2020–2021 BCSC Basic and Clinical Science Course™
1 Update on General Medicine
Chapter 15: Perioperative Management in Ocular Surgery
Management of Medical Conditions Associated with Increased Perioperative Risk
Pulmonary complications after surgery are a significant cause of perioperative morbidity and mortality. This is especially true in patients undergoing major intrathoracic and intra-abdominal surgery. Ophthalmic surgery is usually performed with the patient under local sedation, is of short duration relative to thoracic and abdominal surgery, and doesn’t result in pain for the patient, obviating the need for postoperative opioids that limit pulmonary risks. Intravenous sedation under monitored anesthesia care (MAC) during eye surgery can result in hypoventilation, hypercapnia, hypoxia, and atelectasis in patients with chronic obstructive pulmonary disease (COPD). It is important for the ophthalmic surgeon to ensure that the patient’s respiratory status is optimized preoperatively. If a patient’s history and physical examination identifies a potential comorbidity that could impact pulmonary function and increase risk of administering preoperative sedation, then obtaining a chest x-ray and/or pulmonary function tests would be of value. Medical optimization may involve increasing the patient’s inhaler regimen, administration of antibiotics (if infection is suspected), administration of corticosteroids to reduce inflammation, and/or chest physiotherapy to manage secretions. Patients who are on long-term steroid therapy should receive their usual dose on the day of the surgery; however, “stress-dose” glucocorticoid administration is generally unnecessary prior to ophthalmic surgery. Occasionally, general anesthesia with a laryngeal mask airway may be beneficial, for example, in patients with COPD who have severe dyspnea and cough in a supine position, are unable to lie still, or have high anxiety.
Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77–137.
Rusk MH. Avoiding unnecessary preoperative testing. Med Clin North Am. 2016;100(5):1003–1008.
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.