Anesthesia in Open Globe Injury

Open globe injury (OGI) is a full-thickness injury to the cornea and/or sclera, often caused by trauma, penetrating injuries, or blunt force trauma leading to rupture.

Key Anesthetic Goals in Open Globe Injury

1. Prevent further ocular damage – Avoid increased intraocular pressure (IOP).

2. Provide a stable hemodynamic state – Maintain adequate perfusion to the optic nerve.

3. Achieve adequate analgesia and akinesia – Prevent patient movement during surgery.

4. Protect against aspiration – High-risk patients may need rapid sequence induction (RSI).

5. Minimize intraoperative bleeding – Maintain stable blood pressure.

Preoperative Considerations

1. Patient Assessment

• History of trauma: Mode of injury (penetrating/blunt), time since injury, symptoms (pain, visual loss).

• Systemic injuries: Associated head injury, facial fractures, cervical spine injury, or polytrauma.

• Medications: Anticoagulants, antiplatelets, and steroids must be considered.

2. Ocular Examination (by Ophthalmologist)

• Seidel’s test: Detects leaking aqueous humor.

• Anterior chamber depth: To assess the extent of globe rupture.

• IOP measurement is avoided in OGI to prevent further trauma.

3. Preoperative Optimization

• Nil per oral (NPO) status: Assume full stomach in trauma cases.

• Anti-emetics (Ondansetron 4 mg IV): Prevent vomiting, which can increase IOP.

• Analgesia (IV paracetamol, fentanyl 1-2 mcg/kg): Prevent pain-related IOP elevation.

• Anxiolysis (low-dose midazolam 0.02 mg/kg IV, if needed): Avoid anxiety-related IOP spikes.

Anesthetic Challenges in Open Globe Injury

1. Avoiding Increased Intraocular Pressure (IOP):

• Coughing, straining, laryngoscopy, vomiting, and movement must be minimized.

• Use smooth induction and deep anesthesia to prevent IOP rise.

2. Airway Management:

• Consider RSI with cricoid pressure (Sellick’s maneuver) to prevent aspiration in trauma patients.

• Avoid mask ventilation before intubation to prevent increased IOP.

• Succinylcholine (SCh) is controversial as it may cause a transient IOP rise.

3. Choice of Anesthesia:

1. Choice of Anesthesia

2. Induction of Anesthesia

• Preoxygenation for 3–5 minutes

• Intravenous Induction:

• Propofol (2–3 mg/kg) or Etomidate (0.2–0.3 mg/kg) for hemodynamically unstable patients

• Fentanyl (1–2 mcg/kg) to blunt intubation response

• Rocuronium (1.2 mg/kg) or Succinylcholine (1.5 mg/kg) for RSI

🔹 Succinylcholine Debate in Open Globe Injury

• Succinylcholine causes transient IOP rise (8-12 mmHg) due to extraocular muscle contraction.

• However, this lasts only 1–2 minutes and can be blunted with deep anesthesia and defasciculating doses (0.01 mg/kg vecuronium).

• Use rocuronium (1.2 mg/kg) if time permits.

🚨 AVOID: Mask ventilation before intubation → Increases IOP!

• Intubation should be smooth: Deep anesthesia with opioids, lidocaine (1.5 mg/kg IV) before laryngoscopy.

3. Maintenance of Anesthesia

• Oxygen + Air + Sevoflurane/Isoflurane (volatile agents help lower IOP).

• IV opioids (fentanyl/remifentanil) for analgesia.

• Neuromuscular blockade with vecuronium/rocuronium to maintain akinesia.

• Controlled ventilation to maintain normocapnia (PaCO₂ ~35 mmHg).

🚨 Avoid high PEEP and hypercapnia → Can increase IOP.

4. Emergence & Extubation

• Deep extubation is preferred (extubation under deep anesthesia) to prevent coughing.

• If deep extubation is risky (difficult airway, aspiration risk), ensure smooth emergence with IV lidocaine (1.5 mg/kg).

• Antiemetics (ondansetron, dexamethasone) are mandatory to prevent vomiting.

🚨 Sudden straining or coughing during extubation can cause wound dehiscence or expulsion of intraocular contents!

Postoperative Care

• Adequate analgesia: IV paracetamol + fentanyl (avoid NSAIDs in case of bleeding risk).

• Antiemetics (ondansetron, dexamethasone) to prevent nausea/vomiting.

• Monitor for signs of increased IOP (pain, nausea, headache, vision changes).

MCQs on Anesthesia in Open Globe Injury

1. The preferred anesthetic technique for an open globe injury is:

a) Peribulbar block

b) Retrobulbar block

c) General anesthesia with RSI

d) General anesthesia with spontaneous ventilation

• Answer: (c) General anesthesia with RSI

2. Which of the following drugs is most suitable for induction in open globe injury?

a) Ketamine

b) Propofol

c) Thiopental

d) Midazolam

• Answer: (b) Propofol

3. Which of the following is the most critical step during induction for an open globe injury?

a) Preoxygenation

b) Avoidance of bag-mask ventilation

c) Administration of glycopyrrolate

d) Use of etomidate

• Answer: (b) Avoidance of bag-mask ventilation

4. Why is succinylcholine controversial in open globe injury?

a) Causes prolonged neuromuscular blockade

b) Increases IOP due to extraocular muscle contraction

c) Induces bradycardia

d) Causes severe hypotension

• Answer: (b) Increases IOP due to extraocular muscle contraction