ANESTHESIA FOR

OPHTHALMIC
SURGERY

DR.dr. H.J. LALENOH, Sp.An-KMN-KAO

BAGIAN ANESTESIOLOGI & REANIMASI
FK-UNSRAT 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

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
PRO-BLEM DECREASE IOP IN
PROPORTION TO THE DEPHT OF
ANESTHESIA

THE END OF
LECTURE