Penetrating Eye Injury

Question 1

A 34-year-old gentleman presents to the emergency department following an injury to his face with a broken glass bottle. He is intoxicated but denies any comorbidities, allergies and regular medication. He is listed for emergency surgery due to a penetrating eye injury.

What are your main concerns when assessing this patient?

Answer 1

• The patient is intoxicated, causing challenges for preoperative assessment and the perioperative period:
• Potential for an incomplete or inaccurate medical and anaesthetic history.
• Non-compliance with treatment plans, particularly if a local or regional anaesthetic technique is used.
• An increased risk of aspiration during induction and extubation
  (alcohol may delay gastric emptying).
• Possible lack of capacity to consent to the procedure.
• Potential for additional ingestion of illicit drugs.
• Pharmacological interaction of alcohol with anaesthetic agents.

Question 2

What are your main concerns when assessing this patient?

Continued…

Answer 2

• Unknown factors e.g. starvation status, previous anaesthetic and medical history.
• A penetrating eye injury requires careful control of the patient’s physiology during the perioperative period; consider early escalation to a consultant anaesthetist.
• The history raises the possibility of other trauma if he was involved in an attack. He will need a primary and secondary survey and relevant investigations if there is evidence of other injuries e.g. bruising and bleeding.
• The urgency of surgery requires a multidisciplinary discussion with surgeons regarding the nature of the injury and potential anaesthetic risks.

Question 3

What are the risks of delaying surgery in this patient?

Answer 3

• Infection.
• Endophthalmitis.
• Retinal detachment.
• Vitreous loss.
• Blindness.

Question 4

What are the options for anaesthesia in this patient?

Answer 4

• The options for anaesthesia in a patient with a penetrating eye injury are:
• General anaesthetic.
• Local anaesthetic ± sedation.
• Regional anaesthetic block ± sedation.

Question 5

What are the concerns with a regional anaesthetic technique in this patient?

Answer 5

• Poor compliance due to intoxication, including the inability to remain still during block insertion and lie flat.
• Lack of a skilled operator to facilitate the regional technique if during on-call hours.
• Risks of sedation in an intoxicated patient including loss of the airway and aspiration.
• A regional anaesthetic technique may cause increased intraocular pressure that may worsen the penetrating eye injury.

Question 6

How would you anaesthetise this patient?

Answer 6

• Ensure patient consent, the presence of a senior anaesthetist and trained assistant, AAGBI monitoring, and routine and emergency equipment and drugs readily available, including antihypertensive medication.
• Consider the location of surgery: Ophthalmic theatres tend to be in remote locations, so ensure all staff are familiar with the facilities. If not, carry out the procedure in main theatres after discussing with the surgical and theatre teams.
• The priority is to ensure adequate oxygen delivery to the tissues, while limiting secondary damage from increased intraocular pressure.
• The choice of induction agents needs to favour lowering of intraocular pressure. Avoid ketamine and suxamethonium to reduce the risk of further damage secondary to transient increases in intraocular pressure. Coughing, straining and surges in blood pressure should be minimised.
• Use of a quick-acting opioid and spraying the vocal cords with a local anaesthetic will help blunt the pressor response to laryngoscopy.

Question 7

How would you anaesthetise this patient?

Continued…

Answer 7

Induction:
* Pre-oxygenation with 100% oxygen followed by a rapid sequence induction with cricoid pressure and appropriate doses of alfentanil, propofol and rocuronium would be most suitable in this patient.

• Spray the cords with a weight-appropriate dose of local anaesthetic solution.
• Secure the airway with an endotracheal tube, followed by ventilation with oxygen, air and a volatile anaesthetic agent.
• Avoid tying the tube tie tightly due to the risk of increasing intraocular pressure as a result.

Question 8

What are the concerns when extubating this patient following his procedure?

Answer 8

• Transient increases in intraocular pressure can cause further secondary damage, so coughing and surges in blood pressure should be avoided.
• In order to minimise the risk of secondary damage during extubation, consider:
• Extubation while asleep and exchange the endotracheal tube for a laryngeal mask airway.
• Using a remifentanil infusion while extubating.
• Postponing extubation and transfer the patient to the intensive care unit.