Perioperative Care of the Patient With eye Pathologies Undergoing Nonocular Surgery

Steven Roth, M.D., F.A.R.V.O.; Heather E. Moss, M.D., Ph.D.; Thasarat Sutabutr Vajaranant, M.D., M.H.A.; BobbieJean Sweitzer, M.D., F.A.C.P., S.A.M.B.A.-F., F.A.S.A.


Anesthesiology. 2022;137(5):620-643. 

In This Article

Abstract and Introduction


The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.


Perioperative injury to the eye ranges from corneal injuries producing pain and reversible blurred vision to serious disorders of the retina or optic nerve causing permanent blindness. The eye is the most important sensory organ, with up to 50% of cerebral cortical neurons serving visual function.[1] Low vision or blindness are major disabilities accompanied by significant emotional suffering and high cost to the healthcare system.[2] Accordingly, prevention of vision loss is of paramount concern, and it is critically important that anesthesia providers be competent in prevention, diagnosis, and treatment of vision-impacting complications of nonocular surgery and the important considerations in delivering anesthesia to patients with chronic ophthalmic disease.

Corneal injury from exposure keratopathy is the most common perioperative eye injury, presenting with pain, foreign body sensation in the eye, blurry vision, and photophobia. Its incidence has been dramatically reduced by educating providers in best preventive measures, from 1.20 per 1,000 to 0.09 per 1,000 in one quality improvement study.[3] A full-thickness corneal transplant is associated with a risk for 1 yr of incision dehiscence, leading to catastrophic loss of eye contents.[4] The anesthesia provider needs to protect the eye of such individuals undergoing anesthesia and surgery from even minor trauma or compression.

The leading cause of perioperative blindness is ischemic optic neuropathy. There have been significant advances in determining the perioperative risk factors, publication of multispecialty-driven evidence-based advisories, and encouragingly, a dramatic decrease in its incidence in spinal fusion surgery,[5,6] where the estimated national U.S. incidence was 1.63 per 10,000 spine fusion surgeries in 1998 to 2000 and 0.6 per 10,000 in 2010 to 2012.[5,7] While some patients have regained vision spontaneously or via various treatment modalities, a major remaining challenge is the lack of any proven treatment. Central retinal artery occlusion and cerebral blindness can produce overlapping signs and symptoms; hence, accurate diagnosis of these entities is essential to drive appropriate therapies.

Idiopathic intracranial hypertension is an elevation in cerebrospinal fluid pressure caused by decreased cerebrospinal fluid absorption or elevated cerebral venous sinus pressures.[8,9] Its main permanent morbidity is to the visual system, characterized by papilledema associated with vision loss, and sixth nerve palsy causing diplopia.[10] These patients often present for labor analgesia, and commonly questioned is the safety of placing epidural catheters.[11] There is, however, currently no evidence to justify the withholding of epidural or spinal analgesia.

Less certain are the anesthetic implications of patients with primary open angle glaucoma.[12] To date there are only limited studies on the impact of elevated intraocular pressure from patient positioning for surgery on the functioning of the optic nerve and outcomes. On the other hand, acute angle closure glaucoma in the postoperative period is a medical emergency usually triggered by specific drugs in susceptible individuals that requires immediate reduction of intraocular pressure to prevent permanent damage to the optic nerve.[13]

With the increasingly aging population and rising prevalence of chronic degenerative diseases including cataract, glaucoma, diabetic retinopathy, and age-related macular degeneration, the anesthesia provider is likely to encounter patients with existing vision impairment. Low vision or blindness currently affects about 2.5% of the population of the United States.[2] Circadian rhythm disorders, altered alertness, and mood changes may be present.[14] The lack of visual cues may complicate communication, including difficulties in discussing the anesthetic plan and the obtaining of informed consent.[15]

This review provides a best evidence-based approach to the anesthetic implications of diseases of the eye, and the prevention of perioperative eye complications. The review is organized anatomically, beginning with diseases of the outer covering of the eye, the cornea, followed by the posterior eye, the retina, and the optic nerve.