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N931 Advanced Principles > Ophthalmology Modified > Flashcards

Ophthalmology Modified Flashcards

1
Q

Where are ophthalmic procedures common?

A

ambulatory surgery centers (98.5%)

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2
Q

What are the common procedures of the eye?

A

lens and cataract (70%)
intraocular (10%)
eyelids, cornea, conjunctiva (10%)

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3
Q

Sclera

A

outer, fibrinous protective layer, white and opaque and lies just posterior to the cornea

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4
Q

Cornea

A

the outer, fibrinous protective layer located anteriorly, and it is transparent and colorless

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5
Q

Choroid

A

middle, vascular layer

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6
Q

Retina

A

the inner layer of the posterior half of the eye

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7
Q

Conjunctiva

A

a thin, transparent mucous membrane that covers the posterior surface of the eyelids and the anterior surface of the sclera

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8
Q

Anterior chamber

A

b/w cornea and iris

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9
Q

posterior chamber

A

b/w iris and lens

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10
Q

orbits

A

two symmetrical bony enclosures in the front of the skull

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11
Q

what is the visual axis

A

an imaginary line from the midpoint of cornea to midpoint of retina or macula

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12
Q

What is suspended in the anterosuperior part of the orbit

A

the globe

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13
Q

What are the three layers of the eyeball

A

large posterior segment (vitreous humor, retina, macula and root of optic nerve)
Small convex anterior segment (two chambers)
Anterior chamber: immediately behind cornea filled with aqueous humor that is produced by ciliary body
posterior chamber: contains the lens

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14
Q

How many muscles is the eye surrounded by?

A

6 extraocular muscles

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15
Q

Superior rectus muscle

A

moves the eye upward
supraduction
CN 3

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16
Q

inferior rectus muscle

A

moves the eye downward
infraduction
CN3

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17
Q

Medial retcus muscle

A

move the eyeball nasally (adducts)
adduction
CN3

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18
Q

Lateral recuts muscle

A

moves the eyeball laterally (abducts)

abduction CN6

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19
Q

Superior oblique muscle

A

rotates the eyeball horizontally towards nose and down

intorsion, depression CN 4

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20
Q

Inferior oblique muscle

A

rotates the eyeball horizontally towards temple and up

extorsion, elevation CN 3

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21
Q

What CNs supply the motor innervation to the eye?

A

CN 3, 4, 6

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22
Q

What does the optic nerve extend through?

A

optic canal

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23
Q

What does the optic nerve meet intracranially?

A

optic chiasm

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24
Q

What is the optic nerve covered by?

A

meninges, the fibrous wrappings of the arachnoid, dura, pia mater, which envelop the central nervous system, and surround by CSF

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25
Q

How does a total spinal occur from regional to the eye?

A

any anesthetic agent injected into the optic nerve sheath can find its way back to the midbrain through the CSF

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26
Q

Cranial Nerve 2

A

optic nerve
outgrowth of the brain
part of CNS

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27
Q

Cranial nerve 3

A

oculomotor nerve

primary motor nerve to the extraocular muscles

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28
Q

Cranial nerve 4

A

trochelar nerve

only orbital cranial nerve that enters the orbit from outside the muscle cone

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29
Q

Cranial nerve 5

A

trigeminal nerve

afferent pathway for oculocardiac reflex-> bradycardia and dysrrhythmias

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30
Q

what are the branches of CN5?

A

ophthalmic, maxillary and mandibular branches

sensory and motor

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31
Q

Ophthalmic branch provides

A

sensation of pain, touch, and temperature to the cornea, ciliary body, iris, lacrimal gland, conjunctiva, nasal mucosa, eyelid, eyebrow, forehead and nose

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32
Q

MAxillary branch

A

sensation of pain, touch and temperature to upper lip, nasal mucosa, scalp muscles

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33
Q

CN 6

A

abducens

motor function to lateral rectus muscle

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34
Q

CN7

A

facial nerve
upper branch further divides into the temporal and zygomatic branches, which innervate the orbicular muscles of the eye, the superficial facial muscles and scalp muscles

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35
Q

CN 10

A

vagus nerve

afferent pathway for the oculocardiac reflex-> bradycardia and dysrrhythmias

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36
Q

What muscles raise the upper eyelids?

A

levator muscles

orbicular muscle contracts the eyelid

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37
Q

What is normal intraocular pressure?

A

10-22mmHg

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38
Q

What is the most important determinant of IOP?

A

balance between production and elimination of aqueous humor, maintaining an average volume of 250ml

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39
Q

What decreases IOP?

A

IV and inhalation anesthetics
hyperventilation
hypothermia
hypotension

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40
Q

What increases IOP?

A 
blinking, squinting
succinylcholine (transient 5-10mmHg)
ketamine (nystagmus)
nitrous oxide
atropine/scopolamine (acute angle closure glaucoma in susceptible patients)
valsalva, pressure on eyeball, coughing, vomiting
laryngoscopy/tracheal intubation
hypercapnia, hypoxemia, hypertension
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41
Q

What is aqueous humor?

A

thin watery fluid that fills the space in the anterior chamber between cornea and iris
continually produced by ciliary body
drains out eye via trabecular meshwork into the aqueous veins and eventually into the veins of the orbit

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42
Q

What is the prupose of the aqueous humor?

A

nourishes the cornea and lens

gives the front of the eye its form and shape

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43
Q

What are common adult ophthalmic procedures?

A 
cataract extraction
occuloplastics (ptosis repair)
cornea transplants or grafting
trabeculectomy (for glaucoma)
vitrectomy and retinal buckling
trauma (enucleation or orbital fracture repair)
LASIX
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44
Q

What is the leading cause of blindness in adults 20-74?

A

diabetes

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45
Q

What is the leading cause of blindness in children?

A

vitamin A deficiency

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46
Q

What are common pediatric eye cases?

A 
strabismus
exam under anesthesia
retinoblastoma
glaucoma
cataracts
retinal detachments
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47
Q

Strabismus

A

muscular surgery to fix ocular misalignment
Of the six muscles that innervate the eye, misalignment is present
can effect vision

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48
Q

Strabismus Anesthesia implications

A 
it hurts!
N/V
multiple rounds for pediatrics
emergence delirium
oculocardiac reflex
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49
Q

What are common medications seen in strabismus surgery?

A

acetaminophen (15mg/kg)
ketorlac (0.5mg/kg)
fentanyl (as needed)

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50
Q

What is the oculocardiac reflex?

A

traction on the extraocular muscles of the eye, manipulation of the globe and pressure on the eyeball (increased IOP) cause bradycardia, sinus arrest, v fib, AV block, ventricular ectopy and negative inotropy

51
Q

What is the physiology behind the oculocardiac reflex?

A

5th cranial nerve (afferent) to brainstem

10CN vagus efferent to cardioinhibitory center

52
Q

What is the corneal reflex?

A

CN V (corneal touch) and CN VII (blink, orbicularis oculi)

53
Q

What is the dose of atropine to help correct oculocardiac reflex bradycardia?

A

10mg/kg

54
Q

Dark Adaptation and ERGs (electroretinograms)

A

Prior to EUA to assess the actual cones and rods and their functionality

55
Q

Retinoblastoma

A

ocular cancer of retina primarily affecting kids under age 4

most curable, but increased risk of other cancers later in life

56
Q

LMA will work for what procedures

A

radiation and procedures for retinoblastoma and strabismus
glaucoma
cataracts
Nasolacrimal duct probing

57
Q

Amblyopia

A

Lazy eye
eye doesn’t work correctly in kids, message between teh eye and brain make it such that the worse eye kind of shuts off while the good eye does all the seeing

58
Q

What happens if a lazy eye isn’t corrected?

A

when the brain focuses on the message coming from the good eye this can become permenant even if the weak eye is fixed

59
Q

Who does amblyopia affect?

A

kids from birth to 7 years of age

60
Q

How do you initially treat amblyopia?

A

eye patches or dilation drops on the stronger eye to force the weaker eye to work

61
Q

Chalazion procedures

A

sty won’t go away and needs removal

zit on top of eyelid that wont go away

62
Q

Nasolacrimal duct probing is

A

used to clear clogged tear ducts

63
Q

Will you see stage 2 in eye surgery patients?

A

no

64
Q

What should you travel to PACU with?

A

emergency drugs and a peds mask (propofol)

65
Q

What are emergency eye cases?

A

open globes
corneal transplants melts causing open globes
canaliculi repairs
endopthalmitis

66
Q

What is an open globe?

A

full thickness defect in the cornea (transplant outer covering) or sclera (white outer covering)

67
Q

When should open globes go to surgery?

A

within 12-24 hours of surgery

68
Q

Anesthetic considerations for globes

A

Dehydrated
GETA (succ can raise IOP, neccessity depends on NPO status, viable eye vs difficult airway)
Oral RAE tube
Antibiotics needed

69
Q

What is a corneal transplant melts?

A

corneal transplant has rejected or the suture to the eye has come undone, leaving an opening to the eye

70
Q

Anesthesia for a corneal transplant melt?

A

GETA

LMA vs ETT will depend on severity of melt

71
Q

Anesthesia considerations for canaliculi repairs

A

younger children from dog bites/stratches
can be inner or outre
assuming NPO and patient appropraite can be LMA
fairly quick procedures

72
Q

Endopthalmitis

A

infection of the tissues or fluids inside the eyeball

infection in the vitreous

73
Q

Surgical considerations for endopthalmitis

A

vitrectomy to remove some of the infected vitreous gel and inject antibiotics
discuss anesthesia with surgeon, possible with peribulbar block but may not if infection too bad

74
Q

Ophthalmology and General anesthesia

A

retina cases

consider oral rae tube

75
Q

MAC/PBB/RBB cases?

A

anesthesia provides sedation, surgeon places block in OR to prep

76
Q

MAC/Cutdown

A

used on patients on anticoagulants and unsafe to use PBB/RBB
Done like a cataract from our standpoint. Use sedation and tetracaine gtts and once the surgeon drapes they will inject local by cutting the conjunctiva and placing local in back of eye. A little different than a peri-bulbar block but achieves same idea of localization.

We do these if patient’s are on anticoagulants to reduce risk of bleeding. Also some surgeons just prefer them because of less risk associated with them

77
Q

Topical Anesthesia

A

tetracaine drops only with sedation PRN

78
Q

Take away for eye cases

A 
Use oral RAE tube for ETT
N/V common
paralysis rarely required
Smooth induction 
smooth emergence
79
Q

Anesthesia tips for emergency eye cases

A

if patient awake, ensure comfortable
no airway
Local in helpful

80
Q

What should be placed if doing an extensive open globe case?

A

foley up front

81
Q

Ocular regional anesthesia is effective for

A

analgesia and akinesia of the eye and eyelids

82
Q

What nerves does Ocular regional anesthesia effect?

A

CN 3,4, 5,6, 7

83
Q

What is the anesthetic used for Ocular regional anesthesia?

A

versed and fentanyl +/- small propofol doses to get patient through actual block

84
Q

Retrobulbar block

A

Needle inserted through the skin in the infratemporal area, just above the inferior orbital rim and advanced toward the orbital apex deep into the muscle cone (retrobulbar space)
2-4ml of LA
better akinesia

85
Q

Complications of RRB

A

trauma to optic nerve, blood vessels, globe
retrobulbar hemorrhage b/c anesthetic is put inside the orbital epidural space
spread of LA to CSF causing hemodynamic instability and respiratory depression within 5 minutes
seizures if intravascular

86
Q

Peribulbar Block

A

may require an injection above or below the orbit (although most of our surgeons just do one below)
8-12ml
anesthetic is injected, creating positive extraconal pressure that spreads the agent inside the muscle cone to anesthesize the cranial nerves (avoids muscle cone and vital structures)

87
Q

What is a safer choice block and why?

A

PBB b/c of less risk of hemorrhage and central spinal

88
Q

What is the max dose of tetracaine?

A

3mg/kg

89
Q

How do you administered tetracaine?

A

2-6 drops (divided doses 1-2 minutes apart) in the eye prior to prep

90
Q

Sub-tenon Block

A

greater analgesia than motor block
block performed between rectus muscles of the globe
conjunctiva incised-> tenon tissue is elevated and incised-> a short cannula is inserted into the sub-tenon space
3-4 ml to achieve analgesia
larger doses may give akinesia

91
Q

What is tennon tissue?

A

tissue that encapsulates the globe posteriorly and fuses with the conjunctiva anteriorly

92
Q

What is the objective of the sub-tenon block LA placement?

A

to get posterior spread of the agent

93
Q

What are ophthalmic medications that cause dilation?

A

atropine/scopolamine
epinephrine
phenylephrine
cyclopentolate

94
Q

What class is atropine/scopolamine?

A

anticholinergic

95
Q

What are adverse effects of atropine/scopolamine?

A

central cholinergic syndrome

scopolamine can cause disorientation in some patients

96
Q

What is epinephrine?

A

sympathetic agonist

97
Q

What are side effects of epi?

A

tachycardia, arrhythmias, HTN, headache

98
Q

What is phenylephrine

A

alpha agonist

99
Q

What are side effects of phenylephrine?

A

HTN, arrhythmias, headache, reflex bradycardia

100
Q

What is cyclopentolate?

A

synthetic anticholinergic

101
Q

What are side effects for cyclopentolate?

A

disorientation, psychosis, seizures

102
Q

What ocular medications cause miosis?

A

pilocarpine
carboachol
physostigmine
echothiopate

103
Q

What is pilocarpine? Side effects?

A

muscarinic alkaloid

redness of sclera, irritation

104
Q

What is carboachol? Side effects?

A

synthetic carbamyl ester of choline

used if not responsive to pilocarpine

105
Q

What is physostigmine? side effects

A

indirect acting anticholinesterase

miosis

106
Q

What is echothiopate? side effects?

A

indirect acting organophosphorus cholinesterase inhibitor
increases drainage of intraocular fluid and used to treat glaucoma
irreversibly binds to cholinesterase (effects will last for weeks)– will prolong succinycholine

107
Q

What are ophthalmic glaucoma medications?

A 
timolol
acetazolamide
echothiopate
iatanoprost
brimonidine
108
Q

What is timolol? side effects?

A

potent non-selective beta blocker

bradycardia, asthma, CHF

109
Q

What is acetazolamide? Side effects?

A

carbonic anhydrase inhibitor
mild diuretic, hypokalemia, acidosis, hematuria, paresthesia, gastric disease, flaccid paralysis, seizures
avoid with hepatic renal disease

110
Q

What is iatanoprost?

A

prostaglandin

111
Q

What is brimonidine?

A

alpha 2 agonist

112
Q

How does acetazolamide (diamox) work?

A

used to lower the pressure in the eye by lowering the amount of aqeous humor production in front of the eye

113
Q

What is the dose of acetazolamide?

A

250-500mg mixed with normal saline

114
Q

What is special about acetazolamide?

A

incompatible with IV and other medications (precipates with zofran)

115
Q

Who can not have acetazolamide?

A

pateints with a sulfa allergy

116
Q

How do topical eye medications enter the bloodstream?

A

through the outer eye membrane and lacrimal apparatus

117
Q

How can you reduce the amount of topical medications that enter the bloodstream?

A

patient closes eyes for 60 seconds
avoid blinking
block the tear outflow canal by placing the index finger over the medial canthus after the eye is closed

118
Q

What are ophthalmic complications?

A 
retrobulbar hemorrhage
intravascular LA injection
globe puncture
optic nerve sheath trauma
ocular ischemia
extraocular muscle palsy and ptosis
facial nerve block
oculocardiac reflex
corneal abrasion
central retinal artery occulsion
119
Q

Preoperative considerations for ophthalmology

A

can the patient lie supine for a long time?
evaluate claustrophobia, chronic pain, COPD, tremors, mental status (anxiety, inability to cooperate)
postnasal drip, vasoconstrictive nose drops

120
Q

What is the cause of sudden onset of nausea at home after procedure?

A

increased intra-ocular pressure than anesthetic medications

121
Q

What is intraocular gas?

A

retinal procedures may utilize sulfur hexafluoride

is not removed will dissipate in 10-14 days

122
Q

What needs to be discontinued 15 minutes prior to gas injection?

A

nitrous oxide

123
Q

Cautions of intraocular gas

A

can not fly or go to high altitudes
if needing general anesthesia within 14 days no N2O
may be required to lie face down during recovery

N931 Advanced Principles (14 decks)

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