Anaesthesia for Ophthalmologic

Surgery

PRESENTED BY - DR.VIDYA SAGAR CHAUBEY (PG 2)

BRLSABVMMC , RAJNANDGAON,CG
OCULAR ANATOMY
● The eye is a sphere measuring
approximately 24 mm in diameter. It is
situated in the pyramidal bony orbit.
● Optic foramen transmits the optic
nerve and the ophthalmic artery as
well as the sympathetic nerves from
the carotid plexus.

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The superior orbital fissure transmits the superior
and inferior branches of the oculomotor nerve; the
lacrimal, frontal, and nasociliary branches of the
trigeminal nerve; the trochlear and abducens nerves;
and the superior and inferior ophthalmic veins.
The Inferior orbital fissure contains the infraorbital
and zygomatic nerves and communication between
the inferior ophthalmic vein and the pterygoid
plexus.

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● The wall of the globe has three layers: the
sclera, the uveal tract, and the retina
● The sclera is the outermost layer. It is the
tough, fibrous white of the eye, and it is
continuous with the cornea anteriorly.
● The tissue where the cornea and sclera meet
is the limbus, which contains stem cells
responsible for regeneration of the
epithelium.
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● Immediately superficial to the
sclera is the potential space
bounded by the white and
avascular Tenon’s capsule,
which can be accessed to
administer a Sub-​Tenon’s block.

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 EXTRAOCULAR MUSCLES
EOM INNERVATION ACTION

Medial Rectus III (oculomotor Adduction

Lateral Rectus VI (abducens) Abduction

Superior Rectus III (oculomotor Intorsion,Adductio

n,Elevation

Inferior Rectus III (oculomotor Extorsion,Adducti

on,Depression

Superior Oblique IV (trochlear) Intorsion,Abductio

n,Depression

Inferior Oblique III (oculomotor Extortion,Abductio

n,Elevation

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● The middle layer, the uveal tract, has three structures:the iris, the choroid
and the ciliary body.
● The Iris contains dilator and sphincter muscle fibers that control the central
aperture, the pupil. Parasympathetic stimulation originating from the cranial
nerve (CN) III nucleus contracts iris sphincter fibers, causing pupillary
constriction or miosis. Conversely, sympathetic fibers traveling with the
ophthalmic division of CN V stimulate iris dilator fibers, dilating the pupil.
● The center of the eye is filled with vitreous gel. This thick fluid has
attachments to blood vessels and the optic nerve. Traction of the vitreous on
the retina is a cause of retinal detachment.
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● The posterior part of the uveal tract is a layer of blood vessels and
capillaries called the choroid. These vessels nourish the outer portion of
the retina, providing oxygen and nutrients. Bleeding from the choroid layer
can cause catastrophic intraoperative expulsive hemorrhage.
● The ciliary body had two primary functions: production of aqueous humor
and accommodation.Ciliary muscle fibers adjust the focus by releasing
tension on the suspensory fibers, or zonules, of the lens.
● The retina is a thin, transparent structure that differentiates from the optic
cup and constitutes the inner layer of the medioposterior wall of the globe.
Photoreceptors of the retinal layer convert light into neural signals, which
are processed and carried to the brain via the optic nerve.
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● The eyelids are composed of an outer layer of skin, a muscle layer, a
cartilaginous tarsal plate, and an inner layer of conjunctiva.
● Blood supply to the eye and orbit is by means of branches of both the internal
and external carotid arteries.
● Venous drainage of the orbit is accomplished through the multiple
anastomoses of the superior and inferior ophthalmic veins. Venous drainage
of the eye is achieved mainly through the central retinal vein. All these veins
empty directly into the cavernous sinus.

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OCULAR PHYSIOLOGY

● 80% to 90% of aqueous formation occurs through

active secretion by the ciliary body mediated by
Na-K ATPase and carbonic anhydrase enzymes.
The remainder is from passive filtration and
ultrafiltration across the ciliary epithelium.
● Then the aqueous humor flows into the peripheral
segment of the anterior chamber and exits the
eye through the trabecular network, Schlemm
canal, and episcleral venous system.

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● IOP normally varies between 10 and 21.7 mmHg and is considered
abnormal above 22 mmHg. This level varies from 1 to 2 mmHg with
each cardiac contraction. Also, a diurnal variation of 2 to 5 mmHg is
observed
● Increase in IOP
May result from
- Increases in arterial BP,
- Central or local venous pressure ,
- Local external pressure on the eye
- Hypercarbia
- Hypoxia
● Anesthesia events/procedures that may increase IOP
i) Direct laryngoscopy and intubation
ii) High ventilation pressures—both endotracheal and mask
iii) Trendelenburg position
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OCULO CARDIAC REFLEX / ASCHNER
PHENOMENON / TRIGEMINO VAGAL REFLEX
The OCR is a sudden profound decrease in heart rate in response to traction on the
extraocular muscles or external pressure on the globe.

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● This reflex occurs more commonly in young patients.The OCR is most often
encountered during strabismus surgery but can occur during any type of
ophthalmic surgery. OCR may also occur while performing an ophthalmic
regional anesthetic nerve block. Hypercarbia, hypoxemia, and light planes of
anesthetic depth augment the incidence and severity of OCR
● The reflex arc has a trigeminal nerve afferent limb that generates an efferent
vagal response that may precipitate a variety of dysrhythmias, including
junctional or sinus bradycardia, atrioventricular block, ventricular bigeminy,
multifocal premature ventricular contractions, ventricular tachycardia, and
asystole.
● Awake patients may experience nausea or somnolence.
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Prevention and Treatment

(1) Immediate notification of the surgeon and cessation of surgical stimulation

until heart rate recovers;
(2) Confirmation of adequate ventilation, oxygenation, and depth of anesthesia;
(3) Administration of intravenous atropine (10 mcg/kg) if bradycardia persists;
and
(4) In recalcitrant episodes, infiltration of the rectus muscles with local
anesthetic.

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Intraocular Gas Expansion

a) Gas bubble may be placed by ophthalmologist into posterior chamber

to aid repair of a detached retina.

Avoid nitrous oxide for the entire case or within 10 minutes of any gas
bubble insertion.

Nitrous oxide administration during retinal surgery can cause gas bubble
expansion and ↑IOP secondary to the agent’s increased blood solubility.

b) Sulfur hexafluoride (SF6) may be used for the bubble owing to its
lower solubility and prolonged therapeutic effect.

SF6 bubble will increase in size naturally and stay in place up to 10 days
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 Anesthesia for Ophthalmologic Surgical Procedures

General, regional, and topical anesthesia approaches are available for ophthalmic
surgery patients.
i) Preoperative considerations
(1) Patients undergoing eye procedures frequently include an older population with
significant comorbidities, including cardiac, respiratory, endocrine, and orthopedic
pathology.
(2) Appropriate preoperative testing and evaluation should occur in these patients
even though the inherent risk of most ophthalmic procedures is low.
(3) The patients’ ability/preparedness to cooperate and remain still in the supine
position must be confirmed before sedation is considered for the anesthetic plan.
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ii) Intraoperative considerations
(1) Airway access may be limited as the patient’s head is usually
90-180 degrees from the anesthesiologist.
(2) Standard ASA monitoring requirements apply. Consider special
monitors based on the patient’s medical history and condition.

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GENERAL ANAESTHESIA
Indicated for more invasive procedures and uncooperative
patients.Choice of induction technique is based on patient’s general
medical condition.

(a) Trauma patients may require rapid sequence induction (RSI) without
the use of succinylcholine.

(b) Succinylcholine avoidance with open-globe injuries has been

suggested as it may increase IOP and result in extravasation of ocular
contents. Although clinical evidence supporting such avoidance is very
limited, succinylcholine has been used successfully in open-globe
injuries in patients requiring RSI. 19
(c) Hypoxia and hypercarbia also greatly increase IOP, making a
failed airway an equally problematic situation.
(d) The potential for rapid reversal with sugammadex allows
consideration for an RSI dose nondepolarizing NMB in this
situation.
Oral Ring, Adair and Elwyn (RAE) tubes are useful for eye cases
requiring general anesthesia by providing greater surgical field
access and less likelihood of tube obstruction/ kinking. 20
Patients With Traumatic Rupture (an open globe)

● IOP must be controlled during induction, maintenance, and

extubation to prevent extrusion of vitreous content.
● Deep anesthesia should be maintained to prevent increases in
IOP.
● Paralysis to prevent movement should be strongly considered.
● Hemodynamic control is essential.
● Smooth extubation plan is necessary to avoid Valsalva from
coughing.

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(i) Consider extubating the patient under deep anesthesia
(contraindicated with difficult airway or full stomach).
(ii) Lidocaine 1.5 mg/kg 2 minutes prior to extubation may reduce
laryngeal responsiveness and facilitate extubation.
(iii) Remifentanil (0.025-0.1 μg/kg/min) infusion may also be used to
provide a smooth emergence with reduced coughing.
(iv) Dexmedetomidine (0.75 μg/kg) may be another adjuvant for
smoothing emergence

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 Intraoperative Anesthetic Implications In Patients With
Glaucoma
● Glaucoma is commonly characterized as a sustained increase in IOP that
leads to diminished perfusion of the optic nerve and eventual loss of vision.
● Angle-closure (acute) glaucoma occurs when the angle between the iris
and cornea narrows and obstructs outflow.
● Open-angle (chronic) glaucoma results from sclerosis of the trabecular
meshwork and impaired aqueous drainage.
● Infantile glaucoma may readily progress to blindness, making early surgery
more urgent.
● Many adult glaucoma procedures can be managed with regional
anesthesia and MAC. General anesthesia is requisite for pediatric
glaucoma cases.
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Administration of atropine drops into the eye produce mydriasis and are
contraindicated. Intravenous atropine, on the other hand, is minimally absorbed
by the eye and should be used when indicated during anesthesia.

Anesthesia implications include

(1) avoiding mydriasis by continuing all miotic drops;

(2) understanding the interactions of antiglaucoma medications and anesthetics.

(3) preventing increases in IOP associated with induction, maintenance, and

emergence from anesthesia

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Postoperative considerations
● Postoperative nausea and vomiting (PONV)
(1) Valsalva with vomiting can ↑IOP.
(2) Because PONV is commonplace after strabismus surgery, aggressive
antiemetic medication should be administered.
● Adequate pain control
(1) Important because increased pain can lead to ↑ BP and ↑IOP.

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 NEEDLE BLOCKS

The injection of local anaesthetic agent into the muscle cone behind the globe formed by
the four rectus muscles is known as an intraconal (retrobulbar) block, whereas in the
extraconal (peribulbar) block, the needle tip remains outside the muscle cone.
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Regional and Local Techniques for Eye Surgery
RETROBULBAR BLOCK (INTRACONAL)
i) Local anesthetic is injected behind the operative
eye via the lateral third of the lower eyelid.

ii) A 3.5-cm, 25-gauge needle is advanced along

the floor of the orbit toward the cone formed by the
convergence of the extraocular muscles.

iii) 2.5 mL of local anesthetic (lidocaine or

bupivacaine common) without epinephrine is
injected after negative aspiration to avoid
intravascular or intracranial injection.
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iv) A successful retrobulbar block is accompanied by anesthesia, akinesia, and
abolishment of the oculocephalic reflex (ie, the blocked eye does not move during head
turning).

v) Hyaluronidase is added to improve block spread by increasing connective tissue

permeability of local anesthetic.

Complications
(1) Retrobulbar hemorrhage, globe trauma, optic nerve damage, and systemic/ CNS
injection of local anesthetics

(2) Systemic/CNS injection of local anesthetic may induce seizure, obtundation, apnea, or
cardiovascular collapse due to the anatomic continuity between the optic nerve and the
CNS. 28
PROS AND CONS OF RETROBULBAR BLOCK

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Inferotemporal Peribulbar Block

● The globe is kept in a neutral gaze position, and a

needle less than 31 mm in length is inserted as
far as possible in the extreme inferotemporal
quadrant through the conjunctiva or skin.
● Needle always remains tangential to the globe
along the inferior orbital floor.
● 5–6 ml local anaesthetic agent is
injected.However, more than 60% of patients
require a supplementary injection in the form of
a medial peribulbar block.

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Medial Peribulbar Block

● 25G–27G needle is used.

● A needle is inserted between the caruncle and
the medial canthus to a depth of 1–1.5 cm and
3–5 ml local anaesthetic is injected.
● A single medial peribulbar block with 6–8 ml
local anaesthetic has been advocated if akinesia
is essential in patients with myopic eyes.
● Gentle digital pressure and massage around the
globe help to disperse the anaesthetic and
reduce IOP.
● The maximum pressure should be limited to 25
mmHg to avoid compromise to the globe’s blood
supply. 31
PROS AND CONS OF PERIBULBAR BLOCK

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SUB TENON’S BLOCK

● The lower eyelid is

retracted. The patient is
asked to look upwards
and outwards.
● The conjunctiva and
Tenon’s capsule are
gripped together with a
non-toothed forceps 5–8
mm from the limbus in
the inferonasal quadrant.

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● A small incision is made through these layers with Westcott scissors until the white
sclera is seen. A blunt sub-Tenon cannula (19G, curved, 2.54 cm long, metal,
opening at the end) is inserted gently along the curvature of the globe and should
pass easily without resistance; 3–5 ml of the local anaesthetic of choice is injected
slowly.
● The injected local anaesthetic agent diffuses around and into the intraconal space,
leading to anaesthesia and akinesia.
● Sub-Tenon’s block markedly reduces the incidence of complications of needle
blocks, but its use is associated with some specific minor problems such as
chemosis and subconjunctival haemorrhage.
● This method reduces the risk of central nervous system spread, optic nerve
damage and global puncture, but akinesia may take longer to achieve. 34
Facial Nerve Block

i) It prevents eyelid squinting during surgery

and allows placement of lid speculums.

ii) Multiple techniques are utilized

depending on the location and requirements
of the surgical procedure.

Examples include lacrimal, zygomatic,

supraorbital, supratrochlear, infratrochlear,
and infraorbital nerve blocks.

iii) Complications include local hemorrhage

and block failure.
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Topical Anaesthesia

i) Anaesthetic eye drops, such as oxybuprocaine and tetracaine,

are applied preoperatively at 5-minute intervals for five
applications.
ii) Anaesthetic gel is later applied with a swab to upper and lower
conjunctival sacs.
iii) Common for cataract and other minor anterior chamber surgery
iv) Complications include corneal abrasion and toxic keratopathy

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Anesthesia-Related Eye Injuries
● Corneal abrasion is the most common eye injury,and may be due to direct
contact from the face mask, surgical drapes, or other foreign objects that come
in contact with the eye.
● General anesthesia predisposes to corneal abrasion because it suppresses
corneal reflexes, increases lagophthalmos (incomplete eyelid closure), and
decreases tear production and stability.
● Corneal abrasion can be prevented by lubricating the eyes with ophthalmic
ointment, taping the eyes during surgery, and vigilantly monitoring patients to
ensure that they do not rub their face or eyes during emergence from
anesthesia.
● Treatment of corneal abrasion consists of antibiotic ointment to the affected eye
and patching the eye for 48 to 72 hours 37
● IOP can increase by an average of 13 mm Hg higher than preanesthesia
induction values when a patient is placed in steep Trendelenburg position.
● A devastating but rare complication of surgery is perioperative visual loss
(POVL), which is most often associated with cardiac, spine, and head and
neck operations. Causes of POVL are ischemic optic neuropathy (ION),
central retinal artery occlusion (CRAO), and cortical vision loss.
● ION is the most commonly reported condition associated with POVL. It can be
further subdivided into anterior ischemic optic neuropathy (AION) and
posterior ischemic neuropathy (PION).

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● AION is associated with damage to the optic nerve head and is more
commonly seen after cardiac surgery. Damage to the rest of the optic nerve
results in PION, and it is more commonly reported after spinal surgery.
● ION was associated with estimated blood loss of greater than 1000 mL and
anesthetic duration of more than 6 hours.Although the etiology of
perioperative ION is unknown, a possible hypothesis is that prone surgery
leads to increased venous pressure and interstitial tissue edema that
compromises blood flow to the optic nerve.

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● Prevention involves careful preoperative counseling and screening,
considering surgical options that reduce the risk of stroke, and staging long
spinal surgeries in high-risk patients. Patient positioning should avoid direct
ocular pressure, with the head positioned so that it is higher than the heart to
reduce orbital edema. Hypotension and severe anemia should be avoided.
● In CRAO, interruption of the arterial supply to the retina most commonly
occurs from increased IOP due to external pressure during
positioning.Therapeutic interventions include lowering IOP with acetazolamide
or osmotic diuretic agents,induced hypercarbia, topical hypothermia, locally
applied thrombolytic agents, and hyperbaric oxygen therapy.

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In an ASA closed claims analysis of eye injuries during ophthalmic surgery
associated with anesthesia in 1992, Gild et al. found that patient movement such as
bucking or coughing was the most common single mechanism of injury. The
majority of patient movement occurred during general anesthesia, and the
outcome in all these cases was blindness.The use of a peripheral nerve stimulator to
monitor neuromuscular blockade during ophthalmic surgery should ensure that
patients do not move during general anesthesia.

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Ophthalmic drugs used during surgery and anaesthesia

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 1. South Asian Edition of Manual of CLINICAL

REFERENCES 2.
ANESTHESIOLOGY
Smith and Aitkenhead’s Textbook of Anaesthesia
3. Clinical Anesthesia EIGHTH EDITION Paul G.
Barash, MD
4. Miller’s Basics of ANESTHESIA EIGHTH
EDITION

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