A complete history and physical examination are an essential part of the preoperative assessment of all patients. Determining a patient’s perioperative risk status involves identifying any high-risk conditions and symptoms that may necessitate additional testing as well as specific consultation and management prior to elective ophthalmic surgery. Perioperative risk determination may also influence the decision as to whether the surgery should be performed in an ambulatory surgical center (ASC) versus a hospital outpatient setting.
The American Society of Anesthesiologists Physical Status (ASA-PS) is a classification system that defines a patient’s overall health status prior to surgery; a higher ASA class (ASA III or higher) is associated with increased risk of complications, increased costs, unexpected hospital admission, and increased mortality, even after a low-risk surgery. Preoperative testing in a healthy patient or an asymptomatic stable patient, including electrocardiography and routine blood testing, is not necessary prior to ophthalmic surgery. Preoperative testing is performed only when indicated; that is, the tests would have been done even if surgery was not planned. Multiple clinical trials have failed to show a difference in perioperative adverse events in healthy patients undergoing elective eye surgery. The American Academy of Ophthalmology (AAO) advisory opinion on the responsibilities of the ophthalmologist, Appropriate Examination and Treatment Procedures, provides general guidance on determining the appropriateness and necessity of diagnostic procedures and perioperative treatment. Although ophthalmologists may delegate the acquisition of the data required for the preoperative history and the physical examination, the surgical planning and synthesis of information prior to surgery must be done by the operating ophthalmologist.
Avoiding surgical complications begins with the decision to operate. The risks and benefits of surgery, as well as any alternatives to it, are considered and the surgical plan is devised. Typically, the patient is involved in this process; informed consent is contingent on the patient’s (or legal guardian’s) receipt of a detailed, understandable explanation of the surgical plan. Open communication between the surgeon and the patient enhances patient education and ensures realistic expectations regarding the anesthesia depth, surgical procedure, anticipated recovery, and expected outcomes. If a patient is judged to have some level of cognitive impairment, an assessment should be made to evaluate the capacity of the patient to understand the treatment options and thereby provide informed consent. There are multiple instruments available to assess cognitive capacity. If the patient’s level of cognitive impairment renders them unfit to provide consent, informed consent may be obtained from a legal proxy (power of attorney) designated to make treatment decisions for the patient (see Chapter 11 in this volume for more on informed consent).
A careful review of medication allergies, reactions to previous anesthetics, or family history of a reaction to anesthesia is critical in identifying patients at risk for malignant hyperthermia (see the section Malignant Hyperthermia later in this chapter). For a patient with an implantable cardioverter-defibrillator, the ophthalmologist should discuss the status and possible perioperative disabling of the device with the cardiologist before ocular surgery to avoid surgical complications, including possible electromagnetic interference with the pacemaker.
The operating physician typically provides postoperative eye care. Any transfer of management should be discussed and approved, ideally before surgery, by the referring physician, the physician assuming future care, and the patient.
American Academy of Ophthalmology. Advisory Opinion of the Code of Ethics—Appropriate Examination and Treatment Procedures. San Francisco: American Academy of Ophthalmology; 2016. www.aao.org/ethics-detail/advisory-opinion-appropriate-examination-treatment-2. Accessed February 22, 2019.
American Academy of Ophthalmology. Advisory Opinion of the Code of Ethics—Pertinent Principles and Rules of the Code of Ethics Related to Delegation and Comanagement. San Francisco: American Academy of Ophthalmology; 2014. www.aao.org/ethics-detail/code-of-ethics--delegation-comanagement. Accessed February 22, 2019.
Apfelbaum JL, Connis RT, Nickinovich DG, et al; Committee on Standards and Practice Parameters, American Society of Anesthesiologists task force on preanesthesia evaluation. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522–538.
Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on Non-Cardiac Surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anesthesiology (ESA). Eur Heart J. 2014;35(35):2383–2431.
Children and Adolescents
If surgery is planned on a child who is healthy and does not routinely take prescribed medications, no laboratory tests are necessary, even when general anesthesia is to be used. There is no evidence that abnormalities in a complete blood count affect the choice of anesthetic management for asymptomatic children. However, African American patients should be screened for sickle cell disease or trait if they have not previously been tested, because some aspects of anesthetic management will change in patients with hemoglobinopathy. Routine pregnancy testing of female patients of childbearing age, prior to anesthesia, is a complex issue that may become even more complex in minors, because individual states may have statutes concerning parental notification of test results. Consent for a pregnancy test is required.
The decision whether to perform elective eye surgery in children with an upper respiratory tract infection requires judgment and should be made after careful consideration of the patient’s overall health status. A child who is already ill will likely feel even worse after surgery, and the significance of a postoperative fever may be difficult to interpret. However, in the absence of high fever or findings that suggest a lower respiratory tract infection, many anesthesiologists elect to proceed if the child appears well except for a runny nose.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.