CASE PRESENTATION ON

CATARACT

 NAME –Ram narayan

 AGE- 55 ,SEX- male
 OCCUPATION- farmer
 RESIDENCE- Sikar

1
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.

2
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 age.The 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.

3
PAST HISTORY :
History of chronic diseases - There is no history of
blood pressure, diabetes mellitus, asthma ,heart
diseases.There 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.

4
History of allergy and drug reaction :

There is no allergic reaction to any exogenous

materials
like,dust,fume,pollen,husk,fur,nylon,wool or food.
No history to any drug reaction

5
History of surgery – There is no past history of any
surgery in the eye or any other surgery .

6
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

7
Examination of the Eye : The patient was seated in a
erect position,without any turning of head.
Position of eyeball : central in both the eyes
Movements : movements were normal in all four
quadrants without any restriction.
Lacrimal apparatus : normal in both the eyes
Conjunctiva : normal in both the eyes
Cornea : normal in both the eyes
Anterior chamber : normal in both the eyes
Iris : normal colour
Pupil : round ,regular and reactive in both the eyes
lens : LE;greyish white pupilary reflex on torch light.

8
 RE; greyish reflex on torch light.
 Vision; LE :6/60 ,RE :6/36

9
 DIAGNOSIS

IMMATURE SENILE CATARACT

LE > RE

10
 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
11
Systemic examination ;
 C V S – S1& S2 normal .
No murmurs .
 Respiratory system ;
b/l air entry equal .
No added sound .
 CNS , GIT nomal

12
 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.

13
 Hb – 11.0gm/dl .
 T .L.C -11.0/cu.mm.
 B T- 3min
 C T – 4min
 E .C.G. - WNL
 Chest X Ray – NAD

14
 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
15
 Structure
 The basic lens
consists of a central
nucleus surrounded
by the cortex
contained within
the lens capsule

16
This loss of
transparency, or
opacity formation
is called Cataract

17
 Stages of senile cataract

 Immature cataract
 Mature cataract
 Hypermature cataract

18
 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

19
 Surgical management of cataract.
 Adult management of cataract
-phaco emulsification + IOL
-SICS /ECCE + IOL
-ICCE (outdated now)
 Pediatric cataract surgery
-lens aspiration/lensectomy ± IOL

20
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.

21
Before going into the anaesthetic
consideration,let us discuss two important
aspects of opthalmology from anaesthesia
point of view, IOP and oculo cardiac reflex

22
Physiology of intra ocular
pressure
INTRA-OCULAR PRESSURE
DETERMINANTS:
 Normal IOP ranges from 12-20mmhg
 Factors exerting outward pressure
 Factors exerting inward pressure

23
Intra-ocular pressure

 Aqueous humour
 Vitreous humour
 Blood within the eye
 Scleral compliance
 Extra-ocular muscle tone

24
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

25
 Drugs acting on AH mechanics

  production:
Acetozolamide (carbonic anhydrase
inhibitor)
Beta blockers
 Improve drainage:
Miotics (by contracting ciliary muscle)
Mydriatics affects drainage

26
Variable Effect on IOP

Central venous pressure

↑↑↑
Increase
Decrease ↓↓↓

Arterial blood pressure

Increase ↑
Decrease ↓
Paco2
Increase (hypoventilation) ↑↑
Decrease (hyperventilation) ↓↓

Pao2
Increase 0
Decrease ↑

27
Drug Effect on IOP

Inhaled anaesthetics
Volatial agents ↓↓
Nitrous oxide ↓

Intravenous anesthetics
Barbiturates ↓↓
Benzodiazepines ↓↓
Ketamine ↑
Opiods ↓

Muscle relaxants
Depolarizers(succinylcholine ↑↑
) 0/↓
Nondepolarizers

28
 Vitreous Humour
 Fine unstable gel consisting of water & fine
supporting structure

 Volume & pressure reduced by Mannitol which

is a dehydrating agent & there by ↓ IOP

29
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

30
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

31
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

32
 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

33
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 orbit

34
 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
35
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

36
 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.
37
 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
38
— Smooth emergence from anaesthetic
state without vomiting

— Adequate post-operative analgesia

39
 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
40
Drug Mechanism of Action Effect

Acetylcholine Cholinergic agonist (miosis) Bronchospasm, bradycardia, hypotension

Carbonic anhydrase inhibitor
Acetazolamide (decreases IOP1) Diuresis, hypokalemic metabolic acidosis

Atropine Anticholinergic (mydriasis) Central anticholinergic syndrome 2

Cyclopentolate Anticholinergic (mydriasis) Disorientation, psychosis, convulsions

Echothiophate Cholinesterase inhibitor (miosis, Prolongation of succinylcholine and mivacurium

decreases IOP) paralysis, bronchospasm

Epinephrine Sympathetic agonist (mydriasis, Hypertension, bradycardia, tachycardia, headache

decreases IOP)

Phenylephrine alpha -Adrenergic agonist (mydriasis, Hypertension, tachycardia, dysrythmias

vasoconstriction)

Scopolamine Anticholinergic (mydriasis, Central anticholinergic syndrome

vasoconstriction)

Timolol β -Adrenergic blocking agent Bradycardia, asthma, congestive heart failure

(decreases IOP)

41
 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.
42
 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.
43
- 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.

44
 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 administration45
 of antibiotics for respiratory infections.
- Patients should be assesed for sleep
apnea.Intravenous sedation is contraindicated
in such patients.For 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
preoperatively.Insulin therapy should be used
if necessary
46
 -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 47
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

48
-serious hemorrhagic complications are more
in orbital and oculoplasty surgery.

Intermediate in vitreoretinal,glaucoma
and corneal transplant surgery.

Least in cataract surgery.

49
 Local anaesthesia for cataract
surgery
1)Retrobulbar block
2)Peribulbar block
3)Facial block
4)Subtenons block
5)Topical anaesthesia

50
 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 cone.After
aspiration 1.5 – 3.5ml of local is injected.

51
note the direction of the needle-first
hitting the orbital floor and then turning
inside to penetrate the cone.

52
 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.

53
needle outside the cone

54
 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.

55
 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.

56
 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
57
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

58
 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.

59
 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,unconciousnes
s,convulsions,respiratory and cardiac arrest.
-Forceful injection into the opthamic artery leads
to retrograde flow into the thalamus and
midbrain and cause seizures.
60
-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.

61
 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
62
 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.

63
 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

64
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 jaw.The neddle
is inserted perpendicularly to the skin about
1 cm to the periosteum.As the neddle is
withdrawn 3 ml of anaesthetic is injected.
paralysis of the ocularis occurs in 7 mins.

65
Vin lent technique.
Aim at blocking the nerve at the terminal
branches.The 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 margin.The
disadvandages of this block is patient
discomfort,proximity to the eye and
common postoperative ecchymosis.

66
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.

67
Nadbath rehman technique
Blocks the facial nerve as it exits from
the stylomastoid foramen.The neddle is
inserted perpendicularly to the skin between
the mastoid and the posterior border of the
mandible.The 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
68
A, Van Lint
akinesia. B, O'Brien
akinesia
C, Atkinson akinesia
D, Nadbath-Ellis
akinesia

69
 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.

70
 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.
71
 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.

72
 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.

73
 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

74
 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
75
 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
exposure.so temperature and capnography
monitoring should be done.

76
 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 bandaged.Anaesthet
ic agent may be continued till the suctioning
of the airways.
 Problems encountered: Dark room
face inaccessible
77
78
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
79
 Gradual painless decrease in vision
 Refractive errors
 Corneal dystropies
 Keratoconus
 Open angle glaucoma
 Cataract
 optic nerve compressing lesions
 Nutritional/toxic neuropathies
 Diabetic retinopathy

80