Chandra Mohan Kumar

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.

: Parkinson’s disease (PD) is a chronic neurological degenerative disease affecting the central nervous system, which is responsible for progressive disorders such as slow movements, tremors, rigidity, and cognitive disorders. There are no specific recommendations and guidelines for anesthetic management of patients with PD undergoing ophthalmic procedures. This narrative review aims to summarise the anesthetic considerations in patients with PD presenting for cataract surgery.

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.

Since the recent editorial 2, we were approached to evaluate another video laryngeal mask airway - the Besdata Video Laryngeal Mask (BD-VLM) TM, which has a different design concept, specifications and characteristics (Figure 1) compared to the other two.

Aims This international survey was conducted to study the impact of Covid-19 pandemic on the provision and practices of ophthalmic anaesthesia, evaluate the methods employed by parent ophthalmic units for safeguarding their anaesthesia providers and patients during lockdown, and to assess pandemic’s effect on anaesthesia providers as individuals. The study was done with the hope that the results will help in protecting patients and safeguarding precious human resource by better management if this pandemic was to continue or there was to be another pandemic. Methods An anonymous questionnaire survey was distributed electronically between December 2020–January 2021 to the practicing ophthalmic anaesthesia providers in different parts of the world. Results The survey identified that apart from reducing elective operating services, the ophthalmic units were ill prepared for the pandemic and the overall management was lacklustre. There was a definite lack of effective peri-operative patient screening, and, streaming processes. Measures for personal protection of staff were not optimal especially during regional/local ophthalmic anaesthesia. Severity of the pandemic, sudden job plan changes, and redeployment to intensive care units/acute covid wards had an adverse psychological impact on the affected staff. Conclusion Ophthalmic anaesthesia services worldwide have had poor attentiveness to the life-threatening menace and reality of Covid-19 pandemic. A review of the institutional practices to address correctible deficiencies is urgently required. Robust, mandatory, elective, timely preventative strategies need to be implemented to protect patients, and, the precious ophthalmic workforce from potential adverse physical and psychological injuries.