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Anaesthesia For Ophthalmic Surgery

This document discusses considerations for anaesthesia for ophthalmic surgery. It covers anatomy of the orbit and eye, physiology such as intraocular pressure regulation, and sensory and blood supply. It also outlines requirements for ophthalmic surgery including akinesia, analgesia and intraocular pressure control. Various anaesthetic techniques are reviewed including general, topical, and regional approaches. Complications associated with regional blocks and management of specific clinical situations are also summarized.

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kadek gunadi
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41 views49 pages

Anaesthesia For Ophthalmic Surgery

This document discusses considerations for anaesthesia for ophthalmic surgery. It covers anatomy of the orbit and eye, physiology such as intraocular pressure regulation, and sensory and blood supply. It also outlines requirements for ophthalmic surgery including akinesia, analgesia and intraocular pressure control. Various anaesthetic techniques are reviewed including general, topical, and regional approaches. Complications associated with regional blocks and management of specific clinical situations are also summarized.

Uploaded by

kadek gunadi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Anaesthesia for

Ophthalmic Surgery
Anatomy, Physiology and Practice
T Mphanza FRCA, FFICM

1
Special Considerations

• Proximity to airway
• Age
• Anatomy
• Physiology

2
3
Anatomy

• Orbit - irregular pyramid


• Base at the front
• Axis - points postero-medially
• Optic foramen forms the apex

4
Anatomy

• Orbit - irregular pyramid


• 40 - 50 mm deep
• Volume - 30 mls
• globe - 7 mls

5
Anatomy

• Globe
• Anteriorly
• Closer to the roof
• Nearer to the lateral wall
• Axial length - 25 mm
6
Anatomy

7
Anatomy

• Extraocular muscles
• 4 rectus muscles
• 2 oblique muscles

8
LR6(SO4)3

9
Sensory Innervation

• Trigeminal
•V 1

• Supratrochlear, Supraorbital, Long ciliary, Nasociliary, Infratrochlear, Lacrimal

•V 2

• Infraorbital, Zygomatic

10
Autonomic Innervation
• Sympathetic
• Superior cervical ganglion
• Mydriasis
• Parasympathetic
• Fibres from III
• Miosis

11
12
Blood Vessels
• Arterial
• Ophthalmic artery
• Venous
• Ophthalmic veins
• Superior
• Inferior
13
Anatomy and
Physiology

14
Physiology
• Aqueous humour
• Produced by ciliary body
• Carbonic anhydrase
• Drainage
• Venous channels
• SVC
15
Physiology

• Intraocular pressure (IOP)


• Range 10 - 20 mmHg
• Increases with age
• Direct correlation with axial length
• Main determinant is aqueous humour
16
Physiology
• Factors affecting IOP
• Arterial BP
• Auto-regulation
• Venous BP
• Valsalva, coughing, straining
• Partial pressures - CO , O
2 2

17
Events that Decrease
IOP
• IV anaesthetics

• Volatile anaesthetics

• Mannitol

• Timolol

18
Events that Increase
IOP
• Succinylcholine

• Direct laryngoscopy

• Hypoventilation

19
20
Oculomedullary
Reflexes
• Oculocardiac
• Trigemino-vagal:
• Bradycardia, ectopics, sinus arrest
• Oculorespiratory
• Oculoemetic
21
Anaesthetic
Ramifications of
Ophthalmic Drugs

22
• Ecothiopate
• Anticholinesterase miotic
• Cyclopentolate
• Mydriatic
• Phenylephrine
• Mydriatic
23
• Acetazolamide
• Carbonic anhydrase inhibitor
• Timolol
• Beta blocker
• Sulphur hexafluoride
• Inert gas
24
Requirements for
Ophthalmic Surgery

25
• Akinesia
• Profound analgesia
• Minimal bleeding
• Avoidance of oculocardiac reflex
26
• Control of IOP
• Awareness of drug interactions
• Emergence without coughing, straining or
vomiting

27
Anaesthesia Techniques

• General
• Local
• Topical
• Regional

28
Factors that Influence
Choice of Anaesthesia
• Nature and duration of procedure
• Coagulation status
• Patient’s choice
• Ability to communicate and cooperate

29
General Anaesthesia

• Volatile vs TIVA
• ETT vs LMA

30
General Anaesthesia

• Special consideration
• Head up tilt
• Avoid hypercapnoea
• Avoid N O in vitreoretinal surgery
2

• Smooth emergence
31
Topical Anaesthesia
• Instillation of LA drops
• Advantages
• Minimal complications
• Limitations
• Lack of akinesia
• Only suitable for uncomplicated cases
32
Regional Anaesthesia

• Sub-Tenon
• Peribulbar (Extra-conal)

• Retrobulbar (Intra-conal)

33
Sub-Tenon’s Block

• Tenon’s capsule
• Dense fascial sheath surrounding the
globe and extraocular muscles from the
limbus to the optic nerve

34
Sub-Tenon’s Block
• Sensory block
• Short-ciliary nerves pass through Tenon’s
capsule to globe
• Akinesia
• Direct blockade of ant. nerve fibres as
they enter extra-ocular muscles

35
Retro & Peribulbar
Blocks

36
Retrobulbar Block

37
Complications of
Regional Blocks
• Stimulation of oculocardiac reflex
• Haemorrhage
• Superficial
• Retrobulbar
• Retinal perfusion compromise
• Loss of vision
38
Complications of
Regional Blocks
• Globe penetration
• Intra-arterial injection
• Trauma to optic nerve
• Optic sheath injection

39
Complications of
Regional Blocks

• Extraocular muscle injury


• Central retinal artery occlusion
• Accidental brainstem anaesthesia

40
Anaesthetic
Management of Specific
Situations

41
• Open Eye, Full Stomach
• Aspiration vs Blindness
• Strabismus surgery
• OCR
• MH
• PONV
42
• Intraocular Surgery
• Glaucoma, vitrectomy, cataracts
• IOP control
• Complete akinesia
• Continuation of miotics
• Provide an antiemetic effect
43
• Retinal Detachment Surgery
• SF injection for tamponade
6

• IV acetazolamide or mannitol
• Akinesia is not critical

44
General Vs. Regional
Anaesthesia

45
• Regional Techniques
• Day stay surgery
• Better akinesia
• Less PONV
• Less effect on IOP
46
Evidence Based
Medicine

• Cochrane Reviews
• Peribulbar Vs. Retrobulbar
• Sub-Tenon’s Vs. Topical

47
Evidence Based
Medicine - CRTs
• General Vs Regional for Cataract Surgery
• Cognitive Function
• Perioperative MI
• Plasma catecholamine response

48
Summary

• Anatomy and Physiology


• Drug interactions
• Special Requirements
• Management of Specific Situations

49

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