Ophthal SSU

Question 1

LA solution for eye blocks and rationale

Answer 1

Question 2

reletive risks nad benefits of peribular vs subteneon for eye surgery

Answer 2

Question 3

anaesthetic issues related to strabismus surgery and how are they maangaged

Answer 3

Question 4

incidence of globe perfo with peribulbar nad usbtenon. how tthe risk ca be minimised

Answer 4

Question 4

features and management of brainstem anaesthesia

Answer 4

Question 4

anaes issues with penetrating eye injury

Answer 4

Question 5

methods reducing IOP as part of eye block. risks involved

Answer 5

Question 6

methods of sedation for eye procedure. risks involved.

Answer 6

• Intravenous Sedation (“Twilight Sedation”)
• IV sedatives (e.g., midazolam, propofol, fentanyl) to achieve minimal to moderate sedation.
• Used alone or with topical/regional techniques.
• Patient remains responsive but relaxed; recall possible

Question 7

patient and staff issues involved when performing laser procedures in eye surgery

Answer 7

Question 8

how do you perform subtenon?

Answer 8

1. Obtain full consent from the patient
2. Monitoring in form of an SaO2 attached
3. Patient positioned lying on the bed in a supine position looking up and out
4. Would topicalise the eye with 0.4% oxybuprocaine eye drops
5. Sterilisation of eye using 1⁄2 strength iodine
6. Insert barragner speculum into the eye to keep it open
7. In the inferonasal quadrant avoiding any conjunctival blood vessels would lift the
   conjunctiva with non-toothed forceps.
8. I would then make a cut with the Westcott scissors in the conjunctiva and tenons
   fascia to expose white sclera
9. Pass the Westcott scissors closed around the globe to create a passage
10. I would then remove the scissors and insert the subtenon blunt needle into the same
    space following in contour of the eyeball until the syringe attached is vertical
11. I would then inject my local anaesthetic solution of 5ml 1% ropivacaine

Consent
IV
Monitor
Position
LA + other drugs
Equipment
Document / SBYB

Question 9

how do you perform peribulbar?

Answer 9

Peribulbar Block Viva Script (Australian Context, Using Ropivacaine)

1. Consent and PreparationObtain full, informed consent from the patient, explaining risks, benefits, and alternatives.Attach monitoring, including continuous pulse oximetry (SaO2), and ensure IV access.Position the patient supine on the bed, looking up and slightly outwards.
2. Eye PreparationInstil topical anaesthetic drops (e.g., 0.4% oxybuprocaine) to the eye.Clean the periocular area and conjunctival sac with half-strength povidone-iodine.Insert a sterile eyelid speculum to keep the eye open.
3. Technique for Peribulbar BlockAsk the patient to look straight ahead.Palpate the inferotemporal orbital rim.Using a 25G or 27G 25 mm (1 inch) blunt needle, insert the needle through the skin or conjunctiva at the junction of the lateral third and medial two-thirds of the lower orbital margin (inferotemporal quadrant), directing the needle parallel to the orbital floor.Advance the needle slowly, ensuring no resistance or pain, and avoid globe perforation.Aspirate to exclude intravascular placement.
4. Anaesthetic InjectionInject 5–8 mL of 0.75–1% ropivacaine (with or without hyaluronidase, depending on local protocol).Observe for any signs of globe or orbital compartment syndrome.If necessary, a second injection can be given in the superonasal quadrant for adequate akinesia.
5. Post-Injection CareGently compress the globe with a Honan balloon or digital pressure for 5–10 minutes to facilitate anaesthetic spread and reduce intraocular pressure.Monitor for complications: retrobulbar haemorrhage, globe perforation, optic nerve injury, or systemic toxicity.Confirm adequate anaesthesia and akinesia before proceeding with surgery.
6. Notes on RopivacaineRopivacaine is a long-acting amide local anaesthetic with a favourable safety profile and reduced cardiotoxicity compared to bupivacaine

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Provides effective anaesthesia and prolonged postoperative analgesia

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Australian guidelines recommend use by clinicians experienced in regional anaesthesia

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7. Special ConsiderationsAlways use the lowest effective dose.Avoid intravascular injection—aspirate before and during injection.Adjust dose for elderly, debilitated, or patients with hepatic/renal impairment

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Question 10

consenting process for the block

Answer 10

Eye blocks are generally a very safe procedure to perform and they avoid all the risks of having a general anaesthetic.

There are some complications that can occurs such as bleeding – can present as a bruising of the eye or bleeding behind the eye, swelling (very common), infection and damage to the eye itself.

In incredibly rare occasions there is a risk of a reaction to the block causing unconsciousness and if that happened, we would look after you and you would wake up later on.

Question 11

So you have a registrar who is doing the block. They come out of the room looking concerned and tell you they have inserted the block in the wrong eye. What do you do?

Answer 11

This is a concerning situation that needs to be managed sensitively with regards to all parties involved.

There are a few elements that need to be covered in particular safety of the patient in front of you, colleague safety, institutional safety, and professional responsibilities.

Patient safety – open disclosure about events, discuss with the surgeon and assess urgency of the operation, preferably if the patient has had the wrong eye blocked would come back the next day to block the other eye as high risk of falls/ injury due to poor vision. This needs to be arranged
Colleague safety – registrar – discussion of case with them, what happened, their welfare, learning points, discussion with supervisor of training is this an isolated incident or a pattern of behaviour which would require further escalation
Institutional safety – fill in incidence form for the hospital, discussion of the case at a morbidity and mortality meeting, any strategies to prevent similar events occurring in the future.
Professional responsibilities – does the event need reporting to higher bodies, are there learning points that anaesthetists can use in different centres.

Question 12

You have inserted the block yourself on the correct eye and suddenly the patient becomes unconscious and bradycardic what do you think is the differential diagnosis

What is your immediate management?

Answer 12

• Total spinal – brainstem spread
• Occulocardiac reflex
• Over sedation
• Local anaesthetic
• I would assess the patient in an ABCDE manner.
• Cycle the blood pressure
• Inform the surgeon what had happened and ask them to reduce their stimulation
• Reassure the patient in case total spinal might be aware
• Support airway to ensure adequate oxygenation
• If this did not improve with the above management I would then prepare to intubate
  the patient

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