Repair of ruptured of lacerated globe

Repair of ruptured of lacerated globe

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
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Repair of a globe rupture, laceration, penetration, or perforation is an urgent surgery to repair the corneal or scleral layers of the eye cause by blunt, penetrating, or perforating trauma. This often includes, but is not limited to, replacement of extruded intraocular contents, closure of open defects, and removal of foreign bodies. Anterior injuries are more readily identified and closed. If a posterior injury is suspected, further surgical intervention may be necessary including extraocular muscle removal to fully inspect the scleral surface.

An ophthalmic examination is performed preoperatively, and imaging is occasionally used as an adjunct to aid in identification of the specifics of the defect.

Preoperative management

Patient evaluation

System	Considerations
Airway	Potential concomitant airway trauma
Neurologic	AMS 2/2 trauma
Cardiovascular	CHF, CAD, cardiovascular stability
Pulmonary	Potential lung injuries, smoking hx, asthma hx
Gastrointestinal	NPO status, recent N/V
Hematologic	Potential bleeding

Labs and studies

CBC, CMP

Maxillofacial CT per ophthalmology

Operating room setup

Avoid circumstances that can increase IOP

• Consider anxiolytics such as benzodiazepines anxiety, crying, struggling, straining
• Consider pain medication, but avoid opioids due to concern for increased nausea and vomiting
• Consider antiemetics (ondansetron, Phenergan, ect) to prevent nausea and vomiting

Patient will most likely not have appropriate NPO status and will be considered a full stomach

• Consider metoclopramide and antacids prior to surgery to prevent aspiration pneumonitis

In patients with a smoking history, or asthma, consider pre-treating with albuterol to control coughing and improve oxygenation and ventilation after intubation.

Patient preparation and premedication

Regional anesthesia such as retrobulbar blocks are contraindicated as this can potentially increase IOP, worsening globe injury and surgical outcomes.

Intraoperative management

Monitoring and access

Standard monitoring

PIV x1

Induction and airway management

A smooth induction and intubation are crucial to prevent increasing IOP. Rapid sequence is required both due to NPO status and inability to mask ventilate to prevent increased IOP.

General endotracheal anesthesia

Standard induction

• IV opioid (fentanyl, dilaudid)
• Lidocaine
• Propofol
  • Avoid ketamine as this may potentially increase IOP
• Paralytic
  • Avoid succinylcholine as it may potentially increase IOP

Positioning

Supine

Table turned 90-180 degrees depending on surgeon preference

Maintenance and surgical considerations

Volatile anesthesia and TIVA are appropriate for this case. Avoid nitrous oxide due to concern for trapped air expansion in globe.

Maintain muscle relaxation until eye is surgically closed

Avoid hypercarbia as this can increase IOP

Emergence

Goal of smooth emergence and extubation to prevent increased IOP

Postoperative management

Disposition

PACU, floor bed

Pain management

Tylenol and ibuprofen if not contraindicated by patient comorbidities

Can consider IV or PO opiates, but consider risk of nausea.

Potential complications

• Permanent blindness
• Endophthalmitis
• Retinal detachment
• Hemorrhagic retinopathy
• Sympathetic ophthalmia

Procedure variants

	Variant 1
Unique considerations	Avoid medications or procedure that would increase intraocular pressure
Position	Supine, table turned 90-180 degrees
Surgical time	1-2 hours
EBL	Minimal
Postoperative disposition	PACU
Pain management	Tylenol, ibuprofen, opiates
Potential complications	Endophthalmitis, retinal detachment, corneal abrasion, permanent blindness