Anaesthesia for Eye-surgery

Dr.Shailendra.V.L. Specialist in Anaesthesia Al Bukariya general hospital Saudi Arabia.

Introduction
Technological improvements Improved surgical techniques Improved techniques in anaesthesia Better understanding of the

physiology

Ophthalmic Surgery
Extra

ocular surgerystrabismus correction Intra ocular surgery- cataract with IOL Mixed - drainage operations for glaucoma

Anaesthesia requirements for ophthalmic surgery

Immobile eye Uncongested eye Intra ocular pressure: - to minimize the danger of expulsion of intra ocular contents Smooth recovery Avoidance of PONV
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Physiology of intra ocular pressure

INTRA-OCULAR PRESSURE DETERMINANTS: Factors exerting outward pressure Factors exerting inward pressure

Intra-ocular pressure
Aqueous humour Vitreous humour Blood within the eye Scleral compliance Extra-ocular muscle tone

Aqueous humour dynamics

Ultrafiltration of plasma by ciliary epithelium Formation of A H in ciliary process A H circulate around Iris via pupil Anterior chamber Canal of Schelmn Trabecular spaces of Fontana drains through Episleral venous system

Drugs acting on AH mechanics

production:

Acetozolamide (carbonic anhydrase inhibitor) Beta blockers Improve drainage: Miotics (by contracting ciliary muscle) Mydriatics affects drainage
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Choroidal blood volume effecting AH mechanics

Systemic blood pressure:

Choroidal capillaries auto-regulatory function in Blood pressure causes transient in IOP Venous pressure: in CVP causes acute in IOP Coughing/ vomiting/ valsalva/ straining on tube all IOP PaCO2 causes IOP by choroidal vasodilatation
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Vitreous Humour
Fine unstable gel consisting of water &

fine supporting structure

Volume & pressure reduced by Mannitol

which is a dehydrating agent & there by IOP

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Extra-ocular muscle tone

Tone controlled by the mid-brain GA muscle tone & there by IOP Gentle, constant pressure on the eye

promotes aqueous humour flow & IOP

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Pharmacological modifications of IOP

Pre anaesthetic Medication: IV diazepam & midazolam IOP Parental atropine has no effect on IOP Intravenous anaesthetics: Only ketamine IOP All other agents IOP
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Pharmacological modifications of IOP

Inhalational agents effect IOP by: Central action on mid-brain Alteration of aqueous humour extra-ocular muscle tone Dose dependent reduction in IOP

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Pharmacological modifications of IOP

Neuro-muscular blockers: Succinylcholine- IOP by 10 mmHg

by 1 minute & lasts for 10 minutes IOP due to tonic action of drug on Felderstruktur striated extra0ocular muscle Laryngoscopy & Intubation: IOP
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Oculo-cardiac reflex
Trigemino-vagal reflex Bradycardia, nodal rhythm, ectopic beats,

ventricular fibrillation, asystole Eyeball pressure, traction of extra-ocular muscles, orbital haematoma, ocular trauma & eye pain, eyelid traction Can occur even from enucleated orbit
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Oculo cardiac reflex

Afferent pathway Short & long ciliary nerves Ciliary ganglion via ophthalmic division of trigeminal nerve Trigeminal sensory nucleus Efferent pathway Nucleus of vagus Cardiac branches Bradycardia

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Treatment of OCR
Ask surgeon to stop all the manipulations Intravenous Atropine 15 micro grams /

Kg or intravenous Glycopyrrolate 7.5 micro grams / Kg

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Systemic effects of ophthalmic medications

Eye drops are readily absorbed through hyperemic,

incised conjunctiva causing systemic effects Phenyleohrine(2.5%) cause hypertension, arrhythmia and headache Adrenaline(2%) cause hypertension & arrhythmias Timolol (B-blocker) causes bradycardia, hypotension & exacerbation of asthma Phospoline iodide is a lone acting anticholinesterase used in glaucoma prolongs suxamethonium induced muscle relaxation 18

Anaesthetic management of elective intra ocular surgery

Goals of general anaesthesia: Immobile eye Stable IOP Minimize bleeding Avoidance of Oculo-cardiac reflex Smooth induction Smooth emergence Minimal post-operative nausea & vomiting
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Common Ocular surgeries

Cataract surgeries Lid surgeries Conjuctival surgeries Strabismus surgeries Penetrating eye injuries Vitreous surgeries Retinal surgeries Laser surgeries

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Anaesthetic management of elective intra-ocular surgery

Pre-medication: use of anxiolytics Induction: Thiopentone + Suxamethonium Intubation: Smooth laryngoscopy & intubation Maintenance: O2 + N20 + Isoflurane/Halothane

IPPV with Non-depolarizing muscle relaxant Reversal: Neostigmine + Atropine , extubate in deeper planes Problems encountered: Dark room Face inaccessible
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Anaesthesia for perforating eye injury

Problems: Full stomach patient

Perforated eye Plan: Preoxygenation Induction: Thiopentone + Atracurium Sellicks maneuver Smooth laryngoscopy & intubation Controlled ventilation Smooth extubation Use of Ondansetron to prevent PONV
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Anaesthesia for special ocular surgeries

Glaucoma: Anti-cholinesterase eye drops used in treatment can potentiate effects of succinylcholine precipitating bradycardia & arrhythmias To IOP 20% mannitol is used, hence it is better to catheterize these patients
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Anaesthesia for special ocular procedures

Retinal detachment surgery:
Oculo-cardiac reflex commonly observed Essentially extra-ocular surgery Synthetic silicone strap used to produce scleral indentation

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Anaesthesia for special ocular surgeries

Intra-vitreous gas injection: Intra-vitreous injection of inert gas of low diffusibility such as Sulphar hexafluride (SF6) or Carbon octofluride (C3F6) Gas is absorbed over 10 days and the bubble keeps the sclera intact N20 must be avoided as the bubble size increases upto three 25 times

Anaesthesia for special ocular procedures

Vitrectomy: Closed intra-ocular procedure Surgeon controls IOP manometrically by water tight infusion

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Ophthalmic procedures in children

Naso-lacrimal duct probing / syringing Examination under anaesthesia Intra-ocular pressure measurement Strabismus correction

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Naso-lacrimal duct probing

Done to open up the duct Trachea to be intubated & throat packed

to prevent the fluid entering trachea

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Examination under GA
Very common procedure Done to examine in detail the eyes Total intra-venous anaesthesia technique

should be used as the procedure is short

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IOP measurement in children

General anaesthesia with ketamine must

be avoided as IOP will be raised with ketamine General anaesthesia with nondepolarizing relaxants preferred It is advisable to wait for 10 minutes to take measurements after intubation for the IOP to stabilize
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Strabismus surgery
Incidence of OCR very high Careful monitoring Should be anticipated and treated with

Atropine / Glycopyrrolate Avoidance of PONV by the use of Ondansetrone

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