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
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Principles and Practice of Ophthalmic Anaesthesia
First Edition: 2017
9789386261236
fm5Contributors
- Anjolie Chhabra MBBS MD DNB
- Additional Professor
- Department of Anesthesiology
- Pain Medicine and Critical Care
- All India Institute of Medical Sciences
- New Delhi, India
- Anil Agarwal MBBS MD
- Assistant Professor
- Department of Anaesthesiology
- Pain Medicine and Critical Care
- All India Institute of Medical Sciences
- New Delhi, India
- Chandra M Kumar MBBS DARCS FFARCS FRCA MSc EDRA
- Senior Consultant
- Khoo Teck Puat Hospital
- Yishun Central, Singapore
- Debesh Bhoi MD
- Additional Professor
- Department of Anesthesiology
- Pain Medicine and Critical Care
- All India Institute of Medical Sciences
- New Delhi, India
- Edwin Seet MBBS (Singapore)
- M Med (Anaesthesiology)
- Head and Senior Consultant
- Khoo Teck Puat Hospital
- Alexandra Health Services
- Yishun Central, Singapore
- Evren Eker MD
- Associate Professor
- Baskent University, Faculty of Medicine
- Adana Education and Research Center
- Department of Anesthesiology
- Discipline of Pain Medicine
- Adana, Turkey
- Howard Palte MBChB FCA (SA)
- Associate Professor of Anaesthesiology
- Director Regional Anaesthesia
- Bascom Palmer Eye Institute
- University of Miami Miller School of Medicine
- Miami, Florida, USA
- Ipek Yalcin Pharm D PhD
- Chargé de recherché CNRS
- Institute des Neurosciences Cellulaires et Intégratives
- UPR3212 CNRS, Strasbourg, France
- Jagadeesh V MBBS MD
- Director
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Jaichandran VV MBBS DA PG Dip (Biostatistics)
- Consultant, Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Jawad M Khan BioMedSci MBBS DipMed Ed MRCP FRCP
- Consultant Interventional Cardiologist
- Sandwell and West Birmingham Hospitals NHS Trust
- Birmingham, United Kingdom
- Honorary Senior Clinical Lecturer
- University of Birmingham
- Birmingham, United Kingdom
- Joselo D Macachor MD FPBA
- Clinical Associate
- Department of Anaesthesia and Intensive Care
- Khoo Teck Puat Hospital
- Kritika Chopra MBBS DNB
- Resident (Ophthalmology)
- Nethradhama Superspeciality Eye Hospital
- Bengaluru, Karnataka, India
- K-L Kong MBBS MD FRCA
- Consultant Anaesthetist
- Sandwell and West Birmingham Hospitals NHS Trust
- Birmingham, United Kingdom
- Honorary Senior, Clinical Lecturer
- University of Birmingham
- Birmingham, United Kingdom
- Lakshmi Prasanna S MBBS DA
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation,
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Margareth Kurniawan BS Biochem (Hons) UCLA MBBS (Sydney)
- Medical Officer Specialist (Anaesthesia)
- Khoo Teck Puat Hospital
- Alexandra Health Services
- Yishun Central, Singapore
- Manonmani B MBBS DA
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Marian Pauly MS DNB
- Consultant Oculoplastic Surgeon
- Deparment of Orbit and Oculoplasty
- Giridhar Eye Institute, Kadavanthra
- Kochi, Kerala, India.
- Meenakshi Swaminathan MBBS MS
- Head of Academics, Senior Consultant
- Department of Strabismology
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Oya Yalcin Cok MD EDRA
- Associate Professor
- Department of Anaesthesiology
- Baskent University, School of Medicine
- Adana Education and Research Centre
- Adana, Turkey
- Philip Guise FRCA FANZCA
- Specialist Anaesthetist
- Auckland City Hospital
- Auckland, New Zealand
- Pradnya Senthil Kumar MBBS MD
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Puneet Khanna MBBS MD
- Assistant Professor
- Department of Anaesthesiology
- Pain Medicine and Critical Care
- All India Institute of Medical Sciences
- New Delhi, India
- Pushpa Susan Isaac MBBS DA
- Consultant Anaesthesiologist
- Giridhar Eye Institute
- Kochi, Kerala, India
- Rasesh Diwan MD DA
- Medical Director and Chief Anaesthesiologist
- Raghudeep Eye Hospitals
- Ahmedabad, Gujarat, India
- Renu Sinha MBBS MD
- Additional Professor
- Department of Anaesthesiology
- Pain Medicine and Critical Care
- All India Institute of Medical Sciences
- New Delhi, India
- Renuka Sridevi MBBS DA
- Consultant Anaesthesiologist
- LV Prasad Eye Institute
- Sanjay Bajaj MBBS MD DNB FRCA EDRA
- Khoo Teck Puat Hospital,
- Department of Anaesthesia and
- Intensive Care
- Yishun Central, Singapore
- Shashi B Vohra MBBS MD FFARCSI FRCA
- Consultant Anaesthesiologist
- City Hospital, Sandwell and
- West Birmingham Hospitals NHS Trust
- Birmingham, United Kingdom
- Shobha Ravishankar MBBS DA
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Sonali Raman MBBS DA
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Sri Ganesh MBBS MS DNB
- CMD, Medical Director
- HOD, Phaco-refractive Surgery
- Nethradhama Superspeciality Eye Hospital
- Bengaluru, Karnataka, India
- Steven Gayer MD MBA
- Professor of Anesthesiology and
- Ophthalmology, University of
- Miami Miller School of Medicine
- Miami, Florida, USA
- Suganeswari G DO DNB
- Consultant
- Department of Vitreo-Retina
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Sujatha R MBBS DA DNB
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Sujatha V MBBS DA
- Consultant
- Department of Anaesthesiology
- Medical Research Foundation
- Sankara Nethralaya
- Chennai, Tamil Nadu, India
- Suman Shree R MBBS MD DNB PGDHHM PGDMLS
- Department of Anaesthesia
- Nethradhama Superspeciality Eye Hospital
- Bengaluru, Karnataka, India
- Tom Eke MA MD FRCOphth
- Consultant Ophthalmologist
- Norfolk and Norwich University Hospital
- Norwich, United Kingdom
- Veena MBBS DA
- Consultant Anaesthesiologist
- Department of Anaesthesia
- Nethradhama Superspeciality Eye Hospital
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
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
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.5–6
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
- Fenster J. Ether day. New York: Harper Collins Publisher, Inc; 2001.
- Clapesattle H. The doctors Mayo—Minneapolis University of Minnesota Press: 1941. p. 252.
- Koller C. Personal reminiscences of the first use of cocaine as local anaesthetic in eye surgery. Anaes Analg. 1928;7:9–11.
- Wyklicky H, Koller SC (1857-1944) and his time in Vienna. Regional Anaesthesia. 1884-1984; pp. 12–6.
- Halstead WS. Practical Comments on the use of cocaine. New York Med J. 1885;42:294.
- Halsted. Local anaesthesia: Contribution and complications. Anaesthesiology. 1975;42:479–86.
- Goerig, Argarwal, Schulte AM, Each J. The Versatile August Bier; Father of Spinal Anaesthesia. J Cl Anaesth. 2000;12:561–9.
- Knapp H. On Cocaine and its use in Ophthalmic and general surgery. Arch Opthalmol. 1884;13:40.
- Atkinson WS. Retrobulbar injection of anaesthetic with in the muscular cone. Arch ophthal. 1936;16:494.
- McGoldrick, Gayer. Anaesthesia and the eye. Clinical anaethesia. 2004;5:974–6.
- Swan. Newer drugs and techniques of ocular anaesthesia. Trans Am Acad Ophthalmol. 1956.
- Vachon CA, Warner DO, Bascon DR. Succinylcholine and the open globe: Tracing the teaching. Anaesthesiology. 2003;99:220–3.
- Ophthalmic Anaesthesia Society. www.eyeanaesthesia.org/index.html.