OCULAR

ANAESTHESIA
Syahpikal Sahana
1301-2115-0501
 Subperiosteal space : between the orbital bones
and the periorbita
Peripheral orbital space (anterior space) : bounded
peripherally by periorbita and internally by 4 recti
Central space (muscular cone or retrobulbar space):
Anteriorly : Tenonscapsule
peripherally: 4 recti
posterior : continuous with peripheral space
Sub-Tenons space: between sclera and tenons
capsule
Types of ocular anaesthesia :
General anaesthesia
Local anaesthesia
Topical
Regional
Peribulbar block

Retrofbulbar block

Parabulbar or sub-tenon block

Intracameral block

Facial block

Frontal block
PREFERRED ANAESHETIC TECHNIQUE
LOCAL ANAESTHESIA:

Pterygium
Cataract
Surgery for glaucoma
Minor extra-ocular plastic surgery
Keratoplasty
Dacryocystorhinostomy
Minor anterior segment procedures
Refractive surgey
Vitreo-retinal surgery etc
GENERAL ANAESTHESIA:

Padiatric surgery
Sqint surgery
Major oculoplastic surgery
Orbital trauma repair
Dacryocystorhinostomy
Vitreo-retinal surgery
 GENERAL ANAESTHESIA
FOR OCULAR SURGERY
INDICATION:
1. In children and infant
2. Anxious & uncooperative patient
3. Mentally retarded adult
4. Patients preference

OBJECTIVE:
1. Analgesia
2. Amnesia
3. Loss of consciousness
4. Adequate skeletal muscle relaxation
Advantages:

I. safe operative environment

II. Complete akinesia

III. Controlled intra-ocular pressure

IV. For bi-lateral surgery

V. Avoiding complications of L/A

PRE- ANAESTHETIC CHECKUP
GENERAL:
Nutritional status

Retarded growth

Anaemia

Jaundice

Cough

Temperature

Oedema

History of convulsion
 AIRWAY :
Mouth opening

Neck movement

Dentition

RESPIRATORY SYSTEM : CARDIOVASCULAR SYSTEM :

Cyanosis Pulse

Dyspnoea Blood pressure

Auscultation of lung field Heart sound (auscultation)

Dependent oedema
INVESTIGATIONS
Haematology

Urine analysis *prn

Stool R/E *prn

Chest X-ray *prn

Over 40 years
Blood glucose

ECG

Blood urea

S.Creatinine
Echocardiogram specially for congenital heart disease
(valvular disease) also for adult if indicated

OTHER INVESTIGATIONS:
S. electrolytes

Liver function test

Coagulation screening
Procedure of General Anaesthesia

1) Pre-medication for anaesthesia

2) Induction & intubation

3) Maintenance & Monitoring

4) Extubation and Recovery

 Drugs used in G/A
1.Pre-medication for anaesthesia
Benzodiazepines (diazepam) for sedation and reduce
anxiety
Anti-emetics metaclorpramide , ondansetron
Atropine - prevent bradycardia reduce bronchial and
salivary secretion

Medication for selective patients - hypertensive , diabetic,

coronary artery disease
2.Induction
Thiopentone ( thiopental sodium) 5 mg/kg
Propofol 2.5 mg/kg

3. Maintenance
Muscle relaxants suxamethonium, vecuronium,
atracurium, etc

anaesthetic gas nitrous oxide (N2O) with O2 and

isoflurane,sevoflurane etc.
 Intravenous agent pethidine , Fentanyl , NSAID
(for pain reduction)

4. Recovery

Neostigmine
Atropine
 EFFECTS OF ANAESTHETIC AGENTS
ON IOP
DRUGS EFFECT ON IOP

INHALED ANAESTHETICS
Volatile agents
Nitrous oxide

Intravenous agents
Barbiturates
Benzodiazepines
Ketamine
Opioids

MUSCLE RELAXENT
Depolarizers (succinylcholine)
Non- depolarizers
 LOCAL ANAESTHESIA
Acts by producing reversible block to the transmission
of peripheral nerve impulses
ADVANTAGES:

Patient is conscious and alert

Drugs used in G/A can be avoided

Systemic complication is less Post-operative confusion

Nausea , Vomiting

Urinary retention

Stress response to cardiac patient

DISADVANTAGES:
Painful

Difficult in uncooperative patients

NOT SUITABLE FOR:

Young patient
Mentally unstable patient
Patient with physical disabilities that prevent lying
DESIRED PROPERTIES OF L/A
1. Non-irritating , safe and painless

2. Must be water soluable

3. Rapid onset of action

4. Duration of action appropriate to the operation to be performed

5. Non-toxic

6. No local after effects ( nerve damage , necrosis)

7. Must be effective regardless its application to tissue or mucous
membrane

8. Quickly block motor and sensory nerves

 ACTION OF LA
NERVE AXON MEMBRANE

LOCAL ANAESTHESIA

LA
LAH+ (free base) LAH+
(ionised drug)
(ionised drug)

Na
channel
LA
(free base)
MECHANISM OF ACTION OF L/A
Binds with protein of Na+ channels (at interior side)

Block voltage dependent Na+ conductance ( prevent Na+ influx)

Block depolarization

Initiation and propagation of action potential fails

Afferent impulses can not go to higher center

No pain sensation
Patient preparation for LA

As for GA

Optimal health condition

Friendly rapport

A suitable vein should always be cannulated in all patient

Full cardio-pulmonary resuscitation equipment

Appropriate monitoring
Toxicity of LA:
Light headedness

Numbness or tingling of circumoral area

Anxious

Drowsy

Tinnitus

Convulsion ( To prevent- Diazepam or TPS)

Coma & apnoea develop subsequently (O2)

Cardiovascular collapse may result due to myocardial depression &
vasodilatation

HYPOXAEMIA APNOEA
Types of LA
According to chemical structure

Ester group Amide group

Procaine Lidocaine
Cocaine Bupivacaine
Tetracaine Ropivacaine
benzocaine mepivacaine

Esters may cause more allergies

COMMONLY USED L/A

L/A Onset of Duration of Use

action action (concentration)
Oxybuprocaine 6-20 sec 15 min Topical (0.4%)
5-10 min 30-60 min Infiltration
(1%,2%,4%)
Lidocaine
10- 35 sec 15-20 min Topical (4%)

Bupivacaine Moderate 75-90 min Infiltration (0.25-

0.75%)
OTHERS

L/A Onset of Duration of Use

action action (concentration)

Proparacaine 15-30 sec 15-20 min Topical (0.5%)

Amethocaine 10-25 sec 10-20 min Topical (0.5-1%)

Ropivacaine Moderate 1.5-6hrs Infiltration (1%)

 TOPICAL ANAESTHESIA

ADVANTAGES:
Cost effective

Immediate visual recovery

Avoidance of complication - globe rupture , nerve damage

DISADVANTAGES:
No akinesia

Not suitable for extended surgery

Well informed and motivated patient is required

ADVERSE EFFECT OF TOPICAL ANAESTHESIA

Epithelial and Endothelial toxicity

Allergy to drug

Alteration of lacrimation

Surface keratopathy
USES OF TOPICAL ANAESTHESIA

Manipulation of superficial cornea and conjunctiva

Phacoemulsification in cooperative patient

Prior to regional blocks

 PERIBULBAR BLOCK
Most popular now a days
AIM:
Injected into peribulbar space
Spreads to lid and other spaces
Produces globe and orbicularis akinesia and anaesthesia.

L/A agent :
o Lidocaine 2%
o Bupivacaine 0.75%

Along with
o Hyaluronidase 5-7.5 IU/ml

o Adranaline 1: 200,000
VOLUME :
8-10 ml (approximately)

INSERTION POINT:
1st - Junction of medial 2/3rd and lateral 1/3rd of lower lid adjacent

& Parallel to orbital floor

2nd - Just infero-medial to supra orbital notch or just medial to

medial canthus
POSITION OF PATIENT:
Supine and in primary gaze

USE OF PERIBULBAR BLOCK

1. Cataract

2. Glaucoma

3. Keratoplasty

4. Vitreoretinal surgery

5. Strabismus surgery
ADVANTAGES:
Less chance of globe injury

Less chance of optic nerve damage

DISADVANTAGES:
Pain

Conjunctival chemosis

Less akinesia than retrobulbar block

 RETROBULBAR BLOCK
AIM:
Injected in muscle cone to block
Cilliar nerve and ganglion
3rd , 4th & 6th cranial nerves
provides - akinesia and
anaesthesia of the globe.

POSITION OF PATIENT:
Supine and in primary gaze

SITE OF INJECTION:
In the lower lid margin just above a point between medial
2/3rd & lateral 1/3rd of lower orbital margin
DIRECTION OF NEEDLE:
backward , upwards and medially towards apex of orbit

VOLUME:
2 4 ml usually

ADVANTAGES:
Complete akinesia
Dilatation of pupil
Adequate and quicker anaesthesia
Minimal amount of agent required
Complications :
Retrobulbar haemorrhage

Globe penetration

Optic nerve sheath injury

Optic nerve atrophy

Decrease visual acuity

Retinal vascular occlusion

Cont
Brain stem anaesthesia

Frank convulsion

Extra ocular muscle palsy

Trigeminal nerve block

Oculo-cardiac reflex

Respiratory arrest
Contraindication :

Bleeding disorder ( risk of retrobulbar haemorrhage)

Extreme myopia ( globe perforation)

An open eye injury (may cause expulsion of intraocular contents)

Posterior staphyloma
PARABULBAR OR SUB-TENON BLOCK
DRUG : LIGNOCAINE

Conjunctival incision 2-3 mm

Halfway between inf. limbus & fornix

to open sub-tenon space

Blunt canulla or needle is inserted to post. Sub-tenon space

Bathing the nerves & muscles within the cone

 Infiltration

Dissection
ADVANTAGES:
Avoid vascular and optic nerve injury

Requires lower volume of anaesthetics

Better anaesthesia to iris and ant.segment

DISADVANTAGES:
Subconjunctival haemorrhage

More post-operative morbidity

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

USE: ptosis surgery

SITE OF INSERTION: just below mid-point of supra- orbital

margin transcutaneously
directed towards roof of orbit

VOLUME: about 2 mlw

INTRACAMERAL ANAESTHESIA

AGENT:
lidocain 1%
(without preservative or adrenaline)

USE:
used for phacoemulsification
 FACIAL BLOCK

AIM: blocking the action

of orbicularis oculi.

USE : as an adjunct to
retrobulbar block.

TYPES:

1. Van lint
2. OBrien
3. Nadbath & Rehman
4. Atkinson
 Major sight and life-threatening complications
A. Retrobulbar orbital haemorrhage

SIGNS & SYMPTOMS

rapid intraorbital and intraocular pressure elevation

increasing proptosis

marked pain

ecchymoses in the eyelids

Chemosis

vision down to poor perception or no perception of light

MANAGEMENT:

Evaluation:
Indirect ophthalmoscopy - for evidence of central retinal artery
perfusion compromise.

Immediate medical treatment:

intravenous osmotic agents such as
acetazolamide
mannitol
Surgery:

Surgical decompression such as -

Canthotomy,

Cantholysis

Orbital decompression
B. Globe perforation:
(Exceptionally soft eye ; myopic eye is more prone)

Occurred with retrobulbar and peribulbar anaesthesia

suspected if
marked pain during the delivery of local an aesthesia
hypotony with inability to secure a stable globe - intraoperative signs of
perforation

reduced red reflex due to vitreous haemorrhage

Serious sight threatening vitreoretinal complications may result

**** seek the advice of a specialist vitreoretinal surgeon

C. Nerve Injury
Optic nerve may be damaged by:

direct trauma by needle

ischaemic damage from intrasheath injection or haemorrhage

pressure from retrobulbar haemorrhage

pressure from excess local anaesthetic injection into the

retrobulbar space

excessive applied external pressure.

NEED TO CARE :
avoiding deep injections into the orbit and

injecting with the eye in the primary position

D. Brain stem anaesthesia
Due to spread of local anaesthetic along the optic nerve sheath

SYMPTOMS & SIGNS:

drowsiness

light-headedness

confusion

loss of verbal contact

 cranial nerve palsies

convulsions

respiratory depression or respiratory arrest

cardiac arrest

ONSET OF SYMPTOMS: within 10-20 mins of LA injection

SYMPTOMS LASTS FOR: Hours

E. Muscle palsy

Diplopia and ptosis are common for 2448 hours post-operatively

when large volumes of long-acting local anaesthetics are used.

If this persists or fails to recover, it may be due to muscle damage

as a result of :

intramuscular injection of local anaesthetics

local anaesthetic myotoxicity

ischaemic contracture following haemorrhage/trauma

 F. Oculocardiac Reflex (Trigeminovagal reflex)
Trigeminal nerve afferent and vagal efferent pathway

CAUSES:
Traction on extra-ocular muscle
Pressure on globe

RESULT:
Bradycardia
Ventricular ectopy
Ventricular fibrilation
AFFERENT PATHWAY
Impulses

Long & short cilliary nerve

Cilliary ganglion

Trigeminal gasserian ganglion

main trigeminal sensory nucleus

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

SCN Heart

CG TGG

VN

efferent
Treatment

Stop the surgical stimulus immediately.

Ensure adequate ventilation .

Ensure sufficient anesthetic depth.

Atropine / Glycopyrrolate (anti-cholinergic):

often helpful immediately or prior surgery
 TAKE HOME MESSAGES
All local anaesthetic agents are myotoxic

Direct injection into a muscle should be avoided

No LA technique is entirely free of severe systemic adverse events

Short, fine needle should be used

The eye in the primary gaze position (looking straight ahead)

Gentle aspiration after insertion of needle should be done to

alleviate possible entry to blood vessel.

Bevel of the needle facing the globe and tangenital to sclera.

All occular surgery with LA should be treated as GA.