Nonocular Surgery Research Articles

Postoperative Visual Loss of Non-Ocular Surgery

Postoperative Visual Loss of Non-Ocular Surgery

Prevalence of Corneal Lesions in Dogs After Non-Ocular Surgery: Impact of Preoperative Topical Lubrication and Duration of Anaesthesia

Corneal lesions are the most common ophthalmologic complication that occurs during general anesthesia (GA) for non-ocular surgery (Di Pietro et al., 2021). The aim of this study was to identify the prevalence of corneal lesions in dogs that were administered preoperative ocular lubrication and those that did not and how the duration of anesthesia influences the occurrence of them. A fluorescein test was performed before and after anesthesia in 18 dogs undergoing non-ophthalmic procedures. Subjects were randomly divided into two groups of 9 subjects each, group A which received preoperative ocular lubrication and group B that did not. Subsequently, the subjects were divided into three groups according to the duration of anesthesia in order to highlight the correlation between its duration and the occurrence of corneal lesions: group 1 (under 90 minutes) with 4 subjects, group 2 (between 90 and 180 minutes) with 9 subjects and group 3 (over 180 minutes) with 5 subjects. Only 11% (1 subject) of group A showed postoperative corneal lesion, while no subjects in the group B showed a positive fluorescein test result. 20% of subjects (1 subject) from group 3 had postoperative corneal lesions and a positive fluorescein test result, while no subjects from group 1 and 2 showed a postoperative positive fluorescein test result. The results of the study could not highlight the protective role of preoperative ocular lubrication. Further studies on a larger number of subjects and homogeneous groups are needed for more relevant results.

Risk stratification, prevention and management of perioperative corneal abrasion for non-ocular surgery: Systematic Review.

A corneal abrasion is a flaw in the cornea's epithelial surface, which is located in the front of the eye. It causes recurrent erosions, corneal inflammation, and chronic corneal defects. In a context with limited resources, the goal of this review was to provide an evidence-based procedure for perioperative risk stratification, prevention, and management of corneal abrasion during non-ocular surgery. A medical search engines of PUBMED, GOOGLE SCHOLAR, COCHRANE REVIEW, and PUBMED CENTERAL to get access for current and updated evidence on procedures on risk stratification, prevention and management of corneal abrasion for non-ocular surgery. The authors formulate the key questions, scope, and articles written in English language, human study focuses on corneal abrasion, articles in the last 20 year was implemented to identify or filter high-level evidences were included. Reports contain corneal abrasion due to ocular surgery were excluded. All the research articles, which were identified from searches of electronic databases, were imported into Endnote software, duplicate were removed advanced search strategy of electronic sources from databases and websites was conducted using Boolean operators (cornea AND (abrasion OR injury OR laceration)) AND ("Perioperative Period" OR "general anesthesia"). Screening of literatures was conducted with proper appraisal checklist. This review was reported in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement. From 8767 identified articles, two hundred articles were removed for duplication and 7720 studies were excluded, 1205 articles were retrieved and evaluated for eligibility. Finally, 24 were included in this systematic review. Advanced age, Prominent eyes, exophthalmus, ocular surface abnormalities (dry eye), expected duration of surgery (>1 h), the favourable position of the surgery, prone,Trendelenburg and lateral, risk of bleeding, surgical site of the surgery(head /neck) and diabetes mellitus were risk for corneal abrasion. The use of appropriate intervention with pharmacological and Non-pharmacological strategies minimizes the occurrence of perioperative corneal abrasion was crucial for the quality of care. Preventing and managing corneal abrasion improves patients' quality of life. However, there was insufficient evidence to draw conclusions, and high-quality trials of multimodal interventions matched to risk stratification and prevention of corneal abrasion needed to provide robust evidence to guide prevention and management of perioperative corneal abrasion.

Comparing the effects of vitamin A ointment and liposic gel on corneal abrasion prevention during general anesthesia in nonocular surgeries: a double-blind randomized clinical trial

Purpose The aim of this study was to compare the effects of vitamin A ointment and Liposic gel on perioperative corneal abrasion (CA) prevention during nonocular surgeries. Design A double-blind randomized clinical trial. Methods In this double-blind randomized clinical trial 50 eligible candidates for nonocular surgeries were purposively selected from XXX teaching hospital, XXX. One patient eye was randomly allocated to the vitamin A group and the other eye to the Liposic gel group. Immediately after anesthesia induction and blinking reflex suppression, eye care was provided using vitamin A ointment in the vitamin A group and Liposic gel in the Liposic gel group. CA was assessed using the fluorescein eye stain test at the end of general anesthesia, at the end of postoperative recovery, and 24 h after surgery. Eye problems were also assessed 24 h after surgery using an eye problems questionnaire. The SPSS software (v. 23.0) was employed for data analysis through the Wilcoxon’s, paired-sample t, and Friedman’s tests as well as the repeated measures analysis of variance. Findings The prevalence of CA in the vitamin A and the Liposic gel groups was 32 and 50% at the end of general anesthesia (P=0.039), 32 and 52% at the end of postoperative recovery (P = 0.018), and 0 and 0% 24 h after surgery (P = 1.00), respectively. There were no significant between-group differences respecting postoperative eye problems (P > 0.05). Conclusion Vitamin A ointment is more effective than Liposic gel in significantly preventing CA among patients undergoing non-ocular surgeries under general anesthesia.

We Didn’t See That Coming: Right Eye Blindness Post-Cardiac Surgery

Postoperative visual loss (POVL) is a very rare but devastating event that can occur post-cardiac surgery. The most common cause of POVL is vascular occlusion. We present a case of a 39-year-old male with severe mixed aortic valve disease, who had to undergo double valve replacement (mechanical) due to extensive calcification. On postoperative day 7, he complained of sudden painless loss of vision in the right eye. He was diagnosed with right eye central retinal artery occlusion and was discharged home with permanent right eye blindness. Neuro-ophthalmologic complications following non-ocular surgery occur rarely. POVL occurs more likely when there are calcified heart valvular lesions, higher perioperative blood loss, hypotension, low systolic blood pressure, anaemia, hypothermia, prolonged surgery time and age >50 years old. In our case report we have encountered a couple of risk factors for ischaemia which are heavily calcified aortic and mitral valves, lower mean arterial pressure and bypass time >5 hours. Postoperative blindness can be avery serious and devastating problem with no known or established treatment. Stroke is a well-known and established complication of cardiac surgery, but central retinal artery occlusion causing loss of vision is rarely covered and explained.

"Power" ful eye causing postoperative blurring of vision after non-ocular surgery under general anesthesia.

Dear Editor, Ocular complications can occur in patients following non-ocular surgeries under general anesthesia which range from transient blurring of vision to irreversible blindness.[1] We report a case where preexisting hypermetropia was the cause of postoperative blurring of vision. A 38-year-old man with no comorbidities was posted for laparoscopic orchidectomy for right undescended testis. Preoperative evaluation revealed no abnormalities. General anesthesia was induced with fentanyl 100 mg, propofol 120 mg, atracurium 30 mg, and intubated with 8 mm endotracheal tube. Anesthesia was maintained with oxygen, air, sevoflurane and atracurium 5 mg, and fentanyl 50 mg. Opticlude eye patch (3M India) was used to gently close the eyes during surgery. Surgery in supine position lasted for 1 h and was uneventful. After reversal with neostigmine 2.5 mg and glycopyrrolate 0.5 mg, the patient was extubated. Postoperative recovery was uneventful. 24 h later in the ward, the patient complained of blurring of vision in both eyes while viewing a mobile phone. Ophthalmologist’s opinion was taken. Anterior segment examination including cornea was normal in both eyes. Fundus examination and extraocular movements were normal in both eyes. Uncorrected Snellen’s visual acuity for distance was 6/12 right eye and 6/6 left eye and uncorrected near visual acuity was N6 in both eyes. On refraction testing, the patient had simple hypermetropia of + 1.5 diopters in the right eye and no refractive error in the left eye. On questioning, the patient accepted that he had some difficulty while reading small print even before the surgery but never visited an ophthalmologist. The patient was reassured and glasses were prescribed for hypermetropia following which the blurring of vision resolved. The causes of postoperative blurring of vision after non-ocular surgeries can range from simple corneal abrasion to serious retinal vascular occlusions and ischemic optic neuropathy.[2,3] Our patient complained of blurring of vision postoperatively. We ruled out corneal abrasion and other serious ocular causes. To our surprise, he had hypermetropia which was corrected with spectacles. In a study by Warner et al.[4] on 671 patients undergoing non-ocular surgery under anesthesia, 4.2% of patients experienced new-onset blurred vision of at least 3 days duration postoperatively. In most of them, it resolved spontaneously over weeks. 25% of patients with blurred vision required new corrective lens or changes to existing lens over the next 18 months. The authors found no significant risk factors. Our patient had hypermetropia preoperatively itself which got unmasked after surgery. Preexisting refractive errors can get exaggerated following surgical stress due to transient accommodative weakness and can cause blurring of vision postoperatively. Due to limited mobility in the postoperative period, patients commonly watch mobile and read books for a prolonged time. This constant focus on simple visual tasks may cause patients to notice any small change in their vision. Further studies are required to know the incidence and risk factors for the transient postoperative blurring of vision from refractive errors. It is also important to enquire about the difficulty in vision for both near and far during preanesthetic checkup in all patients coming for surgery as medicolegal documentation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Reporting A Case of Spontaneous Ocular Hypotony After the Neurosurgical Procedure

Spontaneous ocular hypotony is a rare entity. So far in the literature, there have been few cases that report on ocular hypotony in nonocular surgery. The most common nonocular surgery causing hypotony is coronary arterial bypass grafting. It is due to wide fluctuations in blood pressure, central venous pressure, and the use of mannitol intraoperatively. In neurosurgery, previously reported cases were post-thrombectomy and post-aneurysm clipping. In one case, there was a complete occlusion of ophthalmic artery due to emboli, and in another case, it was due to a wide fluctuation in blood pressure. We are reporting a case of ocular hypotony in a patient who underwent right frontal craniotomy and excision of a metastatic lesion. In our case, intraoperatively, mannitol was used, but there were no fluctuations in blood pressure and central venous pressure. The use of mannitol was slated to be the reason for ocular hypotony.

Reporting A Case of Spontaneous Ocular Hypotony After the Neurosurgical ProcedureReporting A Case of Spontaneous Ocular Hypotony After the Neurosurgical Procedure

Spontaneous ocular hypotony is a rare entity. So far in the literature, there have been few cases that report on ocular hypotony in nonocular surgery. The most common nonocular surgery causing hypotony is coronary arterial bypass grafting. It is due to wide fluctuations in blood pressure, central venous pressure, and the use of mannitol intraoperatively. In neurosurgery, previously reported cases were post-thrombectomy and post-aneurysm clipping. In one case, there was a complete occlusion of ophthalmic artery due to emboli, and in another case, it was due to a wide fluctuation in blood pressure. We are reporting a case of ocular hypotony in a patient who underwent right frontal craniotomy and excision of a metastatic lesion. In our case, intraoperatively, mannitol was used, but there were no fluctuations in blood pressure and central venous pressure. The use of mannitol was slated to be the reason for ocular hypotony.

This Month in Anesthesiology

This Month in Anesthesiology

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery.

The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.

Effect of different surgical positions on intraocular pressure: a cross-sectional study

BackgroundIntraoperative intraocular pressure (IOP) elevation is a risk factor for postoperative blindness. Surgical position is associated with intraoperative IOP elevation. In China, there are few studies on the effect of various surgical positions on intraoperative IOP. This study was conducted to explore IOP change and its related factors in four common surgical positions in China.MethodsThis was a cross-sectional observational study. A total of 325 surgical patients who had non-ocular surgery from January 2019 to December 2019 in the hospital, were enrolled in this study. During their surgeries for general anesthesia, these participants were placed in lithotomy position/lateral position/prone position/supine position according to their surgery requirement. IOP was measured by icareTA03 handheld portable tonometer at 9 different time points from admission to exiting the operation room. And general information, postural position, and surgery information were collected through a uniform questionnaire. Multivariate analysis was performed to explore the related factors of IOP change.ResultsIOP of both eyes on lithotomy position, lateral position, and supine position showed statistical differences by ANOVA test at each time point (p < 0.05). IOP of both eyes in the prone position before exit from the operating room was significantly higher than IOP 10-min after anesthesia (p < 0.01). IOP under different postural angles showed statistical differences (F value = 4.85, P < 0.05), and the larger the head-down angle, the higher the IOP. IOP on the compressed side in the lateral position was higher than that on the non-compressed side (p < 0.01). In the multivariate linear regression analysis adjusted by other factors, postural position and baseline IOP were associated with IOP difference between before and after surgery (p < 0.01).ConclusionIOP in the four surgical positions showed different change patterns with the surgical process and position change. Nurses should assist the surgeon to reduce the head-down angle without interfering with the surgical operation and strengthen the inspection of IOP on patients with long-time surgery, to avoid intraoperative rapid IOP changes.

Retinal vascular occlusions after nonocular surgeries

Ophthalmologic complications of nonocular surgeries are rare events, but can lead to irreversible conditions of low visual acuity. They are often associated with spine, heart and neck surgery, however they can occur after procedures on other systems. The main local causes are ischemic optic neuropathies, vascular occlusions, cortical lesions, and acute angle-closure glaucoma. We report two cases of sudden low visual acuity secondary to vascular occlusions after gastrointestinal procedures. In the first case, a 57-year-old patient electively admitted for [...]

Exposure keratopathy and its associated risk factors in patients undergoing general anesthesia in nonocular surgeries.

INTRODUCTION:The most common eye injury during and after general anesthesia is corneal abrasion which can occur at any time after anesthesia and even up to 24 h after it. The aim of this study was to investigate the incidence and factors associated with corneal injury in patients undergoing nonocular surgery.METHODS:This was a descriptive cross-sectional study. A total of 170 patients, who were admitted to the operating room and met the inclusion criteria, were selected through simple nonprobability sampling. Data collection forms were used in order to assess the incidence of corneal injury and its related risk factors. The National Eye Institute scale with fluorescein paper and cobalt blue light by slit lamp were utilized to examine exposure keratopathy.RESULTS:Overall, the results showed that the incidence of keratopathy immediately after eye care removal was found to be 64.7% in the operating room, 65.9% in the recovery room, and 41.2% in 24 h after the surgery. Smokers’ patients and drug abusers under general anesthesia underwent endotracheal intubation, received more opioids preoperatively, and had more perioperative bleeding and fluid intake. Moreover, in patients who had received more oxygen flow in the recovery room; the rate of keratopathy was higher.CONCLUSION:Smoking, drug usage, and receiving endotracheal intubation are the risk factors of keratopathy. Therefore, for high-risk patients and procedures, it is indispensable to both obtain preoperative information and take intraoperative precautions in order to prevent eye injuries. Future studies are needed to demonstrate these finding.

Epidemiology of postoperative visual loss for non-ocular surgery in a cohort of inpatients.

Epidemiology of postoperative visual loss for non-ocular surgery in a cohort of inpatients.

Incidence and risk factors of postoperative visual function impairment in elderly patients undergoing nonocular surgery: a prospective cohort study

BackgroundElderly patients may present with visual function impairment after surgery, which may increase the incidence of postoperative delirium and falls and decrease their quality of life. The aim of this study was to assess visual function in elderly patients after long-duration nonocular surgery to determine the incidence and risk factors for visual function impairment after surgery. MethodsThis prospective and observational study included patients aged between 60 and 80 years who had been scheduled for elective nonocular surgery expected to last longer than 120 minutes under general anesthesia. Ocular examinations were performed before surgery, on postoperative day 3 and on postoperative day 21 and consisted of a LogMAR-Snellen chart test, a Jager chart test, biomicroscopy, optical tonometry, ocular motility assessment and fundoscopy. Baseline characteristics of all patients as well as intraoperative and postoperative data were collected. ResultsA total of 107 patients were included in the final analysis. Visual function impairment was diagnosed in 21 patients (19.6%) at POD 3. Of those, 7 patients (6.5%) still presented with visual changes at POD 21. On POD 3, compared with that at baseline, visual acuity assessed by the Snellen chart test had decreased in these patients. Significant differences regarding refraction tests and intraocular pressure measures were also found. Multivariable analysis identified diabetes mellitus, duration of surgery, hypotension during anesthesia induction, lower peripheral oxygen saturation at the end of the procedure and body mass index as independent risk factors for postoperative visual impairment. ConclusionIn elderly patients undergoing long-duration nonocular procedures under general anesthesia, the incidence of visual function impairment was considerably high. Most patients recovered to baseline visual function, but clinically significant visual changes may still be present 3 weeks after surgery. Obesity, diabetes mellitus, and the duration of surgical and anesthetic techniques appear to increase the risk of visual impairment after surgery.

Corneal Abrasions During Endoscopic Procedures in the COVID-19 Era Are a Preventable Phenomenon: A Quality Improvement Project

Corneal abrasion (CA) is the most common ocular adverse event from non-ocular surgery under sedation. CA is a known but rare complication after gastrointestinal endoscopy described in the left eye due to left lateral decubitus positioning for the procedure. Patients undergoing endoscopy after the onset of the COVID-19 pandemic were required to wear surgical masks during all endoscopic procedures (unless per-orum endoscopy) and post-procedurally in the recovery area. The aim of this quality improvement (QI) project was to chronicle the rate of CA in the COVID-19 era and determine the efficacy of a simple intervention for its prevention.

Ocular complications of perioperative anesthesia: a review.

Ocular complications associated with anesthesia in ocular and non-ocular surgeries are rare adverse events which may present with clinical presentations vacillating between easily treatable corneal abrasions to more serious complication such as irreversible bilateral vision loss. In this review, we outline the different techniques of anesthetic delivery in ocular surgeries and highlight the incidence and etiologies of associated injuries. The changes in vision in non-ocular surgeries are mistaken for residual sedation or anesthetics, therefore require high clinical suspicion on part of the treating ophthalmologists, to ensure early diagnosis, adequate and swift management especially in surgeries such as cardiac, spine, head and neck, and some orthopedic procedures, that have a comparatively higher incidence of ocular complications. In this article, we review the literature for reports on the clinical incidence of different ocular complications associated with anesthesia in non-ocular surgeries and outline the current understanding of pathophysiological processes associated with these adverse events.

Toxic keratopathy related to antiseptics in nonocular surgery

Antiseptics, especially those containing ethanol, are toxic to the ocular surface. Here, we report a 5-year-old girl with antiseptic-related eye injury following an uneventful bilateral tonsillectomy under general anesthesia. Before surgery, her eyes were protected and disinfection of perioral skin with ethanol-containing chlorhexidine followed. Whitening of the lower half of her right ocular surface was found after the surgery, and this indicated severe chemical burn. Prompt irrigation with normal saline, instillation of topical medication, and application of amniotic membrane containing device were performed, which led to a satisfactory result. Toxic eye injury could happen in head and neck surgeries under general anesthesia. Causes of ocular injury include improper eye protection, head positions leading to accumulation of excessive antiseptics, and improper usage of ethanol-containing antiseptics for skin preparation. The use of ethanol-free antiseptic solutions in the peri-ocular region and proper protection of eyes may reduce the risk of severe ocular surface injury in nonocular surgeries.

Effects of Different Doses of Dexmedetomidine on Intraocular Pressure after Suxamethonium in Non-ocular Surgeries: A Randomised Controlled Trial

Introduction: Succinylcholine causes a rise in Intraocular Pressure (IOP) and is deleterious in patients with open globe injuries. Dexmedetomidine, by its virtue of central sympatholytic action can help prevent this rise in IOP. Aim: To find out the optimal dose of Dexmedetomidine in preventing the rise of IOP after administration of Suxamethonium. Materials and Methods: One hundred American Society of Anesthesiologists (ASA) I or II patients posted for non-ophthalmic surgery were included in this randomised, prospective, double blind study. Patients were randomly allocated to four groups. Group A (n=25) received Dexmedetomidine 0.6 μg/kg, Group B (n=25) received Dexmedetomidine 0.8 μg/kg, Group C (n=25) received Dexmedetomidine 1 μg/kg, Group D (n=25) received Normal Saline (NS) over a period of 10 minutes and IOP was measured at different points in time. Results: Premedication with Dexmedetomidine at doses of 0.6 μg/kg, 0.8 μg/kg and 1 μg/kg intravenous (IV) were equally effective in attenuation of the rise in IOP associated with Succinylcholine administration. The IOP recorded was 15.53±1.10 mm of Hg in Group A, 14.49±0.94 mm of Hg in Group B, 14.72±1.03 mm of Hg in Group C as compared to 20.12±1.40 mm of Hg in the control group (Group D) after 60 seconds of injecting Suxamethonium. It also significantly obtunded the sympathetic response to laryngoscopy and intubation. However, the incidence of side effects increased with incremental doses. Conclusion: Dexmedetomidine 0.6 μg/kg IV premedication is the optimum dose to be used for attenuating the rise in IOP associated with Succinylcholine administration in situations where rise of IOP may be detrimental.

Corneal Abrasions in Total Joint Arthroplasty.

IntroductionCorneal abrasion (CA) is the most common ocular complication in patients undergoing nonocular surgery. Corneal abrasions can be caused by a variety of mechanisms, the most common being drying of the cornea due to reduced tear secretions, loss of eyelid reflex, and the loss of pain recognition during surgery. Though CA heals well with eye lubricants, it can result in significant ocular pain and some cases may go on to develop ocular complications. With the current switch to outpatient total joint replacement, CA could potentially lead to discharge delays.Materials and MethodsWe examined the results of a quality improvement project to reduce CA during general anesthesia to determine the rates of CA during hip and knee total joint replacement. We compared rates of CA for 6 months before and 6 months after the intervention.ResultsA total of 670 hip and knee arthroplasty procedures were performed during this period. Two events of CA occurred, one occurred before and one after the intervention to decrease eye injuries. Both incidences occurred during total hip arthroplasty (THA) procedures with the patient in the lateral decubitus position and recovered without long-term deficit.DiscussionSurgeons and anesthesiologists alike should be cognizant of this avoidable complication and take precaution to protect the eyes during surgery, especially during THA when the patient is placed in the lateral decubitus position.ConclusionCorneal abrasion during total joint arthroplasty is a rare complication and is infrequently addressed in the literature. CA is mostly self-limiting, however, but may lead to patient dissatisfaction and to delays if same-day discharge is attempted. Preventative measures and attentive care may help reduce the incidence of CA in patients undergoing total joint arthroplasty. The lateral decubitus position and longer surgeries times are risk factors for CA.