Ophthalmic Problems and Complications

Introduction

For nonocular surgery, the incidence of anesthesia-related eye injury is estimated at 0.06%; this accounts for 3% of the American Society of Anesthesiologists (ASA) nondental closed claims cases. Risk factors for perioperative ocular injury include general anesthesia, long procedures, head and neck procedures, and lateral positioning. For ocular surgery, anesthesia-related eye injury is exceedingly rare. When it occurs, it may be related to perioperative coughing or severe postoperative vomiting, with a related sudden increase in intraocular pressure (IOP). Important ophthalmic complications and issues relevant to pediatric anesthesia include corneal abrasion, postoperative visual loss, retinopathy of prematurity, penetrating ocular trauma, oculocardiac reflex, and postoperative nausea and vomiting. The last occurs in 40% to 90% of children after strabismus surgery.

Corneal Abrasion

Problem Analysis

Definition

Corneal abrasion is the most common perioperative ophthalmic complication, with an incidence of 0.1% to 44%. A higher incidence was reported in the 1970s for anesthetized patients without eye protection or lubrication. Most corneal abrasions result from corneal drying associated with lagophthalmos during general anesthesia.

Recognition

Symptoms of corneal abrasion include photophobia, pain, and foreign body sensation. Excessive tearing and miosis are characteristic physical findings. Staining with fluorescein reveals the abraded zone in green under a cobalt blue light ( Fig. 196.1 ).

Risk Assessment

Although the inciting event for corneal abrasion is not always clear, factors such as prone or lateral positioning and exophthalmos place patients at higher risk. General anesthesia increases the risk, in part owing to lost protective corneal reflexes, abolished Bell’s phenomenon (in which the globe turns upward during sleep), and diminished tear production and stability.

Implications

The majority of children sustaining intraoperative corneal abrasion have a full recovery within 24 hours with appropriate treatment. Extensive injury or delayed treatment results in a 16% incidence of permanent injury. Permanent scarring is usually related to secondary corneal infection or abrasions that are chronic.

Management

Patients with corneal abrasion should be evaluated by an ophthalmologist to document the extent of injury and initiate treatment. Usual recommendations include lubrication, application of a topical antibiotic or cycloplegic agent (or both), and patch closure.

Prevention

To prevent corneal abrasion, ocular contact with masks, stethoscopes, name tags, intubation equipment, sheets, and padding material must be avoided. Eye protection should be established early, before laryngoscopy. Tape should be used to keep the eyelids closed, with ophthalmic lubricants used for longer procedures. Petroleum-based ophthalmic ointments are more likely to cause foreign body sensation and blurred vision postoperatively than are aqueous solutions. Placement of a disposable pulse oximeter probe on the child’s ring finger as opposed to the index finger may lessen the chance of inadvertent eye contact and potential corneal injury in the postoperative period.

Postoperative Visual Loss