OPHTHALMIC ANAESTHESIA
Anaesthesia for paediatric
eye surgery
Ian DM Davies
Steven M Sale
Abstract
Local anaesthesia is often the technique of choice for ophthalmic pro-
cedures performed on adults; however, general anaesthesia is usually
required for procedures on children. The majority of paediatric patients
are fit and healthy but there is a minority in whom the presenting eye
complaint is related to a congenital disorder, which may have signifi-
cant bearing on the conduct of anaesthesia.
Management of the airway and presentation of a quiescent eye for
surgery are key considerations, while control of the oculocardiac re-
flex and intraocular pressure (IOP) are important both intraoperatively
and postoperatively. IOP is affected by almost all aspects of general
anaesthesia and should be considered when choosing an anaes-
thetic technique. Ocular surgery is emetogenic and without prophy-
laxis is associated with a high incidence of postoperative nausea
and vomiting which should be addressed to prevent problematic
increase in intraocular pressure. Most procedures are associated
with mild to moderate postoperative pain and can usually be
managed with simple analgesia. Pain, but also the use of opioid anal-
gesia, is a risk factor for postoperative nausea and vomiting. Exam-
ination under anaesthesia, intraocular surgery, correction of squint
and emergency ophthalmic surgery each presents its own challenge
and all are discussed.
Keywords Anaesthesia; intraocular pressure; oculocardiac reflex;
ophthalmic; paediatric
Royal College of Anaesthetists CPD Matrix: 1A02, 2D02, 3A12
Local anaesthesia is often the technique of choice for ophthalmic
procedures performed on adults; it is usually well tolerated,
effective, and avoids the risks of general anaesthesia. With the
exception of certain mature teenagers, local anaesthesia alone is
rarely tolerated by children.
As a result of the need for specialized equipment, ophthalmic
surgery is usually performed in specialized eye theatres which
can be situated in an isolated location, distant to the main theatre
complex. It is important to ensure that staff are appropriately
trained and familiar with paediatric patients and that appropriate
paediatric equipment is available.
The majority of paediatric patients are fit, healthy, American
Society of Anesthesiologists (ASA) I or II, have a very low risk
Ian D M Davies MB ChB FRCA is an Anaesthetic Registrar at University
Hospitals Bristol NHS Trust, Bristol, UK. Conflicts of interest: none
declared.
Steven M Sale MB ChB FRCA is a Consultant Paediatric Anaesthetist at
Bristol Royal Hospital for Children, Bristol, UK. Conflicts of interest:
none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Davies IDM, Sale SM, Anaesthesia for paediatric eye surgery, Anaesthesia and intensive care medicine (2016),
http://dx.doi.org/10.1016/j.mpaic.2016.10.012
Learning objectives
After reading this article, you should be able to:
C describe the congenital conditions and associated anaesthetic
considerations encountered in paediatric ophthalmic surgery
C classify the anaesthetic factors that affect intraocular pressure
(IOP) and discuss the management of these factors
C describe the oculocardiac reflex, its management and
associations
C demonstrate the management of postoperative nausea and
vomiting following anaesthesia for paediatric ophthalmic
surgery
C describe a sensible anaesthetic technique for the following
procedures: (i) examination of the eye under anaesthesia
including measurement of IOP; (ii) intraocular surgery;
(iii) strabismus surgery
C discuss the potential anaesthetic techniques for emergency
ophthalmic surgery in the paediatric population
associated with general anaesthesia, and can be managed as day
cases. There is a minority in whom the presenting eye complaint
is related to a congenital disorder which may have significant
bearing on the conduct of anaesthesia (Table 1).
Pre-medication
A number of children having anaesthesia for eye surgery have
multiple planned procedures and/or learning difficulties. Mild
sedative premedication (e.g. midazolam or clonidine) should be
considered for patients likely to find general anaesthesia dis-
tressing. Anticholinergic premedication used to be considered
standard practice for any procedure during which bradycardia is
likely (see oculocardiac reflex). However, it is now rarely used.
Intraoperative considerations
Induction of anaesthesia
Both intravenous and inhalational induction may be suitable and
the anaesthetist may make their own assessment based on the
patient in question. If inhalational induction is used, nitrous
oxide should be avoided. Nitrous may increase the risk of nausea
and vomiting, diffuse into the intraocular gas bubbles used in
retinal detachment surgery and increase intra-ocular pressure, or
even diffuse out of those same bubbles once established and risk
recurrence of detachment.
Airway
Unless the patient has associated comorbidities (Table 1) they are
unlikely to present with an airway that is difficult to manage.
However, limited access to the airway intraoperatively necessi-
tates careful choice of airway device. Endotracheal intubation
provides secure airway access and, with paralysis, allows easy
ventilation (controlling CO2 and ensuring no movement during
intraocular surgery) but is associated with coughing on emer-
gence (with raised venous and IOPs). A small dose of lidocaine
(e.g. 1 mg/kg IV) may avoid the raised IOP encountered on
extubation but is seldom required.
1 Ó 2016 Published by Elsevier Ltd.
 OPHTHALMIC ANAESTHESIA

Congenital disorders related to paediatric ophthalmic surgery

Syndrome Anaesthetic considerations Ophthalmic disorder

Mucopolysaccharidoses Difficult mask ventilation and intubation, Cataract, glaucoma, squint

post-extubation stridor and pulmonary collapse
Craniosynostosis disorders Upper airway obstruction due to midface
C Crouzon’s, Apert’s and hypoplasia and secondary nasal obstruction
Pfeiffer’s syndromes due to choanal atresia. Tracheal anomalies,
such as tracheal cartilaginous sleeve,
have been reported in severe cases
Craniofacial syndromes Difficult airway and laryngoscopy secondary
C Goldenhar, Treacher-Collin, to retrognathia, decreased mouth opening,
SmitheLemileOpitz decreased neck extension and relative
macroglossia
HallermaneStreiff syndrome Mandibular hypoplasia and microstomia
results in difficult intubation
Stickler’s syndrome Midface hypoplasia, retromicrognathia, Early retinal detachment, glaucoma
and cleft palate. The mandibular hypoplasia
causes difficulties in mask ventilation
and endotracheal intubation
Congenital phakomatoses Associated with: seizures, intracranial Haemangiomas, ocular melanocytosis,
C SturgeeWeber, neurofibromatosis, lesions and phaeochromocytoma retinal hemangioblastoma
von HippeleLindau disease
Homocysteineuria Hypoglycaemia, thromboembolism Dislocated lenses
Marfan’s syndrome Potential aortic root/valve disorder

Table 1

If intubation is planned then ‘south-facing’ (e.g. RAE tubes)
or flexible endotracheal tubes avoid interference with the surgi-
cal field. Pre-formed south-facing tubes especially should be used
with caution in infants and young children as there is a consid-
erable degree of interpersonal anatomical variation which
predisposes to endobronchial intubation if the bend is incorrectly
located. Alternatively, flexible laryngeal mask airways can be
used safely in children at low risk of regurgitating and when
combined with paralysis, ventilation and modern volatile agents,
allows for a very rapid smooth emergence with minimal
coughing.
Intraocular pressure
Normal IOP is 10e20 mmHg. Control of IOP during anaesthesia
is important as a sudden rise can lead to loss of intraocular
contents or expulsive haemorrhage. Normal regulation of IOP
occurs through regulation of the volume of aqueous humour in
the anterior chamber. The vitreous humour is a relatively fixed
volume. Anaesthetic factors affecting IOP are similar to those
affecting intracranial pressure (Table 2).
Oculo-cardiac reflex (OCR)
This is a common phenomenon and particularly potent in chil-
dren. It can be triggered by a sudden rise in IOP, traction on the
extraocular muscles (particularly the medial rectus) or traction
on the eyelid. Afferent fibres via the ophthalmic branch of the
trigeminal nerve run to a sensory nucleus in the fourth ventricle.
Efferent fibres in the vagus nerve generally result in bradycardia
but can proceed to asystole if left untreated. Incidence varies but
is reported to be as high as 60% during squint surgery. Pro-
phylaxis with vagolytics is protective. Anaesthesia with propofol
may increase the risk of bradycardia and those having total
intravenous anaesthesia (TIVA) may benefit from prophylactic
atropine or glycopyrrolate. It has been suggested that there is an
association between the OCR and post-operative nausea and
vomiting. There is little evidence for this. Karanovic et al. cast
doubt over the association with a study comparing paralysis with
rocuronium in one group with no paralysis in the other. There
was a significant decrease in incidence of OCR on the rocuronium
group but identical incidence of PONV in both groups. It has
been proposed that the use of ketamine may blunt the OCR.
Postoperative nausea and vomiting (PONV)
Ocular surgery is emetogenic and without prophylaxis is asso-
ciated with a high incidence of PONV. The rise in IOP associ-
ated with active vomiting is particularly detrimental in these
patients. This incidence has been quoted as high as 90% in
strabismus surgery and is thought to lie between 50 and 76%
for intraocular surgery. Manipulation of the extraocular mus-
cles, increased ocular volume and changes in IOP can all
potentiate nausea and vomiting. Reported risk reductions can
be seen in Table 3. It should be remembered that PONV sec-
ondary to raised IOP is resistant to antiemetics and if vomiting
persists despite therapy, the patient should be reviewed by the
ophthalmologist.
PONV can be reduced using multi-modal techniques such as
ensuring the patient is well hydrated, avoidance of nitrous oxide
and opioid analgesia, as well as using one or two prophylactic

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 2 Ó 2016 Published by Elsevier Ltd.

Please cite this article in press as: Davies IDM, Sale SM, Anaesthesia for paediatric eye surgery, Anaesthesia and intensive care medicine (2016),
http://dx.doi.org/10.1016/j.mpaic.2016.10.012
 OPHTHALMIC ANAESTHESIA

Factors affecting intraocular pressure (IOP)

Factors affecting IOP Effect on IOP Anaesthetic management

Ventilation \CO2, ZO2 lead to increased IOP Intermittent positive pressure ventilation
and maintenance of high oxygen saturation
and low normal end tidal CO2
Venous pressure High ocular venous pressure Position head up
Tape rather than tie endotracheal tube
Neutral head position
Drugs Suxamethonium e transient \IOP Avoid the use of nitrous oxide for all intraocular
Non-depolarizing muscle relaxants e surgery. Ketamine and suxamethonium should
Zmuscle tone may lead to ZIOP be avoided where possible e there may be a
Volatile agents e ZIOP minority of cases where their use is clinically
Nitrous oxide e \IOP indicated. Propofol, volatile agents and opioids
Propofol e ZIOP will not cause raised IOP and are safe to use
Opioids e ZIOP
Ketamine e no change or
transient \IOP
Direct pressure \IOP Avoid pressure on the eyes, e.g. during mask
ventilation. Ensure the eyes are well
protected prior to surgery
Coughing, straining, fitting All cause increased IOP Smooth induction with adequate levels of anaesthesia
is key. Smooth emergence is also clearly very important
Pain Increased IOP Good postoperative analgesia
Muscle tone Increased tone of extraocular muscles Consider paralysis for the duration of intraocular surgery
causes an increase in IOP
Vomiting \IOP Prophylactic antiemetics are recommended.
Consider total intravenous anaesthesia in adolescents
Blood pressure Sudden hypertension causes a rise in IOP, Ensure adequate depth of anaesthesia prior
while profound hypotension may to laryngoscopy to avoid hypertension.
cause decreased ocular perfusion Remifentanil provides stable blood pressure
and good operating conditions

Table 2

antiemetics. Another simple measure to combat PONV is the Specific procedures

avoidance of long fasting times preoperatively.
Analgesia
Most ophthalmic surgical procedures result in mild to moderate
postoperative pain. This can be effectively managed with simple
analgesia and the intraoperative use of local anaesthetic. Surgery
for squint, evisceration, and vitreoretinal surgery are associated
with more severe pain and are likely to require stronger analgesia
such as tramadol or oral morphine. Topical local anaesthesia or
intra-operative infiltration (such as Subtenon’s block inserted by
the surgeon) is useful in providing effective analgesia and hence
avoiding the need for opioid analgesia in more painful procedures.
Relative risk reduction with prophylactic antiemetic use
Action taken Relative risk reduction
Avoidance of nitrous oxide 0e61%
Metoclopramide 41%
Ondansetron 55%
Table 3
Examination of the eyes
Adequate eye examination is difficult in younger children who
will often require general anaesthesia for even the simplest ex-
amination. A simple, quick examination (e.g. IOP check) can be
performed on a facemask. However use of an LMA allows the
surgeon better access, and may make asepsis easier to achieve if
required. A full non-invasive examination may take up to 60 mi-
nutes for IOP testing, slit lamp exam, biometry, retinoscopy etc.
Measurement of IOP
Accurate measurement of IOP is essential when managing glau-
coma. In young children this often requires an anaesthetic. His-
torically, ketamine has been used as the agent of choice for
anaesthesia for IOP measurement. It was understood that keta-
mine produced less disruption of IOP than other anaesthetic
agents. However, modern standard practice is to use more
familiar techniques such as IV induction with propofol or gas
induction with sevoflurane. Induction is performed with the
ophthalmologist present and IOP measurement can be under-
taken immediately in the anaesthetic room. Only a brief light
general anaesthetic is required which is unlikely to have a
marked effect on IOP.

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 3 Ó 2016 Published by Elsevier Ltd.

Please cite this article in press as: Davies IDM, Sale SM, Anaesthesia for paediatric eye surgery, Anaesthesia and intensive care medicine (2016),
http://dx.doi.org/10.1016/j.mpaic.2016.10.012
 OPHTHALMIC ANAESTHESIA
Suggested anaesthetic techniques for intraocular surgery
Induction IV induction with opioid and propofol 3e5 mg/kg
Airway RAE endotracheal tube following paralysis with
non-depolarizing muscle relaxant (NDMR)
Maintenance TIVA: propofol TCI (or 6e10 mg/kg/hour) þ
remifentanil 0.2e0.5 mg/kg/minute
IPPV throughout
Table 4
Intraocular surgery
Intraocular surgery in children is predominantly performed for
treatment of glaucoma and procedures include: goniotomy, tra-
beculotomy and trabeculectomy. These are similar procedures
aimed at relieving obstruction of flow in the anterior chamber
caused by the trabecular network. Procedures last approximately
an hour and are associated with minimal pain postoperatively.
The eye must remain motionless during intraocular procedures
and a sudden rise in IOP may result in extrusion of intraocular
contents through an incision. Anaesthetic methods to achieve
this can be seen in Table 4. Intraocular surgery is not particularly
painful and paracetamol with or without added ibuprofen is
suitable postoperative analgesia. Prophylactic antiemetics should
be used routinely.
Strabismus surgery
Strabismus surgery is performed to correct a deficit that is both
functional and cosmetic and is therefore an emotive procedure for
children and their parents. It is usually performed as a day case but
the high incidence of PONV leads to occasional overnight stays,
and it is also a potentially painful operation. The oculocardiac re-
flex is common due to extraocular muscle manipulation and
anaesthetists must be vigilant. There is an extremely rare associa-
tion with malignant hyperthermia e temperature monitoring
should be used and suxamethonium avoided. Anaesthesia can be
conducted with a spontaneously breathing patient or with positive
pressure ventilation. However, in some cases the surgeon may
wish to deliver an electromyography-guided injection of botulinum
toxin, in which case the use of muscle relaxants should be avoided.
Enucleation and evisceration
Removal of the eye may be required because of retinoblastoma or
if the child has an unsightly or painful blind eye. Anaesthetic
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Please cite this article in press as: Davies IDM, Sale SM, Anaesthesia for paediatric eye surgery, Anaesthesia and intensive care medicine (2016),
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OR Gas induction with sevoflurane followed by IV access
OR Flexible LMA inserted with or without paralysis
OR Inhaled sevoflurane/desflurane þ regular
administration of NDMR in conjunction with
neuromuscular monitoring. IPPV throughout
management is as for strabismus surgery although the risk of
PONV is much less.
Emergency surgery
Penetrating eye injury may require urgent surgery that cannot
wait for a fasted patient. The anaesthetist is therefore presented
with a dilemma e should a standard rapid sequence induction
(RSI) using suxamethonium be performed, or should a modified
RSI using a non-depolarizing muscle relaxant be used to avoid a
rise in IOP? There have been no reports of vitreous extrusion
secondary to suxamethonium, presumably as the simultaneous
use of induction agents will reduce IOP. Therefore, if there are
concerns about the airway or it is felt that the patient is at high
risk of aspiration suxamethonium may be the muscle relaxant
of choice. However, with rocuronium being licensed for RSI at
higher doses (0.9e1.2 mg/kg) this theoretical problem of raised
IOP can be avoided whilst maintaining airway safety. Most
importantly the technique used should result in smooth in-
duction with no coughing on intubation as this will cause a
significant rise in IOP and has the potential to cause further
ocular damage. A
FURTHER READING
James Ian. Anaesthesia for paediatric eye surgery. Contin Educ
Anaesth Crit Care Pain 2008; 8: 5e10. http://dx.doi.org/10.1093/
bjaceaccp/mkm048.
Karanovic N, Carev M, Ujevic A, Kardum G, Dogas Z. Association of
oculocardiac reflex and postoperative nausea and vomiting in
strabismus surgery in children anesthetized with halothane and
nitrous oxide. Paediatr Anaesth 2006; 16: 948e54.
Stoddart P, Lauder G. Paediatric anaesthesia. InformaHeathcare,
March 2004.
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