Version May 2024
INTRODUCTION — Anesthetic management of patients presenting for urgent or emergent surgery after penetrating eye injury is challenging primarily because of the risk of extrusion of ocular contents if intraocular pressure becomes elevated. Additional concerns include risk of pulmonary aspiration in patients with a full stomach, and the possibility of associated traumatic injuries (eg, orbital or cranial trauma).
A foreign body in the eye is the most common type of eye trauma, accounting for 35 percent of all eye injuries. Open wounds or contusions due to blunt ocular trauma each account for approximately 25 percent of eye injuries; other injuries include burns. Other ophthalmic emergencies that may require surgery include acute angle closure glaucoma and retinal detachment [1]. Nearly 35 percent of eye injuries occur in patients ≤17 years old. Although eye injury is not a significant cause of total blindness, it is the most common cause of monocular blindness [2-9].
The anesthetic management of patients undergoing elective eye surgery is discussed separately. (See "Anesthesia for elective eye surgery".)
Emergency and surgical management of specific eye injuries, including open globe injury, conjunctival injury, traumatic hyphema, and retinal detachment, are discussed in other topics:
●(See "Open globe injuries: Emergency evaluation and initial management".)
●(See "Conjunctival injury".)
●(See "Traumatic hyphema: Management".)
PREOPERATIVE ASSESSMENT
During the preoperative assessment, the anesthesiologist should determine [10]:
●The mechanism of eye trauma, and the possibility of associated traumatic injuries that could impact the anesthetic strategy (eg, orbital or maxillofacial trauma, skull fractures, subdural hematoma, intracranial trauma, cervical spine trauma).
●Findings of the eye exam performed by the ophthalmologist, including the size of any ocular perforation. Larger defects have a greater chance of extrusion of ocular contents. (See 'Goals of anesthesia' below.)
●History of prior anesthetics, with particular attention to history of a difficult airway or nausea and vomiting.
●Timing of last oral intake of fluids and/or solids.
●Standard issues for a preanesthetic consultation (eg, allergies, medications, medical comorbidities). A particularly important aspect of the preanesthetic physical examination is evaluation of airway anatomy to assess the possibility of a difficult airway. (See 'Patients with a difficult airway' below.)
GOALS OF ANESTHESIA — The goals of anesthesia for eye surgery are to provide profound analgesia, and to prevent coughing, retching, vomiting, forceful blinking, or crying so that harmful increases in intraocular pressure (IOP) are prevented [10,11]. Particular care is required if open globe injury is known or suspected because of the risk of extrusion of ocular contents as IOP increases [11,12].
CHOICE OF ANESTHETIC TECHNIQUE — General anesthesia is the most common anesthetic technique for surgical procedures to treat eye trauma, especially for open globe injuries. However, if the patient's airway anatomy or history suggests that laryngoscopy and intubation may be difficult, topical or regional anesthesia may be considered. (See 'Regional anesthesia' below.)
In pediatric patients, general anesthesia is almost always preferred because crying and struggling may increase IOP in excess of 70 mmHg, incurring a very high risk of eye content extrusion [10].
PREMEDICATION — A benzodiazepine (eg, intravenous [IV] midazolam 1 to 2 mg) is often administered to reduce anxiety before surgery for traumatic eye injury. Midazolam does not raise or lower IOP [13]. In older adults, dose is titrated with caution (eg, in 0.5 mg increments).
In patients with open globe injuries, premedication with dexmedetomidine 0.2 to 0.8 mcg/kg administered over 10 minutes prevents significant increases in IOP during intubation with succinylcholine [14,15]. Since dexmedetomidine may cause hypotension and/or bradycardia due to its sympatholytic effects, it should be avoided or administered at the lower dose range with close monitoring in a patient who may develop hemodynamic instability (eg, hypovolemia, cardiovascular disease, older age). (See "Maintenance of general anesthesia: Overview", section on 'Dexmedetomidine'.)
MONITORING — Monitoring should include standard physiologic monitors (table 1), with additional monitoring based on patient comorbidities. (See "Basic patient monitoring during anesthesia".)
GENERAL ANESTHESIA
Induction of anesthesia — Depending on the fasting status, we may employ a rapid sequence induction and intubation (RSII) technique, including administration of a neuromuscular blocking agent (NMBA). Anesthetic induction for emergency surgery for open globe injury is particularly challenging if the patient also has a full stomach or a potentially difficult airway. (See "Rapid sequence induction and intubation (RSII) for anesthesia".)
Airway considerations — Standard considerations for patients undergoing RSII include positioning with the head up to minimize risk of passive regurgitation and pulmonary aspiration, and preoxygenation with 100 percent oxygen to increase oxygen reserve. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Positioning' and "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Preoxygenation'.)
If the patient has fasted for an adequate period of time (table 2) (see "Preoperative fasting in adults" and "Preoperative fasting in children and infants"), we will follow a standard induction technique and attempt mask ventilation prior to intubation. Caution must be taken while mask ventilating the patient to avoid pressure around the eye, which could risk extrusion of ocular contents.
The use of cricoid pressure to minimize risk of aspiration of gastric contents during RSII is controversial (figure 1), and is discussed separately [10,16]. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Cricoid pressure during RSII'.)
Choice of induction and adjuvant anesthetic agents — Most central nervous system depressants beneficially lower IOP, including inhaled anesthetics (eg, isoflurane or sevoflurane), hypnotics (eg, propofol or etomidate), and opioids (eg, fentanyl, remifentanil, sufentanil) [11]. A reasonable induction sequence is an anesthetic induction agent such as propofol 1.5 to 3.0 mg/kg, administered with an opioid and the selected neuromuscular blocking agent (NMBA). (See 'Choice of neuromuscular blocking agent' below.)
Intravenous lidocaine 1 to 1.5 mg/kg may also be administered two minutes before induction to ameliorate the increase of IOP caused by laryngoscopy [17]. This dose of lidocaine also minimizes pain caused by IV injection of propofol or other anesthetic induction agent (if it is administered into the same vein).
Doses of the anesthetic induction agent, opioid, and lidocaine are reduced in older adults and those with hemodynamic instability (eg, propofol may be reduced to 0.5 to 0.8 mg/kg). (See "General anesthesia: Intravenous induction agents", section on 'Propofol' and "General anesthesia: Intravenous induction agents", section on 'Lidocaine'.)
Etomidate is used less often as the sedative-hypnotic induction agent for emergent eye surgery because of a higher risk of post-operative nausea and vomiting (PONV). Also, etomidate may induce myoclonus (ie, skeletal muscle movement) severe enough to increase IOP, even though this agent otherwise reduces IOP [18]. The myoclonic movements may be decreased or eliminated by administration of a benzodiazepine (eg, midazolam 1 to 2 mg), opioid (eg, fentanyl 1 to 2 mcg/kg), and muscle relaxant if etomidate is selected [19,20]. Ketamine is avoided for emergent eye surgery because administration may increase IOP and blood pressure due to its sympathomimetic effects, and may cause nystagmus and blepharospasm that adversely affect surgical conditions [10,20]. (See "General anesthesia: Intravenous induction agents", section on 'Etomidate' and "General anesthesia: Intravenous induction agents", section on 'Ketamine'.)
Choice of neuromuscular blocking agent — If the patient requires precautions for a full stomach, we typically select succinylcholine 1.5 mg/kg as the NMBA for RSII [21]. This dose of succinylcholine offers the advantages of swift onset, superb intubating conditions, and brief duration of action, but is associated with a small increase in IOP [10]. However, there are no published reports of extrusion of ocular contents when succinylcholine is coadministered with an adequate dose of the selected anesthetic induction agent (eg, propofol 1.5 to 3.0 mg/kg) [10,22,23]. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'General indications' and "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Succinylcholine'.)
An alternative technique for RSII is use of a relatively large dose of a nondepolarizing NMBA coadministered with an adequate dose of an anesthetic induction agent to achieve swift onset of excellent intubating conditions without an increase in IOP [24]. If sugammadex is immediately available, a large dose of rocuronium (eg, 0.6-1.2 mg/kg) may be selected for RSII in an "open-globe, full-stomach" scenario. If unexpected difficulty with the airway is encountered (eg, inability to intubate or ventilate), sugammadex can be administered to rapidly reverse the effects of rocuronium [10,25]. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Nondepolarizing NMBAs' and "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Sugammadex'.)
Disadvantages of use of a nondepolarizing NMBA include the risk of pulmonary aspiration of gastric contents during the longer period (compared to succinylcholine) when the airway is unprotected. Also, attempts to perform laryngoscopy and intubation prematurely, before full onset of neuromuscular blockade, may result in coughing and straining with a dramatic rise in IOP [11]. For this reason, we suggest use of a peripheral nerve stimulator to confirm muscle relaxation prior to laryngoscopy and endotracheal intubation when a nondepolarizing NMBA is used [10]. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Endotracheal intubation'.)
Remifentanil intubation as an alternative technique — Use of remifentanil, an ultrashort-acting narcotic, is an alternative technique for RSII when succinylcholine is contraindicated, and the prolonged duration of paralysis caused by an NMBA would be undesirable. Administration of remifentanil 3 to 5 mcg/kg combined with propofol 2 to 2.5 mg/kg provides good to excellent intubating conditions after 1 to 2.5 minutes. These doses of propofol and remifentanil should be reduced for older adults and those with hemodynamic instability. Typically, ephedrine 10 mg is also administered to avoid profound bradycardia and hypotension that may otherwise result from this combination of induction agents. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Remifentanil intubation' and "General anesthesia: Intravenous induction agents", section on 'Dosing considerations'.)
Maintenance of anesthesia — A deep plane of anesthesia is maintained during ophthalmologic surgery so that movement and coughing are prevented. A primary inhalation technique is often employed because potent volatile inhalation anesthetics (eg, isoflurane, sevoflurane, desflurane) beneficially decrease IOP by decreasing production and increasing outflow of aqueous humor, decreasing extraocular tension, and lowering arterial blood pressure [11,23,26,27]. Many clinicians avoid desflurane during induction of anesthesia due to its pungency, with possible airway irritation and coughing when high concentrations are administered. Nitrous oxide does not increase IOP and is not avoided unless there is a recent or planned injection of gas to create an intraocular "bubble" to internally tamponade a detached retina [28-30], or if there is concern regarding vascular air embolism or pneumothorax (see "Maintenance of general anesthesia: Overview", section on 'Inhalation anesthetic agents and techniques' and "Anesthesia for elective eye surgery", section on 'Vitreoretinal surgery'). A total intravenous anesthesia (TIVA) technique (eg, propofol and remifentanil) also decreases IOP and is a reasonable alternative to an inhalation technique. In particular, TIVA with propofol is often selected for patients at high risk for PONV, since it is important to avoid the increases in IOP that occur with PONV [23,26,27] (see "Maintenance of general anesthesia: Overview", section on 'Total intravenous anesthesia'). Combinations of agents administered by both routes (eg, remifentanil infusion plus an inhalation anesthetic) also result in satisfactory anesthesia and a decrease in IOP.
Emergence from anesthesia — It is important to prevent coughing, retching, and vomiting during and after extubation, since these responses greatly increase IOP [11]. (See "Extubation following anesthesia", section on 'Minimizing physiologic response to extubation'.)
Prophylactic antiemetic agents (eg, ondansetron 4 mg and dexamethasone 4 mg) are administered prior to emergence from anesthesia to reduce the incidence of retching and vomiting [23]. (See "Postoperative nausea and vomiting", section on 'Antiemetics'.)
Administration of IV lidocaine 1 to 2 mg/kg before extubation of the trachea may attenuate coughing, but may also prolong the time to awakening [31,32]. A reasonable alternative is infusion of remifentanil ≥0.05 mcg/kg/min, with extubation accomplished as soon as the patient can follow commands, typically prior to spontaneous respiratory efforts or recovery of airway reflexes. (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Remifentanil extubation technique'.)
In selected cases when the patient has fasted prior to general anesthesia, stimulation of airway reflexes with resultant coughing is avoided by extubating the patient while deeply anesthetized ("deep extubation"). Controlled ventilation by mask is then continued until spontaneous ventilation has resumed as the patient emerges from anesthesia.
REGIONAL ANESTHESIA — Regional anesthesia (eg, retrobulbar or peribulbar block) is usually contraindicated in patients with a penetrating eye injury because injection of local anesthetics into the surrounding tissue increases intraocular pressure (IOP) and the potential for extrusion of extraocular contents [10,11]. Also, regional techniques may be technically difficult because the anatomy of the eye and surrounding tissue may be partially or completely distorted by trauma, bleeding, and edema. In many cases, a traumatically injured patient is unable to cooperate for a regional block.
However, in some centers regional anesthesia is preferred for selected open globe injuries in the cornea, limbus, and areas in the globe ≤5 mm posterior to the limbus [33]. A regional block is more likely to succeed if the wound is anterior and relatively small [34]. Also, case reports have described successful use of regional ophthalmic blocks after selected types of traumatic eye injury (eg, intraocular foreign body removal, repair of dehiscence of a previous surgical wound) [34,35]. Furthermore, regional anesthesia may be used when the likelihood of salvaging vision is low, particularly in a patient with a potentially difficult airway, since concerns regarding increased IOP are less critical. (See "Anesthesia for elective eye surgery", section on 'Regional anesthesia'.)
Topical anesthesia with sedation has been reported in selected patients with less severe open-globe injuries, and may be an option in a patient with a difficult airway [36,37]. (See "Anesthesia for elective eye surgery", section on 'Topical anesthesia'.)
SPECIAL POPULATIONS
Patients with a difficult airway — If the patient's airway anatomy or history suggests that laryngoscopy and intubation may be difficult, the anesthesiologist should consult with the ophthalmologist regarding the likelihood of salvaging vision in the injured eye [10]. It is important to know whether any increase in IOP is likely to be critical for future vision.
Regional or topical anesthesia may be an option to avoid general anesthesia in some patients who have a high risk of difficulty with intubation and ventilation, particularly if the likelihood of salvaging vision is low, making concerns regarding increased IOP less critical. (See 'Regional anesthesia' above.)
If a regional technique is not feasible or optimal for ophthalmologic surgery, an awake fiberoptic laryngoscopy may be the safest option. During this procedure, the risk of gagging or coughing with consequent increases in IOP is minimized by thorough topical anesthesia of the airway, nerve blocks that anesthetize the nasopharynx, oropharynx, glottis, and trachea, and adequate sedation (eg, remifentanil or dexmedetomidine infusion, or bolus doses of fentanyl, midazolam, and/or propofol). (See "Awake tracheal intubation", section on 'Airway anesthesia' and "Awake tracheal intubation", section on 'Sedation/analgesia'.)
Pediatric patients — For a pediatric patient who has fasted, induction of anesthesia with inhalation agents administered via a face mask may be the best technique. If the pediatric patient is combative and agitated, sedation with oral agents (eg, midazolam 0.5 mg/kg or dexmedetomidine 2.5 mcg/kg) administered 20 to 30 minutes before the procedure may allow insertion of an IV catheter for anesthetic induction [38,39]. Another option is intranasal administration of dexmedetomidine; a typical dose is 1 to 2 mcg/kg.
Adult patients who are unable to cooperate — Some adult patients (eg, those with developmental delay or dementia) may require general anesthesia due to inability to cooperate with the ophthalmologic evaluation or a brief emergency procedure [40].
SUMMARY AND RECOMMENDATIONS
●Anesthetic concerns for patients requiring emergent eye surgery include the possibility of associated injuries (eg, orbital or maxillofacial trauma, skull fractures, subdural hematoma, intracranial trauma, cervical spine trauma), risk of extrusion of ocular contents if intraocular pressure (IOP) becomes elevated, and risk of pulmonary aspiration if the stomach is full. (See 'Preoperative assessment' above.)
●Anesthetic goals during emergent eye surgery are to provide profound analgesia and to prevent coughing, retching, vomiting, forceful blinking, or crying so that harmful increases in IOP are prevented.
●General anesthesia is the most common anesthetic technique for eye trauma surgery, especially for open globe injuries and in children. (See 'Goals of anesthesia' above and 'General anesthesia' above.)
●Premedication with midazolam 1 to 2 mg or dexmedetomidine 0.2 to 0.8 mcg/kg administered over 10 minutes may alleviate anxiety. Dexmedetomidine may also prevent significant increases in IOP during intubation with succinylcholine. (See 'Premedication' above.)
●For induction of general anesthesia, we select induction and adjuvant agents that minimize risk of increasing IOP.
•A reasonable induction sequence includes propofol 1.5 to 3.0 mg/kg as the sedative hypnotic agent, an opioid (eg, fentanyl 1 to 2 mcg/kg or remifentanil 1 to 1.5 mcg/kg), and a neuromuscular blocking agent (NMBA). (See 'Choice of induction and adjuvant anesthetic agents' above.)
•We suggest administration of lidocaine 1 to 1.5 mg/kg two minutes before induction to minimize increases in IOP during laryngoscopy (Grade 2C). (See 'Choice of induction and adjuvant anesthetic agents' above.)
•If rapid sequence induction and intubation (RSII) technique is necessary (eg, for a patient with an open globe and full stomach), we suggest selection of succinylcholine 1.5 mg/kg as the NMBA because of its swift onset, excellent intubating conditions, and brief duration of action (Grade 2C). If sugammadex is immediately available for rapid reversal of neuromuscular blockade, administration of a large dose of the nondepolarizing NMBA rocuronium (eg, 1.2 mg/kg) is a reasonable alternative. (See 'Choice of neuromuscular blocking agent' above.)
•A reasonable alternative to use of any NMBA is a remifentanil intubation technique, with administration of remifentanil 3 to 5 mcg/kg combined with propofol 2 to 2.5 mg/kg to provide good to excellent intubating conditions after 1 to 2.5 minutes. With this technique, ephedrine 10 mg is also typically administered to avoid profound bradycardia and hypotension. (See 'Remifentanil intubation as an alternative technique' above.)
●Maintenance of a deep plane of anesthesia to prevent movement or coughing may be accomplished with a primary inhalation technique, total intravenous anesthesia (TIVA), or a technique that combines anesthetic agents administered by both routes. (See 'Maintenance of anesthesia' above.)
●During emergence, techniques that reduce the incidence of coughing, retching, and vomiting are used, as these responses significantly increase IOP. (See 'Emergence from anesthesia' above.)
•We suggest administration of prophylactic antiemetic agents (eg, ondansetron 4 mg and dexamethasone 4 mg) prior to emergence from anesthesia to avoid retching and vomiting (Grade 2C).
•We suggest administration of lidocaine 1 to 2 mg/kg before tracheal extubation to attenuate coughing (Grade 2C), although this may delay awakening. A reasonable alternative is infusion of remifentanil ≥0.05 mcg/kg/min, with extubation as soon as the patient can follow commands, typically prior to spontaneous respiratory efforts or recovery of airway reflexes.
●Regional anesthesia (eg, retrobulbar or peribulbar block) or topical anesthesia is usually contraindicated after traumatic eye injury but may be employed when the likelihood of salvaging vision is low, particularly if the patient has a potentially difficult airway, since concerns regarding IOP increases will be less critical. (See 'Regional anesthesia' above.)
ACKNOWLEDGMENTS
The UpToDate editorial staff acknowledges Jeffrey H Silverstein, MD (deceased), who contributed to earlier versions of this topic review.
The UpToDate editorial staff also acknowledges Joseph Bayes, MD, who contributed to earlier versions of this topic review.
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