Peri-operative Corneal Abrasion

R4 ⾬寰

• Injury: • Airway • Eye • Nerves • Muscles and Skin

• Typically arises as a result of extrinsic force applied to the patient

• Many physical injuries occur as a result of human error.

• These injuries can be reduced in frequency and severity through education, training, and quality assurance.

PHYSICAL INJURIES

INJURY TO THE EYE

• Injuries to the eye after non-ocular surgery occur in <0.1% of anaesthetics.

• Risk factors: • Lateral and prone positions • Prolonged surgery • Surgery to the head or neck

• The most common ocular complication: Corneal abrasion

• Definition: Injury to the epithelial layer of the cornea and typically heals within 72 hours

• The cornea contains the most richly innervated tissue • Nerve terminal density 300-400 times greater than skin

• All corneal stimuli (mechanical, chemical, thermal) are perceived as painful

CORNEAL ABRASION

• Abrasions are caused by direct trauma, inadvertent chemical irritation, or exposure keratopathy(EK)

• EK: Damage to the cornea that occurs primarily from prolonged exposure of the ocular surface to the outside environment

• Symptomatic corneal abrasions cause pain, a sensation of grit in the eye, tearing, redness, and photophobia

• May also result in a reduction in vision

• The diagnosis is confirmed using fluorescein staining of the cornea under direct ophthalmoscopy or slit lamp examination

CORNEAL ABRASION

• The threshold for epithelial injury is lower in the unconscious surgical patient • Protective mechanisms are diminished by general anesthesia

• Tear production is reduced with reduction in tear-film stability • Causes corneal epithelial drying and exposes the cornea to direct trauma

• The inner surface of the upper eyelid becomes more adherent to the cornea • Causes injury when the eye is re-opened

ANESTHESIA RELATED…

• the anesthetist ensures that the eyes are fully closed and remain closed throughout the procedure

• Trivial contact can result in corneal abrasions

• Iatrogenic injury of the eyelids is common • Bruising (frequently) and tearing (rarely) of the eyelid can occur when the

adhesive dressing is removed

• Others: (related to General anesthesia) • Suppresses autonomic reflexes (eg. corneal reflex, reflex tearing)

• Increases lagophthalmos (incomplete eyelid closure)

ANESTHESIA RELATED…

RISK

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DIAGNOSIS

• An abrupt pain onset

• Describe a foreign body sensation and excessive tearing, blurry vision, or photophobia

• Need to rule out the presence of a foreign body first =>Removal can be attempted with irrigation, topical anesthetic, or a cotton swab

• Visual acuity, pupil examination, extra-ocular movements should be documented

DIAGNOSIS

• Corneal edema from an abrasion can affect vision but should not cause significant vision loss

• Do not cause persistent visual changes or worsening vision after the immediate post-injury period

• With uncomplicated wound healing, pain improves significantly after the first 24 hours and should be resolved after 48-72 hours

• Any findings atypical for corneal abrasion warrant immediate ophthalmologic consultation

OPHTHALMOLOGIC CONSULTATION

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TREATMENT

• Treatment requires pain control, antimicrobial prophylaxis, close monitoring • Eye drops, ointments and an eye patch, pain-relieving medicines ma be used

• No surgical treatment is necessary

• Visiting ophthalmologist could be considered

TREATMENT

PREVENTION

•No single method to prevent corneal abrasions is 100% effective

•Various strategies themselves may be associated with morbidity

PREVENTION

• Tape is generally sufficient • High-risk cases (e.g., Trendelenburg position) may benefit from use of transparent dressings, such as Tegaderm

• Chemical irritation by regurgitated gastric contents can be mitigated by premedication with proton pump inhibitors and meticulous taping of the eyes

• The adhesive strength may change with body temperature and over-time operation

• Cause the adhesive to stop working and become gooey, allowing the eyelids to move apart, and leaving behind a sticky residue

• Removal of tapes may result in eyelid bruising, tears, or eyelash removal

PREVENTION

• Ocular lubricants support surface moisture • Preservative-free methylcellulose-based ointments are preferred • Prolong tear breakup time and have a low complication rate • Paraffin-based ointments disrupt stability, and carry a higher risk of eye irritation

• There is no advantage to combining lid taping and lubrication over using lid taping alone

PREVENTION

• No single method to prevent corneal abrasions is 100% effective and the various protective strategies themselves may be associated with morbidity

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REFERENCE

1. Physical injuries during anaesthesia, BJA Education, 2018

2. A Department-of-anesthesiology-based management protocol for perioperative corneal abrasions, Clinical Ophthalmology, 2015

3. Corneal abrasion following anaesthesia for non-ocular surgical procedures: A case-controlled study, Journal of Perioperative Practice, 2016

4. Care of the eye during anaesthesia and intensive care, Anaesthesia and Intensive Care Medicine, 2014

5. Comparison of eye protection methods for corneal abrasion during general anesthesia , Anesthesiology and Pain Medicine, 2016

6. Perioperative Corneal Abrasion: Updated Guidelines for Prevention and Management, 2016

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