indicated when there is underlying cardiac disease or
advanced age to identify changes, arrhythmia, and the presence of myocardial ischemia. When
arrhythmias occur perioperatively, the preoperative ECG becomes an important baseline
reference. Further tests include echocardiogram and exercise or pharmacological stress tests
to evaluate the patient's functional capacity and the presence of ischemia. Test selection will
depend on the patient's cardiac symptoms, exercise tolerance, and the type of surgery and
anesthesia in accordance with the American Heart Association and American College of
Cardiology (AHA/ACC) guidelines.
As many elderly patients live alone at home, their safety after surgery is a legitimate concern.
The patient may have residual effects of the sedatives they received intraoperatively, increasing
the risk of falls; there are additional risks if the non-surgical eye also has impaired vision.
Ideally, a responsible adult is arranged preoperatively to watch and help the patient at home, at
least overnight, until the patch is removed and full recovery from anesthesia is achieved.
2) Intraoperative management. The intraoperative management of ophthalmic anesthesia
requires thoughtful planning, skillful technique, and patience in covering the broad spectrum of
procedures, from a short 10-minute cataract surgery under MAC, to a multiple-hour
complicated corneal transplantation under general anesthesia. The key strategy of intra-
operative anesthetic management is summarized below:
a) Because of the natural physiological changes of age, the pharmacodynamics and
pharmacokinetics of drugs in geriatric patients are dramatically different compared to their
younger counterparts. In general, the required dose of drugs is smaller, the onset of action is
slower, and respiratory and myocardial depression is more profound. Underlying disease might
complicate these changes further. For example, in a patient with severe cardiomyopathy
(ejection fraction of 20 %), the onset of drugs will be further delayed and the duration of drug
effects will be prolonged. Careful, slow titration is necessary when sedatives and/or narcotics
are used in geriatric patients.
b) Fast-track anesthesia has been a safe choice for ophthalmic procedures in elderly patients.
(Fast-track anesthesia refers to the art and science of swiftly moving patients out of the OR and
PACU and sending them home in short periods.) Short acting drugs, such as propofol, alfentanil,
remifentanil, and fentanyl, have all been used with good results. A balanced technique, with a
combination of propofol and narcotics, has been shown to be highly effective in providing
analgesia with a moderate level of sedation for orbital blocks. It has the advantage of quick
onset, short duration, and low risk of respiratory complications.
c) Prevention of coughing and bucking is an important part of ophthalmic anesthesia
management, especially during general anesthesia. Coughing can increase intraocular pressure
by 40 to 60 mmHg which can lead to optic nerve ischemia, result in bleeding (especially in DCR
and orbitotomy) and challenge the incisional integrity. Coughing and bucking during
emergence from general anesthesia can also trigger laryngospasm and bronchospasm,
especially in patients with asthma, COPD, or an acute upper respiratory tract infection. If there
is no contraindication, a deep extubation should be strongly considered.
d) Prevention of nausea and vomiting is also a significant part of ophthalmic anesthesia.
Ophthalmic procedures carry a very high incidence of post-operative nausea and vomiting
(PONV), as high as 60 - 70% in strabismus repair. The act of vomiting can raise intraocular
pressure as well. Administration of dexamethasone, ondansetron, adequate hydration, total
intravenous anesthesia (TIVA) and avoidance of nitrous oxide are effective in prevention of
PONV, especially if general anesthesia is required.
e) Prevention of head and body movement during retrobulbar block is essential to prevent
injury to the globe and retrobulbar hemorrhage. In the closed claim study of MAC, 26 % of the
eye injuries during retrobulbar block were associated with head movement. Retrobulbar block
is a very effective block in providing analgesia for ophthalmic procedures, but it can be painful
to perform, especially in patients with a high level of anxiety or the expectation of
"painlessness". Sedation techniques which produce profound analgesia and a moderate level
of sedation are ideal in these cases.
3) Postoperative management. Patients undergoing short procedures under MAC, including
cataract, glaucoma, simple vitrectomy or minimal plastic surgery, can bypass Phase I recovery
and enter Phase II recovery. (Phase I focuses on providing post-anesthesia care in the
immediate post-anesthesia period, with basic life sustaining needs of the patient at the highest
priority and constant vigilance required. Phase II focuses on preparing the patient for care at
home or in an extended care environment.) The average time in the PACU is about 30 to 60
minutes. Since ophthalmic procedures are associated with a high frequency of bradycardia or
other arrhythmias, especially in geriatric patients, continuous ECG monitoring in the PACU is
necessary.
The pain associated with eye surgery is usually mild to moderate and can be treated with oral
or intravenous NSAIDs. However, if the patient’s surgery is complicated by increased IOP,
severe eye pain, nausea, and vomiting can occur. Therefore, an elevation in IOP needs to be
ruled out before large dose of narcotics is administrated for pain, or in patients with refractory
PONV.
3. Ophthalmic Procedures and Their Implications to Anesthesia
1) Cataract surgery. The time to perform a cataract surgery varies from 10 minutes to 40
minutes depending on the density of the cataract, the patient’s cooperation, and the skill and
experience of surgeons. Pain control of the procedure can be achieved by either regional block
(retrobulbar, peribulbar, or sub-tenon blocks) or topical anesthetics (tetracaine or lidocaine)
with intracameral lidocaine, although the latter is gaining popularity currently. General
anesthesia is reserved only for patients with severe mental or cognitive dysfunction, or for
severe claustrophobia. Typically, one surgeon can performed 10 to 20 cataract surgeries per
day.
Since the cataract surgery is very similar between cases, 10 to 20 procedures can be performed
by a single surgeon per day. The small surgical incision without suture required for the cataract
surgery makes topical anesthesia with mild sedation possible. Safely managing this patient
population with significant comorbidity and maintaining smooth operating room work flow
during quick turn-over between cases requires good team work. Adequate preoperative
patient evaluation, efficient patient preparation on the day of surgery, careful titration of
sedatives during MAC to make sure patients are comfortable without pain or movement, and
rapid recovery in the PACU are all important aspects of anesthetic management. Adequate
sedation, avoiding over or under sedation, is especially important during cataract surgery under
topical or local anesthetics. Producing a cooperative patient with globe akinesis is a challenge to
anesthesia providers; every patient hasis different underlying medical conditions, expectation
of sedation, and response to medication. The "balance technique" is a combination of small
doses of propofol and narcotics. It is superior to a larger dose of a single agent in the
prevention of pain during regional blocks, in the maintenance of sedation, and in avoiding over
sedation leading to patient accidental movement when the drug effects wear off.
2) Glaucoma surgery (trabeculectomy, angle procedures, and tube shunt procedures (e.g.
Ahmed Glaucoma Valve and other implants)). It takes approximately 30 to 60 minutes to
perform a glaucoma procedure. Regional block, either retrobulbar, peribulbar, or sub-tenon
block, is usually required for the procedure. The incidence of complications associated with
retrobulbar block is about 1%, including global perforation, retrobulbar hemorrhage, brain stem
injection of local anesthetics, and oculocardic reflex.
The anesthesia consideration is similar to cataract surgery. However, cauterization, dissection
of the conjunctival and scleral tissue, suturing, and manipulation of the iris are all necessary,
leading to postoperative pain. Patients taking anticoagulants are usually advised to stop prior
to surgery because they might increase surgical complications. A moderate level of
sedation/analgesia is often needed to release patients' anxiety and pain if the regional block is
incomplete, which occurs in 1-5% of cases. One surgeon can potential perform 8 to 12 cases a
day. Minimizing delay from human factors during case turn-over requires concise preoperative
patient evaluation, preparation, and intraoperative management, and ensures the efficiency of
the operating rooms.
3) Retinal surgery. The time needed for retinal surgery by vitrectomy alone varies from as short
as 15 minutes for peeling of an epiretinal membrane to several hours for complex retinal
detachment repair. It is usually performed under MAC with retrobulbar block. Scleral buckling
is another method for retinal detachment repair, and involves placement of a silicone band or
sponge around the sclera. This requires access to the orbit and extraocular space and is
therefore more invasive compared to vitrectomy in terms of tissue injury and manipulation.
Similar invasiveness is required for brachytherapy for choroidal melanoma. The procedure
involves suturing a radioactive plaque directly to the sclera, which often requires deep
dissection into the orbit as the largest plaques can reach up to 23 mm in diameter.
Anesthesia can be achieved by retrobulbar block with a relatively larger volume of local
anesthetics plus MAC with adequate dosing of intravenous opiates and sedatives. Alternatively,
general anesthesia can be utilized, depending on the surgeon's preference and patient's
underlying medical conditions.
4) Strabismus surgery. It takes 15 to 30 minutes to repair one eye muscle during a strabismus
repair procedure. However, it could take two to three hours to complete a multi-muscle repair
in bilateral eyes.
Although strabismus repair can be performed under topical anesthetics and MAC for simple
repair, e.g. one to two muscles in only one eye, the majority of procedures are under general
anesthesia. A cooperative patient under MAC during strabismus repair will ideally allow
surgeons to check on the result of the procedure while in the operating room. The final tie-up
of the adjustable sutures is usually performed several hours later in the post anesthesia care
unit (PACU) after patients return to their baseline mental status from general anesthesia, which
could potentially delay patient turnover in the PACU. When general anesthesia is used,
laryngeal mask airway (LMA) is preferred since it causes less irritation to the oropharynx as well
as fewer hemodynamic changes. However, one needs to keep it in mind that LMA is not a
secured airway; the airway is difficult to control if laryngospasm occurs or the sealing of the
LMA fails, especially when the patients' head and airway are remote from the anesthesia
provider during ophthalmic procedures. Strabismus repair causes the highest incidence of
oculocardiac reflex, especially when the medial rectus ocular muscle is manipulated. The
oculocardiac reflex mainly causes sinus bradycardia, but also may cause other types of
dysrhythmia, including PAC, PVC, atrioventricular heart blocks and asystole. Vigilant
monitoring of the cardiac rhythm by electrocardiogram and prompt treatment is imperative.
The incidence of postoperative nausea and vomiting (PONV) is very high in strabismus surgery
making prophylactic treatment of PONV necessary.
5) Corneal transplantation. There are several techniques of corneal transplantation, namely
Penetrating Keratoplasty (PKP), Descemet's Stripping Automated Endothelial Keratoplasty
(DSAEK), Descemet’s Membrane Endothelial Keratoplasty (DMEK), Deep Lamellar Endothelial
Keratoplasty (DLEK), and Keratoprothesis. The majority of corneal transplantation is
performed under MAC with retrobulbar block, although general anesthesia is still needed for
uncooperative patients, prolong combined procedure with vitrectomy, in patients where
retrobulbar block is contraindicated because of their anatomy (e.g. very long axis of the globe
or very tight fissure or small orbit), or after trauma.
Depending on which technique is used, corneal transplantation takes about one to two hours to
complete. The majority of the surgery is under MAC with retrobulbar block, although general
anesthesia is also a common practice. Between the time that the diseased cornea is removed
and the new cornea is secured, patient's globe is fully open and the IOP is the same as
atmosphere. Any movement in the patient can cause a loss of intraocular contents leading to
blindness. Therefore, during this critical time period, a motionless patient is absolutely
required. If patients are under MAC it is important to provide moderate level of sedation to
relieve anxiety and pain but also to avoid over sedation. When elderly patients wake up from
deep sedation in the middle of the procedure, not only they can move without warning, but
their movement is also difficult to control due to their delirium and confusion. If the patient is
under general anesthesia, a muscle relaxant is usually used to provide total paralysis until at
least four sutures are secured on the new cornea. The administration of muscle relaxants are
guided by a nerve stimulator. The recovery time from a muscle relaxant can be considerably
longer in geriatric patients depending on the drug dose, the half-life, the patient's body
temperature, kidney function, and hepatic function. It is always a safe practice to give reversal
medication (neostigmine) only after the surgery is completed, the surgical table is turned back
to the control of the anesthesia providers, the patients are suctioned before weaning the
anesthetics, and a strong 4 of four twitches is demonstrated. Sometimes, waiting until the
muscle relaxant is maximally metabolized and excreted by the kidney before reversal is given
can enhance complete recovery. Suctioning of the patients' airway before turning off the
anesthetics is also an important practice to prevent coughing and bucking. If there is no
contraindication, extubation of patients' endotracheal tube while the spontaneously breathing
patient is at a deep anesthetic level can effectively prevent coughing and bucking, especially in
asthmatic, COPD patients, or patients having acute upper respiratory infection. Infusion of
propofol as total intravenous anesthesia (TIVA) or as a supplement to volatile agents can also
effectively prevent coughing and bucking in smokers and postoperative delirium.
6) Plastic surgery. Ptosis repair or blepheroplasty takes about 30 minutes to two hours
depending on the extensiveness of the repair. It is performed almost exclusively under MAC
with injection of local anesthetics. The presence of 1:100,000 (10 mcg/ml) concentration of
epinephrine with 2% lidocaine can potentially cause tachycardia, hypertension, and
dysrhythmia after the injection, technically mimicking a stress test in an elderly patient. The
concentration of epinephrine contained in the lidocaine injection should be further diluted to
1:200,000 or removed totally in patients who cannot tolerate tachyarrhythmia due to their
underlying cardiac diseases. It is very important to monitor the total dose of lidocaine injected
during the procedure in order to prevent lidocaine toxicity, especially if the procedure is
prolonged and multiple injections are required. In general, the maximum dose of lidocaine
without epinephrine is 3 to 5 mg/kg, and 5 - 7 mg/kg with epinephrine. Orbitotomy and
dacryocystorhinostomy (DCR) are much more invasive in terms of tissue injury and potential of
bleeding compared to eyelid procedures, and take about one to two hours to finish.
Procedures involving the bony structure of the orbital wall or the nasal opening of the tear duct
have the potential for greater pain. Most surgeons prefer to perform both procedures under
general anesthesia because of their concern that patients' pain control may not be adequate by
MAC, exacerbating patient movement intraoperatively. However, some experienced surgeons
prefer to perform these procedures under MAC with injection of local anesthetics based on
their belief that general anesthetics, especially the volatile agents, will cause significant
dilatation of the blood vessels in the surgical field leading to excessive bleeding, making the
visualization of the anatomy more difficult and increasing the risk of surgical complications. At
UCLA, both MAC and general anesthesia are provided depending on the surgeons' preference
and the experience and comfort level of the anesthesia providers. Laryngeal Mask Airway is
used in most of the orbitotomy and DCR cases unless aspiration becomes a major concern, and
in cases bleeding is highly possible (e.g. hemangioma of the orbit or repeat DCR), in which cases
endotracheal intubation is preferred.
Most ophthalmic surgery is performed to improve patients' vision (cataract, corneal
transplantation, retinal detachment) or prevent further deterioration (glaucoma, diabetic
retinopathy), both of which goals are important in improving the elderly patients' quality of life.
For health care providers, taking care of the geriatric population undergoing ophthalmic surgery
requires tremendous work, but is very rewarding.
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