CASE PRESENTATION

ON CATARACT

NAME –Ram narayan

AGE- 55 ,SEX- male
OCCUPATION- farmer
RESIDENCE- Sikar
 CHIEF COMPLAINS ;
The patient complaints of gradual
painless decrease of vision in both the
eyes more on the left eye.
HISTORY OF PRESENT ILLNESS :The
patient complains of gradual diminution
of vision from 6 months in both the eyes
more on the left eye not associated
with any pain. No history of
redness,discharge,photophopia
,trauma or colored halos seen.
The patient has not taken any
medication for
his dimness of vision
Spectacles : The patient has been
prescribed glasses for his near
vision when he was 40 years of
[Link] patients power is +
3,there is been no change in the
power for the last 2 months,the
glasses were prescribed by a
qualified optometrist.
PAST HISTORY :
History of chronic diseases - There is no
history of blood pressure, diabetes
mellitus, asthma ,heart [Link]
is no history of any ocular diseases or
any history of long term ingestion of
steroid.
a)Infective diseases –There is no history
of
tuberculosis,syphilis,leprosy,gonorrhoea
,diptheria and meningites.
History of allergy and drug
reaction :
There is no allergic reaction to any
exogenous materials
like,dust,fume,pollen,husk,fur,nylon,wo
ol or [Link] history to any drug
reaction
History of surgery – There is no past
history of any surgery in the eye or any
other surgery .
Family history : There is no history of
consanguinity among parents ,no
history of glaucoma,
dystrophies ,diabetic retinopathy and
hypertensive retinopathy .
Personal history : the patient is a non
smoker and non alcoholic
Examination of the Eye : The patient was
seated in a erect position,without any
turning of [Link] of eyeball :
central in both the eyesMovements :
movements were normal in all four
quadrants without any [Link]
apparatus : normal in both the eyes
Conjunctiva : normal in both the eyes
Cornea : normal in both the eyesAnterior
chamber : normal in both the eyesIris :
normal colour Pupil : round ,regular and
reactive in both the eyeslens : LE;greyish
white pupilary reflex on torch light.
RE; greyish reflex on torch light.
Vision; LE :6/60 ,RE :6/36
 DIAGNOSIS

IMMATURE SENILE CATARACT

LE > RE
 GPE;
Heart rate -88\min.
R R- 18\min
Temp.- afebrile
B P- 110\70 mm hg (Rt. Arm supine
position)
Wt- 55 kg
G C –fair
No pallor\icterus \cynosis \clubbing \
lymphadenopathy
Systemic examination ;
C V S – S1& S2 normal .
No murmurs .
Respiratory system ;
b/l air entry equal .
No added sound .
CNS , GIT nomal
 LAB . INVESTIGATION
Blood investigations ;
B S [random] – 69 mg /dl
S. urea – 19 mg/dl
S. creatinine – 0.8 mg/dl
Urine complete normal.
LFT- SGOT-45,SGPT-49.
Hb – 11.0gm/dl .
T .L.C -11.0/[Link].
B T- 3min
C T – 4min
E .C.G. - WNL
Chest X Ray – NAD
 DISCUSSION OF THE CASE Brief
anatomy of the lens.

The human lens is

a naturally clear
structure located
behind the iris and
supported by the
zonules
The lens is
avascular-It does
not have a
vascular supply
 Structure
The basic lens
consists of a
central nucleus
surrounded by
the cortex
contained
within the lens
capsule
This loss of
transparency,
or opacity
formation is
called
Cataract
 Stages of senile cataract
Immature cataract
Mature cataract
Hypermature cataract
 CAUSES OF CATARACT
1)Congenital and developmental cataract
2)Acquired cataract :
-senile cataract -toxic cataract
-traumatic cataract -corticosteroid
induced
-complicated cataract -miotics induced
-metabolic cataract -copper/iron
induced
-electric cataract
-radiational cataract
 Surgical management of cataract.

Adult management of cataract

-phaco emulsification + IOL
-SICS /ECCE + IOL
-ICCE (outdated now)
Pediatric cataract surgery
-lens aspiration/lensectomy ± IOL
Nowadays , modern cataract
surgery
(phacoemulsificaion) is advocated
in imma
ture cataract stage only because
mature and
hypermature cataract are
associated with complications like
glaucoma,uveitus and subluxation
of lens.
Before going into the anaesthetic
consideration,let us discuss two
important aspects of opthalmology
from anaesthesia point of view, IOP
and oculo cardiac reflex
Physiology of intra
ocular pressure
INTRA-OCULAR PRESSURE
DETERMINANTS:
Normal IOP ranges from 12-
20mmhg
Factors exerting outward
pressure
Factors exerting inward
pressure
Intra-ocular pressure

Aqueous humour
Vitreous humour
Blood within the eye
Scleral compliance
Extra-ocular muscle tone
Aqueous humour
dynamics
Ultrafiltration of plasma by ciliary
epithelium

Formation of A H in ciliary process

A H circulate around Iris
 via pupil
Anterior chamber

Canal of Schelmn

Trabecular spaces of Fontana
drains through
Episleral venous system
Drugs acting on AH
mechanics
 production:
Acetozolamide (carbonic
anhydrase inhibitor)
Beta blockers
Improve drainage:
Miotics (by contracting ciliary
muscle)
Mydriatics affects drainage
 Vitreous Humour
Fine unstable gel consisting of water
& fine supporting structure

Volume & pressure reduced by

Mannitol which is a dehydrating
agent & there by ↓ IOP
Extra-ocular muscle
tone
Tone controlled by the mid-brain

GA ↓ muscle tone & there by ↓

IOP

Gentle, constant pressure on the

eye promotes aqueous humour
flow & ↓ IOP
Pharmacological
modifications of IOP
Pre anaesthetic Medication:
IV diazepam & midazolam ↓
IOP
Parental atropine has no effect
on IOP

Intravenous anaesthetics:
Only ketamine ↑ IOP
All other agents ↓ IOP
Pharmacological
modifications of IOP
Inhalational agents effect IOP
by:
Central action on mid-brain
Alteration of aqueous humour
↓ extra-ocular muscle tone
Dose dependent reduction in
IOP
 Pharmacological
modifications of IOP
Neuro-muscular blockers:
Succinylcholine- ↑ IOP by 10
mmHg in 1 minute & lasts for 10
minutes
↑ IOP due to tonic action of drug
on striated extraocular muscle
Laryngoscopy & Intubation:
↑ IOP
Oculo-cardiac reflex

Trigemino-vagal reflex
Bradycardia, nodal rhythm,
ectopic beats, ventricular
fibrillation, asystole
Eyeball pressure, traction of
extra-ocular muscles, orbital
haematoma, ocular trauma &
eye pain, eyelid traction
Can occur even from enucleated
 Oculo cardiac reflex
Afferent pathway Efferent pathway
 
Short & long ciliary nerves Nucleus of
vagus
 
Ciliary ganglion Cardiac
branches
via  ophthalmic 
division of trigeminal nerve
Bradycardia

Trigeminal sensory nucleus
Treatment of OCR

One should not panic

Ask surgeon to stop all the
manipulations
Instill local xylocaine(4%)over
the surgical site.
Intravenous Atropine 15 micro
grams / Kg or intravenous
Glycopyrrolate 7.5 micro grams /
Kg
 Choice of anaesthesia for
cataract surgery.
Local anaesthesia is preferred over
general anesthesia because it is
safer,cheaper,quicker,associated with
fewer respiratory and haemodynamic
untoward effects and the incidence of
nausea and vomiting is also less
General anaesthesia is required for
children and in uncooperative adults.
Local with monitored general anaesthesia
preferred for apprehensive patients.
 ANAESTHESIA
CONSIDERATION
Objectives of Anaesthesia in
Intraocular Surgery
— Akinesia of globe and lids—
Anaesthesia of globe and lids and
adnexa— Control of intraocular
pressure— Control of systemic blood
pressure— Relaxation of patient—
Absence of untoward episodes e.g.
Oculocardiac reflex
— Smooth emergence from
anaesthetic state without
vomiting
— Adequate post-operative
analgesia
 Preoperative evaluation
Patients history
- previous hospitilizations and
surgical procedures are reviwed.
-allergies and drug sensitivity are
noted.
-any dementia,deafness,language
difficulty,restless leg
syndrome,obstructive sleep
apnea,tremors,dizziness, and
claustrophobia
-history of ingestion of opthalmic
drugs should be taken
Physical examination
-check for signs of major cardiac
and pulmonary decompensation.
-Particular attention should be paid
on positioning issues , such as severe
scoliosis or orthopnoea.

Laboratory studies
-Complete blood counts
- ECG
-Chest x ray.
Opthalmic evaluation
-visual acuity of both the eyes
should be checked
-The axial length of the globe
should be assesed with the help of an
ultrasound.
-If ultrasound not available, a
myopic eye should be assumed to have
a greater axial length.
-Preoperative glaucoma
history,increased IOP, and increased
axial length are important risk factors for
suprachoroidal hemorrhage.
The risk may be reduced with
control of heart rate and blood
pressure.
Pre operative softening with a
compressive device also may
reduced the risk of increase in IOP.
Cardiovascular evaluation
- a thorough cvs examination should
be done as the patients are aged.
-any history of hypertension.
Pulmonary evaluation
-The patient should be able to lie
comfortably flat.
- any history of intractable cough.
-Pre operative risk reduction include
cessation of smoking,treatment of
airway obstruction with bronchodilators
or steroids and administration
 of antibiotics for respiratory
infections.
- Patients should be assesed for sleep
[Link] sedation is
contraindicated in such [Link]
such patients a mild stimulant like
caffeine may be helpful for keeping
them awake.
Endocrine consideration
-Diabetes mellitus is very common
among cataract patients.
- A fasting blood sugar should be
checked [Link] therapy
should be used if necessary
 -Patients who are on steroid therapy
should be given normal dose of steroid on
the day of the surgery.
-unexpected hypotension,fatigue and
nausea may be signs of patient who needs
additional steroid.

Anticoagulation
- many patients undergoing opthalmic
surgery take anticoagulants
-perioperative management involves
weighing the risks of thrombotic against
hemorrhagic
complications.
-indications are serious complications
from arterial thromboembolic
diseases,like atrial fibrillation or
valvular heart deseases.
-previous episode of
thromboembolism

Risk of hemorrhagic complications

depends on
-degree of anticoagulants
-serious hemorrhagic
complications are more in orbital
and oculoplasty surgery.

Intermediate in
vitreoretinal,glaucoma and corneal
transplant surgery.

Least in cataract surgery.

 Local anaesthesia for
cataract surgery
1)Retrobulbar block
2)Peribulbar block
3)Facial block
4)Subtenons block
5)Topical anaesthesia
 Retrobulbar block
In this technique,local anaesthesia is
injected behind the eye into the cone
formed by the extraocular muscles.A
blunt tipped 23 G needle is injected in
the lower lid at the junction of middle and
lateral one third of the orbit(usually 0.5
cm medial to the lateral canthus).The
patient is asked to stare supranasally,as
the needle is advanced 3.5 cm towards
the apex of the muscle [Link]
aspiration 1.5 – 3.5ml of local is injected.
note the direction of the needle-first
hitting the orbital floor and then
turning inside to penetrate the cone.
 Peribulbar block
In contrast to retrobulbar
block,peribulbar block does not
penetrate the cone of the eye.
Akinesia is achieved in both the blocks
in 5 mins.
Peribulbar has less complications over
retrobulbar block.
If block not achived a superior approach
can be given,superior injection is given
usually nasally to the middle canthus.
 needle
outside the cone
 Advandages of peribulbar block
over retrobulbar block
Lesser chance of retrobulbar
haemorrhage
Lesser chance of perforation of eye or
injury to the optic nerve
The potential of intraocular or
intradural injection is less as the
anaesthesia is deposited outside the
muscle cone of the eye.
 Disadvandages of the peribulbar
block

Akinesia of the extraocular muscle

may be less complete.
Greater volume required,more
time required to achieve
satisfactory block.
Greater incidence of periorbital
ecchymosis and conjunctival
chemosis.
 Complications of eye blocks
Retrobulbar haemorhage
It is the most common complication due to
inadvertent puncture of vessles within the
retrobulbar space.
Characterized excellent motor block of the
globe,closing of the upper eyelid,proptosis
and palpable increase in intraocular
pressure.
Subconjunctival blood and eyelid
ecchymosis may be seen
It can lead to other complications like
central
Retinal artery occlusion and
occulocardiac reflex.
If retrobulbar hemorrhage encountered
it is usually best to postpone the
surgery for 2 to 4 days,because of
repeat hemorrhage and difficulty in
operation due to the increase in orbital
and vitrous pressure.
It is more commonly seen in
retrobulbar block
 Oculocardiac reflex
Central retinal artery occlusion
-can result from retrobulbar
hemorrhage,if not treated can result
in total loss of vision.
-the patients intraocular pressure and
retinal artery pulsations should be
measured.
-if external pressure is very high,then
lateral canthotomy or anterior
chamber paracentesis should be
performed to decompress the orbit.
 Inadvertent brain stem anaesthesia
-Accidental injection of anaesthesia into
the CSF can occur due to perforation of
the meningeal sheath that surrounds the
optic nerve.
-Presents with
disorientation,aphasia,hemiplegia,unconci
ousness,convulsions,respiratory and
cardiac arrest.
-Forceful injection into the opthamic
artery leads to retrograde flow into the
thalamus and midbrain and cause
seizures.
-Apnea occurs in 20 mins and resolves
in an hour
-supportive treatment given with
positive pressure ventilation to
prevent hypoxia.
-cardiac intervention.
-hence a patient should never be
unattended after giving a block.
Puncture of the eye globe
Usually seen in myopic eye(long eyes)
axial length more than 26 cms.

Optic nerve damage

-seen in repeated anaesthetic injection
-patients complains immediate occular
pain,restlesslees following perforation.
-intarocular hemorrhage and retinal
detachment can also occur
 Penetration of optic nerve
-direct injury to the nerve,injection
into the neural sheath with
compression ischemia
and intramural sheath hemorhage.
-can result in optic nerve atrophy and
loss of vision.
Epinephrine toxicity
- In patients with hypertension,angina
and arrthymias,it should be avoided.
 Facial nerve blocks
To prevent a raise in the intraocular
pressure due to squeezing action of
the eyelids during cataract
extraction,a temporary paralysis of the
orbicularis muscle is sometimes given.
vin lint akinesia
O’ brien akinesia
Atkinson’s akinesia
Nadbath-Ellis akinesia
O’Brien technique.
Aims at blocking the nerve at the
proximal
trunk. The mandibular condyle is
palpated inferior to the posterior
zygomatic process and anterior to the
tragus of the ear as the pateint opens and
closes his [Link] neddle is inserted
perpendicularly to the skin about 1 cm to
the [Link] the neddle is withdrawn
3 ml of anaesthetic is injected.
paralysis of the ocularis occurs in 7 mins.
Vin lent technique.
Aim at blocking the nerve at the
terminal [Link] neddle is
placed 1cm lateral to the orbital
rim,and 2 to 4 ml of anaesthetic is
injected deep on the periosteum
just lateral to the superolateral and
inferolateral orbital [Link]
disadvandages of this block is
patient discomfort,proximity to the
eye and common postoperative
ecchymosis.
Atkinson’s technique.

Injection is given at the inferior

edge of the zygomatic bone and
then upward across the zygomatic
arch towards the top of the ear.
Nadbath rehman technique
Blocks the facial nerve as it exits
from the stylomastoid [Link]
neddle is inserted perpendicularly to the
skin between the mastoid and the
posterior border of the [Link]
major disadvantage of this block is that
it is in close proximity of important
structures like carotid artery and
glossopharyngeal nerve and associated
with vocal cord
paralysis,laryngospasm,dysphagia and
respiratory arrest
A, Van Lint
akinesia. B,
O'Brien
akinesia
C, Atkinson
akinesia
D, Nadbath-
Ellis akinesia
 Drugs use in block
Lidocaine 2%
Mix of lidocaine 2% and bupivacaine
0.75 % or 0.5%
Ropivacaine
Hyaluronidase is added to improve
the local drug distribution
Epinephrine in the conc of 1:200000
can be use to prolong the duration of
local.
 Monitored anaesthesia for cataract surgery
It is the use of local anaesthesia in
combination with intravenous sedation.
Intravenous sedation using minimal
doses of propofol(30 to 100mg slowly)or
a short acting barbiturate (10-20 mg of
methohexital or 25-75 mg of
thiopental)can be use.
Midazolam 1 to 2 mg with fentanyl 12.5
to 25 µ is a common regimen.
Deep sedation is avoided,minimal
relaxation and amnesia is maintained to
avoid the risk of apnea.
 Sub-tenons block
-Tenons fasica covers the globe and
the extraocular muscles.
Local anaesthesia injected beneath it
diffuses into the retrobulbar space.
Complications of tenons block is
comparatively less when compared to
retro and peribulbar block.
 Topical anaesthesia

4% xylocaine or proparacaine 1% is
use.
The local drop is applied at an
interval of 5 min for 5 applications.
Topical anaesthesia and subtenons
block requires surgical skill because
these techniques is deprived of
akinesia.
 Special consideration in
general anaesthesia
Maintain low IOP
Check for OCR
Smooth induction and emergence and
adequate deep anaesthesia till the end
of the surgery
 General anaesthesia
Required in children undergoing cataract surgery
premedication:anxiolyitcs midazolam +pyrolate
Induction: Thiopentone + rocuronium
Intubation: Smooth laryngoscopy & intubation(prior to intubation
iv lidocaine(1.5 mg/kg) or an opiod eg fentanyl 2µg/kg,
ramifentanil 0.5 to 1µg/kg or alfentanil 20 µg/kg can be used.
Maintenance:O2 +N2O+Isoflurane/halothane IPPV with Non-
depolarising muscle relaxant.
The possibilty of kinking and obstruction of the tube can be
minimised by using right angle endotracheal tube
ECG minotoring should be done for
OCR
Infant body temperature often
rises during opthalmic surgery
because of head to toe draping
and insignificiant body surface
[Link] temperature and
capnography monitoring should be
done.
Monitoring: pulse oximetry,capnography,
ECG and temperature probe.
PONV : metoclopromide or ondansetron
Reversal : Neostigmine +
atropine ,extubate in deeper planes and
the patient should be kept deep till the
eye is [Link] ic agent may
be continued till the suctioning of the
airways.
Problems encountered: Dark room
face inaccessible
Cataract is associated with pediatric
syndromes
-trisomy 21 -hypothyroidism
-myotonic dystrophy -diabetes mellitus
-pierre robin syndrome -G6PD deficiency.
-phenylketonuria
-homocystinuria
-lowes syndrome
-rubella
-sarcoidosis
-galactosemia
 Gradual painless decrease in
vision
Refractive errors
Corneal dystropies
Keratoconus
Open angle glaucoma
Cataract
optic nerve compressing lesions
Nutritional/toxic neuropathies
Diabetic retinopathy