Dr. H.J. LALENOH, Sp.

An

BAGIAN ANESTESIOLOGI & REANIMASI FK-UNSRAT MANADO / RSUP. MALALAYANG MANADO

INTRAOCULAR PRESSURE DYNAMICS

PHYSIOLOGY INTRAOCULAR PRESSURE (IOP)
NORMAL IOP: 12 20 mmHg EYEHOLLOW SPHERE WITH RIGID WALLIF

SPHERE CONTENTS INCREASE IOP TEMPORARY VARIATIONS IN PRESSUREWELL TOLERATED IN NORMAL EYES

CAUSE OF IOP
OBSTRUCTION OF AQUEOUS HUMOR OUTFLOW

(GLAUCOMA) VOLUME OF BLOOD WITHIN THE GLOBE EXTREME CHANGES IN ARTERIAL BLOOD VOLUME A RISE IN VENOUS PRESSURE VENTILATION, ANY ANESTHETIC EVENT THAT ALTERS THESE PARAMETERS (eg. LARYNGOSCOPY, INTUBATION) AIRWAY OBSTRUCTION COUGHING TRENDELENBURG POSITION

ALL THING CAN MARKED INCREASE IN INTRAOCULAR PRESSURE :

DECREASING SIZE OF GLOBE WITHOUT A

PROPORTIONAL CHANGE IN VOLUME OF ITS CONTENTS PRESSURE ON THE EYE FROM A TIGHTLY FITTED MASK IMPROPER PRONE POSITIONING RETROBULBAR HEMORRHAGE

 WHEN THE GLOBE IS OPEN DURING CERTAIN

SURGICAL PROCEDURES OR AFTER TRAUMATIC PERFORATIONINTRAOCULARE PRESSURE APPROACHES ATMOSPHERIC PRESSRE ANY FACTORS THAT NORMALLY INCREASES INTRAOCULAR PRESSURE WILL TEND TO DECREASE INTRAOCULAR VOLUME (BY CAUSING DRAINAGE OF AQUEOUS OR EXTRUSION OF VITREOUS THROUGH THE WOUND)SERIOUS COMPLICATIONCAN PERMANENTLY WORSEN VISION

OCULOCARDIAC REFLEX (OCR)

TRACTION ON EXTRAOCULAR MUSCLES OR PRESSURE ON THE EYEBALL CAN ELICIT CARDIAC DYSRHYTMIAS RANGING FROM: BRADYCARDIA VENTRICULAR ECTOPY TO SINUS ARREST, OR VENTRICULAR FIBRILLATION

OCULOCARDIAC REFLEX (OCR)

THIS REFLEX CONSISTS OF A TRIGEMINAL

AFFERENT (V1) & A VAGAL EFFERENT PATHWAY OCR IS MOST COMMON IN PEDIATRIC PATIENTS UNDERGOING STRABISMUS SURGERY CAN BE EVOKED IN ALL AGE GROUPS DURING :
CATARACT EXTRACTION ENUCLEATION

RETINAL REPAIR

OCULOCARDIAC REFLEX (OCR)

OFTEN HELPFUL PREVENTING OCR:

ANTICHOLINERGIC MEDICATION (IV ATROPIN OR GLYCOPYRROLATE IMMEDIATELY PRIOR TO SURGERY) REMEMBER : ANTICHOLINERGIC MEDICATIONS CAN BE HAZARDOUS IN ELDERLY PATIENTS (OFTEN WITH SOME DEGREE OF CORONARY ARTERY DISEASE) ALTERNATIVELY: RETROBULBAR BLOCKADE (BY SURGEON) OR DEEP INHALATIONAL ANESTHESIA BUT THESE PROCEDURE IMPOSE RISK OF THEIR OWN.

OCULOCARDIAC REFLEX (OCR)

MANAGEMENT OF OCR :
IMMEDIATE NOTIFICATION OF THE SURGEON TEMPORARY CESSATION OF SURGICAL

STIMULATION UNTIL HEART RATE INCREASES CONFIRMATION OF ADEQUATE VENTILATION, OXYGENATION, AND DEPTH OF ANESTHESIA ADMINISTRATION OF IV ATROPINE (10g/kg) IF THE CONDUCTION DISTURBANCE PERSISTS IN RECALCITRANT EPISODESINFILTRATION THE RECTUS MUSCLES WITH LOCAL ANESTHETIC

EFFECT OF ANESTHETIC DRUGS ON INTRAOCULAR PRESSURE

MOST ANESTHETIC DRUGS EITHER LOWER

OR HAVE NO EFFECT ON IOP INHALATIONAL ANESTHETICS DECREASE IOP IN PROPORTION TO THE DEPHT OF ANESTHESIA INTRAVENOUS ANESTHETICS ALSO DECREASE INTRAOCULAR PRESSURE, EXCEPTION IS KETAMINE RAISE ARTERIAL BLOOD PRESSURE IOP & DOESNT RELAX EXTRAOCULAR MUSCLES

EFFECT OF ANESTHETIC DRUGS ON INTRAOCULAR PRESSURE

THE DECREASE OF ANESTHETIC HAS MULTIPLE CAUSES: A DROP IN BLOOD PRESSURE REDUCES CHOROIDAL VOLUME RELAXATION OF THE EXTRAOCULAR MUSCLES LOWER WALL TENSION PUPILLARY CONSTRICTION FACILITATES AQUEOUS OUTFLOW

EFFECT OF ANESTHETIC DRUGS ON INTRAOCULAR PRESSURE

TOPICALLY ADMINISTERED ANTICHOLINERGIC DRUGS RESULT IN PUPILLARY DILATION (MYDRIASIS) MAY PRECIPITATE ANGLECLOSURE GLAUCOMA
PREMEDICATION DOSES OF SYSTEMICALLY ADMINISTERED ATROPINE ARE NOT ASSOCIATED WITH INTRAOCULAR HYPERTENSION, HOWEVER IN PATIENTS WITH GLAUCOMA

EFFECT OF ANESTHETIC DRUGS ON INTRAOCULAR PRESSURE

SUCCINYLCHOLINE INCREASES INTRAOCULAR PRESSURE BY 5 10 mmHg FOR 5-10 MINUTES AFTER ADMINISTRATION, PRINCIPALLY THROUGH PROLONGED CONTRACTURE OF THE EXTRAOCULAR MUSCLES (NOT RECOMMENDED FOR GLAUCOMA PATIENTS)
A RISE IOP THROUGH AN OPEN SURGICAL OR TRAUMATIC WOUND CAN CAUSE EXTRUSION OF OCULAR CONTENTS

GENERAL ANESTHESIA FOR OPHTHALMIC SURGERY

INDICATION GENERAL ANESTHESIA : IN UNCOOPERATIVE PATIENTS (EVEN SMALL HEAD MOVEMENTS CAN PROVE DISASTROUS DURING MICROSURGERY) LOCAL ANESTHESIA IS CONTRAINDICATED FOR SURGICAL REASONS PREMEDICATION : PATIENTS UNDERGOING EYE SURGERY MAY BE APPREHENSIVE,ESPECIALLY IF THEY HAVE UNDERGONE MULTIPLE PROCEDURES & THERE IS A POSSIBILTY OF PERMANENT BLINDNESS

INDUCTION
THE CHOICE OF INDUCTION TECHNIQUES FOR EYE SURGERY USUALLY DEPENDS

MORE ON THE PATIENTS OTHER MEDICAL PROBLEMS THAN ON THE PATIENTS EYE DISEASE OR THE TYPE OF SURGERY CONTEMPLATED. ONE EXCEPTION IS THE PATIENT WITH RUPTURE GLOBETHE KEY TO INDUCING ANESTHESIA IN PATIENTS WITH OPEN EYE INJURY IS CONTROLLING INTRAOCULAR PRESSURE WITH A SMOOTH INDUCTION. KETAMIN IS CONTRA INDICATE

INDUCTION
SPECIFICIALLY COUGHING DURING

INTUBATION MUST BE AVOIDED BY ACHIEVING A DEEP LEVEL OF ANESTHESIA & PROFOUND PRALYSIS RESPONS IOP TO LARYNGOSCOPY & ENDOTRACHEAL INTUBATION CAN BE BLUNTED BY PRIOR ADMINISTRATION OF INTRAVENOUS LIDOCAINE (1,5 mg/kg), OR FENTANYL (3-5 g/kg)

 NON DEPOLARIZING MUSCLE RELAXANT

DRUGS IS USED INSTEAD OF SUCCINYLCHOLINE (DEPOLARIZING MUSCL RELAX) BECAUSE SUCCINYL INFLUENCE ON IOP, EXCEPTION MOST PATIENTS WITH OPEN GLOBE INJURIES WHO HAVE FULL STOMACHS & REQUIRE A RAPID SEQUENCE INDUCTION TECHNIQUE INHALATIONAL ANESTHETICS IS NO PROBLEM DECREASE IOP IN PROPORTION TO THE DEPHT OF ANESTHESIA

THE END OF LECTURE