Anaesthesia for paediatric eye

surgery
Ian James MB ChB FRCA
Although surgical procedures on the eye in
adults are frequently performed using local
anaesthesia, children undergoing eye surgery
will nearly always require general anaesthesia.
These procedures (Table 1) encompass the
entire paediatric age range, including newborn
infants.
Preoperative assessment
Most children scheduled for eye surgery are
ASA Class I or II and can be managed as day
cases. Anaesthesia is usually straightforward;
however, in some children, the eye problem
may be part of a chromosomal or metabolic
disorder with anaesthetic implications. In many
cases, the associated anomaly is limited to
developmental delay, mental retardation and
behavioural problems and the challenge lies in
managing these patients in a sympathetic
manner. In others, the association may be of
more direct anaesthetic relevance.
A number of syndromes in which there can
be major difculties with intubation are associ-
ated with cataracts, glaucoma or squints. These
include the mucopolysaccharidoses, the cranio-
synostosis disorders (e.g. Crouzons, Aperts
and Pfeiffers syndromes) and the craniofacial
syndromes (e.g. Goldenhar, TreacherCollin
and SmithLemli Opitz). The Hallerman
Strieff syndrome, although rare, may present
for cataract surgery in the neonatal period and
invariably is associated with a particularly dif-
cult airway. Sticklers syndrome, which is
associated with early retinal detachment and
glaucoma, is a progressive connective tissue
disorder that has some of the features of the
Pierre Robin syndrome; it can also present intu-
bation problems. Appropriate precautions and
techniques for patients with potential intubation
difculties should be adopted in these patients.
The congenital phakomatoses, a group of
neuro-oculo-cutaneous disorders that include
the SturgeWeber syndrome, neurobromato-
sis, tuberous sclerosis and von Hippel Lindau
disease, all have ocular lesions that may require
surgery. These disorders are associated with
seizures and other intracranial lesions, cardiac
lesions and occasionally with phaeochromocy-
toma; these patients require careful preoperative
assessment and management.
Patients with homocystinuria, a metabolic
disorder in which hypoglycaemia and throm-
boembolic episodes are common, frequently
have dislocated lenses that will require extrac-
tion. It is important to ensure adequate
hydration in these children and an intravenous
glucose infusion should be started preopera-
tively. Patients with homocystinuria should also
be given aspirin in the perioperative period to
minimize the risk of thromboembolic episodes.
Dislocated lenses are also common in patients
with Marfans syndrome, in whom there may
be aortic root or valve problems. Hypertension
should be avoided and particular care should be
taken with patient positioning.
Infants with congenital cataracts frequently
present for surgery in the rst few days of life.
These cataracts may be part of a metabolic dis-
order, or may occur following intrauterine
infection, with attendant associated anomalies.
Many of these neonates will be at risk of post-
operative apnoeic episodes and will need to be
nursed and monitored following surgery in an
appropriate environment.
Some children with glaucoma will be taking
regular eye-drops containing beta-blockers, e.g.
timolol, betaxolol. Most of the drug drains
through the nasolacrimal canal and is absorbed
systemically by the nasal mucosa. It is unusual
for there to be side effects from systemic
absorption of these agents in children but
haemodynamic adverse events have been
reported in the elderly and it is important to be
aware of this possibility.
Bacterial endocarditis prophylaxis
Some patients presenting for eye surgery will
have a cardiac anomaly; however, the vast
majority of ophthalmic procedures do not
produce a bacteraemia, and antibiotic prophy-
laxis is unnecessary. The exceptions are those
children undergoing a procedure on the
Key points
Bradycardia is readily
produced by traction on
extraocular muscles or
pressure on the globe
(oculocardiac reex).
Squint surgery is associated
with a high incidence of
postoperative vomiting.
Procedures on the
nasolacrimal ducts in
children with a cardiac
lesion require antibiotic
prophylaxis.
Avoid nitrous oxide in
vitreoretinal surgery.
Succinylcholine is not
contraindicated in non-
fasted patients with a
penetrating eye injury.
Ian James MB ChB FRCA
Consultant Anaesthetist
Great Ormond Street Hospital
For Children
London WC1N 3JH, UK
Tel: 44 020 7813 8208
E-mail: jamesi@gosh.nhs.uk
(for correspondence)
5 doi:10.1093/bjaceaccp/mkm048
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 8 Number 1 2008
& The Board of Management and Trustees of the British Journal of Anaesthesia [2008].
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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nasolacrimal ducts in which there is a signicant incidence of bac-
teraemia. Patients with a structural cardiac lesion should receive
appropriate antibiotic prophylaxis.
General principles of anaesthesia
Although most children undergoing eye surgery are otherwise
healthy, day-case patients, particular care should be taken in
approaching and handling those with very poor vision who may
not be able to see or be fully aware of what is happening around
them. Premedication and induction are a matter of personal prefer-
ence. Spontaneous ventilation via a facemask will frequently
sufce for simple eye examinations, although it is often more con-
venient to utilize a laryngeal mask airway to allow the ophthalmol-
ogist unrestricted access to the eyes. Spontaneous ventilation using
a laryngeal mask airway is also satisfactory for the shorter surgical
procedures where a sterile operating eld is not required (e.g. laser
surgery), and in most of the extra-ocular cases in older children.
For intraocular procedures, the surgeon will require a still,
quiet eye and this is most satisfactorily achieved using paralysis
and controlled ventilation. A secure airway is essential because of
the inaccessibility of the airway when the face is covered with
sterile drapes. A preformed RAE tracheal tube is generally used
but this can pose a problem in neonates as the xed length of the
endotracheal portion of these tubes is frequently too long, poten-
tially resulting in endobronchial intubation. While it is possible to
pack out these tubes at the mouth to prevent this, it is more con-
venient to use a reinforced, exible tracheal tube in infants below
6 months; this results in a secure airway that does not conict with
the surgical eld.
For many surgical procedures, a dilated pupil is necessary and
ophthalmologists frequently use mydriatic agents perioperatively.
The most commonly used agents are cyclopentolate 0.5 or 1%
( parasympatholytic) and phenylephrine 2.5% (sympathomimetic).
These are normally administered topically in the preoperative
period but, if adequate pupillary dilatation has not been achieved,
further drops may be applied once the child is asleep. These are
generally well tolerated but serious systemic side effects, conse-
quent upon systemic absorption, have been reported, including
hypertension and pulmonary oedema. On occasion, the surgeon
may wish to inject subconjunctival mydricaine (a mixture of pro-
caine, atropine and epinephrine) to obtain better pupillary dilata-
tion. It is prudent to avoid an anaesthetic technique utilizing a high
concentration of volatile agent ( particularly halothane) and hyper-
capnia in order to minimize the risk of dysrhythmias should there
be systemic absorption of these agents.
Most surgical procedures involving the eye and orbit result in
only mild to moderate pain and discomfort and are well managed
with topical anaesthetic agents and simple analgesics such as para-
cetamol and the non-steroidal analgesics. These can be given
orally preoperatively or rectally at induction. Squint surgery, evis-
ceration of the eye and vitreo-retinal surgery are generally associ-
ated with more severe postoperative pain, and stronger analgesia
may be necessary such as codeine or, in older children, tramadol.
However, as squint surgery is associated with a high incidence of
postoperative vomiting (POV), intraoperative opioid analgesia
should be avoided if possible.
Specic procedures
Examination of the eyes
Anaesthesia may be required in some children for eye examination
simply because they are too young or uncooperative to allow an
adequate examination when awake. Normally, this can be carried
out satisfactorily using an inhalational technique and a facemask.
Occasionally, it is easier for the surgeon if a laryngeal mask
airway is inserted, particularly where it is necessary to use the
operating microscope. Many of these children will require regular
follow-up examinations and repeated anaesthetics; therefore, it is
essential that induction is managed in a gentle and sympathetic
manner.
Measurement of intraocular pressure
Special consideration is required if the primary purpose of the
examination is to measure intraocular pressure (IOP). Most anaes-
thetic agents reduce IOP and there is a risk that injudicious anaes-
thesia will lower IOP to such an extent that a high IOP will be
masked, potentially compromising treatment. For this reason, some
anaesthetists use ketamine which does not reduce IOP. It is not
always possible to secure venous access in children before they are
asleep and, on these occasions, a dose of 510 mg kg
21
ketamine
intramuscularly will produce within a few minutes a child who is
Table 1 General anaesthesia may be required for the following procedures
Examination of the eye general examination; fundoscopy
measurement of IOP
retinoblastoma follow-up
Extraocular procedures excision of orbital dermoids/tumours
On the lids and orbit excision of meibomian cysts
steroid injection of haemangiomas
tarsorrhaphy
ptosis surgery
On the nasolacrimal apparatus syringing and probing of ducts
dacryocystorhinostomy
On the eye strabismus surgery
laser surgery/cryotherapy
episcleral dermoid excision
corneal surgery
enucleation
evisceration
Intraocular procedures to reduce IOP
goniotomy
trabeculectomy/trabeculotomy
lensectomy+articial lens insertion
vitrectomy
vitreoretinal surgery
Anaesthesia for paediatric eye surgery
6 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 1 2008

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quiet and still enough to permit a thorough eye examination. It is
essential to ensure the airway is well maintained. There may be a
slight increase in IOP using ketamine, although there are conict-
ing reports about this. However, it is probably safer to have a
falsely high rather than a falsely low IOP reading as the latter may
result in treatment being delayed.
Many anaesthetists prefer not to use ketamine because of a
reluctance to administer intramuscular injections to small children
and its association with increased pharyngeal and tracheobronchial
secretions. An alternative, equally effective technique is to under-
take an inhalation induction using sevourane. The ophthalmolo-
gist should be present or close by during induction and available to
measure IOP the instant the child stops moving and while the eyes
are still central. It is important to limit the sevourane to 5% if
possible in order to minimize the fall in IOP and ensure that the
facemask does not encroach upon and compress the eye, as this
will erroneously elevate IOP.
Both anaesthetic techniques are acceptable; perhaps the more
important issue is to ensure that due account is taken of the technique
used when comparing IOP measurements over a period of time.
Whichever method of induction is utilized, IOP measurements
should be taken before laryngoscopy or laryngeal mask airway
(LMA) insertion, even though the latter does not appear to raise IOP.
Syringing and probing of nasolacrimal ducts
Some children have blocked nasolacrimal ducts which usually
present within the rst year of life requiring probing of the duct
with a small blunt needle and irrigation with 12 ml of saline.
This is a short procedure and can be managed safely with a laryn-
geal mask airway. Rarely, where a simple probing has failed, it
may be necessary to pass a ne silicone catheter through the duct
into the nose and secure it in place for a few weeks. Occasionally,
it is necessary for the surgeon to manipulate or fracture the
inferior turbinate to relieve an obstruction at the lower end of the
duct. A very small amount of saline or blood may appear in
the nose or nasopharynx; this should be suctioned before removal
of the laryngeal mask airway.
Sometimes, it is necessary to proceed to a dacryocystorhinost-
omy. This is a more extensive procedure involving surgical
exposure of the duct and creating a new opening from it into the
nasal cavity through the bony upper lateral aspect of the nose. A
modest degree of hypotension should be induced and application
of a topical vasoconstrictor to the nasal mucosa may be benecial.
As blood may pass into the nasopharynx, airway protection with a
tracheal tube and throat pack is necessary and opioid analgesia
should be provided. All procedures on the nasolacrimal ducts can
cause bacteraemia; antibiotic prophylaxis should be given to chil-
dren with structural heart defects.
Strabismus surgery
This is the most common ophthalmic paediatric surgical procedure.
It is usually performed on a day-case basis but the high incidence
of postoperative nausea and vomiting associated with this pro-
cedure occasionally results in unplanned overnight admission.
Strabismus surgery is also associated with the oculocardiac reex,
a bradycardic response to extraocular muscle traction, and it has
been postulated that these two events might be associated.
Although very rare, an increased incidence of malignant hyperpyr-
exia has been reported in patients with a squint, and a high index
of suspicion should be maintained for this. Succinylcholine should
be avoided and temperature monitoring should be utilized.
In a few older children, the surgeon may elect to place an adjusta-
ble suture as part of the technique. This allows the surgeon to make
ne adjustments to the repair when the patient is awake using topical
anaesthesia. In some patients with small degrees of strabismus, a
minute quantity of botulinum toxin is injected directly into the
extraocular muscles to affect eye movement. This may be done using
EMG control, so muscle paralysis should be avoided.
Oculocardiac reex
The oculocardiac reex occurs frequently during squint surgery
(60% of cases). It has been well described;
1
traction on the
extrinsic eye muscles or pressure on the globe causes sinus brady-
cardia which reverts almost immediately after the stimulus is
removed. It is very unusual to see a more serious rhythm disturb-
ance, though very occasionally sinus arrest or major dysrhythmias
may occur. Traction on any of the extraocular muscles can evoke
the reex but it is generally believed that it occurs most commonly
when the medial rectus muscle is manipulated. Children with a
positive oculocardiac reex are much more likely to develop post-
operative nausea and vomiting (PONV) than those with no measur-
able reex
2
and it has been suggested that preventing the
oculocardiac reex may reduce the incidence of vomiting.
Blocking the afferent limb of the reex using a peribulbar block is
one way of achieving this, but this carries a risk of perforating the
globe and is inadvisable in children. It is preferable to administer
atropine 20 mg kg
21
at induction and to accept the resultant modest
tachycardia. The administration of atropine is especially necessary
if propofol, which has a bradycardic effect, is used for induction
or maintenance of anaesthesia.
Spontaneous ventilation is commonly employed during squint
surgery; sevourane is more suitable than halothane as it is associ-
ated with less oculocardiac reex (OCR). Some surgeons prefer a
completely immobile eye and hypercarbia has been shown to
double the incidence of signicant bradycardia;
1
therefore, con-
trolled ventilation may be more suitable. If muscle relaxation is
utilized, consideration should be given to the choice of relaxant as
some relaxants (e.g. rocuronium) appear to attenuate the oculocar-
diac reex. Atracurium is associated with a greater incidence of
oculocardiac reex than pancuronium but its shorter duration of
action makes this a more appropriate relaxant.
Postoperative vomiting
Nausea alone is a difcult entity to quantify in children, who
generally have a higher incidence of POV than adults. POV is a
Anaesthesia for paediatric eye surgery
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well-recognized complication following strabismus surgery, par-
ticularly in children over the age of 2 years. Experience suggests
that about two-thirds of children undergoing strabismus surgery
vomit if no preventative measures are taken. A systematic review
of publications between 1981 and 1994 on vomiting in children
following squint surgery established a mean incidence of vomiting
within 6 h of 54% in children receiving no prophylactic anti-emetic
and 59% within 48 h.
3
The reason for an increased incidence of vomiting following
squint surgery and its precise mechanism remain unknown but it is
postulated to be part of an oculo-emetic reex, involving the
ophthalmic division of the trigeminal nerve and the vomiting
centre in the medulla. Blocking the afferent nerves by way of a ret-
robulbar or peribulbar block reduces the incidence. It is probable
that there are local anatomical reasons for the reex, as different
surgical techniques have been shown to affect the incidence of
vomiting. In particular, squint repair utilizing the Faden myopexy
technique has a signicantly higher incidence of POV than the
simpler muscle recession/resection technique.
There have been numerous publications on the management of
POV in children in general and following squint surgery in parti-
cular. Many different strategies to reduce its incidence have been
proposed with varying success, including the use of anticholinergic
agents, dimenhydrinate, dexamethasone, clonidine, anti-emetics
(e.g. metoclopramide, droperidol, ondansetron) or utilizing the
putative anti-emetic properties of propofol either as an induction
agent or as part of a total intravenous anaesthesia (TIVA) tech-
nique. Studies have also examined the role of nitrous oxide and the
use of neostigmine to reverse muscle relaxants. These publications
have been comprehensively reviewed.
4
It is not possible to compare satisfactorily the studies relating
specically to strabismus surgery because they involve very differ-
ent underlying anaesthetic techniques and have often not taken
into account different surgical techniques. However, there is no
doubt that the introduction of the 5-HT
3
(serotonin) antagonists
has led to a signicant reduction in the incidence of POV,
5
and
they should be administered intraoperatively. Ondansetron 0.1 mg
kg
21
is very effective, although it has been shown that smaller
doses may be equally effective. Combination therapy (e.g. ondan-
setron and dexamethasone) is better than ondansetron alone.
Cheaper 5-HT
3
antagonists (e.g. dolasetron 0.35 mg kg
21
) have
been shown to be as effective as ondansetron,
6
although dolasetron
is not currently universally available. It is possible to reduce the
incidence of vomiting to less than 10% using a multimodal
approach adopting several of these methods.
Postoperative analgesia
Although squint surgery is one of the most painful ophthalmic pro-
cedures, intraoperative opioids should be avoided. They undoubt-
edly increase the incidence of vomiting and are usually
unnecessary for adequate analgesia, which can usually be achieved
satisfactorily using paracetamol and a non-steroidal anti-
inammatory analgesic, e.g. diclofenac, ibuprofen. Where
analgesia is inadequate, as it may be for the more painful myopexy
repair or repeat surgery, ketorolac has been shown to be as effec-
tive as morphine or meperidine. Occasionally, it may be necessary
to administer a stronger analgesic, e.g. codeine phosphate.
Peribulbar block is effective in producing good analgesia, as
well as reducing the incidence of the oculocardiac reex. However,
as noted earlier, most paediatric anaesthetists remain cautious
about utilizing this technique in children because of the risks of
globe perforation and retrobulbar haemorrhage.
Pain relief can be enhanced signicantly if a sub-Tenon block
is administered at the end of the procedure. Tenons capsule is the
fascial layer that extends from the limbus, fusing posteriorly to the
optic nerve, separating the globe from orbital fat. Sensation of
the eye is provided by ciliary nerves that cross the episcleral space
after emerging from the globe. Strabismus surgery on the extraocu-
lar muscles is carried out within this space and instilling local
anaesthetic here can be very effective.
Alternatively, satisfactory postoperative analgesia following
squint surgery can be obtained using either diclofenac 0.1% or
oxybuprocaine 0.4% eye drops alone. If these are administered
selectively to the operative site by the surgeon prior to suturing the
conjunctiva, the problems associated with an anaesthetic cornea
can be minimized.
Enucleation and evisceration
Removal of the whole eye may be required because of retinoblas-
toma, or for cosmetic reasons when there is an unsightly blind eye.
As the surgical technique involves dissection of each of the
extra-ocular muscles off the globe, the oculocardiac reex may
readily be evoked. Anaesthetic management should be as for stra-
bismus surgery, although the risks of POV are much reduced.
In evisceration, the contents of the globe are removed rather
than the whole eye, leaving the sclera behind. There are no specic
anaesthetic problems but the procedure can be painful and appro-
priate analgesia, including an intraoperative opioid (e.g. fentanyl)
may be necessary.
Intraocular surgery
Intraocular surgery in children is performed predominantly for the
management of glaucoma, or for cataract extraction with or
without an intraocular lens implant. These are being inserted now
even in infants.
Normal IOP is between 10 and 22 mmHg and depends on the
balance between the production of aqueous humour, mainly from
the ciliary body in the posterior chamber, and its drainage via a
trabecular meshwork to the canal of Schlemm in the anterior
chamber. Most paediatric glaucoma is a result of an intrinsic dis-
order of aqueous outow, and medical therapy is of limited value.
The principal surgical drainage procedures to treat glaucoma
include goniotomy, trabeculotomy and trabeculectomy. Where sur-
gical procedures are unsuccessful, cyclocryotherapy to ablate the
Anaesthesia for paediatric eye surgery
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aqueous-producing ciliary body is performed. This involves the
painful application of a cryoprobe at 260 to 2808C behind the
corneoscleral limbus. Opioid analgesia may be necessary.
Venous drainage from the eye is valveless and any rise in
venous pressure (e.g. coughing, straining) leads to an immediate
rise in IOP by altering the volume of the choroid and by impeding
aqueous drainage via the canal of Schlemm. Generally, arterial
pressure has little effect on IOP.
It is essential that the eye is motionless during intraocular pro-
cedures; sudden rises in IOP must be avoided to prevent the extru-
sion of intraocular contents through the incisions. This is
particularly important during corneal grafting ( penetrating kerato-
plasty) when a large defect is created over the cornea.
Neuromuscular paralysis and controlled ventilation should be
employed and neuromuscular blockade should be monitored using
a peripheral nerve stimulator.
Acetazolamide, which reduces aqueous production, or mannitol
may be administered intravenously during these procedures to
lower the IOP. It is important in penetrating keratoplasty to prevent
the IOP from falling too low as the eye can collapse inwards. The
surgeon may suture a ring around the cornea to support the eye
during the procedure.
It is good practice to try to prevent an increase in IOP at the
end of the procedure caused for example by coughing on the tra-
cheal tube at extubation although, with the advent of very ne
suture material allowing complete closure of the ocular wounds,
this is less critical than it used to be. Anaesthesia is best main-
tained until neuromuscular blockade has been reversed, the patient
is breathing spontaneously and extubation has been performed. A
useful technique to obtain a smooth extubation is to give a small
dose of propofol (0.5 mg kg
21
) immediately prior to extubation. In
older children, topical anaesthesia to the airway can be helpful
although this should be avoided in infants, as the simplest way to
avoid the elevated IOP associated with crying in the immediate
postoperative period is to allow them an early feed.
After initial concerns about possible gastric insufation and
reux, it has now been shown that pressure controlled ventilation
in children using a laryngeal mask is safe and effective;
7
it can be
used for intraocular surgery, even in small children. This has the
advantage of smoother extubation with less coughing and reduced
likelihood of acute IOP elevation compared with a conventional
tracheal tube.
8
However, if a laryngeal mask is used, it is impera-
tive to ensure that it is perfectly positioned and well secured
before proceeding with surgery. If there is any doubt, a tracheal
tube should be used.
Intraocular surgery is not particularly painful; a combination of
paracetamol and diclofenac is usually satisfactory.
Vitreoretinal surgery
Repair of a retinal detachment may be necessary in children; it gen-
erally takes place in very specialized centres. This usually involves
the creation of a chorioretinal scar using cryotherapy and the
placement of a scleral buckle towards the back of the eye to obtain
apposition of the neuroretina and the retinal pigment epithelium.
Sometimes, an intraocular gas bubble containing sulphur hexauor-
ide or peruoropropane may be injected into the eye to tamponade
the detached surfaces together while adhesions develop. It is impera-
tive that nitrous oxide is not administered when these gases are
used, as it will rapidly diffuse into the gas bubble and alter its size.
These gases may remain in the eye for several weeks and patients
and their carers should be given very clear instructions about
passing this information on to other anaesthetists, should they
require further surgery during this time. Diffusion of nitrous oxide
into an existing intraocular gas bubble can result in rapid expansion
of the bubble and an acute rise in pressure within the globe causing
irreversible ischaemic damage to the retina and optic nerve.
9
Vitreo-retinal surgery is painful and appropriate analgesia
should be administered perioperatively. In adults, a sub-Tenon
block has been shown to be very effective in providing analgesia
and is likely to be equally effective in children.
Emergency surgery
Penetrating eye injury may require removal of any foreign bodies
and early wound closure and sometimes cannot be delayed to ensure
an empty stomach. This has been a contentious issue for anaesthesia
because of two conicting arguments. On one hand, the possibility
of a full stomach demands prompt intubation for airway protection
that is conventionally achieved by the rapid inductionintubation
sequence using succinylcholine. On the other hand, it has been tra-
ditionally taught that there is the need to protect the eye from any
acute rise in IOP, since this may cause extrusion of ocular contents
through even very small wounds, leading to total loss of vision in
that eye. As succinylcholine causes a transient but denite rise in
IOP, it has been recommended that it be avoided and intubation per-
formed using a large dose of a non-depolarizing relaxant while
cricoid pressure is maintained.
There have actually been no well-documented reports describ-
ing vitreous extrusion following the administration of succinylcho-
line
10
and, in those difcult situations where the eye is at risk and
regurgitation is a concern, succinylcholine should be used as part
of a conventional rapid sequence induction, particularly if there are
any concerns about the airway. If succinylcholine is contraindi-
cated, or if there is less concern about risk of regurgitation, a tech-
nique using a non-depolarizing relaxant can be utilized. Premature
attempts at intubation provoke coughing which signicantly raises
IOP; they should be avoided and a nerve stimulator is helpful in
indicating when full relaxation has occurred.
Retinopathy of prematurity
Despite meticulous neonatal care, severe retinopathy of prematurity
(ROP) still occurs and can lead to total blindness. Babies at risk
for severe ROP are those of birth weight ,1500 g and/or ,31
weeks gestational age. ROP, which is characterized by abnormal
Anaesthesia for paediatric eye surgery
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blood vessel growth in the retina, is classied in ve stages,
ranging from mild (stage 1) to severe (stage 5). Infants who
develop the more severe ROP (stage 3 and above) are at great risk
of retinal detachment and blindness. The outcome of the disease
process can be signicantly improved by cryotherapy or laser
therapy to ablate the peripheral retina and remove the stimulus to
new growth. This needs to be done early in the disease, so early
identication is essential and eye examinations in at-risk infants
should take place between 6 and 7 weeks postnatal age and contin-
ued 2-weekly until the risk has passed.
Although the examinations, and in some centres the cryotherapy
or laser therapy, may take place within the neonatal unit, some pre-
mature infants may be transferred to theatre for their treatment.
Cryotherapy is a painful procedure and warrants administration of
opioid analgesia, e.g. fentanyl. This has implications for the post-
operative care of the patients who, because of their gestational age,
will already be at risk of apnoeic episodes following anaesthesia.
Provision should be made to provide postoperative ventilation with
appropriate support for these babies. Many of these infants will
have other systemic disorders consequent upon their extreme pre-
maturity (e.g. bronchopulmonary dysplasia) which may inuence
both the conduct of anaesthesia and the need for postoperative
support; they need careful assessment.
References
1. Blanc VF, Hardy JF, Milot J, Jacob JL. The oculocardiac reex: a graphic and
statistical analysis in infants and children. Can Anaesth Soc J 1983; 30: 3609
2. Allen LE, Sudesh S, Sandramouli S, Cooper G, McFarlane D, Willshaw
HE. The association between the oculocardiac reex and postoperative
vomiting in children undergoing strabismus surgery. Eye 1998; 12:
1936
3. Trame`r M, Moore A, McQuay H. Prevention of vomiting after
paediatric strabismus surgery: a systematic review using the
numbers-needed-to-treat method. Br J Anaesth 1995; 75:
556561
4. Olutoye O, Watcha MF. Management of postoperative vomiting in pedi-
atric patients. Int Anesthesiol Clin 2003; 41: 99117
5. Sennaraj B, Shende D, Sadhasivam S, Ilavajady S, Jagan D. Management
of post-strabismus nausea and vomiting in children using ondansetron:
a value-based comparison of outcomes. Br J Anaesth 2002; 89:
4738
6. Olutoye O, Jantzen EC, Alexis R, Rajchert D, Schreiner MS, Watcha MF.
A comparison of the costs and efcacy of Ondansetron and Dolasetron
in the prophylaxis of postoperative vomiting in pediatric patients
undergoing ambulatory surgery. Anesth Analg 2003; 97:
3906
7. Engelhardt T, Johnston G, Kumar MM. Comparison of cuffed,
uncuffed tracheal tubes and laryngeal mask airways in low ow
pressure controlled ventilation in children. Pediatr Anaesth 2006; 16:
1403
8. Gulati M, Mohta M, Ahuja S, Gupta VP. Comparison of laryngeal mask
airway with tracheal tube for ophthalmic surgery in paediatric patients.
Anaesth Int Care 2004; 32: 3839
9. Lee EJ. Use of nitrous oxide causing severe retinal loss 37 days after
retinal surgery. Br J Anaesth 2004; 93: 4646
10. Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open
globe: tracing the teaching. Anesthesiology 2003; 99: 2203
Please see multiple choice questions 58
Anaesthesia for paediatric eye surgery
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