Summary
The major factors controlling intraocular pressure during surgery are the dynamic balance between aqueous humour production in the ciliary body and its elimination via the canal of Schlemm; the autoregulation and chemical control of choridal blood volume; the extraocular muscle tone and vitreous humour volume. Prior to surgical incision of the anterior chamber in open intraocular procedures, a low-normal intraocular pressure is mandatory to avoid the hazards of iris or lens prolapse and vitreous loss associated with sudden decompression. In general, the central nervous system depressant drugs, hypnotics, narcotics, major tranquillizers, volatile anaesthetic agents are associated with a reduction in intraocular pressure, with the exception of ketamine and possibly trichloroethylene.
The mechanism of action of anaesthetic agents in reducing intraocular pressure may involve a direct effect on central diencephalic control centres, reduction of aqueous production, facilitation of aqueous drainage or relaxation of extraocular muscle tone. Succinylcholine administration is associated with a significant rise in intraocular pressure, with a peak increase between two to four minutes following administration and a return to base line values after six minutes. The intraocular hypertensive effect may be due to a tonic contraction of the extraocular muscles, choroidal vascular dilatation or relaxation of orbital smooth muscle. Despite many claims to the contrary, no reported method to date has been shown to consistently prevent the intraocular hypertensive response to intravenous succinylcholine administration.
Because the non-depolarizing relaxants are associated with a reduced intraocular pressure, a barbiturate-non-depolarizing relaxant technique utilizing preoxygenation and cricoid pressure has evolved as the most commonly employed induction technique for the emergency repair of a penetrating eye injury. The alternative non-depolarizing relaxant pretreat-ment-barbiturate-succinylcholine technique may offer the advantages of more rapid onset of relaxation with only minor increases in intraocular pressure and in a carefully controlled rapid sequence induction technique may be the most acceptable method of handling emergency penetrating eye injuries.
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References
Foulds WS. The changing pattern of eye surgery. Br J Anaesth 1980; 52:643–7.
Stark WJ, Leske ML, Worthen DM, Murray GG. Trends in cataract surgery and intraocular lenses in the United States. Am J Ophthalmol 1983; 96:304–10.
Aaberg TM. Changing perspectives on vitrectomy for complications of diabetic retinopathy. Am J Ophthalmol 1983; 95:115–7.
Adams AK, Jones RM. Anaesthesia for eye surgery: general considerations. Br J Anaesth 1980; 62:663–9.
Duncalf D. Anesthesia and intraocular pressure. Bull N Y Acad Med 1975; 51:374–9.
Donlon JV. Anesthesia for ophthalmic surgery.In: Anesthesia. Eds. Miller RD. 39, p. 1265–86. Churchill Livingstone, New York, 1981.
Adler FH. Physiology of the eye: clinical application. Mosby, St. Louis, 1970.
Aboul-Eish E. Physiology of the eye pertinent to anaesthesia.In: International Ophthalmology Clinics, eds. Smith RB. pp. 1–18, 1973.
Scurr C., Feldman S. Scientific foundations of anaesthesia. FA Davis Company, Philadelphia, pp 1–24, 1970.
Rohen JW, Lutjen E, Barany E. The relationship between the ciliary muscle and the trabacular mesh-work and its importance for the effect of miotics on aqueous outflow resistance. Arch Ophthalmol 1967; 172:23–47.
Jay JL. Functional organization of the human eye. Br J Anaesth 1980; 52:649–54.
Adams AD, Barnett KC. Anaesthesia and intraocular pressure. Anaesthesia 1966; 21:202–10.
Schroeder M, Linssen GH. Intraocular pressure and anaesthesia. Anaesthesia 1972; 27:165–70.
Macri FJ. Vascular pressure relationship and intraocular pressure. Arch Ophthalmol 1961; 65:571–4.
MacDiarmid JR, Holloway KB. Factors affecting intraocular pressure. Proc R Soc Med 1976; 69:601–2.
Wilson TM, Stang R, McKenzie FT. The response of the choroidal and cerebral circulation to changing arterial PCO2 and acetazolamide in the baboon. Invest Ophthalmol Vis Sci 1977; 16:576–82.
Duncalf D, Weitzner SW. The influence of ventilation and hypercapnea on intraocular pressure during anesthesia. Anesth Analg 1963; 42:232–46.
Smith RB, Aass AA, Nemoto EM. Intraocular and intracranial pressure during respiratory alkalosis and acidosis. Br J Anaesth 1981; 53:967–71.
Petounis AD, Chondreli S, Vadaluka-Sekioti A. Effect of hypercapnea and hyperventilation on human intraocular pressure during general anaesthesia following acetazolamide administration. Br J Ophthalmol 1980; 64:422–5.
Krupin T, Oestrich C, Bass J, Podos S, Becker B. Acidosis, alkalosis and aqueous humour dynamics in rabbits. Invest Ophthalmol 1977; 16:997–1001.
Marcus DK, rubin T, Podos S, Becker B. The effect of exercise on intraocular pressure. I. Human Beings. Invest Ophthalmol 1970; 9:749–52.
Becker B. The mechanism of the fall in intraocular pressure induced by the carbonic anhydrase inhibitor, Diamox. Am J Ophthalmol 1955; 39:178–84.
Saltzman HA, Anderson B, Hart L, Duffy E, Becker HO. The retinal vascular functional response to hy-perbaric oxygenation.In: Hyperbaric oxygenation. Proceedings of the Second International Congress. Livingstone; London, pp. 202, 1965.
Von Sallmann L, Lowenstein O. Responses of intraocular pressure, blood pressure and cutaneous vessels to electrical stimulation in the diencephalon. Am J Ophthalmol 1955; 39:11–29.
Holloway KB. Control of the eye during general anaesthesia for intraocular surgery. Br J Anaesth 1980;52:671–9.
Stinson TW, Donlon JV. The interaction of intraocular air and sulfur hexafluoride with nitrous oxide: a computer simulation. Anesthesiology 1982; 56:385–8.
Wolf GL, Capuano Harting J. Nitrous oxide increases intraocular pressure after intravitreal sulphur hexafluoride injection. Anesthesiology 1983; 59:547–8.
LeMay M. Aspects of measurement in ophthalmology. Br J Anaesth 1980; 52:655–62.
Perkins ES. Hand held applanation tonometer. Br J Ophthalmol 1965; 49:591–3.
Schiotz HJ. Tonometry. Br J Ophthalmol 1925; 9:1–2.
Langham ME, McCarthy E. A rapid pneumatic applanation tonometer. Arch Ophthalmol 1968; 71:389–95.
Cooper RL, Beale D. Radiotelemetry of intraocular pressure in vitro. Investigative Ophthalmology 1977; 16:168–71.
Kornbueth W, Aladjemoff L, Magora F, Gabbay A. Influence of general anaesthesia on intraocular pressure in man. Arch Ophthalmol 1959; 61:84–7.
Magora F, Collins VJ. The influence of general anaesthetic agents on intraocular pressure in man. Arch Ophthalmol 1961; 66:806–11.
Al-Abrak MH, Samuel JR. Further observations on the effects of general anaesthesia on intraocular pressure in man. Halothane in nitrous oxide and oxygen. Br J Anaesth 1974; 46:756–9.
Adams AP, Freedman A, Henville JD. Normocapnic anaesthesia for intraocular surgery. Br J Ophthalmol 1979;63:204–10.
Al-Abrak MH, Samuel JR. Effects of general anaesthesia on intraocular pressure in man. Trichloro-ethylene in nitrous oxide and oxygen. Br J Ophthalmol 1975; 59:107–10.
Rose NM, Adams AP. Normocapnic anaesthesia with enflurance for intraocular surgery. Anaesthesia 1980; 35:569–75.
Runciman JC, Bowen-Wright RM, Welsh NH, Downing JW. Intraocular pressure changes during halothane and enflurane anaesthesia. Br J Anaesth 1978;50:371–4.
Ausinsch B, Graves SA, Munson ES, Levy NS. Intraocular pressure in children during isoflurane and halothane anesthesia. Anesthesiology 1975; 42:167–72.
Joshi C, Bruce DL. Thiopental and succinylcholine: action on intraocular pressure. Anesth Analg 1975; 54:471–5.
DeRoeth A, Schwartz H. Aqueous humour dynamics in glaucoma. Arch Ophthalmol 1956; 55:755–60.
Thompson MF, Brock-Utne JG, Bean P, Welsh N, Downing JW. Anaesthesia and intraocular pressure: a comparison of total intravenous anaesthesia using etomidate with conventional inhalational anaesthesia. Anaesthesia 1982; 37:758–61.
Yoshikawa K, Murai Y. The effect of ketamine on intraocular pressure in children. Anesth Analg 1971; 50:199–200.
Peuler M, Glass DD, Arens JF. Ketamine and intraocular pressure. Anesthesiology 1975; 5:575–8.
Ausinch B, Rayborn RL, Munsen ES, Levy NS. Ketamine and intraocular pressure in children. Anesth Analg 1976; 55:773–5.
Ivankovich AD, Lowe HJ. The influence of methoxy-flurane and neuroleptanesthesia on intraocular pressure in man. Anesth Analg 1969; 48:933–9.
Presbitero JV, Ruiz RS, Rigor BM, Drouilhet JH, Reilly EL. Intraocular pressure during enflurance and neurolept anesthesia in adult patients undergoing ophthalmic surgery. Anesth Analg 1980; 59:50–4.
Leopold IH. Effect of intramuscular administrarion of morphine, atropine, scopolamine and neostig-mine on the human eye. Arch Ophthalmol 1948; 40:285–90.
Lincoff HA, Ellis CH, DeVoe AG et al. The effect of succinylcholine on intraocular pressure. Am J Ophthalmol 1955; 40:501–10.
Hoffman H, Holzer H. Die Wirkung Von Muskel-relaxantien auf den intraokularen Druck Klin Monatsbl Augenheilk 1953; 123:1–16.
Pandley K, Badola RP, Kumar S. Time course of intraocular hypertension produced by suxametho-nium. Br J Anaesth 1972; 44:191–6.
Cook JH. The effect of suxamethonium on intraocular pressure. Anaesthesia 1981; 36:359–65.
Dillon JB, Sabawala P, Taylor DB, Gunter R. Depolarizing neuromuscular blocking agents and intraocular pressure in vivo. Anesthesiology 1957; 18:439–42.
Hess A, Pilar G. Slow fibers in the extraocular muscles of the cat. J Physiol 1963; 169:780–98.
Miller JE. Cellular organization of rhesus extra-ocular muscle. Invest Ophthalmol 1967; 6:18–39.
Self WG, Ellis P. The effect of general anesthetic agents on intraocular pressure. Survey Ophthalmol 1977; 21:494–9.
Bjork A, Halldin M, Wahlin A. Enophthalmos elicited by succinylcholine. Acta Anaesthesiol Scand 1957; 1:41–53.
Carballo AS. Succinylcholine and acetazolamide (Diamox) in anaesthesia for ocular surgery. Can Anaesth Soc J 1965; 12:486–98.
Miller RD, Way WL, Hickey RF. Inhibition of succinylcholine-induced intraocular pressure by non-depolarizing muscle relaxants. Anesthesiology 1968; 29:123–6.
Myers EF, Krupin T, Johnson M, Zink H. Failure of non-depolarizing neuromuscular blockers to inhibit succinylcholine-induced increased intraocular pressure - a controlled study. Anesthesiology 1978; 48:149–51.
Bowen DJ, McGrand JC, Hamilton AG. Intraocular pressures after suxamethonium and endotracheal intubation. Anaesthesia 1978; 33:518–22.
Verma RS. “Self-taming” of succinylcholine-in-duced fasciculations and intraocular pressure. Anesthesiology 1979; 50:245–7.
Myers EF, Singer P, Otto A. A controlled study of the effect of succinylcholine self-taming on intraocular pressure. Anesthesiology 1980; 53:72–4.
Cunningham AJ, Albert O, Cameron J, Watson AG. The effect of intravenous diazepam on rise of intraocular pressure following succinylcholine. Can AnaesthSocJ 1981;28:591–6.
Cunningham AJ. Oiazepam and intraocular pressure. Anaesthesia 1983; 38:814–5.
Feneck RO, Cook JH. Failure of diazepam to prevent the suxamethonium-induced rise in intraocular pressure. Anaesthesia 1983; 38:120–7.
Stoelting RK. Circulatory changes during direct laryngoscopy and tracheal intubation. Anesthesiology 1977; 47:381–8.
Stoelting RK. Blood pressure and heart rate changes during short duration laryngoscopy for tracheal intubation: influence of viscous or intravenous lido-caine. Anesth Analg 1978; 57:197–9.
Smith RB, Babinski M, Leano N. The effect of lido-caine on succinylcholine-induced rise in intraocular pressure. Can Anaesth Soc J 1979; 26:482–3.
Al-Abrak MH, Samuel JR. Effects of general anaesthesia on the intraocular pressure in man. Comparison of tubocurarine and pancuronium in nitrous oxide and oxygen. Br J Ophthal 1974; 58:806–10.
Litwiller RW, Difazio CA, Rushia EL. Pancuronium and intraocular pressure. Anesthesiology 1975; 42:750–2.
Cunningham AJ, Kelly CP, Farmer J, Watson AG. The effect of metocurine and metocurine-pancu-ronium combination on intraocular pressure. Can Anaesth Soc J 1982; 29:617–21.
Haigh JD, Nemoto EM, Bleyaert AL. Influence of atracurium and succinylcholine on intraocular pressure and intracranial hypertension in monkeys. Anesthesiology 1984; 61:A 371.
Maharaj RJ, Humphrey D, Kaplan N et al. Effects of atracurium on intraocular pressure. Br J Anesth 1984; 56:459–62.
Burn RA, Knight P. Anaesthesia in ophthalmic surgery. Br J Hosp Med 1969; 2:1527–44.
Lynch S, Wolf GL, Berlin I. General anesthesia for cataract surgery: a comparative review of 2217 consecutive cases. Anesth Analg 1974; 53:909–13.
Backer CL, Tinker JH, Robertson DM. Myocardial reinfarction following local anesthesia. Anesthesiology 1979; 51:S61.
Mirakhur RK, Clarke RSJ, Dundee JW, McDonald JR. Anticholinergic drugs in anaesthesia - a survey of their present position. Anaesthesia 1978; 33:133–8.
Blanc VF, Hardy JF, Milot J, Jacob JL. Theoculo-cardiac reflex: a graphic and statistical analysis in infants and children. Can Anaesth Soc J 1983; 30:360–9.
Cozanitis DA, Dundee JW, Buchanan TAS, Archer DB. Atropine versus glycopyrrolate. Anaesthesia 1979; 34:236–8.
Schwartz H, de Roeth A, Papper EM. Pre-anes-thetic use of atropine in patients with glaucoma. JAMA 1957; 165:144–6.
Steward DJ. Anticholinergic premedication for infants and children. Can Anaesth Soc J 1983; 30:325–6.
Schwartz H. Oculocardiac reflex: is prophylaxis necessary?In Mark, LC and Ngai SH eds: Highlights of Clinical Anesthesiology, pp. 111–4. Harper and Row, New York, 1971.
Hvidberg A, Kessing SW, Fernandes A. Effect of changes in and body position on intraocular pressure during general anaesthesia. Acta Ophthalmol 1981;59:465–75.
Rawstron RE, Hutchinson BR. Pupillary and circulatory changes at the termination of relaxant anaesthesia. Br J Anaesth 1963; 35:795–802.
Duncalf D, Rhodes DH. Anaesthesia in Clinical Ophthalmology, pp. 3. Williams and Wilkins, Baltimore, 1963.
Cameron AE. Intraocular pressure too low. Anaesthesia 1982; 37:735–7.
George R, Nursingh A, Downing JW, Welsh NH. Non-depolarizing neuromuscular blockers and the eye: a study of intraocular pressure. Br J Anaesth 1979;51:789–92.
Balamoutsos NG, Tsakona H, Kanakoudes PS, Iliadelis F, Georgiades CG. Alcuronium and intraocular pressure. Anesth Analg 1983; 62:521–3.
Wolf GL, Lynch S, Berlin I. Intraocular surgery with general anaesthesia. Arch Ophthalmol 1975; 93:323–6.
Palazzo MGA, tunin L. Anaesthesiaandemesis.il: prevention and management. Can Anaesth Soc J 1984;31:407–15.
Cunningham AJ, Slazenger M. Aspiration pneumonia - Mendelson syndrome; a review. Ir Med J 1984; 77:252–5.
Foulkes E, Jenkins LC. A comparative trial of cimetidine and sodium citrate to decrease acidity: effectiveness at the time of induction of anaesthesia. Can Anaesth Soc J 1981; 28:29–31.
Williams JG. H2 receptor antagonists and anaesthesia. Can Anaesth Soc J 1983; 30:264–9.
Dobb G, Jordan MH, Williams JG. Cimetidine in prevention of pulmonary acid aspiration syndrome. Br J Anaesth 1979; 51:967–9.
James WB, Hume R. Action of metoclopramide on gastric emptying and small bowel transit time. Gut 1968; 9:203–5.
Iwomoto K, Schwartz H. Antiemetic effect on droperidol after ophthalmic surgery. Arch Ophthal-mol 1978; 96:1378–9.
Brown EM, Krishnaprasad D, Smiler BG. Pan-curonium for rapid induction technique for tracheal intubation. Can Anaesth Soc J 1979; 26:489–91.
Fabian LW. The experts opine. What are your prime considerations in providing anesthesia for eye surgery? Survey of Anesthesiology 1979; 23:488–94.
Bennet EJ. Pancuronium bromide: a double-blind study in children. Anesth Analg 1973; 52:12–8.
Lerman J, Kiskis AA. Effects of high-dose pancuronium and endotracheal intubation on intraocular pressure in children. Anesthesiology 1984; 61:A434.
Lerman J, Kiskis AA. Effects of intravenous lido-caine and high-dose pancuronium on intraocular pressure in children. Anesth Analg 1985; 64:245.
Goudsouzian NG, Liu LMP, Cote CJ. Comparison of equipment of equipotent doses of non-depolarizing muscle relaxants in children. Anesth Analg 1981; 60:862–6.
Miller RD, Rupp SM, Fisher DM, Cronnelly R, Fahy MR, Sohn YJ. Clinical pharmacology of vecuronium and atracurium. Anesthesiology 1984; 61:444–53.
Doherty WG, Breen PJ, Donati F, Bevan DR. Accelerated onset of pancuronium with divided doses. Can Anaesth Soc J 1985; 32:1–4.
Schwarz S, Ilias W, Lackner F, Mayrhofer O, Foldes FF. Rapid tracheal intubation with vecuronium: the priming principle. Anesthesiology 1985; 62:388–91.
Mehta MP, Choi WW, Gergis SD, Sokoll MD, Adolphson AJ. Facilitation of rapid endotracheal intubations with divided doses of non-depolarizing neuromuscular blocking drugs. Anesthesiology 1985; 62:392–5.
Marshall Ban A, Thornley BA. Thiopentone and pancuronium crash induction. Anaesthesia 1978; 33:25–31.
Marshall Barr A, Thornley BA. Thiopentone and suxamethonium crash induction. Anaesthesia 1976; 31:23–9.
Konchigeri HN, Lee YE, Venugopal K. Effect of pancuronium on intraocular pressure changes induced by succinylcholine. Can Anaesth Soc J 1979;26:479–81.
Katz RL, Eakins KE, Lord CO. The effect of hexafluorenium in preventing the increase in intraocular pressure produced by succinylcholine. Anesthesiology 1978; 29:70–8.
Bruce RA, McGoldrick DE, Oppenheimer P. Anesthesia for ophthalmology. Birmingham, Aesculapius, 1982, pp. 74–5.
Libonati MM, Leahy JL, Ellison N. The use of succinylcholine in open eye surgery. Anesthesiology 1985; 62:637–40.
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Cunningham, A.J., Barry, P. Intraocular pressure -physiology and implications for anaesthetic management. Can Anaesth Soc J 33, 195–208 (1986). https://doi.org/10.1007/BF03010831
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DOI: https://doi.org/10.1007/BF03010831