PRESENTER : DR. RAJESH .

M
MODERATOR : DR. RONY MATHEW
HOD : DR. ARUN KUMAR A
SSIMS & RC , Davangere
 Anesthesia for EYE surgery presents
many unique challenges.

 In addition to possessing technical

expertise, the anesthesiologist must
have detailed knowledge of ocular
anatomy, physiology, and
pharmacology to prepare appropriate
anesthesia plan.
 Ocular anatomy
 Physiology of intraocular pressure and
effect of anesthetic drug on it,
 Systemic effects of ophthalmic drugs
 Technique of anesthesia: advantage
and limitations
 Pre op evaluation
 General anaesthesia
 Complications
 Oculo cardiac reflex and other reflex
 Specific considerations for eye
surgeries
 Eye
is a sphere measuring appropriately
24mm in diameter
 Themean distance from the inferior
orbital margin to The apex is 55 mm.
3 layers : sclera , uvea , retina
 Movement of the globe is controlled by the
six extra-ocular muscles.
 The eye is hollow sphere with a rigid wall.
 Intraocular pressure 12—20 mmHg
 Middle layer uvea has 3 structures : choroid
, iris and ciliary body .
 Choroid is a layer of blood vessels located
posteriorly.
 Bleeding in this layer is one cause of
intraoperative expulsive haemorrhage .
 Iris
controls light entry through pupil by
change in its size
 Sympathetic : dilates pupil
 Parasympathetic : constricts the pupil.
 Centre of eye is filled with vitreous gel .

 It
has attachments to blood vessels and
optic nerve.

 Traction of vitreous on retina Is a cause

for retinal detachment.
 Tenon’s fascia surrounds the eyeball.

 Itarises from corneo scleral junction ( the

limbus) , fuses posteriorly with the dural
sheath of the optic nerve and seperates
the globe from the intra and extra conal
fat which surrounds the ocular muscles

 Theextraocular muscles and nerves

penetrate this fascia
 Cranial nerve II : optic nerve carries signals
from retina
 III
(oculomotor) , IV (trochlear) , VI (
abducens) control the extra ocular muscles.
 Facialnerve (VII) exits at the skull from the
stylomastoid foramen . It supplies motor
innervation to the orbicularis muscle via the
zygomatic branch.
 Localanesthetic block of facial nerve can
prevent lid squeezing
 Theeye is hollow sphere with a rigid
wall.

 Intraocular pressure 12—20 mm Hg

 If
the contents of the sphere increase,
the intraocular pressure rise.
Any anesthetic event that alters these
parameters can affect intraocular
pressure

 Laryngoscopy
 Intubation
 Airway obstruction
 Coughing
 Trendelenburg position
 Mostanesthetic drugs either lower or
have no effect on intraocular pressure.

 Inhalationalanesthetics decrease
intraocular pressure in proportion to the
depth of anesthesia.

The decrease has multiple causes:

1. A drop in blood pressure reduces
choroidal volume.
2. Relaxation of the extraocular muscles
lowers wall tension
3. pupillary constriction facilitates
aqueous outflow.
 Iv
succinylcholine causes IOP to increase
by 6-12mmhg, this lasts for 5-10mins.

 The use of succinylcholine for induction

of anesthesia in cases of open globe
injury with full stomach has been
controversial .

 Lossof vitreous by succinylcholine has

actually not been reported .
 Topical ophthalmic drugs can be
absorbed through the conjunctiva, or
they drain through the nasolacrimal
duct and be absorbed through the
nasal mucosa.

 Usage of topical medications can have

implications for the anesthesiologist
 Acetazolamide : used for glaucoma, induces
alkaline diuresis and causes potassium
depletion.
 Atropine :The 1% solution contains 0.2 to 0.5
mg of atropine per drop
tachycardia, dry skin, agitation, fever
 Ectothiopate : topical anticholinesterase used
to maintain miosis in treatment of glaucoma :
total body inhibition of plasma cholinesterase.
 Mannitol : catheter required to avoid bladder
distension .
 Increases circulatory volume , can lead to CHF
in patients with poor LV function.
 Phenylephrine : 10%: severe hypertension
2.5%: safer , but can exacerbate hypertension.

Pilocarpine & ach : bradycardia & acute

bronchospasm.

Timolol : bradyardia , bronchospasm ,

exacerbation of CCF .
 The Oculocardiac Reflex(OCR) is
manifested by

 Bradycardia
 Bigeminy
 Ectopics
 Nodal rhythm
 Atrioventricular block
 Cardiac arrest
 Ventricular fibrillation
Caused By:
 Traction on the extraocular muscles
(medial rectus)
 Ocular manipulation
 Manual pressure on the globe

The OCR is seen during:

 Eye muscle surgery
 Detached retina repair
 Enucleation
 Factorscontributing to the incidence of
the oculocardiac reflex:

 Preoperative anxiety
 Hypoxia
 Hypercarbia
 Increased vagal tone owing to age
 Afferent pathway  Efferent pathway

Short and long ciliary Nucleus of vagus

nerves
Cardiac branches
Ciliary ganglion
via ophthalmic
division of trigeminal Bradycardia
nerve
Trigeminal sensory
nucleus
❖One should not panic
❖Ask surgeon to stop all the manipulations
❖Instil local xylocaine(4%)over the surgical
site.
❖Intravenous Atropine 15 micro grams / Kg
or intravenous Glycopyrrolate 7.5 micro
grams / Kg
Ensure
 depth of general anesthesia
 normocapnia
 surgical manipulation is gentle
 May cause shallow breathing, reduced
respiratory rate and even full
respiratory arrest.
 Trigemino vagal reflex- connection
exists between the trigeminal sensory
nucleus and the pneumotactic centre
in the pons and medullary respiratory
centre.
 Commonly seen in strabismus
surgery
 Atropine has no effect.
 Itis likely responsible for the high
incidence of vomiting after squint
surgery (60-90%).
 Trigemino-vagal reflex with traction
on the extraocular muscles
stimulating the afferent arc.
 Antiemetics may reduce the
incidence, a regional block technique
provides the best prophylaxis
 Challenges for the anaesthesiologist are

 Akinesia
 Analgesia
 Minimal Bleeding
 Awareness of drug interactions
 Regulation of intraocular pressure
 Prevention of the oculocardiac reflex
 Management of oculocardiac reflex
 Control of intraocular gas expansion
 Smooth emergence
History Example Problem optimisation

Previous Scleral explant Limit insertion of Use of topical

surgery tenon cannula anesthetic or
peribulbar block
CNS Tremor/movement Unable to lie still Consider GA
disorder/vertigo/an
xiety/confusion
CVS Orthopnea Unable to lie flat Table adjustment
Hypertension Bleeding risk Continue antihtn
RS Dyspnea Unable to lie flat Medical
optimisation
COPD Hypoxaemia 02 + careful
draping to
prevent retention
 Cataract surgery can be performed
safely while maintaining patients
receiving warfarin .
 For intermediate risk procedures such as
some glaucoma procedures , stopping
warfarin for 4 days preoperatively is
indicated .
 For high risk cases for hemorrhage or
thrombosis , conversion from warfarin to
heparin may be required.
 Facial nerve block
 Retrobulbar block
 Peribulbar block
 Sub Tenon block
 Topical anesthesia
 General anesthesia
It is performed when complete akinesis of
the eyelids is desired.

 modified van lint block

 O’brien block
 Nadbath rehman block
 The needle is placed 1cm lateral to the
orbital rim , and 2 to 4ml of anesthetic is
injected deep on the periosteum just
lateral to superolateral and inferolateral
orbital rim .

 Disadvantages : discomfort , proximity to

eye , postop echymoses
 Mandibular condyle is palpated inferior
to the posterior zygomatic process and
anterior to the tragus of the ear as the
patient opens and closes the jaw .
 Needle is inserted perpendicular to the
skin approximately 1cm to the
periosteum.
 As the needle is withdrawn 3ml of
anesthetic is injected.
 A12mm , 25G needle is inserted perpendicular to
the skin between the mastoid process and the
posterior border of the mandible .
 Needle is advanced its full length and after
careful aspiration 3ml of anesthetic injected as
the needle is withdrawn.
 Blocks entire trunk of facial nerve .
 Patient should be told to expect a lower facial
droop for several hours postoperatively .
 Disadvantages: proximity to important structures
such as carotid artery and 12th nerve
 Drug Characteristics
Lignocaine 2% Onset : 5-10min
Duration of anesthesia : 30-60mins
Duration of analgesia : 1-2hr
Bupivacaine 0.5% Onset : 10-15min
Duration of anesthesia : 2-4hr
Duration of analgesia : 6-8hr

Ropivacaine 0.75% Onset : 10-15min

Duration of anesthesia : 1.5-2hrs
Duration of analgesia: 4-6hrs

Lignocaine 2% + bupivcaine 0.5% Onset : 5-10mins

Duration of anesthesia : 1-3hrs
Duration of analgesia: -6hrs
 Provides excellent akinesia and anesthesia for the eye .
 3cm , 23-25G atkinson needle is recommended to protect
against ocular perforation.
 Needle placed at the junction of inferior and lateral wall of
orbit just above the inferior orbital rim .
 Needle advanced approximately 15mm along the wall of the
orbit until it is past the equator of the eye .
 Turned superiorly to aim towards the superior orbit.
 Needle is advanced until it enters between the extraocular
muscles. 2-3ml of anesthetic solution is injected .
 Retrobulbar haemorrhage

 Proptosis

 Subconjuctival echymoses

 Monitoingof IOP : mandatory , if

increased pressure lateral canthotomy is
performed to decompress orbit.
 Accidental intra arterial injection can give
high brain levels via retrograde flow in the
internal carotid artery .

 CNS excitation , seizures and respiratory

arrest are reported.

 Itis thought to be due to injection into optic

nerve sheath which is continuous with the
subarachnoid space.

 Optic nerve damage and ocular perforation

 A blunt 23G 7/8 inch atkinson needle is placed at the
junction of middle and lateral thirds of the lower lid just
above inferior orbital rim .
 1ml is put just below orbital septum
 3ml at equator
 2ml posterior outside the muscle cone.
 If no bulge at superior nasal lid area , 2nd injection of 2-
3ml is administered inferonasally.

 Disadvantages : longer onset (9-12mins) and lower

incidence of complete akinesia .
 Technique using blunt cannula under the fascia of
tenon.
 Using topical anesthesia with sedation , a speculum is
placed to retract the lid.
 A 2-3mm spot of cautery can be made 5mm from the
limbus in the inferonasal and the inferolateral
quadrant .
 A 2mm snip is made in the conjuctiva with blunt
dissection through the fascia of tenon.
 A blunt cannula is directed under fascia of tenon
posteriorly , but not beyond the equator of the globe
with injection of 1-3ml of local anesthetic .
 Excellent analgesia
 Cataract surgeries.

Drugs used are

 Tetracaine 0.5%
 Lidocaine 4%
 0.5% proparacaine

 They block trigeminal nerve endings in

cornea and conjuctiva leaving the
intraocular structures in the anterior
segment unanesthetised.
 Manipulation of iris and stretching of
ciliary and zonular tissues during
surgery can irritate the ciliary nerves
resulting in discomfort.

 Combining 0.5ml of 1% lignocaine

injected through side port incision after
evacuation of aqueous (intrcameral
anesthesia).

 Disadvantages : visual sensations ,

anxiety , discomfort
Goals :
 Smooth intubation
 Stable IOP
 Avoidance of oculocardiac reflexes
 Balanced opioid anesthesia
 Smooth extubation
 Use of LMA
 Influid gas exchange : surgeon injects
intravitreal bubble to tamponade retina
against wall of globe

 N20diffuses and causes bubble

expansion and leads to increase IOP

 N20should be shut for 15mins before

placing sulfur hexaflouride bubble and
should be avoided for 7-10 days
thereafter.
A patient with eye trauma is a challenge
to anesthesia provider.

 Dilemma is to protect patient from

pulmonary aspiration of gastric contents
& to protect eye from acute changes in
IOP which could cause vitreous loss ,
retinal detachment and blindness.

 Rapid sequence induction to be done .

 Increase in IOP can cause loss of ocular
contents.
 It may be difficult to fit a facemask when
the eye is covered with dressing.
 Smooth intubation and extubation
needed.
 Avoid hypoxia and hypercarbia.
 Hypertermia can lead to increase IOP
 Avoid ketamine
Premedication :
 -analgesics as required
 -atropine at the time of induction.
 Ondansetron to prevent nausea/vomiting

 Induction with IV thiopentone and

pancuronium.
 Cricoid pressure to avoid aspiration.
 Cuffed ET tube preferred

 Lignocaineand beta blocker to blunt the

cardiovascular and IOP response to
laryngoscopy and intubation
 Control ventilation and maintain
anesthesia with N20 and halothane .
 Adequate reversal in the end
 Fully awake extubation in lateral position.

(stoelting’s anesthesia nd co exsting

diseases -2nd south asian edition)
 Regional techniques can be performed
Factors to consider include:
 Size of the perforation : small punctures
have higher resistance to vitreous loss
with changes in IOP.
 Pulmonary status
 NPO status
 Length of procedure.
 Small children may require examination
under anesthesia.
 Im ketamine is the choice when iv is
problematic.
 Ketamine is preferred because it does
not reduce IOP as other barbiturates do.
 Most commone eye surgery is for
strabismus.

 Droperidol 5-75mcg/kg for postop
nausea and vomiting.

 If
force ductal testing is used to asses the
muscle tightness , the surgeon should be
notified if succinylcholine is used.

 Succinylcholinecauses a tonic increase in

eye muscle tone which resolves in
approximately 20mins.

 Malignant hyperthermia and myotonic

dystrophy are assocciated with
strabismus.
 Corneal abrasion
 Chemical injury
 Photophobia
 Blurred vision
 Haemorrhagic retinopathy
 Retinal ischemia
 Retinal artery occlusion
 Ischemic optic neuropathy
 Cortical blindness
 Acute glaucoma
 ptosis
 Miller’sanesthesia – 8th edition
 Stoelting’s anesthesia and coeisting
diseases – 2nd south asian edition
Thank you !!!