ANESTHESIA IN

OPHTHALMIC
SURGERIES
Moderator – Dr. Jyoti Bhatt
Dr. Pankaj Jeswani

Presenter- Dr. Ashima Varshney

 TOPICS
1. Basic anatomy
2. Anesthetic agents
3. Types of anesthesia
 ORBITAL ANATOMY
• Base directed forwards, laterally & slightly downwards.
• Apex lies between optic foramen & medial end of Superior orbital fissure.
• Shortest orbital wall is floor ~47.6mm
• Depth along medial wall 42 and lateral wall 54mm

• Lateral wall makes an angle of 45 degree

with median plane.

• Orbital rim 35mm vertically and 40 mm

horizontally in diameter.

• Axial length -24mm.

• Intraorbital length of optic nerve is about 30mm

• Capacity of the orbit- 30cc
Fig shows plane of Iris & midsagittal plane of the globe in primary gaze
7 BONES MAKING ORBIT &
FORAMEN AND FISSURES
NERVES & CILIARY GANGLION
 EXTRAOCULAR
• 4 recti-SR-IR-MR-LR
MUSCLES
• 2 Obliques-SO,IO
• 1Protractor-orbicularis oculi
• 1 Retractor –LPS, Mullers
• Relationship between muscle
insertions and the ora serrata is
clinically important. A
misdirected suture passed thru
the insertion of the superior
rectus could perforate the retina.

• MR-5.5mm
• IR-6.5mm
• LR-6.9mm
• SR-7.7mm
ORBITAL SPACES
 SURGICAL SPACES IN THE ORBIT

 Knowledge of the main compartments of the orbit & their boundaries helps in
choosing the most direct approach to the tumor & ocular anaesthesia .

 From surgical point of view ,orbit divided into 4 spaces :

1. Subperiosteal space
2. Peripheral Orbital space /Anterior space/Extraconal space
3. Central space/Intraconal space
4. Sub - Tenon's space
 SUBPERIOSTEAL SPACE

o This is a potential space between orbital

bones and the periorbita [periosteum].

o Limited anteriorly by the strong adhesions

of periorbita to the
orbital rim.
 PERIPHERAL ORBITAL SPACE /ANTERIOR
SPACE/ EXTRACONAL SPACE
• This space is bounded
• Peripherally by periorbita,
• Internally by the four extra ocular muscles with
their intermuscular septum,
• Anteriorly by the septum orbitale(including tarsal
plates & tarsal ligaments).
• Posteriorly, it merges with the central space.
• Contents :peripheral orbital fat, superior & inferior
oblique
muscle,LPS ;lacrimal ,frontal,trochlear,anterior &
posterior ethmoidal nerves;superior & inferior
ophthalmic veins;lacrimal gland & half of lacrimal
 CENTRAL SPACE / CONAL SPACE/
RETROBULBAR SPACE
• Bounded anteriorly by tenon’s capsule lining back of
the eye &
• peripherally by extraocular rectus muscles & their
intermuscular septa(in anterior part)
• Contents : optic nerve and its meninges, superior and
inferior divisions of oculomotor nerve, abducent
nerve, nasociliary nerve, ciliary ganglion, ophthalmic
artery, superior ophthalmic vein and central orbital
fat.

SUB TENON'S SPACE

• It is a potential space around the eyeball between
the sclera and tenon’s capsule.
 TYPES OF ANESTHESIA

Regional Facial nerve GA

Local anesthesia anesthesia block
• Topical • Peribulbar
• Subconjuctival • Parabulbar
• Intracameral • Retrobulbar
• LAs are amphipathic,
• Cross lipid bilayer cell membrane (neurilemma)

• bind voltage gated sodium channels ionised

forms.

• conformational changes Voltage-gated sodium (Na) channels exist in (at least)

blockage of entry of sodium ions.
• no depolarisation , no propagation of the
stimulus to the brain.
three states—resting, activated (open), and
inactivated. Note that local anesthetics bind and inhibit
the voltage-gated Na channel from a site that is not
directly accessible from outside the cell, interfering
with the large transient Na influx associated with
membrane depolarization.
 LOCAL ANESTHETICS

Types of LA :

According to chemical structure

Ester group Amide group

Procaine Lidocaine
Cocaine Bupivacaine
Tetracaine Ropivacaine
Benzocaine Mepivacaine
 COMMONLY USED LA :
Agents Chemical Concentration Max dose Onset of Duration
(Trade name) classes (mg/kg) action of action
(min)

Procaine (novocaine) Ester 1-4 % 12 7-8 30-45 min

Mepivacaine (Carbocaine) Amide 1-2 % 7 3-5 120 min
*Lidocaine (Xylocaine) Amide 1-2 % 7 4-5 40-60 min
*Bupivacaine (Marcaine, Amide 0.25-0.75 % 3 5-11 4-12 hrs
sensocaine)

Etidocaine (Duranest) Amide 0.25-0.75 % 400 3-5 5-10 hrs

*Preferred regional anesthetic agent by most of the ophthalmic surgeons.

All commonly used topical anaesthetics are of ester type except lidocaine gel,
while
All injectable anaesthetics are of amide type except procaine
 LOCAL ANAESTHESIA
 ADVANTAGES :
 Patient is conscious and will maintain mental alertness during surgical procedure
 Drugs used in G/A can be avoided
 Lowers risks of systemic complications: like nausea and vomiting
 Superior post-operative pain control and recovery time
 Early mobilisation

DISADVANTAGES :
 Painful
 Difficult in uncooperative patients
 Injection complications
 Not suitable for : children
Mentally unstable patient
PATIENT PREPARATION FOR LA

 Detailed history & examination as for GA

 Optimal health condition
 IV cannula
 Lignocaine test dose
 Full cardio-pulmonary resuscitation equipment
 Appropriate monitoring
LA agent :
o Lignocaine 2%
o Bupivacaine 0.50 -0.75%
Along with
o Hyaluronidase 5 – 7.5 IU/ml
o Adrenaline 1: 200,000

Adrenaline :causes local vasoconstriction, increase duration of LA.

Decreases blood loss during surgery.
Hyaluronidase : facilitate local spread of LA in the tissues.Reduce the pressure rise in limited
orbital space, produce less distortion of surgical site, decrease the risk of postop strabismus &
myotoxicity
 RETROBULBAR BLOCK
AIM:
• Site muscle cone
• Cilliary nerve and ganglion
• 3rd , 6th cranial nerves .
• Action- akinesia, anesthesia & analgesia.
• Superior oblique muscle is not usually paralysed
POSITION OF PATIENT:
Supine and in primary gaze
SITE OF INJECTION:
The point between medial 2/3rd & lateral
1/3rd of lower orbital margin.
 DIRECTION OF NEEDLE:
• Backward , upwards and medially towards apex of orbit, with
bevelled edge upward.

• Needle: 25G, 1.5 inch(38.1mm), bevelled, rounded blunt-tip,

disposable, retrobulbar needle (e.g., Atkinson needle)
 OCULAR MASSAGE
# After the injection intermittent firm digital pressure on the eye applied
# It produces hypotony ( decrease IOP), diffusion of anesthetic agent.
# May use Superpinkie or Honan balloon for 10 minutes.
4ml of LA increases IOP by 6.2 mmHg.
Ocular compression decreases IOP by 8.8mmHg
after 5min & 14.3mmHg after 40min.

ADVANTAGES:
 Complete akinesia
 Dilatation of pupil
 Adequate and quicker anaesthesia
 Minimal amount of anaesthetic agent required
 COMPLICATIONS OF RETROBULBAR BLOCK
 Retrobulbar hemorrhage.
 Globe perforation.
 Intravascular anesthetic injection
 Intraocular anesthetic injection.
 Optic nerve injury with intrathecal injection or
Optic nerve sheath hematoma.
 Brain stem anesthesia
 Oculo-cardiac reflex
 Frank convulsion
 Extra ocular muscle palsy
 Decreased visual acuity
 Trigeminal nerve block
 Respiratory and cardiovascular depression.
CONTRAINDICATION :
Bleeding disorder ( risk of retrobulbar haemorrhage)
High myopia ( globe perforation)
An open eye injury (may cause expulsion of intraocular contents)
Posterior staphyloma
Nystagmus
 PERIBULBARBLOCK
AIM:
 Injected into peribulbar space
 Spreads to lid and other spaces
 Produces globe and orbicularis akinesia and anaesthesia.

POSITION OF PATIENT:
Supine and in primary gaze

VOLUME :

8ml (approximately)
SITE OF INJECTION:
1st: The point between medial 2/3rd &
lateral 1/3rd of lowerorbital margin
adjacent to infraorbital notch (4 – 5 ml )
2nd : Just infero-medial to supra orbital
notch or between medial
canthus & caruncle. (4 – 5 ml)

# Bevel of needle should be directed toward globe and

# needle advanced parallel to orbital floor &
# no redirection as in retrobulbar block .
# Hub of needle should not go beyond the inferior orbital rim.
ADVANTAGES :
 Anesthetic agents are deposited outside the muscle cone(extraconal).
 Needle is further away from the globe,blood vessels, optic nerve, & dural sheaths.
 Less pain on injection.

DISADVANTAGES :
 Conjunctival chemosis
 Less akinesia than retrobulbar block

COMPLICATIONS :
 Perforation of eye with peribulbar needle.
 Intraocular anesthetic injection.
 optic nerve sheath hematoma.
 Respiratory and cardiovascular depression.
 PARABULBAR OR SUB-TENON BLOCK
Topical anesthetic (e.g., 0.5% proparacaine)

With blunt Westcott scissors and 0.12 mm forceps, Halfway between inferior limbus
& fornix(5-10 mm medial to limbus) in inferomedial quadrant, Conjunctival incision
2-3 mm given & dissection of tenon’s fascia to open sub-tenon space.

Using 15 mm, 25G blunt tipped curved cannula or needle

Cannula kept straight ,parallel to the optic nerve

Slowly inject 2–3 ml of LA in the periequatorial

region Bathing the nerves & muscles within the cone

ADVANTAGES :

Uses blunt end cannula less chance of penetrating globe or dural sheath or vessels .
 Lack of elevation of blood pressure and transitory cardiac arrhythmia
 Requires lower volume of anaesthetics
 Better anaesthesia to iris and ant.segment

DISADVANTAGES:
 Subconjunctival haemorrhage
 More post-operative morbidity
 FRONTAL BLOCK

AIM: to block supra-orbital and supra-trochlear nerve supplying the upper lid.

USE: ptosis surgery

SITE OF INJECTION: just below mid-point of supra- orbital margin

transcutaneously directed towards roof of orbit

VOLUME:2 ml of LA .
 FACIAL NERVE BLOCK {ORBICULARIS OCULI
BLOCK}
• AIM :For paralysis of orbicularis oculi muscle to prevent
blepharospasm which causes rise of IOP (by10mmHg).

• USE :adjunct to retrobulbar block

• VOLUME : 3–5 ml of LA
• 25G, 1.5 inch disposable needle
TYPES :
1.Van lint
2. O’Brien
3.Nadbath / Rehman
4. Atkinson
CLASSIC VAN LINT TECHNIQUE
:
 Peripheral branches of facial nerve are blocked.
 Introduce the needle 1 cm behind the lateral margin of
orbit at the level of the inferior orbital rim.

 Advance needle horizontally and inject 1–2 ml

subcutaneously along inferotemporal orbital rim
while withdrawing needle.
 Then redirected superonasally and inject along the
superotemporal orbital rim.
MODIFIED VAN LINT TECHNIQUE :
1st superior & slightly anteriorly.
Do not remove needle from skin.
2nd inferior and slightly anteriorly.

Supplemented with:
3rd 1 cm inferonasal to original entry site along
inferior orbital rim
4th 1 cm superotemporal to original
entry site along superior orbital rim.
 O’BRIEN TECHNIQUE
 Facial nerve is blocked near the condylar process of mandible.
 Located 1 cm anterior to the tragus of the ear and inferior to the posterior
aspect of the zygomatic process.

 Insert needle until the periosteum of the condyloid process is reached.

 Withdraw needle to its tip & then advance it superior & anteriorly
over zygomatic arch.Redirect inferiorly along the posterior edge of
ramus of mandible
 Inject ~2 ml of anesthetic solution.
 Do not inject into periosteum.
 Do not inject into temporomandibular joint space.
ATKINSON TECHNIQUE
• The superior branches of the facial nerve are blocked.

• Insert needle subcutaneously at inferior edge of zygomatic bone

directly below lateral orbital rim.

• Advance needle across zygomatic arch, aiming ~30

degrees upward towards top of ear.

• Inject ~3–4 ml of anesthetic solution as needle is withdrawn.

• High failure rate

 NADBATH AND REHMAN TECHNIQUE :

•LA is Injected where the main trunk of the facial nerve

emerges from the stylomastoid foramen.

•The injection site is located between the mastoid process

and the posterior edge of the mandible.

• A short needle (12-16 mm) , 2-4 mI of LA injected.

Associated with the highest risk of serious complications

1. Dysphagia
2. laringospasm
3. distressed respiration
May cause permanent facial nerve paralysis
MAJOR SIGHT & LIFE THREATENING COMPLICATIONS
A. RETROBULBAR HEAMORRHAGE:
• Most commonly in retrobulbar injections.
SIGNS & SYMPTOMS :
• rapid intraorbital and intraocular pressure elevation
• increasing proptosis
• marked pain
• ecchymoses in the eyelids
• Chemosis
• vision down to poor perception or no perception of light
MANAGEMENT:
Indirect ophthalmoscopy - for evaluation of central retinal
artery perfusion compromise. (r/o CRAO ).

Immediate medical treatment: intravenous osmotic agents

such as –
 acetazolamide
 Mannitol
Surgery:
Surgical decompression such as -
 Canthotomy
 Cantholysis
 Orbital decompression

 General anesthesia is recommended in patients

having repeated retrobulbar hemorrhage.
 B. GLOBE PERFORATION:
o Penetration of globe in retrobulbar and peribulbar blocks.
High myopes (AL >26 mm)

SIGNS AND SYMPTOMS :

• Sudden pain during the delivery of local anesthesia.
• Hypotony with inability to secure a stable globe –intraop.
• Reduced red reflex due to vitreous hemorrhage.
• Loss of vision.
• Serious sight threatening vitreoretinal complications viz retinal detachment and
intraocular hemorrhage.

If a penetrating or perforating wound is suspected, it is not advisable to explore the sclera

since needle entry site is small and self-sealing.

 C. OPTIC NERVE INJURY
Optic nerve may be damaged by:

● Direct injury to the optic nerve or central retinal vessels by the retrobulbar needle with resulting optic
atrophy or secondary intraocular hemorrhage due to presumed damage to retinal artery or vein have been
reported.
● ischaemic damage from intrasheath injection or haemorrhage
● pressure from retrobulbar haemorrhage
● pressure from excess local anaesthetic injection into the retrobulbar space
● excessive applied external pressure.

 The position of the globe may influence the rate of injury…primary position reduces the danger of
nerve or vessel damage.
 Avoiding long needles & deep injections into the orbit.
 D. MUSCLE PALSY
 Diplopia and ptosis are common for 24–48 hours post-operatively when large volumes of long-acting
local anaesthetics are used. If this persists or fails to recover, it may be due to muscle damage

Causes of prolonged postoperative diplopia & ptosis :

 Intramuscular injection
 Local anaesthetic myotoxicity
 Ischaemic contracture following haemorrhage/trauma
 Others: Eyelid speculum
Bridle suture
Pressure on the globe and upper lid &
Prolonged upper lid patching.
 E. BRAIN STEM ANAESTHESIA
• Due direct injection of local anaesthetic into optic nerve sheath & subsequent travel to the CNS
via subdural or subarachnoid space.

SYMPTOMS & SIGNS:

 amaurosis  cranial nerve palsies
 drowsiness  convulsions
 respiratory depression or respiratory
 light-headedness
arrest
 confusion  cardiac arrest .
 loss of verbal command
 loss of consciousness
 shivering & tachycardia
ONSET OF SYMPTOMS:
2-40mins of LA injection

MANAGEMENT :
• 100% oxygen
• Maintenance of vitals
• Tracheal intubation and controlled ventilation

Placing the eye in the primary position reduces t he risk

 F. OCULOCARDIAC REFLEX (TRIGEMINOVAGAL
REFLEX)
Oculocardiac reflex is a dysrhythmic physiological
response to the physical stimulation of eye or adnexa. •Factors contributing to the
Afferent – Trigeminal nerve & Efferent - Vagal nerve incidence of the oculocardiac
CAUSES: reflex:
• Traction on extra-ocular muscle
• Pressure on globe
o Preoperative anxiety
SEEN DURING:
• Eye muscle surgery o Hypoxia
• Retinal detachment repair
• Enucleation o Hypercarbia

RESULT:
 Bradycardia
o Increased vagal tone
 Ventricular ectopy owing to age
 Ventricular fibrillation
 AFFERENT PATHWAY
Impulses

Long & short cilliary

nerve Cilliary ganglion

Trigeminal gasserian
ganglion

main trigeminal sensory nucleus

in the floor of the 4th ventricle
 EFFERENT
PATHWAY
Cardiovascular center of medulla
afferent

LCN Vagus nerve

SCN
Heart

CG TGG

VN

efferent
TREATMEN
T
 Stop the surgical stimulus immediately.
 Ensure adequate ventilation .

 Ensure sufficient anesthetic depth.

 Local injection of lidocaine near the eye muscle

 Atropine (0.01 mg/kg IV)/ Glycopyrrolate (anti-

cholinergic): often helpful immediately or prior surgery
 TOPICAL ANAESTHESIA
ADVANTAGES:
• Cost effective, Least invasive procedure,immediate effect and recovery
• Compression of eye is not required.
• Useful for monocular patients.
• Avoidance of :
 Postoperative ptosis
 Sight threatening complications (e.g. globe perforation,optic nerve damage)

DISADVANTAGES:
• No akinesia
• Not suitable for extended surgery
• Proficient experienced surgeons
• Well informed and motivated patient,
• Inability to handle intraoperative complications
• Unsuitability for anxious, deaf and those having dense cataract.
 USES OF TOPICAL ANAESTHESIA :

o Manipulation of superficial cornea and conjunctiva

o Prior to regional blocks
o Diagnostic procedures like applanation tonometry &
gonioscopy
o Removal of small superficial foreign body & suture removal
o Intraocular procedures like Phacoemulsification in cooperative
patient
o Specialised procedures like forced duction test,
electroretinography & corneal epithelial debridement.
 TOPICAL ANAESTHETIC AGENTS

 Several drops of 0.5 % Proparacaine , 0.75 % bupivacaine or 4 % lidocaine

instilled at 5 to 10 minutes before surgery.
 2% Xylocaine gel into inferior fornix .
 Use of preservative & adrenaline free intracameral lidocaine 1% in
phacoemulsification.
 ADVERSE EFFECTS OF TOPICAL
ANAESTHESIA

 Epithelial and Endothelial toxicity.

 Allergy to drug: presents as conjunctival hyperemia,
chemosis, swelling of eyelids, lacrimation and itching.

 Tear film instability and reduced reflex tearing & thus complicate the
clinical picture in dry eye pateints.

 Surface keratopathy (diffuse punctate keratitis)

 GENERAL ANESTHESIA
INDICATION
 Pediatric ocular surgery
 Mentally retarded & psychiatric patients
 Patients with painful arthritis, epilepsy or frequent
coughing
 Anxious, apprehensive patients
 Patient’s preference
ADVANTAGES
 Safe operative environment
 Loss of consciousness & amnesia
 Complete akinesia ,analgesia
 Adequate skeletal muscle relaxation
 Controlled intraocular pressure
 For bilateral surgery
 Avoiding complications of L/A
PRE- ANESTHETIC CHECKUP
1. Detailed history & General Physical Examination
2. Adequate Airway & Systemic Examination
3. Investigations

PROCEDURE OF GENERAL ANESTHESIA

1) Pre-medication for anesthesia
2) Induction & intubation
3) Maintenance & Monitoring
4) Extubation and Recovery
PRE-MEDICATION Sedation+Anxiolytic
->intramuscular injection of combination of meperidine(pethidine) with promethazine
(phenergan). Alternatively, Benzodiazepines like diazepam 5 mg orally 2 hours
preoperatively.
Anti -emetics
->metaclorpramide , ondansetron
->Prevent bradycardia, reduce bronchial and salivary secretion
Atropine

->Medication for selective patients - hypertensive , diabetic , asthma , coronary artery

Selective cases
disease

Thiopentone ( thiopental
sodium) – 5 mg/kg
INDUCTION

Propofol – 2.5 mg/kg

Ketamine least suitable

Halothane is most suitable

 INTUBATION
Suxamethonium (1-1.5 mg/kg body weight) • provides adequate condition for intubation (muscle
intravenous relaxation) and avoids coughing which causes rise of IOP.
Endotracheal intubation and controlled
ventilation
MAINTAINENC

MUSCLE Suxamethonium, Vecuronium

RELAXANTS

ANESTHETIC
AGENTS Nitrous oxide(N2O) with O2((33-66%) and Halothane(0.5-1.5%) , isoflurane
E

INTRAVENOUS
AGENTS Nitrous oxide (N2O) with O2 Intravenous agent – pethidine , Fentanyl , NSAID(for pain
reduction)
IPPV
For good hypotony
 RECOVERY:
Neostigmine (50 mg/kg)
Atropine (20 mg/kg)

COMPLICATIONS OF
GA:
• Hypoxia
• Laryngospasm
• Respiratory depression
• Aspiration pneumonitis
• Cardiac arrythmia
• Hypotension / Hypertension
• Convulsion
THANK YOU