Never Delay in Responding to a Call from the PACU about an Eye Complaint

Never Delay in Responding to a Call from the PACU about an Eye Complaint

Anagh Vora MD


Eye complications during the perioperative period are actually quite common. In one study, the incidence was 44% after general anesthesia when appropriate protective measures for the eye were not taken. Although ophthalmic complications after anesthesia are often less dramatic than the airway and cardiopulmonary issues that receive so much focus, the importance of promptly recognizing and appropriately managing ophthalmic complications in the perioperative period cannot be overestimated.

Remember that the American Society of Anesthesiologists (ASA) Closed Claim Study demonstrates that there is a significant cost to ignoring or trivializing the patients’ risk of perioperative eye injuries. Of the total claims against anesthesia providers for ocular injuries, an astonishing 81% of cases did not meet the standard of care and could have been prevented.

Common anesthesia-related eye injuries include corneal abrasions, exposure keratitis, chemical keratitis, movement during ophthalmic surgery, or improper positioning with direct pressure on the eyes. Other less common, but much more serious, ocular complications include postoperative visual loss (POVL) from ischemic optic neuropathy or central retinal artery occlusion.

The underlying etiology of perioperative eye injuries, as with most complications in medicine, is often multifactorial. General anesthesia causes changes in ocular physiology that predispose the eye to injury. These changes include a decrease in both tear production and tear-film stability, suppression of the Bell’s phenomenon (normal upward gaze upon closure of the eyelids), inactivation of the blink reflex, and an increase in lagophthalmos (incomplete closure of the eyes). The suppression of these reflexes abolishes the innate protective mechanism of the eye that guards against direct trauma and corneal desiccation and can lead to an increased incidence of corneal abrasions and exposure keratitis.


Corneal Abrasions.

Corneal abrasions result from disruption of the corneal epithelium, usually as the result of direct trauma to the cornea. Common
scenarios include direct injury from stethoscopes, identification badges, and watches during intubation; improper face-mask positioning or surgical draping; and even the patient himself rubbing his eyes.

Exposure Keratitis.

Exposure keratitis (EK) is inflammation of the cornea from exposure and drying of the corneal epithelial surface. The most common cause of EK during anesthesia is lagophthalmos or incomplete closure of the eyelids for prolonged periods. Partial exposure of the eye, coupled with decreased tear-film production and stability, leads to breakdown of the corneal epithelium. Sequelae of EK include epithelial defects, corneal infiltrates, ulceration, perforation, and even endopthalmitis.

Chemical Keratitis.

Chemical keratitis is serious eye condition, resulting from exposure of the eye socket and globe to potentially toxic substances, such as surgical preparatory solutions. A commonly used agent for surgical scrubs is Hibiclens, a preparation of 4% chlorhexidine antiseptic solution and detergent. Remember that in very dilute concentrations (0.005%), chlorhexidine is a valuable ophthalmologic agent and has been used as a preservative for soft and gas-permeable contact-lens solutions. Also, concentrations of 0.02% can be used with propamide to treat Acanthamoeba keratitis. However, the 4% solution should be considered toxic to the eye. Injuries usually involve epithelial defects associated with epithelial-cell death and desquamation, which is potentiated by the presence of the detergent. Other described injuries include conjunctival hyperemia, chemosis, hypotony, anterior-chamber flare, and corneal edema. Rarely, exposure to large amounts of chlorhexidine has necessitated corneal transplant.



  • Foreign-body sensation (usually described as a gritty sensation);

  • Pain, burning, itching;

  • Decreased vision; and

  • Photophobia.


  • Dye uptake of the cornea on fluroscein staining;

  • Specific pattern of staining related to etiology;

  • Circumcorneal injection (limbal reaction); and

  • Severe cases may manifest as corneal epithelial defects or ulcerations.

Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Never Delay in Responding to a Call from the PACU about an Eye Complaint
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