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Chua AW, Chua MJ, Harrisberg BP, Kumar CM. Retinal artery occlusion after ophthalmic surgery under regional anaesthesia: A narrative review. Anaesth Intensive Care 2024; 52:82-90. [PMID: 38041616 DOI: 10.1177/0310057x231215826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Two recent cases of central retinal artery occlusion under otherwise uncomplicated sub-Tenon's block that resulted in significant visual loss after cataract surgery prompted us to undertake a literature review of such cases. We identified 97 cases of retinal artery occlusion after ophthalmic surgery under regional anaesthesia that had no immediate signs of block-related complications. These occurred after various intraocular (87%) and extraocular (13%) operations, across a wide range of ages (19-89 years) on patients with (59%) or without (39%) known risk factors. The anaesthetic techniques included 40 retrobulbar blocks, 36 peribulbar blocks, 19 sub-Tenon's blocks, one topical anaesthetic and one unspecified local anaesthetic. Different strengths of lidocaine, bupivacaine, mepivacaine and ropivacaine, either alone or in various combinations, were used. The details of the anaesthetic techniques were often incomplete in the reports, which made comparison and analysis difficult. Only nine cases had their cause (optic nerve sheath injury) identified, while the mechanism of injury was unclear in the remaining patients. Various mechanisms were postulated; however, the cause was likely to be multifactorial due to patient, surgical and anaesthetic risk factors, especially in those with compromised retinal circulation. As there were no definite risk factors identified, no specific recommendations could be made to avoid this devastating outcome. We have provided rationales for some general considerations, which may reduce this risk, and propose anaesthetic options for ophthalmic surgery on the fellow eye if required, based both on our literature review and our personal experience.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Matthew J Chua
- Department of Anaesthetics, Liverpool Hospital, Liverpool, Australia
| | - Brian P Harrisberg
- Department of Ophthalmology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Chandra M Kumar
- Newcastle University Medical School, EduCity, Johor, Malaysia
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Chua AW, Kumar CM, Harrisberg BP, Eke T. Anaesthetic considerations for the surgical management of ocular hypotony in adults. Anaesth Intensive Care 2023; 51:107-113. [PMID: 36524304 DOI: 10.1177/0310057x221111183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Chandra M Kumar
- Department of Anaesthetic, Khoo Teck Puat Hospital, Singapore.,Newcastle University, Newcastle upon Tyne, UK.,Newcastle University Medical School, Johor, Malaysia
| | - Brian P Harrisberg
- Department of Ophthalmology, 2205Royal Prince Alfred Hospital, Camperdown, Australia
| | - Tom Eke
- Department of Ophthalmology, 156671Norfolk and Norwich University Hospital, Norwich, UK
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Chua AW, Chua MJ, Harrisberg BP, Kumar CM. Inexpensive home-assembled human skull model for training and learning the peribulbar block technique. Anaesth Intensive Care 2022; 50:400-402. [PMID: 36076352 DOI: 10.1177/0310057x211063892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Matthew J Chua
- Department of Intensive Care Medicine, 8539Westmead Hospital, Westmead, Australia
| | - Brian P Harrisberg
- Department of Ophthalmology, 2205Royal Prince Alfred Hospital, Camperdown, Australia
| | - Chandra M Kumar
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore.,Newcastle University, Newcastle upon Tyne, UK.,Newcastle University Medical School, Johor, Malaysia
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Chua AW, Chua MJ, Leung H, Kam PC. Reply to: Intellectual impairment is not commonly a feature of Turner syndrome. Anaesth Intensive Care 2021; 50:263-264. [PMID: 34927471 DOI: 10.1177/0310057x211005787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Matthew J Chua
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Australia
| | - Harry Leung
- Department of Ophthalmology, Sydney Children's Hospital, Randwick, Australia
| | - Peter Ca Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Chua AW, Kumar CM, Chua MJ, Harrisberg BP. Anaesthesia for ophthalmic procedures in patients with thyroid eye disease. Anaesth Intensive Care 2020; 48:430-438. [PMID: 33198476 DOI: 10.1177/0310057x20957018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thyroid eye disease is an autoimmune inflammatory disorder of the orbit in adults. It causes inflammation, expansion and fibrosis of orbital fat, muscles and the lacrimal gland, leading to facial disfigurement, functional disability and, in severe cases, blindness. Overall, approximately 20% of affected patients need some form of surgical intervention requiring anaesthesia. This narrative review explores the background of thyroid eye disease, surgical procedures performed and their implications for anaesthesia. General anaesthesia is used for orbital decompression procedures, strabismus correction surgery and complex oculoplastic procedures. Local anaesthetic infiltration or regional anaesthesia under monitored anaesthesia care are the techniques most commonly employed for eyelid retraction surgery. It is important to limit the volume of local anaesthetic agent used during infiltration and continuously monitor the orbital volume and ocular pressure with a ballottement technique. In addition, the contralateral eye should be checked and, if necessary, protected against corneal exposure. Retrobulbar, peribulbar and sub-Tenon's blocks are best avoided. Topical anaesthesia has been used for some strabismus correction surgery but its use is limited to motivated and cooperative patients only.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Chandra M Kumar
- Department of Anaesthetics, Khoo Teck Puat Hospital, Singapore.,Newcastle University, Newcastle upon Tyne, UK.,Newcastle University Medical School, Johor, Malaysia
| | - Matthew J Chua
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Australia
| | - Brian P Harrisberg
- Department of Ophthalmology, Royal Prince Alfred Hospital, Camperdown, Australia
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Abstract
Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery. Repeated surgery is common as each operation has a 60%-80% chance of successful correction. The benefits of early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaesthetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional ophthalmic block is at the discretion of the team.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Matthew J Chua
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Harry Leung
- Department of Ophthalmology, Sydney Children's Hospital, Sydney, Australia
| | - Peter Ca Kam
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Chua AW, Chua MJ, Kam PC, Broekhuis D, Karunaratne S, Stalley PD. Anaesthetic challenges for pelvic reconstruction with custom three-dimensional-printed titanium implants: A retrospective cohort study. Anaesth Intensive Care 2019; 47:368-377. [PMID: 31430173 DOI: 10.1177/0310057x19864599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Custom 3D printed titanium implant pelvic reconstructive surgery was implemented as a novel technique at our institutions in the last five years. It provided an option for pelvic bone malignancy patients who were previously deemed unsuitable for re-implantation of irradiated resected bone segments, as well as in revision total hip arthroplasty associated with excessive acetabular bone loss. A retrospective cohort study of the anaesthetic management of patients who underwent pelvic reconstructive surgery using custom 3D printed titanium implants from August 2013 to July 2018 was conducted. Twenty-seven patients were included in the study; 23 patients completed single-stage procedures with a mean (standard deviation) duration of surgery of 7.5 (3.3) hours (median 6.8, range 3.0–15.8 hours), and mean intraoperative blood loss of 5400 (3100) mL (median 6000, range 1400–10,000 mL). Surgery involving the sacrum ( n = 7) was associated with longer intensive care stay, longer total length of hospital stay and, in three cases, unplanned two-stage procedures. The twenty procedures not involving the sacrum were successfully completed in a single stage. The major anaesthetic challenges included massive blood loss, prolonged surgery, interventions to prevent calf compartment syndrome, and perioperative thromboembolism. Preoperative pelvic radiotherapy, malignant tumours, and procedures involving the sacrum were associated with massive intraoperative blood loss and more prolonged surgery.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | | | - Peter Ca Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia.,University of Sydney, Sydney, Australia
| | | | - Sascha Karunaratne
- Surgical Outcomes Research Centre, Sydney Local Health District, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Paul D Stalley
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
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Affiliation(s)
- A W Chua
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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