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The most common ophthalmic procedures in current clinical practice comprise cataract, glaucoma, and vitreoretinal surgeries. An anesthetic approach is required for all of these procedures, and each specific procedure has its anesthetic considerations. Additionally, a perioperative eye injury can serve as a basis for a malpractice claim, underscoring the importance of protecting and caring for the eyes during anesthesia and mitigating the risks associated with regional anesthetic techniques.[3] This activity reviews the anesthetic considerations and implications for ophthalmic procedures, including general, regional, and topical anesthetic techniques. The indications, contraindications, complications, and clinical significance of these techniques and the role of the interprofessional team in caring for patients undergoing ophthalmic procedures requiring an anesthetic approach are discussed. Objectives: Differentiate between the absolute and relative contraindications to anesthetic techniques commonly employed during ophthalmic procedures. Select the most appropriate anesthetic technique for a patient undergoing an ophthalmic procedure. Identify and manage the complications of the anesthetic techniques utilized during ophthalmic procedures. Develop and employ interprofessional strategies to improve outcomes for patients undergoing ophthalmic surgery with anesthesia. Access free multiple choice questions on this topic.

The most common ophthalmic procedures in current clinical practice comprise cataract, glaucoma, and vitreoretinal surgeries. Approximately 26 million individuals in the United States have symptomatic cataracts. Cataract surgery is the most commonly performed surgical procedure in the United States, with nearly 3.6 million cataract extractions completed annually.[1] Glaucoma affects almost 67 million people in the United States. An anesthetic approach is required for all of these procedures, and each specific procedure has its anesthetic considerations.[2] According to the Anesthesia Closed Claims Program, eye injury occurred in 3% of all registered claims, underscoring the importance of protecting and caring for the eyes during anesthesia and mitigating the risks associated with regional anesthetic techniques.[3] This activity reviews the anesthetic considerations and implications for ophthalmic procedures, including general, regional, and topical anesthetic techniques. The indications, contraindications, complications, and clinical significance of these techniques and the role of the interprofessional team in caring for patients undergoing ophthalmic procedures requiring an anesthetic approach are discussed.

Regardless of the anesthetic approach, the inadvertent intravascular injection of local anesthetic can result in systemic toxicity. The retrobulbar block has the highest incidence of adverse events due to injuries to surrounding anatomical structures.[9] The complications associated with retrobulbar blocks include globe perforation, the risk of which is increased when the axial length of the eye exceeds 26 mm, respiratory arrest secondary to intrathecal spread of anesthetic to the brainstem from inadvertent puncture through the optic nerve dura, and severe vision loss from increased IOP related to retrobulbar hemorrhage or optic nerve compression from local anesthetic infiltration.[23] A retrobulbar hemorrhage can be sight-threatening; clinical signs like proptosis and increased IOP suggest retrobulbar hemorrhage and warrant consideration of a lateral canthotomy. Complications of peribulbar blocks are less severe and less common, increasing the popularity of this regional block. The most common complication of a peribulbar block is temporary swelling of the conjunctiva secondary to the accumulation of larger volumes of local anesthetic within the confined space of the orbit. Similarly, a sub-Tenon block has lower complication rates because anesthesia can be achieved using a blunt needle. A sub-Tenon block is a reasonable approach in patients taking anticoagulants or with an increased axial eye length; using a sharp needle in these circumstances would increase the risk of adverse events. If the oculocardiac reflex is stimulated intraoperatively, hemodynamic compromise may occur. Stimuli of the oculocardiac reflex include pressure on the globe, ocular pain, manipulation of the eye, and traction on the extraocular musculature, particularly the medial rectus muscle. The afferent nerve of this reflex is the trigeminal nerve (cranial nerve V), and the efferent nerve of the reflex arc is the vagus nerve (cranial nerve X). The reflex triggers severe bradycardia, bradyarrhythmias, and hypotension, which must be immediately recognized and treated. Treatment entails cessation of surgical stimulation and pharmacotherapy with atropine or glycopyrrolate to increase heart rate; atropine is preferred due to its faster onset.[24]

Providing anesthesia for ophthalmic procedures requires a collaborative effort from an interprofessional team, aiming to enhance outcomes following eye surgery through comprehensive patient evaluation, personalized treatment planning, optimized perioperative management, multidisciplinary support, continuity of care, and patient education. The clinical nursing staff plays a crucial role in the perioperative period by preparing patients for surgery, obtaining intravenous access, preparing and reviewing procedural and anesthesia consent documents, reconciling medications, monitoring patients throughout the perioperative period, and preparing patients for discharge. Effective communication between team members during eye surgeries is imperative. Surgical technicians and operating room nurses maintain and monitor the sterile field to minimize infection and patient injury. The ophthalmologist and anesthesia team monitor intraocular pressure and must effectively communicate any changes in this critical vital sign to avoid adverse patient outcomes. Patient-centered care delivered by an interprofessional team enhances team performance, resulting in better patient outcomes.