Anesthesia for Ruptured Globe Repair

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 by Anna Murchison, MD, MPH on July 5, 2020.


Introduction

Open globe injuries are estimated to occur at 2-3.8/100,000 in the United States and often require prompt surgery. [1] For these injuries, the goal of anesthesia is to provide paralysis and insensitivity while minimizing increases in intraocular pressure (IOP).[2,3] However, anesthetic management is multifaceted and can be challenging.

Classification

Ocular injuries are classified by extent of injury, mechanism, and location. Open globes involve a full thickness injury to the cornea or sclera. These injuries primarily occur from blunt trauma or projectiles.[4] The location of damage is classified into three zones: isolated to the cornea, <5mm posterior to the limbus, and >5mm posterior to the limbus, respectively.[5]

Timing of Repair

The timing of repair requires balancing the urgency to save vision, the risks of pulmonary aspiration, and the complications of delaying treatment. In healthy patients requiring general anesthesia, the minimum fasting recommendations for clear liquids, light meals, and heavy meals are 2, 6, and 8 hours, respectively.[6] If a patient with ocular injury has little chance of improving sight, surgery can usually be delayed to optimize the patient’s preoperative conditions. However, delays are carefully weighed with the increased risk of infection, endophthalmitis, and extrusion of intraocular content.[7]

Physiology of Ocular Pressure

The eyeball can be viewed as a hollow sphere with a rigid shell, therefore increasing intraocular content or decreasing the spherical volume can raise IOP. Coughing, vomiting, pain, and Valsalva increases intraocular content by impeding the outflow of aqueous humor and increasing the volume of choroidal blood.[8] On the other hand, administering inhaled anesthetics or using face masks can cause external compression and raise IOP.[7] In a patient with an open globe, it is vital to blunt these changes because ocular hypertension risks expulsion of intraocular content.[8]

Premedication

Preoperative medications can optimize conditions to restore vision and provide necessary comfort. Midazolam is a good option for its anxiolytic, sedative properties and lack of rise in IOP.[9,10] Pain can be controlled with presurgical narcotics and postsurgical peribulbar blocks.[11] Vomiting prevention can be addressed with antiemetics such as ondansetron.[7] Specific situations can also necessitate premedication. For example, in general anesthesia (GA), lidocaine and remifentanil can be given before intubation and extubation to attenuate intraocular hypertension.[7] Similarly, dexmedetomidine acts as a sympatholytic to blunt the increased IOP associated with succinylcholine, a common neuromuscular blocking agent used during intubation.[12]

General vs. Regional Anesthesia

GA is typically performed with rapid sequence induction and intubation. GA is the predominant anesthetic method for open globe patients as it provides profound anesthesia and akinesia to perform safe microsurgery. It is particularly used in pediatric and uncooperative patients because they might not tolerate administration of regional anesthesia (RA) or remain still during the operation.[8] Furthermore, absorption of RA can transiently increase IOP and risk intraocular extrusion.[2]

RA typically consists of retrobulbar or peribulbar blocks with facial nerve blocks as needed. Select cases may warrant the use of RA, particularly if the patient has a difficult anatomy for intubation.[8] Furthermore, the severity and location of injury can affect the anesthetic method; one study found that smaller open globe injuries located in zones 1 or 2 were more likely to receive RA compared to GA.[13] Some even found success in open globe repairs using topical anesthetics or a combination of RA with intracameral anesthesia.[14][1]

Conclusion

Safely providing anesthesia for open globe surgery can be challenging particularly due to risks of intraocular extrusion. The timing of repair, administration of premedication, and choice of anesthesia depend on several factors; however, GA, antiemetics, and analgesics are the most used to give patients an optimal outcome.

References

  1. Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: A review of the literature. J Emerg Trauma Shock. 2015;8(4):216-223.
  2. Kelly DJ, Farrell SM. Physiology and Role of Intraocular Pressure in Contemporary Anesthesia. Anesthesia & Analgesia. 2018;126(5):1551-1562.
  3. McGoldrick KE, Foldes PJ. General anesthesia for ophthalmic surgery. Ophthalmol Clin North Am. 2006;19(2):179-191.
  4. Blair K, Alhadi SA, Czyz CN. Globe Rupture. In: StatPearls. Treasure Island (FL)2020.
  5. Pieramici DJ, Sternberg P, Jr., Aaberg TM, Sr., et al. A System for Classifying Mechanical Injuries of the Eye (Globe). American Journal of Ophthalmology. 1997;123(6):820-831.
  6. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2017;126(3):376-393.
  7. Gupta S, Mehta A. Open Eye Injury with Full Stomach. The Internet Journal of Anesthesiology. 2009;22(2).
  8. Morgan GE, Mikhail MS, Morgan GE, Butterworth JF, Mackey DC, Wasnick JD. Morgan and Mikhail's clinical anesthesiology. [electronic resource]. 5th edition / John F. Butterworth, David C. Mackey, John D. Wasnick. ed: McGraw-Hill; 2013.
  9. Carter K, Faberowski LK, Sherwood MB, Berman LS, McGorray S. A randomized trial of the effect of midazolam on intraocular pressure. J Glaucoma. 1999;8(3):204-207.
  10. Gillmann K, Hoskens K, Mansouri K. Acute emotional stress as a trigger for intraocular pressure elevation in Glaucoma. BMC Ophthalmology. 2019;19(1):69.
  11. Deb K, Subramaniam R, Dehran M, Tandon R, Shende D. Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery. Paediatr Anaesth. 2001;11(2):161-167.
  12. Mowafi HA, Aldossary N, Ismail SA, Alqahtani J. Effect of dexmedetomidine premedication on the intraocular pressure changes after succinylcholine and intubation. Br J Anaesth. 2008;100(4):485-489.
  13. McClellan AJ, Daubert JJ, Relhan N, Tran KD, Flynn HW, Jr., Gayer S. Comparison of Regional vs. General Anesthesia for Surgical Repair of Open-Globe Injuries at a University Referral Center. Ophthalmol Retina. 2017;1(3):188-191.
  14. Auffarth GU, Vargas LG, Klett J, Völcker HE. Repair of a ruptured globe using topical anesthesia. Journal of cataract and refractive surgery. 2004;30(3):726-729.
    1. Regional anaesthesia for surgical repair in selected open globe injuries in adults. Chakraborty A, Bandyopadhyay SK, Mukhopadhyay S. Saudi J Ophthalmol. 2013 Jan;27(1):37-40. doi: 10.1016/j.sjopt.2011.12.002. Epub 2012 Jan 30. PMID: 23964185