Principles and Practice of Ophthalmic Anaesthesia Jaichandran VV, Chandra M Kumar, Jagadeesh V
INDEX
Page numbers followed by f refer to figure and t refer to table.
A
ACC/AHA guidelines 53
Accentrix 298
Acetazolamide 26, 31
Acetylcholine, against 330
Achoo syndrome 200
Acid base status 45
Acid burn patient 327
Acoustic monitoring 178
Acute primary angle closure 302, 303
Adequate applanation pressure 21f
Adolescent cataract surgery, anaesthesia for 259
Adrenaline solution 272
Advance Westcott scissors 146
Advanced cardiac life support 197
Adverse medical effects, causes for 206
Aesthetic oculofacial surgery, anaesthesia for 337
Airway
anomalies 39
considerations 37
difficulties 72
disease, chronic 206, 218
management 259
Akinesia, good 150, 151
Alfentanil 182
Allergic reaction 72, 75, 197
anaphylaxis 32
to local anaesthetic 213f
Allergy 210
to local anaesthetic agents 213f
Alpha-adrenergic agonist 26
Alveolar bone 319
Amaurosis fugax 340
American Society of Anesthesiologists 175, 207, 345
Amethocaine 161
Amide agents 109
Amide local anaesthetic agents 110
Amniotic membrane 318
Ample 255
Anaemia 56
Anaesthesia 292, 323, 326, 340
awareness during 74
care, monitored 174, 175
considerations 322t, 325t
depth of 226, 228
effect of 223
examination under 269, 310
induction of 326
maintenance of 326, 344
techniques of 163, 278, 309
type of 52
unexpected awareness during 72
Anaesthesia-cum-surgery type 52
Anaesthetic agents 238
influence of 279
on lacrimation, effect of 228
Anaesthetic concerns 321
in preterm neonates and infants 265
in syndromic patient 38
Anaesthetic implications 36
Anaesthetic management, principles of 342
Anaesthetic manoeuvres, physiological effect of 234
Anaesthetic mortality 72
Anaesthetic plan 256
Anaesthetic technique 291, 305
influence of 309
Analgesia 176
good 150
Analgesics 179, 358
Anaphylaxis 197, 214t
Anticholinergic 27, 234
dosage of 28t
efficiency of 28t
syndrome 27
Anticoagulant
medications 290
patients on 65
therapy 56
Anticoagulated patients, safer in 150
Anticonvulsant 356
Antidepressants 356
antiglaucoma
drugs, systemic effects of 29
medications 26
systemic side effects of 310
Antiplatelet and anticoagulant medication 80
Antiplatelet medications 65, 290
Anxiety 169
Anxiolysis 177
Aortic stenosis 38
Apert's syndrome 276, 325
Apnoea-hypopnoea index 40
Applanation tonometry 20
Applied anatomy 228, 275
Aqueous drainage pathway 17f
Aqueous fluid dynamics 16
Aqueous humour 16
role of 301
Arrhythmias 280t
Arterial supply 121
Aspiration 47
Associated systemic abnormalities 276
Asthma 217
Asystole 280
Atkinson technique 124
Atracurium 234
Atrial septal defect 38
Atropine 2628, 248
premedication 27
toxicity 28t, 32
central symptoms of 28t
peripheral symptoms of 28t
Autonomic nervous system, effect of 17
Avastin 298
Axial myopia 126, 127
Axially myopic globe 127f
B
Bacterial endocarditis prophylaxis 37
Benoxinate 161
Benzodiazepine 179, 234
Beta blockers 25, 26
eye drops, adverse effects of 30t
Betaxolol 26
Bevel 123
direction 123
length 123
Binocular indirect
ocular microscope 321
ophthalmomicroscope 294
Birmingham eye trauma terminology system 326
Bispectral index 177, 235, 246
Blind, treatment options for 358t
Blood
dyscrasias 31
pressure
monitoring, noninvasive 248
noninvasive 296
urea nitrogen 289
vessels of
globe 121
orbit 121
Blow-out orbital fracture 341
Blunt cannula-based block 187
Blunt injuries 341
Blunt tips 123
Blunt vs sharp bevel tips 123
Boehringer ingelheim 153
Bony orbit 5
Boston keratoprosthesis 318
sutured, type 2 318f
Botulinum toxin 356
Bradycardia 30, 56, 196, 216
management of 212f
treatment of 210
Brainstem anaesthesia 195, 207, 207f
Breath, shortness of 30
Breathing 214
Brimonidine 26, 29, 32
adverse effects of 30t
British Ophthalmic Anaesthesia Society 91
Bronchospasm 30, 47
Buccal mucosa, reflection of 321f
Buckle removal, anaesthesia for 294
Buphthalmos 305
Bupivacaine 109, 111
C
Canine tooth 320f
Cannula 147
anterior 129
short 148
touching sclera 147
Cannula-based block 5
Capnography 178
Capsular opacification, posterior 254
Capsule rupture, posterior 99, 164
Capsulotomy
anterior 253
forceps 254f
Carbon dioxide, partial pressure of 16
Carbonic anhydrase
enzyme 31
inhibitors 26, 31
Carboplatin 270
Cardiac arrests 47
Cardiac arrhythmias 210
Cardiac complications 73
Cardiac compromise 72
Cardiac defect anomalies 44
Cardiac disease 64, 215
Cardiac malformations 38
Cardiac valve disease 215
Cardiorespiratory changes, acute 23
Cardiovascular
system 266
toxicity 197
Carotid artery, surgical complications with internal 164
Cataract 251
surgery 88f
high volume 92
Central burr hole 320f
Central corneal trephination 321f
Central nervous system 90, 93, 196, 208, 266
depression 28
toxicity 197, 210
Central retinal
artery occlusion 342, 346
vein thrombosis 340
Central venous pressue 18, 23, 102
effect of 18
Chemical injuries 346
Chemosis 150, 151, 188
Chemotherapeutic agents 270
Chemotherapy 270
side effects of 270
Choroidal blood volume 17
Choroidal melanoma 271f
Chromosomal abnormalities 276t
Cicatricial ectropion 333f
of right eye upper lid 33f
Ciliary ganglion 121, 121f
Classical retrobulbar block 4, 13
Claustrophobia 52, 169
Clonidine 113
Coagulation profile 56
Cocaine 109, 110, 161
Co-existing systemic diseases 64
Common dysmorphic craniofacial abnormalities 37
Common emergencies 340
Common syndromes encountered 38
Complete ecchymosis of
lower eyelid 189f
upper eyelid 189f
Congenital corneal disorders 325t
anaesthesia for 324
Congenital heart disease 37
Congenital ptosis of right eye, unilateral 330f
Congenital rubella syndrome 38, 39t
Congenital syndromes 276f
Congenital X-linked retinoschisis 264
Congestive heart failure 64
Conjunctival cut small 146
Conscious sedation 176, 177
Cooperative sedation 335
Corneal abrasions 229
Corneal damage 166
Corneal disease 316, 353
Corneal surgery, anaesthesia for 316
Corneal transplant surgery 321
anaesthesia for 323
Coronary artery disease 290
Corticosteroids 358
Cosmesis 275
Cotrimoxazole 317
Cranial conditions 353
Cri du chat syndrome 276
Crouzon syndrome 40f
considerations in 41t
Crouzon's disease 276
Crouzon's syndrome 39
Cryoprobe 297f
Cryotherapy 297, 297f
Current drug therapy 64
Curvilinear capsulotomy, posterior continuous 254
Cyanosis 255
Cyclo-ablation 304
Cyclopentolate 26, 28
systemic adverse effects of 29t
Cyclophosphamide 270
Cycloplegics, systemic effects of 26
Cyclosporine A 354
D
Dacryocystorhinostomy 330, 333, 334
Dark environment 87
Dark room 68
Darkened operation theatre environment during eye surgery 87f
Deep lamellar endothelial keratoplasty 323
Deep sedation/analgesia 177
Deep vein thrombosis 71, 72, 296
Dehydration 32
Dental damage 72, 78
Depolarising muscle relaxant 233
Depression 30, 32
Descemet's membrane endothelial keratoplasty 323
Descemet's stripping endothelial keratoplasty 323
Deterioration in pre-existing medical conditions 214
Dexamethasone implant 298
Dexmedetomidine 114, 335
Diabetes mellitus 64, 206, 216, 289
Diabetic control, long-term 54
Diabetic maculopathy 298
Diazepam 180
Diffuse cutaneous flush 28
DiGeorge syndrome 256
Digital ocular compression 100
Dilation drops, effects of 68
Diplopia 193
Discharge criteria 261
Diseased cornea 322f
Dizziness 30
Donor tissue 323
Dorsal root ganglion 356
Down's syndrome 38, 39f, 256, 276, 325
considerations in 40t
Doxorubicin 270
Drowsiness 30
Drugs with significant systemic effects 26t
Dry eye 45
Dry mouth 30
Dynamic contour tonometer 22
Dyspnoea, significant 56
Dysrhythmias 47, 56
Dystonia 292
E
Eccentric eye position 308
Ehler-Danlos syndrome 325
Electrocardiography 168
Electromyogram 279
Electroretinography 244
Emergency retinal surgery 289
Emergency surgery 342
Endocarditis prophylaxis 215
Endophthalmitis
acute post-surgical 346
with hypopyon, acute 288f
Endoscopic laser photocoagulation 304
Endothelial keratoplasty 323
Endotracheal tube 66, 235, 258, 267, 333
End-stage surgery 358
Enucleation 359
anaesthesia for 272
Ephedrine 248
Epinephrine 113, 248, 308
Equipment malfunctions 72, 76
Erythema 199f
Ester agents 109
Ester local anaesthetic agents 110
Etidocaine 109, 112, 270
Evisceration 359
Exacerbations of asthma 217
Expulsive haemorrhage 307
Extracellular fluid 32
Extraconal
area 4f
block 134f, 136f
ophthalmic block 136
Extraocular muscle 10, 120
inflammation 354f
malfunction 193
paresis 152
tone 18
Extraocular pressure 343
Extremities, tingling of 31
Extubation, effect of 235
Eye 17f
abnormalities of front of 128
and surgery, anaesthesia complications to 72
blocks 67
complications to 78
drops, systemic effects of 90
injuries with anesthesia 345
pain 353t
causes of 352
prominent 336f
surgery 84, 90
anaesthesia for emergency 340
patients, syndromes in 36
preoperative evaluation for 53
preparation for 53
sedation for 174
surgical drapings for 85
under regional anaesthesia 206
upper lid, right 333f
with long axial length, safe in 150
Eyelashes touching cornea 333f
Eyelid 13
right lower 333f
F
Face masks, effect of anaesthesia 234
Facial block required 150
Facial myofascial pain syndromes 357
Facial nerve blocks 141
Facial pain syndromes 357
Familial exudative vitreoretinopathy 264
Fasting for surgery 57
Fatigue 30
Fentanyl 324, 335
citrate 181
Fifth cranial nerve 228
Flash burns 346
Fluid management 259
Force duction test 279, 283
Force generation test 279
Foreign bodies 341
Frontalis sling 332
Full blood counta 56
Functional residual capacity 251
Fundus with yellow ring depicting macula, normal 287f
G
Gabapentin 358
Gamma-aminobutyric acid-a 179
Gastric
aspiration 72
contents, aspiration of 73
Gastrointestinal irritation 31
Gel anaesthesia 165
General anaesthesia 52, 63, 105, 170, 176, 177, 237, 243, 245, 257, 259, 278, 291, 303, 324, 342, 345
complications from 305
conduct of 68
effect of 228, 229
indications for 63, 292t
morbidities of 72t
General anaesthetic agents
on pupil, effect of 225
pharmacological effect of 233
Genetic investigations 269
Genitourinary defects 44
Gentle digital pressure, apply 147
Geriatric 79
Giant cell arteritis 340
Glaucoma 353
acute 302
chronic 302
classification of 301
patients 305
general anaesthesia in 310
primary
angle closure 301
angle open 301
surgery
anaesthesia for 300
techniques for 310
surgical procedures for 302, 303
Glaucomatous eye 99
Globe contents 8
Globe injuries, anaesthesia for open 325
Globe-orbit relationship, abnormal 126
Globe-orbit-needle 119
static dynamic relationship 119
Glucose
homeostasis 266
random blood sugar 256
supplementation 259
Goldenhar's syndrome 43, 44f, 44t, 276
Goldmann applanation tonometer 21, 21f, 23
Greenbaum 148
cannula 148f
H
Headache 30, 357
Heart
failure 32
rhythm abnormalities 209f
Hepatic complication of general anaesthesia 75
Herpes zoster ophthalmicus 355
Hess technique 225
Homatropine 26, 28
Homatropine bromide 28
Homocystinuria 276
Homologous domains, four 106
Honan's intraocular pressure reducer 101
Hyaluronidase 112, 192, 306
allergy 198
in sub-Tenon's block, role of 149
injection 198f
orbitopathy 306
Hydrocortisone 212
Hylenex 149
Hyperosmolar drug 26
Hypersensitivity 210
Hypertension 64, 214, 289
right ventricular 38
uncontrolled 53
Hyperthermia 227
malignant 72, 77, 274
Hypokalaemia, relative 31
Hyponatraemia 31
Hypotension 30, 196
Hypothermia 227
I
Idioventricular rhythm 280
Immobile eye 308
Immunomodulatory therapy 354
Implantable cardioverter defibrillators 215, 216
acute 346
Incision closure 254
Indentation tonometry 22
Induction agents, effect of 233
Infection, postoperative 165
Inferolateral retrobulbar block 125f
Influencing intraocular pressure, physiological factors 16
Infraorbital nerve block 334f
Infratrochlear nerve block 334f
Infusion, target controlled 329, 335
Inhalation agents 69, 234
effect of 234
Inhalational anaesthetic agents 225, 258
Intelligence quotient 39
Intermittent positive pressure ventilation 235, 344
Intra-arterial chemotherapy 270
Intracameral anaesthesia 158, 160, 161t, 166, 311
Intracapsular cataract cryoextractio 319f
Intraconal
area 4f
block 124, 134f, 136f
ophthalmic block 135
vs extraconal block 135f
Intracranial pressure 357
Intradermal skin prick test with hyaluronidase 199f
Intraocular
gases 295
lens 253, 303
implantation 254
pressure 15, 66, 68, 97, 98, 151, 232, 236, 243, 244,
control of 20, 68, 90, 301, 358
fluctuations in 342t
in general anaesthesia 236
in peroperative period 19
maintenance of 16, 237, 260
measuring 20
normal 260
physiology of 15
regulation 17
tumours, brachytherapy for 271
Intraoperative analgesia 150
Intravenous agents 225
Intravenous anaesthetics agents 180
Intravenous cannula 257
Intravenous induction agents 68
Intravenous lignocaine 236
Intravenous mannitol, systemic adverse effects of 32t
Intravitreal chemotherapy 270
Intravitreal injections 298
Inturned lower lid margin 332f
Ipsilateral eye 228
Ischaemic heart disease, symptoms of uncontrolled 56
Isoflurane 344
J
Joubert syndrome 46
considerations in 46t
Junctional rhythm 280
Juxtacanalicular portion 17
K
Keratolimbal allografting 318
Ketamine 181, 234, 247
Kumar-Dodds cannula 148f
Kyphoscoliotic elderly patients 88f
L
La for ophthalmic surgery 163
Lacerated eyelid 341
Lacrimal apparatus 12
Lacrimal gland 13
Lacrimal system 223, 228, 229
function of 228
Lacrimation, depth of 228
Lamellar keratoplasty
anterior 322
posterior 323
Lamina, removal of 321f
Laryngeal mask airway 38, 66, 234, 235, 245, 297
effect of insertion of 235
Laryngoscopy, effect of 235
Laryngospasm 47
Laser photocoagulation 297
Laser use during anaesthesia 68
Lateral decubitus positions 19
Lemon (look, evaluate, mallampatti, obstruction and neck) 256
Lens 8
cross-section through 252f
Levator palpebrae 13
Levobunolol 26
Levobupivacaine 109, 111
Libido, decreased 30
Lid
crease, absence of 330f
malpositions, anaesthesia for correction of 332
margin 33f
retraction 336f
with optic protruding out 318f
Lidocaine 109, 110, 161, 210, 272
Lipid sink hypothesis 210
Liver failure, severe chronic 56
Local anaesthesia 105, 109, 158, 303
complications from 305
hypersensitivity to 107
technique 313
Local anaesthetic 149
agent 90, 105, 291
classification of 109
management of 214f
pharmacochemical properties of 109t
pharmacokinetics of 108
regional blocks with 356
solution 188f
systemic toxicity 197
toxicity of 107, 208f, 212f
toxicity/overdose 207
Local orbital complications 188
Long cannulas 148
Lorazepam 180
Low molecular weight heparin 290
Lowe oculocerebrorenal syndrome 45, 45t
Lower lip buccal mucosa 333f
Low-molecular-weight heparin 336
Lucentis 298
Lumbar spine problems 52
Lung cancer 358
Lymphadenopathy 255
M
Macula 288f
Macular degeneration, age-related 63
Mannitol 26, 31
Marchesani syndrome 325
Marfan's syndrome 41, 42f, 43t, 276, 325
Maxillary alveolar bone 320f
Mccusick's book 200
Medial canthal ophthalmic block 137
Medial compartment extraconal block 125
Medial longitudinal fasciculi 281
Medial peribulbar block 5, 12
Medical events 164
Medical treatment 358
Mentally challenged patients 292
Mepivacaine 109, 112
Metabolic acidosis 31, 32
Methotrexate 354
Meticulous monitoring 174
Metoclopramide IV 234
Microincision vitrectomy system 294, 295, 295f
anaesthetic implications in 295
Midazolam 180, 234, 296, 334
Migraine 357
Minimal alveolar concentrations 225
Minimum alveolar concentration 258
Minor procedures, anaesthesia for 297
Minute ventilation 178
Mobile eye 170, 308
Modern needle-based blocks 13
Modern retrobulbar block 5
Modified osteo-odonto keratoprosthesis 318
stages 319, 322
Moebius syndrome 276
Monoamine oxidase 30
inhibitors 27
Motor nerves supplying rectus muscles 11f
Mucopolysaccharidosis child 255f
Mucous membrane graft 332
Multifocal premature ventricular complex 280
Multiple connective tissue bands 9f
Multiple diuretics therapy 56
Multiple yellow spots of fresh laser photocoagulation 297f
Muscarinic receptor antagonist 27
Muscle relaxant, non-depolarising 238, 279
Muscular layers of iris, contractility of 224f
Myasthenia gravis 330
Mydriatics, systemic effects of 26
Myeloid leukaemia, acute 270
Myocardial infarct 53
Myocardial infarction 64
Myopia 140f
Myotoxicity 114
N
Narrow angle glaucomas 301
Nausea and vomiting, postoperative 71, 260, 274, 276, 281, 296, 345
Needle damage to optic nerve 306
Needle insertion 14
Needle trajectories 124
Needle-based blocks 97, 187
Needleless techniques 158
Neonatal intensive care unit 265
Neostigmine 234
Nerve
and vascular supply 10
conduction, physiology of 106
distribution 356f
Neurologic conditions 353, 355
Neuromuscular blockade 70
agents 113, 226
effect of 233
Neuropathic pain 352
Neurotrophins 352
Newer sedative agent 182
Nil-per-oral instructions 278
Nitrous oxide 66, 236
induced expansion 79
interaction of 295
Nociception 352
Nomenclatures 133
Non-ophthalmic surgery 237
Non-contact air puff tonometer 21, 22f
Nondepolarising muscle relaxant, effect of 234
Non-ophthalmic surgery 237
Nonsteroidal anti-inflammatory drugs 260, 282, 296, 317, 358, 360
O
O'brien's block 345
Obstructive airway disease, chronic 290
Obstructive pulmonary disease, chronic 30, 64, 207, 217
Obstructive sleep apnoea 39, 217
Ocular complication 317
Ocular compression 100
methods of 100
Ocular conditions 89, 353
Ocular drugs
pharmacodynamics of 26
pharmacokinetics of 25
Ocular emergency 340t, 347
Ocular examination 269
anaesthesia for 271
Ocular massage, avoid 147
Ocular medications, systemic effects of 25
Ocular reflexes 260
Ocular surface 321f
diseases 317
disorders 316
surgery, anaesthesia for 337
Ocular surgery, complications to 78
Ocular trauma 340
Ocular/orbital factors 305
Oculocardiac reflex 67, 91, 199, 212, 213, 247, 260, 279, 280, 283, 293
pathway 280f
result of 214f
Oculoemetic reflex pathway 281f
Oculomotor nerves 10
Oculoplastic surgical procedure 330, 330t
anaesthesia for 329
Oculoplasty 329
Oculorespiratory reflex 260, 280
pathway 280f
Oedema 255
Ondansetron IV 234
Open angle glaucomas 301
Open globe injury 236, 325
Operation theatre 102, 257
Ophthalmic anaesthesia practice 1
Ophthalmic Anaesthesia Society 91
Ophthalmic blocks 199
Ophthalmic drugs 246
Ophthalmic evaluation 243
Ophthalmic examination, preoperative 252
Ophthalmic Forum of Indian Society of Anaesthesiologists 91
Ophthalmic hospital
anaesthesia in single speciality 49
set up 84
Ophthalmic operation theatre conditions 85
Ophthalmic pain 351
chronic 351
Ophthalmic parameters 243
Ophthalmic regional
anaesthesia 13, 95
block terminology 3
Ophthalmic surgery 53, 187
implications in 65
Ophthalmic techniques 141
Ophthalmology
general anaesthesia in 62
subspecialities, anaesthesia for 241
Opioid 226, 234
analgesics 181
effect of 233
Optic nerve 120
during gaze shift, anatomy of 126
head 7, 300
blood flow, impaired 306
blood supply 310
impingement 125f
injury 194
mass lesion around 355f
Optic neuritis 340
acute 354f
Optic neuropathy 152, 354
Optimal operating conditions 66
Optimisation, preoperative 93
Optimising systemic diseases 87
Oral acetazolamide, systemic adverse effects of 31t
Orbicularis muscle 13
Orbit 119
Orbital cellulitis 152
Orbital complications 187
Orbital compression 100
Orbital decompression 336
Orbital fractures 337
Orbital haemorrhage 152
Orbital infection 353
Orbital inflammatory pseudotumour 354
Orbital la block 308
Orbital myositis 354, 354f
Orbital surgery, anaesthesia for 335
Orbital tumour invasion 354
Orbital vascular damage 126
Orbital vessel injury 123
Oropharynx 327
Osteogenesis imperfecta 325
Osteo-odonto alveolar lamina 321f
Osteo-odonto keratoprosthesis 45, 319, 321, 322t
lamina 320
patient 320
Outpatient set-up 84
Outpouching of sclera 6f
Oxybuprocaine 109, 110, 161
Ozurdex 298
P
Pacemaker 215, 216, 346
tachycardia 216f
Paediatric cataract
stages 252
surgery 253
anaesthesia for 251
types 252
Paediatric corneal pathology 327
Paediatric ocular injuries 347
Paediatric retinal disorders, anaesthesia for 263
Pain 170, 349
management of 358
postoperative 296
mechanism of 351
on eye movement 354f
pathways 351
phenotype 352
postoperative 260, 282
relief, postoperative 71
syndromes 351
types of 352
Painful blind eye 358
Painful eye 358t
Pancuronium 234
Paraaminobenzoic acid 108, 210
Parabulbar anaesthesia 291
Parasympathetic 224f
fibres 121f
Parasympatholytics 26, 27
Parasympathomimetic drugs 26
Parkinson's disease 292
Pars plana vitrectomy 294, 294f
Partial pressure of
CO2, effect of 18
O2, effect of 18
Pathologic classification 269
Patient's systemic and ocular conditions 87
Penetrating eye injuries 341
Penetrating keratoplasty 237, 322
Perfluoropropane 293
Perflurocarbon 79
Peribulbar anaesthesia 198f
Peribulbar block 5, 52, 99, 99t, 291
needle for 122
Peribulbar haemorrhage, risks of 63
Peribulbar injection 188f
Periocular 133
chemotherapy 270
Perioperative care 153
Peripheral anterior synechiae 301, 303
Peripheral nerve damage 72
Peripheral neuropathic pain 352
Perkins applanation tonometer 21
Peroperative difficulties 169
Persistent fetal vasculature syndrome 264
Phacoemulsification 302, 303
surgery 160f
Phantom eye
pain 359
syndrome 359
Phenylephrine 26, 248
acts 27
hydrochloride, conjunctival instillation of 26
side effects of 27t
systemic adverse effects of 27t
Phospholine iodide 310
Photopsias 359
Pilocarpine 25, 26
hydrochloride 29
systemic adverse effects of 29t
Platelet count, low 56
Plus disease 265
Pneumatic retinopexy 292
Pneumotonometer 22
Post-herpetic neuralgia 355
treatment options for 356t
Postoperative posture 71
Postoperative vomiting, prevention and reduction of 281
Potency 109
Potential disadvantages 163
Povidone iodine 165
Preanaesthetic evaluation 276
Prednisolone 211
Pre-plus disease 265
Preterm babies 272
for vitreoretinal surgery, anaesthetic
implications in 265
Prilocaine 109, 111
Probing and syringing 333
Procaine 109
Prolonged surgery 52
Prone position, effect of 19
Proparacaine drops 298
Proparacaine hydrochloride 110
Prophylaxis 71
Propofol 180, 234, 334
sedation 200
Proptosis 336f
Protein binding 109
Proxymetacaine 161
Pterygium, avoid 147
Ptosis 193
correction, anaesthesia for 330
regional blocks for 331
Pulmonary congestion 32
Pulmonary embolism 72
Pulmonary oedema 27, 200
Pulmonary stenosis 38
Pulmonary vascular resistance 38, 39
Pulse oximetry 178, 248
Pulsed radiofrequency 356
lesioning 356
Pupil 223, 226
Pupillary repsonse to pain 226
Pupillary response to general anaesthesia 227
Pupillometry 224
Q
QTc interval 69
R
Rapidly adapting stretch receptors 235
Raynaud's syndrome 30
Rebound tonometer 22
Record keeping 59
Rectus muscle 9f
arise 11f
insertion of 7f
of eye 10f
Red eye, acute 340
Reese Ellsworth classification 269
Reflex bradycardia 27
Regional anaesthesia 64, 67, 90, 98, 98f, 102, 105, 187, 278, 291, 324, 345
administration of 98
effect of 99
implications of 305
physiological effects of 97
Regional ophthalmic anaesthesia 84
Relevant static anatomy 119
Remifentanil 182
Renal abnormalities 45
Renal complication of general anesthesia 75
Renal compromise, hepatic and 72
Renal disease, chronic 206
Renal failure, chronic 56, 217
Renal stones, formation of 31
Respiratory rate 178, 216f
Respiratory system 266
Respiratory volume monitor 178
Retina 223, 232, 287f
inferior detached 287f
Retinal anatomy 287
Retinal artery occlusion 340
Retinal detachment 264, 287, 340, 342
bisecting macula 287f
Retinoblastoma 268, 269
classification of 269
investigations for 269
Retinopathy of prematurity 263, 264
aggressive posterior 265
classification of 265t
severity of 265
Retrobulbar 99, 124, 132
block 52, 99t
needle for 122
haemorrhage 189, 189f, 306
risks of 63
Ringer's lactate 268
Rocuronium 234
Root canal, expose 320f
Ropivacaine 109, 112
Rotate syringe 147
Routine preoperative medical testing 55
Routine screening tests 80
Rupture of globe 192
S
Schiotz indentation tonometer 22f
Schiotz tonometer 22
Sclera over tumor 271f
Scleral buckle
care with 147, 150
technique 293f
Scleral buckling, anaesthesia for 293
Scleral perforation 152
Scleritis 353
posterior 360
Sclerocorneal junction 7
Sclero-corneal tunnel in cataract surgery 255f
Sedation 175177, 245
advantages of 179
complications of 182
role of 296
Sedative agents 179
Seidel test 341
Sensory 121f
innvervation 11
nerves 12f
Serious complications, low risk of 150
Serum creatinine 45
Serum electrolytes 45
Sevoflurane 344
Shield's international classification 269
Sight-threatening complications 150
causes for 308
Sine qua non component 105
Single speciality hospital set up 84
Skin, scarring of 333f
Skull showing several foramina 6f
Sneezing 199
Society of Ambulatory Anaesthesia 54
Socket surgery, anaesthesia for 335
Sodium bicarbonate 113
Soft eye before surgery 99
Spine surgery 232
Sponge anaesthesia 161
Spontaneous, effect of 235
Staphyloma 6, 6f, 127, 140f
incidence of 127t
Steep Trendelenburg position, effect of 19
Steven-Johnson syndrome 44f, 45t, 316318, 317f, 319f
Stevens-type metal cannula 148
Stickler syndrome 40, 41f, 276
considerations in 42t
Strabismus 274, 276t
evaluation of 275, 279
surgery 277t, 281
anaesthesia for 274
indications for 274, 275t
types of 275t
Strength povidone iodine 146
Sturge-Weber syndrome 42, 43f, 43t
Styphyloma, posterior 127f
Subconjuncitval
anaesthesia 308, 311, 313
haemorrhage 150, 151, 188, 188f
injection of mydricaine 67
oedema 188f
Subcutaneous 336
pouch 321f
Subretinal fluid, drainage of 293f
Sub-Tenon block 52
Sub-Tenon chemotherapy 270
Sub-Tenon space 3, 52, 147, 305, 310
Sub-Tenon's anaesthesia 102, 291
Sub-Tenon's block 14, 89, 102, 121, 128, 129, 129f, 144, 146f, 153, 154
advantages of 150
anatomy relevant to 145
complications of 151
posterior 313
Sub-Tenon's injection 152
Sub-Tenon's local anaesthesia 170, 313
Sub-Tenon's space 5f, 9, 9f, 128, 129
Sub-Tenon's supplementation 293
Sufentanil 181
Sulphonylureas 54, 56
Sulphur hexafluoride 293
Superomedial gaze of eye 126
Superpinkie 100
Supraglottic devices 267
Supraorbital block 138f
Supraorbital landmarks 138
Supraorbital nerve
block 331f
divisions, blocking 356f
Supraorbital neuralgia 356
Supratrochlear nerve block 332f
Supratrochlear nerve divisions, blocking 356f
Surgery
involving lacrimal system, anaesthesia for 333
principles of 275
types of 166
Surgical table, preparation of 290
Suture technique, anaesthesia for adjustable 282
Suxamethonium 236, 343
Sympathetic divisions of autonomic nervous system 224f
Sympathetic fibres 121f
Syncope 56
Syndromic children 47
Systemic blood pressure 17
Systemic chemotherapy 270
Systemic complications 187, 195
Systemic examination 256
Systemic investigations 269
Systemic vascular resistance 39
T
Tachycardia 27, 56
with local anaesthetic toxicity,
management of 211f
Temperature 266
Tenon's capsule 8, 9f, 129, 146
anatomy of 145f
Teo-odonto-keratoprosthesis 327
Tethering tests 126
Tetracaine 109, 110
Thiopentone 234
Thromboembolism 71
Thrombophlebitis 32
Thyroid
associated ophthalmopathy 336
function test 56
ophthalamopathy, bilateral 336f
Tidal volume 178
Timolol 26
TNM classification 269
Tonometry 244, 247
Tonopen 22
Topical agents 356
Topical anaesthesia 158, 160f, 278, 312
Topical eye medications 25
Topical lidocaine 355
Topical-intracameral anaesthesia 160f, 313
Topical-subconjunctival-intracameral anaesthesia 311f, 312f
Torch titres 253
Total intravenous anaesthesia 19, 329, 344, 345
Toxic epidermal necrolysis 44, 317
Toxicity 109
Trabecular bypass surgery 304
Trabeculectomy 302, 309, 311f, 312f
anaesthesia for 305
bleb needling for failed 303
procedures 302
Tracheal mucosa 327
Tractional retinal detachment 288f, 294
Transcutaneous
CO2 monitoring 178
pacemaker 213f
Transient strabismus 193
Trans-scleral
cryotherapy 304
cyclo-destructive procedures 313
laser ablation 304
ultrasound ablation 304
Trauma 340
Traumatic eye injuries 340
Tremors 292
Trigeminal autonomic cephalalgias 357
Trigeminal ganglion 351
Trigeminal neuralgia 356
Tropicamide 26, 28, 29
True ocular emergencies 346
Tumour invasion 353
Turner's syndrome 276, 325
Twitch monitoring 74
U
Ultrashort cannula 148f
Ultrasound 269
Unique hospital identification 255
Upper respiratory tract infection 277
Urine for ketones 45
Usher's syndrome 46, 46t
Uveitis 353
V
VACTERL association 256
Vascular causes 358
Vascular conditions 353
Vascular occlusion 298
Vascular supply 12
Vasoconstrictor, complications of 307
Vecuronium 234
Venous drainage 122
Ventilation, controlled 235
Ventricular arrhythmias 27
Ventricular bigeminy 280
Ventricular tachycardia 280
Vigorous sneezing 200
Vincristine 270
Viscoelastic containing local anaesthesia 162
Vision loss, acute 340
Visitek metal cannula 148
Visual
acuity, corrected 251
axis opacification 254
disturbance 340
effects of ocular anaesthesia 194
field, wipe-out of 307
loss, postoperative 237
sensations
perception of 89
retained 151
Vital signs, monitoring 93
Vitrectomy
anterior 254f
hand rest 292f
Vitreoretinal 286
procedures 54
procedures, anaesthesia for 292
surgery 64, 286, 298
anaesthesia for 286
for preterm babies, anaesthetic
management of 267
in right eye 198f
indications for 287
indications for emergency 289t
Vitreous haemorrhage 288f
Vitreous humour volume, effect of 18
Vitreous loss 164
Vitreous opacities 288
Volatile agents 238
W
Waardenburg syndrome 325
Westcott scissors closed 146
Whittaker TV pupillometer 225
Wound to prevent fish mouthing 255f
×
Chapter Notes

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fm1Principles and Practice of Ophthalmic Anaesthesiafm2
fm3Principles and Practice of Ophthalmic Anaesthesia
Jaichandran VV MBBS DA PG Dip (Biostatistics) Consultant Department of Anaesthesiology Medical Research Foundation, Sankara Nethralaya Chennai, Tamil Nadu, India Chandra M Kumar MBBS DARCS FFARCS FRCA MSc EDRA Senior Consultant Department of Anaesthesiology Khoo Teck Puat Hospital Yishun Central, Singapore Jagadeesh V MBBS MD Director Department of Anaesthesiology Medical Research Foundation, Sankara Nethralaya Chennai, Tamil Nadu, India Foreword SS Badrinath
fm4
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Principles and Practice of Ophthalmic Anaesthesia
First Edition: 2017
9789386261236
fm5Contributors Foreword
The history of anaesthesia for eye surgery dates back to 2,500 years. Since the discovery of cocaine as topical anaesthetic agent in 1884 by Carl Koller and demonstration of cocaine for retrobulbar injection for eye surgery by Herman Knapp, various regional anaesthetic techniques from needle or cannula-based to topical anaesthesia have been developed and refined. Ophthalmic anaesthesia as a specialized field has come a long way since then, and anaesthesiologists are now actively involved in performing regional blocks and monitored anaesthesia care for patients undergoing ocular surgery. They are also involved in taking care of patients in the postoperative period with regard to pain, emesis and related issues.
There was no standard textbook written primarily on ophthalmic anaesthesia. After the establishment of the Ophthalmic Forum of Indian Society of Anaesthesiologists (OFISA) in the year 2009 and the deliberations following the meet, it was perceived that it would be worthwhile to have a book solely dedicated to ophthalmic anaesthesia techniques for various ocular surgeries. I wish to extend my sincere appreciation to Dr Jagadeesh V, Dr Jaichandran VV and Dr Chandra M Kumar, for their sincere efforts in giving shape to this perception by taking the major initiative to publish a well-researched and informative textbook, the first of its kind, titled Principles and Practice of Ophthalmic Anaesthesia. The authors have taken great care to cover the critical topics of interests to ophthalmic anaesthesiologists like systemic effects of ocular medications, various perioperative factors influencing IOP, effects of regional as well as general anaesthesia on IOP, effects of anaesthesia on pupil and lacrimation and also on the management of chronic eye pain. The book is a boon to beginners as it gives a thorough insight of basic sciences ranging from anatomy of the orbit, pharmacology of local anaesthetic agents to the different techniques of regional anaesthesia. It also effectively cautions ophthalmic surgeons on the adverse effects and emergencies that may occur during the administration of anaesthesia.
The book deals with anaesthestic management of different types of ocular surgeries—cataract, vitreoretinal, squint, glaucoma, cornea, oculoplasty and emergency eye procedures and would be a most useful addition to anaesthesiologists who wish to practice ophthalmic anaesthesia. It is noteworthy to mention that the contributing authors are the eminent anaesthesiologists and ophthalmologists in their respective fields.
As a member of an institution deeply committed to the cause of disseminating knowledge for the goodness, it gives me great pleasure that an authoritative and in-depth work on the best practices in ophthalmic anaesthesia is being released. I am sure that it will come in as a handy reference to practitioners of this niche specialization.fm9
My heartiest congratulations to the authors and chief editors, for their hard work in bringing out this book, and also I extend my thanks to the publisher, M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing this book on time. It gives me pleasure to present the foreword to this unique book which, I am sure, will serve as an extended manual for both ophthalmologists and anaesthesiologists.
With best wishes,
SS Badrinath
Chairman Emeritus
Sankara Nethralaya
Medical Research Foundation
Chennai, Tamil Nadu, Indiafm10
PREFACE
The primary aim of Principles and Practice of Ophthalmic Anaesthesia is to provide basic knowledge and practical clinical information about anaesthesia for ocular surgery. The unique feature of this book, the first of its kind, is intended to be of assistance to both anaesthetists and ophthalmologists in their practices. The emphasis is on the commonly used techniques and recent developments.
The practical advice is provided on preoperative medical testing, sedation techniques, monitoring of patients, perioperative care and management of anaesthetic complications. Chapters are also dedicated to anaesthesia techniques suitable for different ocular surgeries (cataract, squint, glaucoma, vitreoretinal procedures, paediatric procedures, etc.).
The book includes chapters on ocular physiology, pharmacology, systemic effects of ocular medications, effect of anaesthesia on pupil and intraocular pressure, and management of painful blind eye. Numerous illustrations have been included so that readers can understand and collate the information easily. The contributors of the book are world famous anaesthetists, ophthalmologists and scientists. The surgeons have highlighted surgical prerequisites, and the anaesthetists have detailed how to achieve these prerequisites for successful procedural/surgical outcome. The end of each chapter contains important practical points for a quick recap in the form of practical clinical pearls.
We are grateful and indebted to all the contributors for their efforts. We have taken the liberty to undertake revision and edited the manuscripts where appropriate to achieve uniformity of style and format. We are thankful to M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who have redrawn the figures and incorporated a large number of new figures in a standard format.
We thank our respective spouses and family members, for their wholehearted support and sacrifices, which enabled us to edit and publish this textbook in the stipulated time.
Jaichandran VV
Chandra M Kumar
Jagadeesh Vfm11
fm21INTRODUCTION: OCULAR ANAESTHESIA—HISTORY AND DEVELOPMENT
Jagadeesh V
Every operative procedure places unique demand on the anaesthesiologist to provide surgical anaesthesia with minimal physiological trespass on the patient as well as the surgical procedure. In eye surgery, the question for an anaesthetic agent that does not harm the eye or patient can be a challenge. Ocular procedures have exerted enormous influence on the discovery of anaesthetic modalities. The eye surgery was difficult before discovery of surgical anaesthesia in 1840. The sensitive organ would not yield to the surgeon's knife. After the demonstration of anaesthetic effect of ether on October 16, 1846,1 operations were performed that had only been thought about of centuries before. After 20 years when Lister conquered infection, surgery had an explosive growth and new surgical operations were successfully performed the world over.
Ocular surgery progressed and William and Charles Mayo performed procedure on the eye after their graduation. The first operation at St Mary Hospital was an eye operation.2 Since thin suturing material was not available to close the eye, the wound was left open, and since ether caused postoperative retching and vomiting, there was damage to the eye, and so an alternative measure was needed.
In Vienna, Sigmund Freud was working with cocaine, and he shared the crystals with Carl Koller. Koller's tongue became numb when he put cocaine crystal on his tongue. Koller felt that the same solution would cause the corneal surface to become numb. He applied it on the cornea of animals and was able to touch the eye without reaction. Later, he applied it on his eye and his assistant. He knew that he now had a topical anaesthetic for the eye.3 Koller used it in a large number of patients in eye surgery, and his result were put together in a paper that was presented in 1884 by his friend, Josef Brittaeur at ophthalmology meeting in Heidelberg, Germany. Many began to realise the potential of cocaine as an anaesthetic agent.4 William Halsted in US worked with cocaine. He infiltrated his skin and dissected his nerve trunks and applied cocaine on the nerves to cause blockage of nerve transmission—the first regional anaesthetic. He entered treatment for cocaine addiction.56
Koller's fellow European picked up the idea of regional anaesthesia. Bier7 injected cocaine intrathecally and produced spinal analgesia. James Corning in New York produced the first epidural anaesthetic agent. The question for better anaesthesia for ophthalmic surgery resulted in a new form of anaesthesia, i.e. regional anaesthesia.
 
REGIONAL ANAESTHESIA
Knapp, in 1884, described a block very similar in technique to retrobulbar block.8 His work never gained popularly because of properties of cocaine. The blocks caused hypertension, tachycardia, fm22and increase in IOP; there was extrusion of intraocular contents as the ocular wounds could not be closed due to nonavailability of fine sutures.
In 1905, procaine was synthesized and had predictable effects and function.
In 1934, Atkinson9 described classical retrobulbar block and used procaine; this block was successful and gained popularity.
Retrobulbar block had significant complications—bleeding, globe perforation, and damage to optic nerve. Cadaveric studies demonstrated that local anaesthetics placed outside orbital muscles could spread and cause an anaesthetic eye.
In 1986, the peribulbar block10 was introduced and it was safer than retrobulbar block; the needle was outside the cone and hence farther away from the globe and the optic nerve.
In early 1990, sub-Tenons block11 was introduced and involved injection of local anaesthetics into the episcleral space. A volume 6–8 mL made the eye and surrounding muscles anaesthetised.
Topical anaesthesia was reintroduced in 1990. The experience of surgeon is critical in ensuring a successful procedural outcome.
 
GENERAL ANAESTHESIA
In ocular surgery, general anaesthesia has been used for children, for those who cannot co-operate due to their clinical status—mentally retarded, cerebral palsy, parkinsonism (due to tremors) and for ocular trauma. In most trauma cases because of full stomach, rapid securing of the airway is necessary and the use of succinylcholine has been recommended. Succinylcholine raises IOP and concerns are raised about the use in open globe procedures.12 Experimentally, it was noted that vitreous humor could be extruded, when the eye muscles fasciculated. This potentially had devastating consequences for the patients. Anecdotal reports of such phenomenon were found. Indeed, penetrating eye trauma, difficult airway, and full stomach are nightmare for the anaesthesiologist. It was accepted that succinylcholine was not indicated for open globe injuries.
In 1990, evidence-based medicine12 made physicians question about accepted teaching. On reviewing the literature, there were no peer reviewed case reports of ocular damage after use of succinylcholine for induction. The subject is inconclusive.
 
SUB-SPECIALITY SOCIETY
The Ophthalmic Anaesthesia Society (OAS) and British Ophthalmic Anaesthesia Society (BOAS) were formed to ensure that “the highest quality anaesthesia care was provided to patients undergoing cataract and other ophthalmic surgical procedure”.13 The Society holds 2-day annual meetings where matters of importance to the field, new research and developments are presented.
In India, the Ophthalmic Forum of the Indian Society of Anaesthesiologist (OFISA),14 affiliated to Indian Society of Anaesthesiologists (ISA) was established in the year 2009, to provide quality care to patients undergoing ocular surgery. The forum holds 2-day meetings every two years, and a newsletter is published every six months.
 
SUMMARY
The history of ocular anaesthesia reflects the broader history of anaesthesiology. Carl Koller's search for anaesthetics led to topical anaesthesia which still remains in use. The popularity of fm23cutaneous regional anaesthesia is responsible for the subsequent introduction and popularity of Atkinson's retrobulbar block; further research has developed peribulbar and sub-Tenon's block. The use of succinylcholine as an anaesthesia in open globe is an example of the continuing examination of evidence in medicine. The results obtained from old data along with new investigation can challenge the accepted ideas in medicine.
REFERENCES
  1. Fenster J. Ether day. New York: Harper Collins Publisher, Inc;  2001.
  1. Clapesattle H. The doctors Mayo—Minneapolis University of Minnesota Press:  1941. p. 252.
  1. Koller C. Personal reminiscences of the first use of cocaine as local anaesthetic in eye surgery. Anaes Analg. 1928;7:9–11.
  1. Wyklicky H, Koller SC (1857-1944) and his time in Vienna. Regional Anaesthesia. 1884-1984; pp. 12–6.
  1. Halstead WS. Practical Comments on the use of cocaine. New York Med J. 1885;42:294.
  1. Halsted. Local anaesthesia: Contribution and complications. Anaesthesiology. 1975;42:479–86.
  1. Goerig, Argarwal, Schulte AM, Each J. The Versatile August Bier; Father of Spinal Anaesthesia. J Cl Anaesth. 2000;12:561–9.
  1. Knapp H. On Cocaine and its use in Ophthalmic and general surgery. Arch Opthalmol. 1884;13:40.
  1. Atkinson WS. Retrobulbar injection of anaesthetic with in the muscular cone. Arch ophthal. 1936;16:494.
  1. McGoldrick, Gayer. Anaesthesia and the eye. Clinical anaethesia. 2004;5:974–6.
  1. Swan. Newer drugs and techniques of ocular anaesthesia. Trans Am Acad Ophthalmol. 1956.
  1. Vachon CA, Warner DO, Bascon DR. Succinylcholine and the open globe: Tracing the teaching. Anaesthesiology. 2003;99:220–3.
  1. Ophthalmic Anaesthesia Society. www.eyeanaesthesia.org/index.html.