Objective of Eye Surgery

Physiology & Pharmacology of Eye
UKSO
Dr Naeem Sheikh
Aim
To enable the participants to demonstrate
• Anatomy of Eye
• Extraocular Muscles and their movements
• IOP and factors affecting IOP
• Occulocardic reflex arch
• Factors causing pupillary dilation and constriction
• Eye Blocks
Structure of the Eyeball
Three Layers of Eyeball
• Fibrous Layer
Cornea
Sclera
Limbus
• Vascular Layer
Choroid
Ciliary Body
Iris
• Nervous Layers
Sensory Retina
Retinal Pigment Epithelium
Interior of the Eyeball
Anterior Segment
The Said Segment is
further divided into
following
Anterior Chamber:
It is bounded anteriorly by Cornea
posteriorly by front surface of lens,
peripherally by anterior chamber
angel it contains aqueous humor
Posterior Chamber:
it is bounded anteriorly by iris,
posteriorly by anterior surface of
lens and zonulae & peripherally by
ciliary process. It contains aqueous
humor
Posterior Segment
Posterior Segment:
It is bounded anteriorly
by lens, zonules and
ciliary process and
posteriorly by retina and
optic disc
It contains Vitreous
humor
Arterial Supply to Eye
Internal Carotid Ophthalmic Artery
• Central Retinal artery

• Short and long posterior ciliary arteries
• Anterior ciliary arteries
Venous Drainage of eye
• Superior and inferior ophthalmic veins Cavernous sinus & cranial system
• Anastomosis of superior and inferior

Facial Venous System
ophthalmic veins & Angular vein
• A branch of inferior ophthalmic vein Inferior orbital fissure

Pterygoid venous plexus
Visual Acuity
It is the power of eye by which objects are distinguished from each other.
It is a measure of smallest retinal image, which can be appreciated
regarding its shape and size
USES
• Refractive Status
• Outcome measure for a treatment
• Medicolegal purposes
• Criteria for a person's fitness to drive
• Eligibility for entrance into a profession
Extraocular Muscles
Rectus Muscles
• Superior Rectus
• Inferior rectus
• Medial rectus
• Lateral rectus
Oblique Muscle
• Superior Oblique
• Inferior Oblique
Intraocular Pressure
Definition
IOP is the fluid pressure of the eye. As pressure is a measure of the force
Per area, IOP is a measurement involving the magnitude of force exerted by
aqueous humor on the internal surface area of anterior eye.
• It ranges from 12- 20 mmHg

• Increases with age
• Increased IOP impairs blood flow to retina leading to loss of vision
Event that decrease Events that Increase
IOP IOP
• IV Anesthetics • `P` on eye from a mal
• Volatile anesthetics positioned mask
• Mannitol • Improper prone positioning
• Timolol • Retrobulbar hemorrhage
• Betaxolol • Succinylcholine
• NDMR • Direct laryngoscopy
• Hyperventilation • Arterial hypoxemia
• Hypothermia • Increased Venous Pressure
Oculocardiac Reflex
Causes
Reflex triggered by
• Pressure on globe
• Traction on extraocular muscle
• Ocular Trauma
• Orbital Compression due to hematoma or edema
• Procedures under tropical anesthesia
• Orbital injuries
• Hypercapnia or hypoxemia
Oculocardic Reflex
• Bradycardia
• Bigeminy
• Ventricular ectopy
• AV Block
• Cardiac Arrest
Treatment
• Inform Surgeon, Stop stimulation

• Verify adequate ventilation & Oxygenation
• Atropine ( 10 ug/kg) or glycopyrrolate( 10- 20 ug/kg)
• In recalcitrant episodes, infiltration of the rectus muscles with local anesthetic
EXOPTHALMOS
It occurs when soft tissue builds up in the eye socket

and causes the eyeballs to protrude, forcing the eye lids open
Causes
Exophthalmos is most often caused by thyroid problems, particularly grave`s

disease
Less often it can be caused by something in the eyesocket such as
• cancerous tumor
• mucocele
• Blood clots
• Eye injury
• Sinus infection
• Bacterial infection
Retinal Detachment
It is the separation of sensory retina from the retinal pigment epithelium
by subretinal fluid
Predisposing Factors
• Posterior vitreous detachment
• Peripheral retinal degenerations
• High myopia
• Trauma
• Proliferative diabetic retinopathy
• Retinopathy of prematurity
• Penetrating posterior segment trauma
• Peripheral uveitis
• Excessive cryotherapy
• Posterior scleritis
• Retinoblastoma
• Malignant melanoma
• Systemic hypertension
• Toxemia of pregnancy
Ophthalmic Blocks
• Retrobulbar Block
• Peribulbar Block
• Sub-Tenon Block
Retro bulbar Block
Aim `
Injected in muscles cone to block
• Ciliary nerve & ganglion
• 3rd, 4th, 6th cranial nerve
• Provide akinesia & anesthesia of globe
Site of Injection
A Blunt tipped 25 G needle penetrates lower lid at junction of middle & lateral
one third of orbit
Usually, 0.5 cm medial to lateral Canthus
Technique
Pt looks supranasally as needle is advanced 1.5 cm along the inferotemporal
wall of the orbit
The needle is than redirected upward & nasally toward the apex of the
orbit & advanced until its tip
penetrates muscle cone.
L /A agents:
• Lignocaine 2%
• Bupivacaine 0.75%
Along with
• Hyaluronidase 5- 7.5 IU/ml
• Adrenaline 1:2oo,ooo
Volume
• 2-5 ml of local anesthesia
Advantages
• Complete Akinesia
• Dilation of pupil
• Adequate and quicker anesthesia
• Minimal amount of agent required
Complications
Optic nerve sheath injury Post bulbar block apnea syndrome
• Retrobulbar Hemorrhage
• Globe penetration
• Optic nerve injury
• Decreased visual acuity
• Retinal vascular occlusion
• Brainstem anesthesia
• Frank conversion
• Extraocular muscle palsy
• Trigeminal nerve block
• Occulocardic reflex & respiratory arrest
Contra- Indications
• Bleeding disorder (risk of retrobulbar hemorrhage)

• Extreme Myopia( Global perforation)
• An open eye injury ( may cause expulsion of intraocular contents )
Peribulbar Block
Position of pt
Supine & in primary gaze
Technique
Eyelid is located and an inferotemporal injection is given halfway between
the lateral canthus & lateral
Limbus- needle is advanced under the globe, parallel to orbital floor when it
passes equator of eye, it is directed slightly medial (20 degrees) & cephalad
( 10 degrees)
& 5ml of local anesthesia is injected to ensure akinesia the anesthesia
provider may give a second 5ml injection through the conjunctiva on nasal
side, directed straight back parallel to medial orbital wall pointing slightly
cephalad ( 20 degree)
Advantages
• Less risk of penetration of globe

• Less chance of optic nerve and artery
injury
• Less Pain
Disadvantages
• Conjunctival Ecchymosis
Sub Tenon Block
Technique
After Topical anesthesia, a small conjunctival incision is given in inferonasal
quadrant with the blunt tipped
scissors which are than slid underneath to create path in Tenons' fascia
The Cannula is inserted, 3 to 4 ml of local anesthetic is injected.
Complications
• Globe perforation
• Hemorrhage
• Cellulitis
• Permeant visual loss
• L/A spread into CSF
Facial Nerve Block
Aim
• Blocking action of orbicularis oculi to prevent squinting
Types
• Van Lint
• Atkinsons
• O`Brien
Complication
• Sub Cut Hemorrhage

Miotics
Miotics are drugs that cause constriction of pupil
These are used in the management of glaucoma`s and the treatment of
esotropias and accommodation inefficiency
Types
• Pilocarpine
• Carbachol
• Phospholine iodide
• Physostigmine sulphate
Stage of Anesthesia Depth Eyeball Position Pupil Size Pupillary Light
Response
Stage I Not anesthetized Central Normal Yes
Stage II excitatory Not anesthetized Central, possible May be dilated Yes

stage nystagmus
Stage III, Plane 1 Light Central or rotated, Normal Yes

light anesthesia may be nystagmus
Stage III, Plane 2 Moderate Often rotated ventrally Slightly dilated Sluggish
surgical anesthesia
Stage III, Plane 3 Deep Usually central, may Moderately dilated Very sluggish or absent
deep anesthesia rotate ventrally
Stage III, Plane 4 Overdose Central Widely dilated Unresponsive
Stage IV Dying Central Widely dilated Unresponsive

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Physiology & Pharmacology of Eye

• Central Retinal artery

• Anastomosis of superior and inferior

• A branch of inferior ophthalmic vein Inferior orbital fissure

• It ranges from 12- 20 mmHg

• Inform Surgeon, Stop stimulation

It occurs when soft tissue builds up in the eye socket

Exophthalmos is most often caused by thyroid problems, particularly grave`s

• Bleeding disorder (risk of retrobulbar hemorrhage)

• Less risk of penetration of globe

• Blocking action of orbicularis oculi to prevent squinting

• Sub Cut Hemorrhage

Stage II excitatory Not anesthetized Central, possible May be dilated Yes

Stage III, Plane 1 Light Central or rotated, Normal Yes

Stage III, Plane 4 Overdose Central Widely dilated Unresponsive

Stage IV Dying Central Widely dilated Unresponsive

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