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    Safety Update: Ocular Anesthesia

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    Although anesthesia-related malpractice claims are relatively rare, serious injuries do occur. A retrospec­tive review of the Ophthalmic Mutual Insurance Company (OMIC) database yielded 63 anesthesia-related closed claims by 50 patients, or 2.8% of total claims against OMIC’s ophthalmolo­gists, between 2008 and 2018.1

    “The review provides clarity about where we can make improvements,” said Michael Morley, MD, ScM, at Ophthalmic Consultants of Boston and Harvard Medical School.

    What went wrong? Globe perfora­tion (n = 17) was the most common complication, followed by death (n = 13) and retrobulbar hemorrhage result­ing in blindness (n = 7). Other adverse outcomes included optic nerve damage and vascular occlusions.

    A clear majority of cases involved either retrobulbar or peribulbar an­esthesia (64%; n = 16 each). General anesthesia was an alleged factor in four deaths, and sedation a factor in five.

    The role of medical comorbidities. Nearly half the claims (48%) were as­sociated with cataract surgery, followed by retina procedures (24%). Although the study wasn’t structured to assess the inherent risk of assorted surgical proce­dures, Dr. Morley said type of surgery may not matter as much as the type of anesthesia or the severity of a patient’s comorbidities. All but one of the 13 deaths occurred in patients who had preexisting significant comorbidities, notably diabetes and/or cardiovascular disease.

    Avoiding adverse events. Although the researchers acknowledged that it is impossible to reduce the risk of an­esthesia-related complications to zero, they provided a list of 10 recommen­dations for minimizing risk. Among them:

    • Use the least invasive method of anesthesia when possible.
    • Evaluate new anesthesia providers’ skills in administering needle-based blocks.
    • Consider pre-op testing and health optimization for patients with serious comorbidities or active medical prob­lems.
    • Manage perioperative anticoagu­lants in concert with the patient’s other physicians.

    Bottom line. “Ophthalmic anesthesia is generally very safe, but some patients undergo avoidable anesthesia-related complications,” Dr. Morley said. “Our job is to focus on these avoidable inju­ries using proven quality improvement methodology. The goal is to develop systems and workflows that lower the chance or opportunity of error and harm.”

    Procedure-specific consent forms, including those for anesthesia-related potential complications, are available at

    —Miriam Karmel


    1 Morley M et al. Ophthalmology. Published online Dec. 25, 2019.


    Relevant financial disclosures—Dr. Morley: None.

    For full disclosures and the disclosure key, see below.

    Full Financial Disclosures

    Dr. Chen Research related to this study was funded by a career development award from Research to Pre­vent Blindness and by the NEI.

    Dr. Humayun Allergan: C,L; Duke Eye Center: P; Eyemedix: C,O,P,S; Iridex: P; Johns Hopkins University: P; Lu­tronic Vision: C,O; MTTR: C,O; Outlook Therapeutics: C; Regenerative Patch Technologies: C,O,P; Replenish: C,O,P; Santen: C,L; Second Sight Medical Products: O,P; USC: E,P.

    Dr. Morley None.

    Dr. Rose-Nussbaumer None.

    Disclosure Category



    Consultant/Advisor C Consultant fee, paid advisory boards, or fees for attending a meeting.
    Employee E Employed by a commercial company.
    Speakers bureau L Lecture fees or honoraria, travel fees or reimbursements when speaking at the invitation of a commercial company.
    Equity owner O Equity ownership/stock options in publicly or privately traded firms, excluding mutual funds.
    Patents/Royalty P Patents and/or royalties for intellectual property.
    Grant support S Grant support or other financial support to the investigator from all sources, including research support from government agencies (e.g., NIH), foundations, device manufacturers, and/or pharmaceutical companies.


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