Eye injuries during general anaesthesia

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Eye injuries during general anaesthesia are reasonably common if care is not taken to prevent them.

Contents

Incidence of eye injuries

The incidence of eye injuries during general anaesthesia has been studied, and different methods of eye protection have been compared.[ citation needed ]

When eyes are untaped during general anaesthesia, the incidence of ocular injury has been reported to be as high as 44%. [1] [2] If tape is used to hold the eyes closed, ocular injury occurs during 0.1-0.5% of general anaesthetics, and is usually corneal in nature. [3] [4]

Intraoperative eye injuries account for 2% of medico-legal claims against anaesthetists in Australia and United Kingdom, [3] [1] and 3% in the USA. [5]

Effect of general anaesthesia on eyes

General anaesthesia reduces the tonic contraction of the orbicularis oculi muscle, causing lagophthalmos i.e. the eyelids do not close fully in 59% of patients. [3]

In addition, general anaesthesia reduces tear production and tear-film stability, resulting in corneal epithelial drying and reduced lysosomal protection. The protection afforded by Bell's phenomenon (in which the eyeball turns upwards during sleep, protecting the cornea) is also lost during general anaesthesia. [6]

Mechanism of injury

Corneal abrasions are the most common injury; they are caused by direct trauma, exposure keratopathy/keratitis [1] [7] [8] or chemical injury. [7] [9]

An open eye increases the vulnerability of the cornea to direct trauma from objects such as face masks, laryngoscopes, identification badges, stethoscopes, surgical instruments, anaesthetic circuits, and drapes. [6]

Exposure keratopathy/keratitis refers to the drying of the cornea with subsequent epithelial breakdown. [10] When the cornea dries out it may stick to the eyelid and cause an abrasion when the eye reopens. [11]

Exposure keratitis Clare-314.jpg
Exposure keratitis

Chemical injury can occur if cleaning solutions such as povidone-iodine (Betadine), chlorhexidine or alcohol are inadvertently spilt into the eye, for example when the face, neck or shoulder is being prepped for surgery. [4] [1]

Therefore, the anaesthetist ensures that the eyes are fully closed and remain closed throughout the procedure. Seemingly trivial contact can result in corneal abrasions and the risk of this occurring is markedly increased if exposure keratopathy is already present. [1] Corneal abrasions can be excruciatingly painful in the postoperative period, may hamper postoperative rehabilitation and may require ongoing ophthalmological review and after care. In extreme cases there may be partial or complete visual loss.[ citation needed ]

Iatrogenic injury of the eyelids is also common. Bruising (frequently) and tearing (rarely) of the eyelid can occur when the adhesive dressing used to hold the eye closed is removed. Removal of eyelashes can also occur.

Methods available for eye injury prevention

Methods to prevent intraoperative corneal injuries include[ citation needed ]

However, none of the protective strategies are completely effective; vigilance is always required i.e. the eyes need to be inspected regularly throughout surgery to check they are closed. [3]

Discussion of methods

The most commonly employed method is to use tape or a general purpose adhesive dressing. Unfortunately the adhesive used on the tape or dressing will generally be inappropriate for this use. The adhesive strength may change when reaching body temperature, or over time. [12]

As the operation progresses this can cause the adhesive to stop working and become gooey, allowing the eyelids to move apart, and leaving behind a sticky residue. This leaves the cornea exposed to epithelial drying and/or abrasions, sometimes caused by the tape that was originally applied to protect the cornea. Alternatively, the adhesive strength may increase, which upon removal can result in eyelid bruising, tears, or eyelash removal[ citation needed ].

Tape being removed off eye Tape removal.jpg
Tape being removed off eye

Rolls of tapes are often “laying around” the operating theatre or kept in health care workers' pockets.

Tape awaiting placement Tape on scrubs.jpg
Tape awaiting placement

Therefore, they can be a source of hospital-acquired infections (HAI's) such as Methicillin-resistant Staphylococcus aureus (MRSA) & Vancomycin-resistant Enterococcus (VRE), with a 2010 study showing that 50% of partially used tape rolls tested positive for MRSA, VRE or both. [13]

Most tapes and dressings are non-transparent and so it is not possible to see if the patient’s eyes are opened or closed throughout the case. It is not uncommon for the eyelids to move open as the case progresses, even with adhesive tapes stuck onto them. In a practical sense, these medical tapes/dressings may be difficult to remove from a patient because their ends can become stuck flush with the skin. The possibility of tape removal causing trauma is also significantly increased in older people, people with sensitive skin, dermatitis, dehydration or side effects of medications. [14]

As noted above, there have been several studies looking at the efficacy and safety of eye ointments/lubricants as adjuncts with tape or as a stand-alone management for intra-operative eye closure. Unfortunately many in common use have problems. Petroleum gel is flammable and is best avoided when electrocautery and open oxygen are to be used around the face. Preservative-free eye ointment is preferred, as preservative can cause corneal epithelial sloughing and conjunctival hyperemia. [9] They have been implicated in blurred vision in up to 75% of patients and they do not protect from direct trauma. [6] [15]

Specially made eyelid occlusion dressings are available commercially, such as EyeGard (manufactured in the USA by KMI Surgical and marketed by Sharn Anesthesia), EyePro (Innovgas Pty Ltd, Australia) and Anesthesia-Aid (Sperian Protection). These dressings overcome most of the problems associated with tape or general purpose dressings.

Adverse outcomes associated with intra-operative eye injuries

Some of the adverse outcomes associated with intra-operative injuries include:

Related Research Articles

Photokeratitis or ultraviolet keratitis is a painful eye condition caused by exposure of insufficiently protected eyes to the ultraviolet (UV) rays from either natural or artificial sources. Photokeratitis is akin to a sunburn of the cornea and conjunctiva.

<span class="mw-page-title-main">Cornea</span> Transparent front layer of the eye

The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power. In humans, the refractive power of the cornea is approximately 43 dioptres. The cornea can be reshaped by surgical procedures such as LASIK.

<span class="mw-page-title-main">General anaesthesia</span> Medically induced loss of consciousness

General anaesthesia (UK) or general anesthesia (US) is a method of medically inducing loss of consciousness that renders a patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general anaesthetic medications, which often act in combination with an analgesic and neuromuscular blocking agent. Spontaneous ventilation is often inadequate during the procedure and intervention is often necessary to protect the airway. General anaesthesia is generally performed in an operating theater to allow surgical procedures that would otherwise be intolerably painful for a patient, or in an intensive care unit or emergency department to facilitate endotracheal intubation and mechanical ventilation in critically ill patients.

This is a partial list of human eye diseases and disorders.

<span class="mw-page-title-main">Chalazion</span> Medical condition

A chalazion or meibomian cyst is a cyst in the eyelid usually due to a blocked meibomian gland, typically in the middle of the eyelid, red, and not painful. They tend to come on gradually over a few weeks.

<span class="mw-page-title-main">Thygeson's superficial punctate keratopathy</span> Medical condition

Thygeson's superficial punctate keratopathy (TSPK) is a disease of the eyes. The causes of TSPK are not currently known, but details of the disease were first published in the Journal of the American Medical Association in 1950 by renowned American ophthalmologist Phillips Thygeson (1903–2002), after whom it is named.

<span class="mw-page-title-main">Eye injury</span> Physical or chemical injuries of the eye

Physical or chemical injuries of the eye can be a serious threat to vision if not treated appropriately and in a timely fashion. The most obvious presentation of ocular (eye) injuries is redness and pain of the affected eyes. This is not, however, universally true, as tiny metallic projectiles may cause neither symptom. Tiny metallic projectiles should be suspected when a patient reports metal on metal contact, such as with hammering a metal surface. Corneal foreign body is one of the most common preventable occupational hazard. Intraocular foreign bodies do not cause pain because of the lack of nerve endings in the vitreous humour and retina that can transmit pain sensations. As such, general or emergency department doctors should refer cases involving the posterior segment of the eye or intraocular foreign bodies to an ophthalmologist. Ideally, ointment would not be used when referring to an ophthalmologist, since it diminishes the ability to carry out a thorough eye examination.

<span class="mw-page-title-main">Recurrent corneal erosion</span> Medical condition

Recurrent corneal erosion is a disorder of the eyes characterized by the failure of the cornea's outermost layer of epithelial cells to attach to the underlying basement membrane. The condition is excruciatingly painful because the loss of these cells results in the exposure of sensitive corneal nerves. This condition can often leave patients with temporary blindness due to extreme light sensitivity (photophobia).

<span class="mw-page-title-main">Corneal abrasion</span> Scratch to the surface of the cornea of the eye

Corneal abrasion is a scratch to the surface of the cornea of the eye. Symptoms include pain, redness, light sensitivity, and a feeling like a foreign body is in the eye. Most people recover completely within three days.

A topical anesthetic is a local anesthetic that is used to numb the surface of a body part. They can be used to numb any area of the skin as well as the front of the eyeball, the inside of the nose, ear or throat, the anus and the genital area. Topical anesthetics are available in creams, ointments, aerosols, sprays, lotions, and jellies. Examples include benzocaine, butamben, dibucaine, lidocaine, oxybuprocaine, pramoxine, proxymetacaine (proparacaine), and tetracaine.

<span class="mw-page-title-main">Corneal ulcers in animals</span> Veterinary inflammatory condition of the cornea

A corneal ulcer, or ulcerative keratitis, is an inflammatory condition of the cornea involving loss of its outer layer. It is very common in dogs and is sometimes seen in cats. In veterinary medicine, the term corneal ulcer is a generic name for any condition involving the loss of the outer layer of the cornea, and as such is used to describe conditions with both inflammatory and traumatic causes.

<span class="mw-page-title-main">Vernal keratoconjunctivitis</span> Medical condition

Vernal keratoconjunctivitis is a recurrent, bilateral, and self-limiting type of conjunctivitis having a periodic seasonal incidence.

<span class="mw-page-title-main">Lagophthalmos</span> Medical condition

Lagophthalmos is the inability to close the eyelids completely.

<span class="mw-page-title-main">Punctate epithelial erosions</span> Medical condition

Punctate epithelial erosions are a pathology affecting the cornea.

<span class="mw-page-title-main">Corneal ulcer</span> Medical condition of the eye

Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.

<span class="mw-page-title-main">Lattice corneal dystrophy</span> Medical condition

Lattice corneal dystrophy type is a rare form of corneal dystrophy. It has no systemic manifestations, unlike the other type of the dystrophy, Lattice corneal dystrophy type II. Lattice corneal dystrophy was first described by Swiss ophthalmologist Hugo Biber in 1890.

<span class="mw-page-title-main">Herpes simplex keratitis</span> Medical condition

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

Ocular surgery may be performed under topical, local or general anesthesia. Local anaesthesia is more preferred because it is economical, easy to perform and the risk involved is less. Local anaesthesia has a rapid onset of action and provides a dilated pupil with low intraocular pressure.

Neurotrophic keratitis (NK) is a degenerative disease of the cornea caused by damage of the trigeminal nerve, which results in impairment of corneal sensitivity, spontaneous corneal epithelium breakdown, poor corneal healing and development of corneal ulceration, melting and perforation. This is because, in addition to the primary sensory role, the nerve also plays a role maintaining the integrity of the cornea by supplying it with trophic factors and regulating tissue metabolism.

Exposure keratopathy is medical condition affecting the cornea of eyes. It can lead to corneal ulceration and permanent loss of vision due to corneal opacity.

References

  1. 1 2 3 4 5 C Marcucci, NA Cohen, DG Metro & JR Kirsch 2008, Avoiding Common Anesthesia Errors, Lippincott Williams & Wilkins, Philadelphia PA USA.
  2. ↑ Kocaturk, O, Kocaturk, T, Kaan, N & Dayanir V 2012 'The Comparison of Four Different Methods of Perioperative Eye Protection under General Anesthesia in Prone Position', Journal of Clinical and Analytical Medicine, vol. 3, no. 2, pp. 163-5 "Read Article"
  3. 1 2 3 4 S Contractor & JG Hardman 2006, 'Injury During Anaesthesia', Continuing Education in Anaesthesia, Critical Care & Pain, vol. 6, no. 2, pp. 67-70, "Read Article"
  4. 1 2 VK Grover, KV Kumar, S Sharma & SP Grewal 1998, 'Comparison of Methods of Eye Protection under General Anaesthesia', Canadian Journal of Anesthesia, vol. 45, no. 6, pp. 575-7, "Read Article"
  5. ↑ J Anson, 'Perioperative Corneal Abrasions: Etiology, Prevention, and Management', Pennsylvania Society of Anesthesiologists, "Read Article".
  6. 1 2 3 PN Nair & E White 2014, 'Care of the Eye During Anaesthesia and Intensive Care', Anaesthesia and Intensive Care Medicine, vol. 15, no. 1, pp. 40-43, "Read Article".
  7. 1 2 E White 2004, 'Care of the eye during anaesthesia', Anaesthesia and Intensive Care Medicine, vol. 5, pp. 302-3 "Read Article".
  8. ↑ K Zheng, CG Guta, V Kulkarni & J Brock-Utne 2009, 'Prevention of Corneal Abrasions in Patients with Autoimmune Dry Eyes', Anaesthesia and Analgesia, vol. 108, no. 1, pp. 385-6, "Read Article"
  9. 1 2 A Grixti, M Sadri & MT Watts 2013, 'Corneal Protection during General Anesthesia for Nonocular Surgery', The Ocular Surface, vol. 11, no. 2, pp. 109-18, "Read Article"
  10. ↑ NJ Friedman & PK Kaiser 2007, Essentials of Ophthalmology, Elsevier Health Sciences, Philadelphia PA USA.
  11. ↑ N Tarmey & LA White 2009, 'Section 5: Damage to the eye during General Anaesthesia', Risk Associated with your Anaesthetic, Royal College of Anaesthetists website, "Read Article".
  12. ↑ AN Gent 1996, 'Adhesion and strength of viscoelastic solids. Is there a relationship between adhesion and bulk properties?', Langmuir, vol. 12, no. 19, pp. 4492-96, "Read Article".
  13. ↑ Clinical and Laboratory Standards Institute 2010, 'Performance Standards for Antimicrobial Susceptibility testing: Twentieth Informational Supplement', CLSI Document M100-S20 "Read Article".
  14. ↑ C Konya, H Sanada, J Sugama, M Okuwa, Y Kamatani, G Nakagami & K Sakaki 2010, 'Skin Injuries Caused by Medical Adhesive Tape in Older People and Associated Factors', Journal of Clinical Nursing, vol. 19, no. 9-10, pp. 1236-1242 "Read Article".
  15. 1 2 3 M Weed & N Syed 2012, 'Perioperative Corneal Abrasions: Systems-based review and analysis', EyeRounds.org, "Read Article".
  16. 1 2 S Prakash 2013, 'Perioperative Eye Protection under General Anaesthesia', Journal of Anaesthesiology Clinical Pharmacology, vol. 29, no. 1, pp. 138-139 "Read Article".
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