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Anesthesia Concepts 4 (Butera) > Ophthalmic Anesthesia > Flashcards

Ophthalmic Anesthesia Flashcards

1
Q

Optic Neve photo

A
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2
Q

The ophthalmic artery is ______.

A

the main blood supply to the eye. It branches from the internal carotid artery near the Circle of Willis

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3
Q

The ophthalmic artery divides into the ______.

A

central retinal artery and the posterior ciliary arteries
The superior and inferior ophthalmic veins transport venous blood to the cavernous sinus

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4
Q

photo of the vascular supply to the eye

A
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5
Q

Function of the lacrimal gland

A
  • produces the aqueous layer of the eye’s tear film
  • aqueous layer of tears is made up of water, proteins, vitamins, electrolytes, and other substances
  • these substances help lubricate the eye, wash away debris, and promote overall eye health
  • tears get to the eye through the puncta
  • can trigger reflex tears when something gets in your eye
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6
Q

Miosis = ____
What medications cause miosis?

A

constriction of the pupil

acetylcholine

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7
Q

Glaucoma = ____

What meds treat it?

A

increased intraocular pressure

Acetazolamide, Echothiophate ,Timolol

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8
Q

Mydriasis = ______

What causes it?

A

Pupillary dilation, ophthalmic capillary decongestion

Atropine, Cyclopentolate, Epinephrine, Phenylephrine, Scopolamine

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9
Q

Phenylephrine drops: clinical use? Systemic effects?

A

causes MYDRIASIS

systemic effects: SEVERE HTN, ARRYTHMIAS, HEADACHES, TREMORS, MYOCARDIAL ISCHEMIA

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10
Q

Epinephrine drops: clinical use? Systemic effects?

A

used for: REDUCES IOP

systemic effects: TACHYARRHYTHMIAS , PVC

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11
Q

Timilol drops: clinical use? Systemic effects?

A

used for: REDUCES IOP & TREATS GLAUCOMA

systemic effects: BRADYCARDIA, HYPOTENSION, CHF, EXACERBATION OF ASTHMA AND MYASTHENIA GRAVIS

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12
Q

Echthiophate drops: clinical use? Systemic effects?

A

used for: TREATS GLAUCOMA & MIOSIS

systemic effects: PROLONGED RESPONSE TO SUCCINYLCHOLINE AND ESTER LINKED LOCAL ANESTHETICS

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13
Q

Acetylcholine drops: clinical use? Systemic effects?

A

causes miosis

systemic effects: BRADYCARDIA, HYPOTENSION, BRONCHOSPASM, INCREASES SECRETIONS

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14
Q

CYCLOPENTOLATE drops: clinical use? Systemic effects?

A

causes MYDRIASIS. Used to dilate pupil.

systemic effects: DISORIENTATION, DYSARTHRIA, SEIZURES

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15
Q

SCOPOLAMINE drops: clinical use? Systemic effects?

A

causes MYDRIASIS. Used to dilate the pupil.

systemic effects: DISORIENTATION AND HALLUCINATIONS

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16
Q

COCAINE drops: clinical use? Systemic effects?

A

causes VASOCONSTRICTION

systemic effects: SEVERE BRADYCARDIA

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17
Q

Class of acetylcholine

A

cholinergic agonist

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18
Q

Class of acetazolamide
Systemic effect?

A

Carbonic anhydrase inhibitor
Systemic effect: Diuresis, hypokalemic metabolic acidosis

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19
Q

Class of Echothiophate
Systemic effects?

A

Irreversible cholinesterase inhibitor

Prolongation of succinylcholine’s effects
Reduction in plasma cholinesterase activity up to 3-7 weeks after discontinuation
Can cause Bradycardia, bronchospasm

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20
Q

Class of Timilol
Systemic effects?

A

b-Adrenergic antagonist

Atropine-resistant bradycardia, bronchospasm, exacerbation of congestive heart failure; possible exacerbation of myasthenia gravis

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21
Q

Atropine is a ____
It could cause ____

A

Anticholinergic

Central anticholinergic syndrome; delirium, agitation, fever, flushing, xerostomia, and anhidrosis
Blurred vision (cycloplegia, photophobia)

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22
Q

Cyclopentolate is a ____
It could cause _____

A

Anticholinergic
Disorientation, psychosis, convulsions, dysarthria

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23
Q

Epinephrine is a ____
Is could cause ____

A

a-, b-Adrenergic agonist
Hypertension, tachycardia, cardiac dysrhythmias; epinephrine paradoxically leads to decreased intraocular pressure and can also be used for glaucoma

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24
Q

Phenylephrine is a ___
It could cause _____

A

a-Adrenergic agonist, direct acting vasopressor

Hypertension (one drop, or 0.05 mL, of a 10% solution contains 5 mg of phenylephrine)

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25
Scopolamine is a ____ It could cause _____
Anticholinergic Central anticholinergic syndrome (see atropine above)
26
Goals of an eye block/meds to use
Reduce pain, amnesia, limit patient movement, with minimal respiratory and cardiovascular side effects Propofol Remifentanil Midazolam Fentanyl
27
Retrobulbar Block
A needle steeply inserted from the orbital rim into the muscle cone behind the globe, sm. volume of local anes.
28
Peribulbar Block
A needle minimally angled shallow and outside the muscle cone, safer larger volume of local anes. are needed and slower onset
29
Sub Tenon Block
Local anes. Injected into the sub- Tenon space
30
photo of Sub Tenon block
31
Complications of eye blocks
Oculocardiac Reflex (OCR) Hemorrhage Brainstem Anesthesia Globe perforation Myotoxicity Optic nerve damage Seizures
32
Trigeminovagal or OCR
Pressure on the globe or traction on the extraocular muscles can result in bradycardia, atrioventricular block, or asystole. OCR occurs most often during strabismus surgery in children Hypercarbia, hypoxemia and light anesthesia augment the incidence and severity
33
Treatment of Trigeminovagal or OCR
The first step in treating OCR is to stop the stimulation by the surgeon. Repeated and sustained stimulation cause OCR to fatigue. Atropine 10mcg/kg IV If GA ensure adequate depth Maintain normal PaCO2
34
Retrobulbar Hemorrhage = ____ treatment?
Usually noted during injection, eye tenses and pushes forward Complication is less likely with peribulbar or sub-tenon blocks Treatment 1. gentle pressure 2. Lateral canthotomy may be necessary to relieve pressure on the optic nerve 3. reschedule surgery
35
Brainstem anesthesia
Clinical picture includes: Amaurosis Gaze Palsy Dysphagia Cardiac arrest Shivering Apnea Tachycardia hypertension Loss of consciousness Dilatation of the contralateral pupil
36
Other serious complications that occur with anesthesia to the eye
Myotoxicity of local anesthesia resulting in diplopia Direct trauma to the eye Seizures
37
Normal Intraocular pressure = ____
10-22 mmHg
38
Diurnal Variation & Positional Changes = ___
1-6 mmHg
39
Formula for Intraocular perfusion pressure =
MAP-IOP
40
Major determinants of IOP
Aqueous humor dynamics Changes in the choroid blood volume(CBV) Central Venous pressure Extraocular muscle tone Valsalva Maneuver
41
Aqueous Humor Dynamics
Major physiologic determinant of IOP Balance between production and elimination Produced by the ciliary process (Posterior Chamber) filtered by the trabecular meshwork and reabsorbed by the Canal of Schlemn (Anterior Chamber) exits the eye into episcleral veins.
42
Factors that influence IOP
- Venous congestion, A direct relationship exists between CVP and IOP - Coughing straining or vomiting can increase IOP 40 mmHg - Laryngoscopy and intubation - Sudden increases or decreases in blood pressure will increase or decrease IOP transiently - External compression of the globe - Hypoxemia and hypoventilation increase - Hyperventilation and hypothermia decrease
43
CNS depressants generally do what to IOP?
CNS DEPRESSANTS GENERALLY LOWER IOP These centers are depressed by sedatives, narcotics, barbiturates, and volatile anesthetics
44
What can increase IOP?
- Succinylcholine increases IOP, Ketamine may increase IOP - Laryngoscopy and endotracheal intubation will increase IOP
45
Acetazolamide and its effect on the aqueous humor
Reversible inhibitor of the carbonic anhydrase Decreases formation of aqueous humor through decreased carbonic anhydrase activity results in reduction of hydrogen ion secretion at the renal tubule and an increased renal excretion of sodium, potassium, bicarbonate, and water.
46
How does Mannitol work in the eye?
Mannitol reduces IOP by dehydrating the vitreous along an osmotic gradient.  Mannitol dehydrates the vitreous humor by drawing water out of the vitreous humor and into the blood vessels. The vitreous humor has less water, after being dehydrated by the mannitol, it has less mass and thus creates less pressure.
47
When CVP is increased, what happens to IOP?
marked increase
48
When CVP is decreased, what happens to IOP?
marked decrease
49
When arterial BP is increased, what happens to IOP?
mild increase
50
When arterial BP is decreased, what happens to IOP?
mild decrease
51
When paCO2 is increased (hypoventilation), what happens to IOP?
moderate increase
52
When paCO2 is decreased (hyperventilation), what happens to IOP?
moderate decrease
53
When paO2 is increased, what happens to IOP?
no effect
54
When paO2 is decreased, what happens to IOP?
mild increase
55
effect of volatile agents on IOP
moderate decrease
56
effect of nitrous oxide agents on IOP
mild decrease
57
effect of barbiturates on IOP
moderate decrease
58
effect of benzodiazepines on IOP
moderate decrease
59
effect of ketamine on IOP
conflicting evidence
60
effect of opioids on IOP
mild decrease
61
effect of depolarizing muscle relaxants on IOP
moderate increase
62
effect of non-depolarizing muscle relaxants on IOP
no change or mild decrease
63
To prevent an increase in IOP, avoid direct pressure on the ____.
Globe Use a plastic shield over the eye No peribulbar or retrobulbar injections Careful facemask technique
64
To prevent an increase in IOP, avoid increase in ____
CVP Prevent coughing during induction and intubation Ensure a deep level of anesthesia and relaxation prior to laryngoscopy Avoid head down position Extubate under deep anesthesia
65
AVOID PHARMACOLOGIC AGENTS THAT INCREASE IOP (PREVENTING ASPIRATION) by using ______
Metoclopramide, Histamine H2 receptor antagonists, non-particulate antacids ? Nasogastric tube RSI Induction/ extubate awake
66
Intravitreal injection of gas for ?cataract surgery (re-listen to his lecture? this slide is weird)
Sulfur hexafluoride (SF6) and Carbon octofluorine (perfluoropropane)(C3F8) are commonly used during retinal detachment surgery. Nitrous oxide: avoid 7-10 days w/ SF6, 30 days w/ C3F8, 5 days w/ air, 0 days w/ silicone oil Air travel can cause increase in IOP
67
Strabismus
Surgery for poor alignment of the visual axis, which must be treated by 4 months of age for proper stereoscopic visual development Three problems associated with these patients are MH, PONV, and OCR
68
Measures to decrease PONV
Minimal use of opioids The use of Propofol and +/- volatile anesthetic Avoid the use of N2O Administration of serotonin (5HT3) antagonist Use of dexamethasone Insertion and removal of orogastric tube Gentle manipulation of the eye muscles Maintenance of adequate hydration Placement of lidocaine near the extraocular muscle during surgery to minimize afferent impulses and post operative pain
69
Measures to decrease PONV
Minimal use of opioids The use of Propofol and +/- volatile anesthetic Avoid the use of N2O Administration of serotonin (5HT3) antagonist Use of dexamethasone Insertion and removal of orogastric tube Gentle manipulation of the eye muscles Maintenance of adequate hydration Placement of lidocaine near the extraocular muscle during surgery to minimize afferent impulses and post operative pain
70
Perioperative vision loss (POVL)
POVL assumed to be related to ischemic optic neuropathy or central retinal artery occlusion High risk patients are spine surgeries positioned prone for prolonged procedures with substantial blood loss Surgeons should inform patients Rare incidence less than 0.2% of spine surgeries
71
Preventing/recognizing post op vision loss
Monitoring IOP during steep trendelenberg Molloy Bridgeport Anesthesia Associates Observation Scale (MBOS) Eyelid edema is a sign of rise in IOP OPP=MAP-IOP
72
Chemosis =
swelling of the eyelids Chemosis identifies IOP greater than 40 mmHg and a need to use intervention to lower IOP
73
Perioperative vision loss risk factors
Prolonged prone or head down position Male gender Obesity Increased blood loss
74
Corneal abrasion
Postoperative eye pain most commonly caused by corneal abrasion Treatment by topical application of antibiotic and covering with an eye patch for 48hr Topically applied anesthetic or steroids are contraindicated
75
Most eye surgeries are performed under ___
MAC with or without regional blocks
76
Keratoplasty = ___
Replacement of cornea with donor tissue
77
Pterygium = ____
Benign growth of conjunctiva removed when vision is impaired
78
Trabeculectomy = ___
To treat glaucoma
79
Vitrectomy = ___
Surgical extraction of vitreous chamber
80
Ectropion Repair = ___
Remove excess upper eyelid tissue
81
Entropion Repair = ___
Remove excess lower eyelid tissue
82
Blepharoplasty = ___
Any plastic surgery of the eyelids
83
Dacryocystorhinostomy = _____
Correction of obstructed tear ducts
84
Emergency surgery could necessitate balancing the need for what?
rapid sequence induction against prevention of increases in IOP that could cause further eye injury Discuss the medications needed to blunt the CV response to laryngoscopy and endotracheal intubation before RSI.

Anesthesia Concepts 4 (Butera) (15 decks)

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