O A S I S

OAS and Audio-Digest: The Eye Meets the Ear

OAS is proud of the long relationship we have with Audio-Digest Foundation, "The gold standard of audio CME and CE." Since 2001, Audio-Digest has offered a number of Annual Meeting lectures in cassette, CD, or most recently MP3 formats.

Two of our colleagues' presentations at the 20th Annual Meeting are combined onto one disc, #4180 AN4920: Marc Feldman's "Ophthalmic Anesthesia for the Cardiac Patient" and Howard Palte's "Obstructive Sleep Apnea: Ophthalmic Perspectives." Elie Chidiac's excellent 2005 discussion, "Succinylcholine and the Open Eye" is found on #3830 AN4817. That lecture had its origin in an incisive commentary published in Anesthesiology (100:1035-1037,2004) and was later expounded upon for Ophthalmology Clinics of North America (19(2):279-85,2006). Apropos for the diverse membership of our organization, two talks from our 19th Annual Meeting are featured in both the Anesthesia and Ophthalmology versions of Audio-Digest: Bobbi Jean Sweitzer's "Preparing Patients for Anesthesia and Ophthalmic Surgery" and Leonid Skorin's  "Treatment for Blind and Seeing Painful Eyes" (#3568 AN4703 & OP4303).

Earlier still, lectures by Ronald Wender ("Fast-tracking in Outpatient Anesthesia"), Marlene Moster ("Blitz Snesthesia for Trabeculectomy"), Cynthiane Morgenweck ("Ethical Issues in Informed Consent"), William Rand ("Rand-Stein Analgesia Protocol"), and Steven Gayer ("Regional Anesthesia for Open Globe Injuries") were featured.

Since our 2001 Annual Meeting, OAS has been the grateful recipient of three $5000 grants from Audio-Digest (2001, 2004, 2007). You may have noticed that the Audio-Digest representative was taping our recent meeting; no tapes have been produced as of this date, but keep watch on their web site if you are interested.

Diplopia Study

During our recent Annual Meeting in Chicago, Dr. David Guyton, an ophthalmologist who specializes in strabismus surgery and is Director of the Krieger Children’s Eye Center at Johns Hopkins, presented "Postoperative Diplopia after Retrobulbar Block." Dr. Guyton emphasized the potential toxic effects of bupivacaine on the small extra-ocular muscles. His lecture was followed by a lively discussion of the incidence of diplopia noted by OAS members who routinely perform those blocks. While there was general acknowledgement of the complication, there was also an apparent lack of agreement on the rate of incidence; most in the audience believing the incidence much lower than that postulated by Dr. Guyton.

Later, OAS Member Dan Simonson CRNA, discussed the issue with Dr. Guyton, including the need for a study to analyze the incidence among those OAS members who perform large numbers of retrobulbar blocks on a diverse population.  Dr. Guyton agreed the study would be worthwhile, and Mr. Simonson broached the subject with OAS President, Dr. Gary Cass.  Dr. Cass confirmed the study had merit, and further discussed the issue with Dr. Ric Rivers who offered that Wilmer Eye Institute at Johns Hopkins could assist with various administrative details of the study.

After returning to Spokane, Mr. Simonson did a brief review of the literature using PUBMED.  He found a number of studies, the most impressive and statistically significant done outside the United States, presumably under different conditions than those at an ASC in the US.  Mr. Simonson reported findings with the OAS Scientific Advisory Board and with Dr. Guyton, and submitted a study proposal.  The proposal was posted on the Ophthalmic Anesthesia listserv, eliciting encouragement as well as thoughtful critiques.

Dr. Marc Feldman pointed out that the number of patients required to accurately demonstrate statistical differences made for a daunting task, and the lack of controlled conditions administering the survey instrument at various institutions could make analysis difficult. He pointed out that his facility, the Cole Eye Institute, was performing a similar study and he alluded to difficulties creating a valid study.

Mr. Simonson countered that the study could be useful in many ways, even if conclusions lacked statistical rigor. Variations in techniques among subject institutions and the incidence of diplopia, even if its causation remained unclear, would still be useful in evaluating studies such as those at Cleveland Clinic.

Now Mr. Simonson is in the process of creating study documents and obtaining local Institutional Review Board approval to begin his own pilot version. The OAS Board has moved in support of the study, and Dr. Cass wrote a cover letter. Mr. Simonson will begin the study at the Spokane Eye Surgery Center and use that experience, along with advice and input from Dr. Guyton and OAS members, to refine the process and documents before requesting the assistance of OAS member volunteers.

Please contact Mr. Simonson if you are interested in becoming a study participant or learning more details; email is preferred.

Dan Simonson CRNA MHPA
The Spokane Eye Surgery Center
208 W. Fifth Ave.
Spokane, WA 99204
P. 509 456-8150 F. 509 455-9887 C. 509 981-6274
Email:

 

A Case of Enlarging Bilateral Hemangiomatosis

Jacqueline Tutiven MD
Vania Fernandez MD
Department of Anesthesiology
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Miami, FL

The ambulatory setting can often be a challenge for the anesthesiologist.  The accelerated nature of this environment along with the assumption by many surgeons, ancillary staff, patients and their families that surgery at an outpatient center is always a benign process can make the identification of important implications difficult.  Attempting action to correct these problems preoperatively, which often involves delaying the surgery, is likely to be met with resistance.

This is a case of a 2-month old female who was referred to our institution for urgent ophthalmic surgery due to enlarging bilateral ocular lesions that threatened her vision.   Preoperative exam revealed signs and symptoms of decompensated congestive heart failure (CHF) in a baby with no previous history of cardiac dysfunction.  We chose to delay the case and transport the patient to a tertiary care hospital for optimization and cardiac consultation prior to vision-saving surgery.  Timely identification, appropriate work-up and preoperative treatments are paramount in assuring a good outcome for patients with a life-threatening condition undergoing any type of surgery in an urgent setting.

Figure A

The picture demonstrates the progressive ocular lesion, later diagnosed as a hemangioma that was compromising vision bilaterally.

 

Infantile hemangiomas (IH) “ strawberry” hemangiomas are rapidly proliferating tumors that present in the first few months of life in as many as 10% of children.  They are often confused with vascular malformation.  Whereas vascular malformations are relatively static, these lesions are characterized by rapid proliferation with subsequent self-resolution.  They proliferate most rapidly between 3 and 6 months of age and generally reach maximal size by 12 months of age, at which time slow involution begins.

Diffuse Neonatal Hemangiomatosis (DNH) is a rare form of IH in which these endothelial cell tumors involve at least three organ systems.  The hemangiomas are most commonly found in the skin, pulmonary system, gastrointestinal tract and central nervous system.  These lesions can either be asymptomatic or they can lead to devastating and even life-threatening complications, depending on their location.

The Ophthalmic surgeon accepted the transfer of this patient to our institution from a neighboring hospital, for urgent EUA, laser therapy and surgery. Pre-operative assessment revealed an infant with tachypnea, tachycardia, and diaphoresis. Upon further questioning and examination, it was evident that the patient may not be able to undergo general anesthesia without further compromising cardiac status. A formal pediatric cardiac consultation was obtained and found high output cardiac failure with a 2-D echocardiograph demonstrating abnormal diastolic pressures, all chambers dilated and functional pulmonary stenosis. The patient subsequently received treatment and optimization of cardiac status and proceeded with ophthalmic surgical treatment under general anesthesia.

Figure B & C

Resolution of the hemangioma seen after several treatments.

In addition to cutaneous lesions, DNH can present with hepatomegaly, anemia and high output cardiac failure. In our case, the initial presentation was less obvious.  In fact, of the 67 previously reported cases in the literature, this is the first of its kind.  When the diagnosis of enlarging bilateral hyphema was made, this patient was immediately referred to our eye hospital.  Thus, the surgery was considered urgent, if not emergent in nature.  Typically, we examine and treat over 30 ophthalmology cases on our designated pediatric operating days.  Most of our patients have Retinoblastoma, ROP, Peter’s Anomaly or Coats disease; which requires serial examinations.  Thus, preoperative evaluation of these patients must be thorough, yet efficient.  In a teaching institution, residents are focusing on assessing and preparing patients to undergo anesthesia for same day surgery in a timely manner. They learn to become acutely tuned to signs and symptoms that raise flags in the middle of a busy peri-operative environment.  Prompt recognition of indicators of decompensated CHF was key to preventing further myocardial depression due to exposure to anesthetic agents on an already stressed cardiovascular system.  In this case, taking time to properly diagnose and optimize the patient’s status resulted in a good outcome, not only for the patient’s general health, but also for her vision.  

As anesthesiologists, we are called to be the patient advocates. Ophthalmologists who operate almost exclusively in ambulatory surgical centers rely on us to minimize risk for all concerned (patients, surgeons, anesthesia staff, the facility). The pace at an ambulatory care center is rapid, but recognition of important patient issues; taking time to assess, discuss, and plan are vital for our mission. A plan of care that, in this case, included a transfer to a tertiary care facility, can far outweigh the benefits (and potential harm) of immediate surgical treatment.