Anesthesiology

Open Globe Injuries

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What the Anesthesiologist Should Know before the Operative Procedure?

An open globe occurs when there is a breach in the sclera or cornea, usually as a result of either blunt or penetrating trauma. The major concerns in this case include infection of intraocular contents (endophthalmitis) and possible expulsion of intraocular contents, which may cause distortion of ocular anatomy and vision loss. The injury from blunt force trauma usually occurs where the sclera is weakest: at the limbus of the eye, the insertions of extraocular muscles, or at previous sites of surgery/ injury. Penetrating trauma may be associated with higher rates of endophthalmitis, and may be associated with an intraocular foreign body (IOFB). Depending on the nature of the IOFB, removal may be necessary in order to prevent endophthalmitis, retinal detatchment, and metallosis.

Open globe injuries may be associated with trauma to other areas of the body as well. Such associated trauma may complicate anesthetic management of open globe repair, and is some cases, may need to be addressed prior to the repair. Pediatric patients with open globe injuries may not be cooperative or communicative, such that a history of injury and physical exam are extremely limited. Adult patients with open globe injuries may have conditions leading to the trauma that make communication/ cooperation difficult, such as drug intoxication, delirium, or dementia. Finally, eye injuries that are inconsistent with purported mechanism should raise suspicion for abuse.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Risks of delay are related to the development of endophthalmitis and risk for extrusion (or if extrusion is already present, further extrusion) of intraocular contents. Increases in intraocular pressure (IOP) increase the risk of expulsion of intraocular contents; these increases can occur with coughing, straining, hypoxia, hypercarbia, acidosis, and squeezing of the eyes shut (such as during crying). Risks for endophthalmitis increase >24 hours after injury.

Emergent: Full stomach and/or drug intoxication, if pre-existing, likely still present.

Urgent: Full stomach and/or drug intoxication, if pre-existing, may still be present.

Elective: N/A

2. Preoperative evaluation

Medical conditions common to trauma, such as drug intoxication, may complicate anesthetic management. Timing of presentation may not allow for resolution of acute intoxication. Patients with coexisting medical conditions that place them at risk for falls, such as cerebrovascular disease, diabetes, dementia, and arthritis, may present with open globe from trauma.

Delay of surgery may be indicated if other life-threatening conditions coexist and require priority in management. This may be modified based upon the probability of restoring useful vision in the injured eye.

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation

Management of coexisting conditions should be handled in a manner similar to any other urgent surgery.

Perioperative risk reduction strategies

Management of coexisting conditions should be handled in a manner similar to any other urgent surgery. Delay should be discussed with the ophthalmologist as it may increase the risk of damage to the eye.

a. Cardiovascular system

Acute/unstable conditions

Such conditions may preclude management of the open globe until they are no longer life-threatening to the patient.

Baseline coronary artery disease or cardiac dysfunction

Goals of management should be consistent with previously published guidelines regarding perioperative care of the patient with cardiac disease.

b. Pulmonary

Chronic obstructive pulmonary disease

Avoidance of coughing is important to avoid expulsion of ocular contents prior to closure. Avoidance of hypoxia and hypercarbia is important as both can increase IOP secondary to retinal venodilation.

Reactive airway disease (asthma)

Avoidance of coughing is important to avoid expulsion of ocular contents prior to closure.

c. Renal-GI

Management of renal and hepatic insufficiency should be consistent with previously published guidelines.

d. Neurologic

Dementia and/or delirium can be a risk factor for falls leading to ocular trauma. This may make obtaining a history, physical exam, or patient cooperation difficult. Otherwise, management of neurologic disease should be consistent with previously published guidelines.

e. Endocrine

Management of endocrine disease should be consistent with previously published guidelines.

f. Additional systems/conditions may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

The patient may not be able to give a history of all medications taken, secondary to pre-existing conditions (extremes in age), or intoxication.

a. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

This may include medications specific to diseases associated with surgery. Patients on anticoagulants may have life-threatening bleeding secondary to their trauma; this may need to be addressed prior to their ocular injuries. Patients whose trauma is a result of intoxication may still be under the influence of, or withdrawing from, their intoxicants. A screen for drugs of abuse may be necessary if the patient is unable to cooperate.

b. What should be recommended with regard to continuation of medications taken chronically?

Continuation of preoperative medication will be contingent upon coexisting conditions such as other trauma.

c. Latex allergy - If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

d. Does the patient have any antibiotic allergies?

N/A

e. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Documented: Avoid all trigger agents including succinylcholine and inhalational agents:

  1. Proposed general anesthetic plan

  2. Ensure MH cart available: [MH protocol]

  3. Family history or risk factors for MH

5. What laboratory tests should be obtained and has everything been reviewed?

Laboratory tests should be guided by the patient's underlying condition (such as coexisting trauma to other areas of the body) and any acute exacerbations of chronic medical conditions. In addition to an examination by the ophthalmologist, other imaging studies may be used to determine the extent of injury to the eye. Plain films may reveal IOFB while CT scans provide more detail regarding IOFB and their location, as well as identify other injuries to the eye. Ideally, axial and coronal views are obtained, although this will require the ability of the patient to cooperate with repositioning and neck flexion. MRI does not require patient repositioning or exposure to ionizing radiation and can detect radiolucent IOFB; MRI is contraindicated for ferric IOFB.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

General anesthesia for this procedure provides the surgeon with the most desirable operating conditions, as patient anxiety, inability to lie flat, intoxication, and extremes of age may preclude cooperation. The concern for patient coughing or retching during induction/emergence, as well as the presence of severe coexisting chronic medical conditions, represent the challenges associated with this technique. Conversely, adequate regional anesthesia may be difficult to obtain and is not without risk. Loss of patient cooperation during the procedure can present risks of further damage to the eye, including extrusion of ocular contents. Typically, MAC is more appropriate in smaller more anterior globe injuries, because these repairs are shorter, involve less discomfort, and require less manipulation of the eye. However, in infants and children general anesthesia is required in order to assure ideal operating conditions.

Regional anesthesia

Topical anesthesia to the globe, as well as retrobulbar/peribulbar block have been used in conjunction with MAC in some small series as an alternative to general anesthesia. Topical anesthesia does not provide akinesis, nor is it sufficient to blunt all surgical stimuli. The concern with regional anesthesia is an increase in IOP leading to extrusion of intraocular contents secondary to either the volume of local anesthetic or from retrobulbar hemorrhage following injection. In addition, traumatic distortion of the globe and surrounding tissues may alter anatomical landmarks and not only decrease the chance of a successful block, but also increase the risk of further damage.

Optimal operating conditions, regardless of case duration and location of globe injury.

Drawbacks

Induction of general anesthesia may be more complicated in patients with multiple medical conditions, the greatest concern being an increase in IOP. Such an increase can be caused by hypoxia, hypercarbia, acidosis, succinylcholine, and laryngoscopy, all of which may lead to expulsion of ocular contents. As a result, close attention should be paid to minimizing these triggers during anesthetic induction, maintenance, and emergence. In addition, the risk-benefit ratio must be considered in the trauma patient with a full stomach and possible difficult airway.

What analgesic modalities can issues

Much has been written on the use of succinylcholine as a muscle relaxant for rapid sequence induction. The increase in IOP after the administration of succinylcholine is typically mild (6-9 mm Hg for 5-10 min) and does not seem to be related to fasciculations of extraocular muscles. Therefore, the use of succinylcholine for induction should be based on a risk-benefit ratio specific to each individual patient presentation. The increased IOP secondary to laryngoscopy and intubation however, is significantly higher (even with the use of nondepolarizing muscle relaxants). Administration of medications such as dexmedetomidine, remifentanil, or alfentanil prior to intubation serves to blunt not only this effect, but also blunts increases in heart rate and blood pressure in response to intubation (which may be desirable in patients with coexisting coronary or cerebrovascular disease). These short-acting medications tend to be well-tolerated hemodynamically. If a rapid-acting nondepolarizing muscle relaxant is chosen instead, accommodations must still be made for the increase in IOP secondary to laryngoscopy and intubation. With the availability of Sugammadex, the use of rocuronium, even for cases of short duration (EUA of the eye for suspected open globe injury), has obviated the need for succinylcholine since reversal from a dense nondepolarizing block can be accomplished in 3-5 minutes. If Sugammadex is not available, remifentanil (4 mcg/kg) may be used in conjunction with propofol to achieve a rapid sequence induction of short duration.

Airway concerns

A patient with a full stomach requires an endotracheal tube to secure the airway. In the absence of a full-stomach a laryngeal-mask airway may be used, but controlled ventilation may still be necessary due to the depth of anesthesia/muscle relaxation required for an akinetic eye. During induction extreme care must be taken to avoid exerting pressure on the eye with the mask, which may lead to extrusion of ocular contents. A rapid sequence induction may avoid this risk. Coughing and straining should be avoided during emergence; in patients without a full stomach, a deep extubation may be beneficial.

Monitored anesthesia care

Benefits

Induction and emergence are shorter, provided there are no complications.

Drawbacks

Requires patient cooperation and adequate local anesthesia. Patients may still experience mild discomfort making a motionless surgical field difficult to achieve. Misjudging depth of anesthesia and loss of patient cooperation are among the most concerning risks as airway access may be difficult to achieve expeditiously. Inadequate sedation as well as rescue airway maneuvers (mask ventilation) can cause coughing/straining, which in turn may cause expulsion of ocular contents.

Other issues

The use of MAC for the open globe is controversial; small case series exist in the literature. Some of these series exclude patients with coexisting medical conditions, full stomachs, and anxiety. No plan for MAC should lack a plan for conversion to general anesthesia; patient selection is extremely important. MAC is most suitable for short procedures and simple, small, anterior ocular wounds.

6. What is the author's preferred method of anesthesia technique and why?

Since virtually all infants and young children will present challenges with keeping still, general anesthesia is the preferred method. Induction is with a rapid sequence intubation involving lidocaine (1 mg/kg), propofol (2-4 mg/kg), and rocuronium (1 mg/kg). Maintenance of anesthesia is with air, oxygen, and sevoflurane. Analgesics such as acetaminophen and opioids are administered both for intraoperative and postoperative pain. Ondansetron (0.1 mg/kg) and dexamethasone (8mg) are administered for prophylactic PONV. If 3 of 4 twitches are present, reversal of neuromuscular blockade is with neostigmine and atropine or if the procedure is of short duration and the neuromuscular block is dense (absence of a train of 4), then sugammadex is administered. With the patient adequately reversed from the neuromuscular blockade and the patient breathing spontaneously the patient's stomach and oropharynx are suctioned and the patient is extubated deep and turned on their side. If Sugammadex is not available, a rapid sequence induction of short duration may be achieved with propofol (2-4 mg/kg) and remifentanil (4 mcg/kg).

What prophylactic antibiotics should be administered?

Prophylactic antibiotics should cover a broad-spectrum of bacteria and provide sufficient ocular penetration. Coverage should include Bacillus sp., coagulase-negative Staphylococcus, and Streptococcus. Common regimens include vancomycin and ceftazidime (or ciprofloxin in penicillin-allergic patients). Additional coverage may depend on the mechanism of injury (i.e., rural setting).

What do I need to know about the surgical technique to optimize my anesthetic care?

Some complicated eye injuries may first be repaired with a primary closure followed by a delayed comprehensive repair. In some instances, a comprehensive repair may be undertaken at the time of injury. Such instances include removal of a traumatic cataract, vitrectomy, and/or scleral buckling. To determine the extent of the patient's repair at initial presentation and expected length of the procedure, communication with the surgeon is essential. In some cases, initial exam may not reveal the extent of injury and decision making must occur intraoperatively.

What can I do intraoperatively to assist the surgeon and optimize patient care?

For the patient under general anesthesia, deep anesthesia and/ or muscle relaxation may be required for a motionless field. For the patient under sedation, patient cooperation is essential to achieve this end.

What are the most common intraoperative complications and how can they be avoided/treated?

Any patient reaction that increases IOP can risk expulsion of ocular contents in an open globe. For this reason, avoidance of intraoperative coughing or straining is essential whether general anesthesia or sedation is used.

Cardiac complications

The ocular-cardiac reflex may occur with pressure on or manipulation of the eye (especially traction on the extraocular muscles). A retrobulbar block may also trigger this reflex. The most common manifestation of this reflex is bradycardia mediated by the vagus nerve. However, junctional rhythms, bigeminy, or even sinus arrest can be seen. If the reflex occurs in response to a surgical stimulus, the surgeon should be immediately notified, as cessation of the stimulus may relieve the dysrhythmia. If unsuccessful, a vagolytic medication such as atropine (10-20 mcg/kg IV) or glycopyrrolate (10 mcg/kg) should be administered.

a. If the patient is intubated, are there any special criteria for extubation?

No.

b. Postoperative management

What analgesic modalities can I implement?

Postoperative pain should be minimal for repair of open globe injuries. Multimodal analgesics involving acetaminophen and NSAIDs, if there are no contraindications, can be used.

What level bed acuity is appropriate?

Coexisting acute and chronic conditions will determine the acuity of post-operative monitoring.

What are common postoperative complications, and ways to prevent and treat them?

Endophthalmitis is the most common complication, with closure >24 hours after injury, timely administration of antibiotics, and removal of intraocular foreign bodies being important in prevention.

What's the Evidence?

Justice LT, Valley RD, Bailey AG, Hauser MW. Anesthesia for ophthalmic surgery. In Davis PJ, Cladis FP, Motoyama EK: Smith's anesthesia for infants and children. 8th ed. Philadelpha: Elsevier Mosby; 2011.

(This is a good overall review.)

Castellarin AA, Pieramici DJ. Open globe management. Comp Ophthal Update 2007;8:111-24.

(Good review of preoperative assessment and surgical management.)

Regional anesthesia

Scott IU, McCabe CM, Flynn HW, Lemus DR, Schiffman JC, Reynolds DS, et al. Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries. Am J Ophthalmol 2002;134:707-11.

(Study of 218 patients. In a retrospective study, 80 patients had general anesthesia and 140 patients had MAC. Patients with MAC received either a retrobulbar or peribulbar block. Patients with MAC tended to have smaller, more anterior occular wounds.)

Boscia F, La Tegola MG, Columbo G, Alessio G, Sborgia C. Combined topical anesthesia and sedation for open-globe injuries in selected patients. Ophthalmology 2003;110:1555-9.

(A series of 10 patients. Surgeon and patient conditions were mildly suboptimal. Patients with injuries more than 5 mm posterior of the limbus, full stomachs, anxiety/uncooperativeness, and ASA 3 or greater were excluded.)

Niemi-Murola L, Immonen I, Kallio H, Maunukesela EL. Preliminary experience of combined per- and retrobulbar block in surgery for penetrating eye injuries. Eur J Anaesth 2003;20:478.

(Twenty patients in a prospective study. Patients were NPO with no eye injuries >8 mm or >4 mm posteriorly from the limbus.)

General anesthesia

Chidiac EJ, Raiskin AO. Succinylcholine and the open eye. Ophthalmol Clin N Am 2006;19:279-85.

(Good review regarding physiology and treatment.)

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;100:485-9.

(Forty patients received 0.6 mcg/kg over 10-minute premedication.)

Ng H-P, Chen F-G, Yeong S-M, Wong E, Chew P. Effect of remifentanil compared with fentanyl on intraocular pressure after succinylcholine and tracheal intubation. Br J Anaesth 2000;85:785-7.

(In 45 patients, remifentanil 1 mcg/kg was compared with placebo and fentanyl 2 mcg/kg. Fentanyl was not shown to be effective.)

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