Penetrating Eye Injuries

Airway: ETT usual given emergent surgery and remote airway.
Access: Any
Pain: Substantial intraoperative stimulation, requiring deep analgesia or anaesthesia.
Position: Aim head elevated to reduce IOP
Time: Variable
Blood loss: Negligible
The Bottom Line: * IOP control critical: intubation, extubation, and PONV prevention * Oculocardic reflex

Major issues with anaesthetic management include:

Surgical Stages

Preoperative

Assessment:

  • Size of defect
    Affects risk of evacuation of ocular contents.
  • Mechanism
    Associated injuries.

Premedication:

  • Consider anxiolytic

Intraoperative

  • Goal is to avoid ↑ in IOP
    Most anaesthetic agents lower IOP, including:
    • Opioids
    • Volatiles
    • IV hypnotics

Induction:

  • RSI
  • Suxamethonium can be used, noting that it is associated with a (mild) rise in IOP
  • Rocuronium/sugammadex is also an appropriate combination
  • Lignocaine 1-1.5mg/kg prior to induction to minimise IOP ↑ with laryngoscopy

Maintenance:

  • Deep anaesthesia required to avoid coughing
  • Nitrous oxide is acceptable provided there is no air in the eye

Emergence:

  • Cough-free extubation is critical to avoid associated rise in IOP

Postoperative

Control of PONV to avoid vomiting and rise in IOP:

  • Two antiemetics prior to emergence

Complications

References

  1. Murgatroyd H, Bembridge J. Intraocular pressure. Contin Educ Anaesth Crit Care Pain. 2008;8(3):100-103. doi:10.1093/bjaceaccp/mkn015