ANESTHESIA AND ANALGESIA . . . Current Researches VOL.56, No. 3, MAY-JUNE,1977
363
Corneal Abrasions During General Anesthesia YATINDRA
K.
BATRA, MBBS*
INDER M. BALI, MS (Surg), MS (Anaelsth), PhD, FFARCSt Chandigarh, India$
The eyes of 200 healthy adult patients undergoing general anesthesia were stained with fluoresceinstrips for detection of corneal abrasion in the immediate postoperative period. Twenty-six of 59 patients in whom the eyes remained partly open showed positive staining -an incidence of 44 percent. The remaining
anesthesia.
C
with vaseline gauze in 25. No eye ointment or other medication was used.
abrasion has been mentioned as the most frequent ophthalmic complication following general anesthesia.lY2 Some of these may be the result of direct trauma, like rubbing of the cornea by surgical drapes or a part of the anesthetic mask.3 Most, however, are probably due to the drying effect of the exposed cornea.4 Scanning the literature, it is strange to find little information regarding the incidence of this complication, and it is for this reason that the present study was undertaken. ORNEAL
METHODS
141 patients in whom the eyes were naturally closed or protected with adhesive tape or vaseline gauze did not develop exposure keratitis. It is suggested that covering of eyes is necessary in all cases undergoing general anesthesia so as to avoid this frequent complication of
Anesthesia was induced with thiopental (5 mglkg) , and ventilation was controlled with the help of an endotracheal tube passed after succinylcholine ( 1mg/kg) administration. No volatile anesthetic agent was used. For analgesia, small supplements of morphine or diazepam were added. The temperature and humidity of the operating theatre was kept constant at 24" C and 55 percent, respectively, and at no time was a direct draught of air permitted to strike the eyes.
This investigation was done with 200 adult patients scheduled for elective surgery under general anesthesia. None had any previous corneal pathology.
The eyes were examined for corneal abrasion under good direct light a t the end of the anesthetic period in the recovery room. Sterile strips impregnated with fluorescein Patients were divided into 2 equal groups were used for staining. The tip of the strip (table 1). Of the 100 patients in whom the was touched to the inner surface of the lower eyes were left uncovered, the eyes remained lid for half a minute and, as the patient partly open in 59, while in the remaining 41, closed the eyes, dye spread well into the there was natural approximation of the eye- tear film. The denuded area of corneal epilids. Of the 100 patients whose eyes were thelium was stained brilliant green, whereas deliberately closed, simple adhesive tape the normal surface was left unaltered. This was used in 75 and the eyes were protected was considered positive staining. *Senior Registrar. ?Associate Professor. $Department of Anaesthesiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Paper received: 7/30/76 Accepted for publication: 9/3/76
ANESTHESIA AND ANALGE~IA . . . Current Researches VOL.56, No. 3, MAY-JUNE,1977
364
TABLE 1 Patients Studied: Clinical Data Sex
Number of cases
Group
I: Eyes uncovered Partly open Naturally closed Total
Duration of anesthesia, min Mean rk SD
M
F
Age. Yr
59
25
34
34 t 13
128 rt 52
41
20
21
33 2 14
97 -I 44
100
45
55
75
42
33
36 k 15
162 rt 87
12
13 -46
34 t 13
155 rt 64
11: Eyes covered Adhesive tape Vaseline gauze
25
Total
-
-
100
54
TABLE 2 Results of Fluorescein Staining Number of cases
Group
I: Eyes uncovered Partly open Naturally closed 11: Eyes covered Adhesive tape
Vaseline gauze Total
Stain Positive
Negative
Unilateral
Bilateral
59
26 (44%)
33
10
16
41
Nil
41
-
-
75
Nil
75
-
-
-
-
-
25
-
200
26
174
10
25
Nil
16
RESULTS In 59 cases, where the eyes were partly open, 26 patients showed positive staining due to corneal exposure, an incidence of 44 percent. In 16 patients of this group, both eyes were involved (table 2).
N y1
w 0
2g
z w V
None of the patients where the eyes were naturally closed or covered with adhesive tape or vaseline gauze showed positive staining. It was observed that the maximum incidence of corneal abrasion (25%) was seen when the duration of anesthesia was between 90 to 150 minutes (fig 1). Three patients complained of foreignbody sensation and watering of eyes; all these were treated with eye patch and local antibiotic ointment. Within 24 hours, the abrasions, irrespective of their nature, had completely healed.
U a
w e g g
m
w
: n V 0
30
60 90 I 2 0 I50 I80 210 240 n0 300 330 360
TIME
I N MINUTES
FIG1. Percentage distribution of cases showing positive fluorescein staining in relation to duration of anesthesia. ( 1 = number of cases.
was left exposed. The characteristics of these abrasions varied; in some they occuIn all positive cases, the staining was pied only a part of the cornea while in present in the inferior third of cornea (cres- others, the entire lower third of the cornea cent shaped) as this was the only area that was involved (fig 2).
Corneal Abrasions
A
. . . Batra and Bali
365
B
FIG 2. Typical crescent-shaped corneal surface, showing patterns of corneal abrasion seen after eye exposure during general anesthesia: A--complete abrasion; B-scattered abrasion.
DISCUSSION This study shows that eyelid closure, whether naturally or by adhesive tape and vaseline gauze, prevents the cornea from being exposed to room air. Even when the eyelids were only partly open, a trauma incidence of 44 percent was found. Other causes responsible for ocular injury during anesthesia, documented by various workers,2,3~5,Finclude trauma to the eyes by the hands or fingernails of anesthesiologists during laryngoscopy or intubation, pressure by instrument or surgeons’ hands on an open eye, irritant effects of anesthetic agents like ether or ophthalmic hypersensitivity to halothane, sitting or prone position of the patient in certain neurosurgical or orthopedic operations, spillage of sterilizing solutions during skin preparation for head or neck operations, failure to instill saline
or other appropriate solution during ophthalmic procedures, and/or failure to guard anatomically prominent eyes in proptosis or exophthalmos. All the above conditions may strip the corneal epithelium from Bowman’s membrane and produce foreign-body sensation, tearing, photophobia, and ocular pain. Secondary infection, while rare, may also lead to corneal ulcers.
CONCLUSIONS It is suggested that approximation of the eyelids, either with adhesive tape or vaseline gauze, is mandatory in general anesthesia to avoid the risk of iatrogenic corneal abrasions.
REFERENCES 1. Duncalf D, Rhodes DH: Anesthesia in Clinical Ophthalmology. Baltimore, The Williams & Wilkins Company, 1963, pp 143-145
2. Snow JC, Kripke BJ, Norton ML, et al: Corneal injuries during general anesthesia. Anesth Analg 54:465-467, 1975 3. Terry HR, Kearns TP, Love JG, et al: Untoward ophthalmic and neurologic events of anesthesia. Surg Clin North Am 45:927-929, 1965 4. Dripps RD, Eckenhoff J E , Vandam LD: Introduction to Anesthesia. Principles of Safe Practice. Fourth edition. Philadelphia, WB Saunders Company, 1972, pp 362-363
5. Wylie WD, Churchill-Davidson HC: A Practice of Anaesthesia. Third edition. Lloyd-Luke, London, 1972, p 1266
6. Boyd CH: Ophthalmic hypersensitivity to anaesthetic vapour. Anaesthesia 27: 456-457, 1972
363
Corneal Abrasions During General Anesthesia YATINDRA
K.
BATRA, MBBS*
INDER M. BALI, MS (Surg), MS (Anaelsth), PhD, FFARCSt Chandigarh, India$
The eyes of 200 healthy adult patients undergoing general anesthesia were stained with fluoresceinstrips for detection of corneal abrasion in the immediate postoperative period. Twenty-six of 59 patients in whom the eyes remained partly open showed positive staining -an incidence of 44 percent. The remaining
anesthesia.
C
with vaseline gauze in 25. No eye ointment or other medication was used.
abrasion has been mentioned as the most frequent ophthalmic complication following general anesthesia.lY2 Some of these may be the result of direct trauma, like rubbing of the cornea by surgical drapes or a part of the anesthetic mask.3 Most, however, are probably due to the drying effect of the exposed cornea.4 Scanning the literature, it is strange to find little information regarding the incidence of this complication, and it is for this reason that the present study was undertaken. ORNEAL
METHODS
141 patients in whom the eyes were naturally closed or protected with adhesive tape or vaseline gauze did not develop exposure keratitis. It is suggested that covering of eyes is necessary in all cases undergoing general anesthesia so as to avoid this frequent complication of
Anesthesia was induced with thiopental (5 mglkg) , and ventilation was controlled with the help of an endotracheal tube passed after succinylcholine ( 1mg/kg) administration. No volatile anesthetic agent was used. For analgesia, small supplements of morphine or diazepam were added. The temperature and humidity of the operating theatre was kept constant at 24" C and 55 percent, respectively, and at no time was a direct draught of air permitted to strike the eyes.
This investigation was done with 200 adult patients scheduled for elective surgery under general anesthesia. None had any previous corneal pathology.
The eyes were examined for corneal abrasion under good direct light a t the end of the anesthetic period in the recovery room. Sterile strips impregnated with fluorescein Patients were divided into 2 equal groups were used for staining. The tip of the strip (table 1). Of the 100 patients in whom the was touched to the inner surface of the lower eyes were left uncovered, the eyes remained lid for half a minute and, as the patient partly open in 59, while in the remaining 41, closed the eyes, dye spread well into the there was natural approximation of the eye- tear film. The denuded area of corneal epilids. Of the 100 patients whose eyes were thelium was stained brilliant green, whereas deliberately closed, simple adhesive tape the normal surface was left unaltered. This was used in 75 and the eyes were protected was considered positive staining. *Senior Registrar. ?Associate Professor. $Department of Anaesthesiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Paper received: 7/30/76 Accepted for publication: 9/3/76
ANESTHESIA AND ANALGE~IA . . . Current Researches VOL.56, No. 3, MAY-JUNE,1977
364
TABLE 1 Patients Studied: Clinical Data Sex
Number of cases
Group
I: Eyes uncovered Partly open Naturally closed Total
Duration of anesthesia, min Mean rk SD
M
F
Age. Yr
59
25
34
34 t 13
128 rt 52
41
20
21
33 2 14
97 -I 44
100
45
55
75
42
33
36 k 15
162 rt 87
12
13 -46
34 t 13
155 rt 64
11: Eyes covered Adhesive tape Vaseline gauze
25
Total
-
-
100
54
TABLE 2 Results of Fluorescein Staining Number of cases
Group
I: Eyes uncovered Partly open Naturally closed 11: Eyes covered Adhesive tape
Vaseline gauze Total
Stain Positive
Negative
Unilateral
Bilateral
59
26 (44%)
33
10
16
41
Nil
41
-
-
75
Nil
75
-
-
-
-
-
25
-
200
26
174
10
25
Nil
16
RESULTS In 59 cases, where the eyes were partly open, 26 patients showed positive staining due to corneal exposure, an incidence of 44 percent. In 16 patients of this group, both eyes were involved (table 2).
N y1
w 0
2g
z w V
None of the patients where the eyes were naturally closed or covered with adhesive tape or vaseline gauze showed positive staining. It was observed that the maximum incidence of corneal abrasion (25%) was seen when the duration of anesthesia was between 90 to 150 minutes (fig 1). Three patients complained of foreignbody sensation and watering of eyes; all these were treated with eye patch and local antibiotic ointment. Within 24 hours, the abrasions, irrespective of their nature, had completely healed.
U a
w e g g
m
w
: n V 0
30
60 90 I 2 0 I50 I80 210 240 n0 300 330 360
TIME
I N MINUTES
FIG1. Percentage distribution of cases showing positive fluorescein staining in relation to duration of anesthesia. ( 1 = number of cases.
was left exposed. The characteristics of these abrasions varied; in some they occuIn all positive cases, the staining was pied only a part of the cornea while in present in the inferior third of cornea (cres- others, the entire lower third of the cornea cent shaped) as this was the only area that was involved (fig 2).
Corneal Abrasions
A
. . . Batra and Bali
365
B
FIG 2. Typical crescent-shaped corneal surface, showing patterns of corneal abrasion seen after eye exposure during general anesthesia: A--complete abrasion; B-scattered abrasion.
DISCUSSION This study shows that eyelid closure, whether naturally or by adhesive tape and vaseline gauze, prevents the cornea from being exposed to room air. Even when the eyelids were only partly open, a trauma incidence of 44 percent was found. Other causes responsible for ocular injury during anesthesia, documented by various workers,2,3~5,Finclude trauma to the eyes by the hands or fingernails of anesthesiologists during laryngoscopy or intubation, pressure by instrument or surgeons’ hands on an open eye, irritant effects of anesthetic agents like ether or ophthalmic hypersensitivity to halothane, sitting or prone position of the patient in certain neurosurgical or orthopedic operations, spillage of sterilizing solutions during skin preparation for head or neck operations, failure to instill saline
or other appropriate solution during ophthalmic procedures, and/or failure to guard anatomically prominent eyes in proptosis or exophthalmos. All the above conditions may strip the corneal epithelium from Bowman’s membrane and produce foreign-body sensation, tearing, photophobia, and ocular pain. Secondary infection, while rare, may also lead to corneal ulcers.
CONCLUSIONS It is suggested that approximation of the eyelids, either with adhesive tape or vaseline gauze, is mandatory in general anesthesia to avoid the risk of iatrogenic corneal abrasions.
REFERENCES 1. Duncalf D, Rhodes DH: Anesthesia in Clinical Ophthalmology. Baltimore, The Williams & Wilkins Company, 1963, pp 143-145
2. Snow JC, Kripke BJ, Norton ML, et al: Corneal injuries during general anesthesia. Anesth Analg 54:465-467, 1975 3. Terry HR, Kearns TP, Love JG, et al: Untoward ophthalmic and neurologic events of anesthesia. Surg Clin North Am 45:927-929, 1965 4. Dripps RD, Eckenhoff J E , Vandam LD: Introduction to Anesthesia. Principles of Safe Practice. Fourth edition. Philadelphia, WB Saunders Company, 1972, pp 362-363
5. Wylie WD, Churchill-Davidson HC: A Practice of Anaesthesia. Third edition. Lloyd-Luke, London, 1972, p 1266
6. Boyd CH: Ophthalmic hypersensitivity to anaesthetic vapour. Anaesthesia 27: 456-457, 1972
