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Dr Damita Wijewardena

Consultant Anaesthetist
National Eye Hospital

Paediatric Patients
Multiple congenital problems
Relevant investigations
Fasting guidelines
?Premedication EMLA, Antiemetics,

Paracetamol
EUA and other surgeries

Examination of the Eye


Fundoscopy
IOP measurement
Retinoblastoma follow-up

Measuring IOP

Extraocular procedures

Excision of orbital dermoids/tumours


Lid surgery - excision of meibomian cysts,
steroid injection of haemangiomas,
tarsorrhaphy, ptosis surgery
NLD surgery - syringing and probing,
dacryocystorhinostomy
Strabismus surgery, laser surgery/cryotherapy,
episcleral dermoid excision, corneal surgery,
enucleation, evisceration

Squint Surgery
Oculocardiac reflex
Post-operative nausea and vomiting
Pain
Muscle relaxation

Probing of nasolacrimal
ducts
Bacteraemia
Protection of Airway

Intraocular procedures

Intraocular procedures to reduce IOP such


as goniotomy, trabeculectomy/trabeculotomy
lensectomy artificial lens insertion
vitrectomy
vitreoretinal surgery

Adult Patients
Adults who object/have contra-indications to

Local Anaesthesia
Adults undergoing extensive orbital surgery
Unco-operative patients, such as
mentally retarded
movement disorders
Excessive anxiety and claustrophobia
IOP needs to be controlled

Cross section of the


eye

Factors determining
IOP
Volume of aqueous humour
Volume of vitreous humour
Choroidal blood volume
Extraocular muscle tone

The major controlling influence on

intraocular pressure is the dynamic


balance between aqueous humour
production in the ciliary body and its
elimination via the canal of Schlemm

(1) The Choroid


A highly vascular area in which there are

extensive anastomoses between the


anterior ciliary arteries and the long and
short posterior ciliary arteries.

(a) Autoregulation of
Choroidal blood flow

To control
IOP
Adequate depth of anaesthesia
Good analgesia
Control blood pressure
Avoid hypertensive response to laryngoscopy

and intubation

(b) Chemical control of


Choroidal blood flow

To control
IOP..
Adequate FIO2 to maintain SpO2 greater than

96- 97%
Controlled ventilation to ensure an ETCO 2 of
around 37 mm Hg

(c) Venous drainage of


the eye
Venous drainage from iris, ciliary body

and choroid 4 vortex veins pass


through sclera behind the equator
venous plexus of orbit cavernous
sinus

To control
IOP.
Prevent kinking of great veins
Prevent coughing or bucking on the tube
Slight head-up tilt which is not practical

(2) Extraocular muscle


tone
IOP may rise markedly with

pressure on the eye


contraction of extraocular muscles
contraction of orbicularis oculi muscle
eyelid closure

To control
IOP.

Use of non-depolarising muscle relaxants


Peripheral nerve stimulator
Avoid suxamethonium

(3) Vitreous Humour


Volume of vitreous and its pressure

effect maybe reduced by dehydrating


the vitreous
Urea 30% solution in water
20% Mannitol
Oral glycerol

To control
IOP..

Intravenous infusion of mannitol, 30 40


minutes prior to surgery

(4) Effects of different drug


groups
Inhalational anaesthetics decrease IOP
Intravenous anaesthetics decrease IOP

except for ketamine


Suxamethonium transient increase in
IOP
Non-depolarising muscle relaxants
decrease IOP

Open Eye Injuries


Problems
Possible prolapse of vitreous and lens
Other associated injuries
Full stomach