EYE

IOP
Q).
a) What is normal intraocular pressure?
b) What are the factors affecting IOP during GA?
c) What is oculocardiac reflex? How you manage it?

Ans.)
a. Normal IOP 12-20mmHg.
b. Factor that affect IOP during GA are:
1. Venous pressure IOP
2. Globe volume IOP
3. Laryngoscopy IOP
4. Intubation IOP
5. Airway obstruction IOP
6. Coughing, vomiting, valsalva IOP
7. Trendelenburg position IOP
8. Tightly fitted face mask IOP
9. Improper prone position IOP
10.Retrobulbar hemorrhageIOP
11.Blinking / squinting IOP
12.Anticholinergics IOP
13.Suxamethonium IOP

All anesthetic agents IOP except:

1. Suxamethonium.
2. Atropine.
3. Ketamine.

Effect of cardiac and respiratory variables on IOP

Variable Effect
CVP IOP
CVP IOP
Arterial BP IOP
Arterial BP IOP OCR
PaCO2 IOP Ans c) OCULOCARDIAC REFLEX:
PaCO2 IOP Traction on extraocular muscles or pressure on
PO2 No effect eye ball can elicit cardiac dysrhythmia ranging
PO2 IOP from bradycardia and ventricular actopy to
sinus arrest or ventricular fibrillation.
OCR is most common in pediatric pts. undergoing strabismus surgery.Also
occur in cataract extraction, enucleation, retinal detachment
In awake pts associated with somnolence and nausea
This reflex consists of trigeminal afferent (V1)and vagal efferent path
described in 1908

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Dr. Tariq Mahar
Management:
1. Immediate notification of surgeon and temporary cessation of surgical
stimulation until HR
2. Confirmation of adequate ventilation, oxygenation and depth of anesthesia
3. Administration of IV atropine (10g/kg)
4. In recalcitrant episodes infiltration of rectus muscles with local anesthetics
The reflex eventually fatigues itself with repeated traction on EOM. (Extra Ocular Muscle)

PERIBULBAR BLOCKADE
The needle does not penetrate the cone formed by the extraocular muscle
Advantage: Less risk of eye penetration, optic nerve and artery, and less pain on
injection
Disadvantage: Slow onset and likelihood of ecchymosis
Technique: Patient supine position looking direct head typical anesthesia
conjunctivae one or two trans-conjunctival rejection eyelid retracted
inferotemporal injection b/w lateral limbus. Needle advanced orbital
floor slightly medial to and cephalad to 5ml L/A
Second 5ml through conjunctiva on nasal side

Strabismus
Q. what are the anesthetic concerns in a seven year old child presenting for
strabismus surgery?

Ans.)
Anesthetic concerns:
GOALS:
To maintain IOP and to prevent OCR

PREOP. CONCERNS:
1. GA is indicated in children and uncooperative patients as even small head
movements could be disastrous during microsurgery.
2. Pts may be apprehensive possibility of permanent blindness.
3. Pediatric patients have associated congenital disorders e.g. downs
syndromes.
4. Elderly pts often have co-morbidities like DM, HTN, CAD
5. GPE and airway assessment with relevant history. (General Physical
Examination)

INTRAOP. CONCERNS:
1. Choice of induction technique depends on other medical problems.
2. Laryngoscopy and intubation duration must be as short as possible to control
IOP- Also blunted by prior I.V Lidocaine or opioid
3. Coughing during intubation must be avoided by deep anesthesia and
profound paralysis.

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Dr. Tariq Mahar
 4. A NDMR is used instead of Suxamethonium IOP. (non depolarizing muscle
relaxants)
5. Most pts with open globe injury have full stomach and require a RSI with
cricoids pressure.
6. Pulse oximetry and capnograph monitoring particularly important.
7. Kinking and obstruction of ETT, breathing circuit disconnection and
unintentional extubation minimized by reinforced or preformed RAE tube.
8. More chances of hyperthermia in infants because of head to toe draping
9. ETCO2 differentiate this hyperthermia with MH.
10.Adequate IV hydration to avoid hypotension (deep anesthesia CVS
stimulation)
11.Intraoperative IV metoclopramide or 5HT3 antagonist (Ondansetron) PON
dexamethasone 4mg in adults if strong H/O PONV.

POSTOP CONCERNS:
1. PONV IV metoclopramide, 5HT3 antagonist and dexamethasone
2. Coughing on ETT could be prevented by extubating indeepanesthesia
3. IV Lidocaine 1.5mg/kg to prevent cough reflexes temporarily
4. Severe postop pain is unusually sufficient following ophthalmic procedure.
5. Meperidine 15-25 mg are usually sufficient
6. Sever pain signal intraocular HTN, corneal abrasion or other surgical
complications.

Retrobulbar blockade
LA (lidocaine or bupivacaine) is injection behind the eyeinto the cone formed by
EOM. Addition of epinephrine bleeding and prolongs anesthesia. Hyaluronidase
3-7ut/ml enhances the Retrobulbar spread of local anesthetic.

Complications:
1. Retrobulbarhemorrhage
2. Globe perforation
3. Optic Nerve atrophy.
4. Frank convulsions Rx
5. OCR Positive (PPV)
6. Trigeminal Nerve block To prevent hypoxia, bra
7. Respiratory arrest. and cardiac arrest
8. Post-Retrobulbar apnea syndrome
unconsciousness +apnea

Contraindications:
1. Bleeding disorder.
2. Extreme myopia. 3. Open eye injury
OPEN EYE INJURY:
Q. 12 years old boy is scheduled for emergency repair of ruptured globe, after being
shot in the eye with pellet gun?
What are the anesthetic concerns?

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Dr. Tariq Mahar
Ans. )
GOALS:
1. To prevent further damage to eye by avoiding IOP
2. To prevent pulmonary aspiration with a full stomach.

PREOP CONCERNS:
1. Routine history, physical examination and last oral intake.
2. Consider to have a full stomach as gastric emptying is delayed by pain and fear
that follow trauma.
3. Despite the aspiration risk these pts require GA.
4. Metoclopramide LES tone, speeds gastric emptying, lowers gastric fluid volume
and excretes antiemetic effect.
5. Ranitidine (H2 receptor blocker) inhibits gastric acid secretions.
6. Non particulate antacid (sodium citrate) should be given prior to induction.

INTRAOP CONCERNS:
7. RSI with cricoid pressure. Avoid direct pressure on globe and CVP
8. STP and Propofol are ideal induction agents as they IOP
9. Prior administration of fentanyl or lidocaine attenuates the hypertensive
response to laryngoscopy and intubation IOP
10.Rapid onset of action that aspiration risk and profound muscle relaxation that
risk of valsalva response during intubation
11.Succinylcholine should be given even knowing that it intragastric and
intraocular pressures

POSTOP CONCERN:
1. Pt. again at risk of aspiration during extubation and emergence so it should be
delayed until pt. awake and has intact airway reflexes
2. Intra op antiemetic + NG suction risk of PONV.

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Dr. Tariq Mahar