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Electroretinogram Recording for Infants and Children under Anesthesia to Achieve Optimal Dark Adaptation and International Standards

Electroretinogram (ERG) is the only clinical objective test available to assess retinal function. Full-field ERG (ffERG) measures the panretinal rod and ...

University of Miami

University of Miami Miller School of Medicine

Ophthalmic pathology in infants and children undergoing eye surgery ranges from the rare and atypical to the commonplace. These pathologies include nasolacrimal duct obstruction, strabismus, congenital or traumatically induced cataracts, penetrating eye injuries, glaucoma, retinopathy of prematurity, intraorbital tumors, and more. Nasolacrimal duct stenosis, cataracts, and traumatic eye injuries often occur in otherwise healthy pediatric patients; however, many ophthalmopathies can be associated with other congenital disorders that may have important anesthesia implications. In this article, we will review pertinent anesthesia issues within the context of various ophthalmic diseases.

Anesthesia for pediatric ocular surgery.

Eye procedures are considered to be low risk; however, many ophthalmic surgery patients are elderly and are a unique vulnerable group with a myriad of concomitant health issues that put them at greater risk for perioperative medical complications. A trend to shift operative venues from hospitals to ambulatory facilities and more recently to specialty eye-care surgery centers limits the resources available to manage major, and even minor, medical issues that arise on the day of surgery. The role of the internist in the preoperative evaluation and optimization of medical issues before surgery and availability for perioperative consultation and intercession is increasingly essential.

Perioperative management of the elderly undergoing eye surgery.

To document that with proper patient and procedure selection, children undergoing general inhalational anesthesia for ophthalmologic exams (with or without photos, ultrasound, laser treatment, peri-ocular injection of chemotherapy, suture removal, and/or replacement of ocular prosthesis) can be safely anesthetized without the use of an intravenous (IV) line. Children are rarely anesthetized without IV access placement. We performed a retrospective study to determine our incidence of IV access placement during examinations under anesthesia (EUA) and the incidence of adverse events that required intraoperative IV access placement.

Can children undergoing ophthalmologic examinations under anesthesia be safely anesthetized without using an IV line?

In this study, we measure the radial artery internal diameter (RAID) in children up to 4 years of age before and after the induction of anesthesia. A B-mode portable color Doppler ultrasound was used to measure the RAID. Three sets of measurements were taken for each child before and after the induction of anesthesia and with the wrist in the neutral and dorsiflexed positions. The reliability of the mean value of the RAID in the three sets in 24 patients was established. There were discrepancies between the RAID and the proposed catheter size in some individuals, which may not only render placement difficult but also have potential for arterial injury. There are good reasons to measure the RAID in small children prior to insertion of an intra-arterial catheter.

Evaluation of distal radial artery cross-sectional internal diameter in pediatric patients using ultrasound.

Intraoperative Management of Increased Intraocular Pressure in a Patient with Glaucoma Undergoing Robotic Prostatectomy in Trendelenburg Position.

Venous air embolism (VAE) during pars plana vitrectomy (PPV) can occur owing to improper positioning of the infusion cannula in the suprachoroidal space and may lead to sudden compromise of cardiac circulation and death. This was an in vivo demonstration of fatal VAE during PPV to show that air can travel from the suprachoroidal space into the central circulation.

In Vivo Porcine Model of Venous Air Embolism During Pars Plana Vitrectomy.

Needle-based and cannula-based eye blocks are 'blind' techniques prone to rare but serious complications. Ultrasound, an established adjunct for peripheral nerve block, may be beneficial for ophthalmic anesthesia application. The present review details the evolution of ultrasound-guided eye blocks, outlines safety issues, and reviews recent studies and editorial opinions.

Ultrasound-guided ophthalmic regional anesthesia.

Ophthalmic pediatric regional anesthesia has been widely described, but infrequently used. This review summarizes the available evidence supporting the use of conduction anesthesia in pediatric ophthalmic surgery. Key anatomic differences in axial length, intraocular pressure, and available orbital space between young children and adults impact conduct of ophthalmic regional anesthesia. The eye is near adult size at birth and completes its growth rapidly while the orbit does not. This results in significantly diminished extraocular orbital volumes for local anesthetic deposition. Needle-based blocks are categorized by relation of the needle to the extraocular muscle cone (ie, intraconal or extraconal) and in the cannula-based block, by description of the potential space deep to the Tenon capsule. In children, blocks are placed after induction of anesthesia by a pediatric anesthesiologist or ophthalmologist, via anatomic landmarks or under ultrasonography. Ocular conduction anesthesia confers several advantages for eye surgery including analgesia, akinesia, ablation of the oculocardiac reflex, and reduction of postoperative nausea and vomiting. Short (16 mm), blunt-tip needles are preferred because of altered globe-to-orbit ratios in children. Soft-tip cannulae of varying length have been demonstrated as safe in sub-Tenon blockade. Ultrasound technology facilitates direct, real-time visualization of needle position and local anesthetic spread and reduces inadvertent intraconal needle placement. The developing eye is vulnerable to thermal and mechanical insults, so ocular-rated transducers are mandated. The adjuvant hyaluronidase improves ocular akinesia, decreases local anesthetic dosage requirements, and improves initial block success; meanwhile, dexmedetomidine increases local anesthetic potency and prolongs duration of analgesia without an increase in adverse events. Intraconal blockade is a relative contraindication in neonates and infants, retinoblastoma surgery, and in the presence of posterior staphylomas and buphthalmos. Specific considerations include pertinent pediatric ophthalmologic topics, block placement in the syndromic child, and potential adverse effects associated with each technique. Recommendations based on our experience at a busy academic ophthalmologic tertiary referral center are provided.

Article	Year
Anesthesia for pediatric ocular surgery. Ophthalmology clinics of North America\| PubMed ID: 16701164	2006
Perioperative management of the elderly undergoing eye surgery. Clinics in geriatric medicine\| PubMed ID: 18984381	2008
Can children undergoing ophthalmologic examinations under anesthesia be safely anesthetized without using an IV line? Clinical ophthalmology (Auckland, N.Z.)\| PubMed ID: 21573039	2011
Evaluation of distal radial artery cross-sectional internal diameter in pediatric patients using ultrasound. Paediatric anaesthesia\| PubMed ID: 23577822	2013
Intraoperative Management of Increased Intraocular Pressure in a Patient with Glaucoma Undergoing Robotic Prostatectomy in Trendelenburg Position. A & A case reports\| PubMed ID: 26771296	2016
In Vivo Porcine Model of Venous Air Embolism During Pars Plana Vitrectomy. American journal of ophthalmology\| PubMed ID: 27349413	2016
Ultrasound-guided ophthalmic regional anesthesia. Current opinion in anaesthesiology\| PubMed ID: 27652513	2016
Regional Anesthesia for Pediatric Ophthalmic Surgery: A Review of the Literature. Anesthesia and analgesia\| PubMed ID: 30676353	2020

Steven Gayer

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