RevBrasAnestesiol.2014;64(6):446---449
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
LETTERS
TO
THE
EDITOR
Post-operative
cycloplegia
following
ophthalmic
surgery:
it
is
NOT
anesthesia
Cicloplegia
no
pós-operatório
de
cirurgia
oftalmológica:
NÃO
é
a
anestesia
DearEditor,
Thepracticeofanesthesiahaslongbeensurroundedwitha degreeofmystique.Thiscanbeillustratedbythecurrent lackof full-proofevidenceonthemechanism ofaction of volatileanestheticsforexample,whichisforthemostpart hypothesized.1These blurredmarginsof knowledge
cross-overintonon-anesthesiologistpractitionersusinganesthetic techniques,sometimes,withoutfullygraspingthefullscope ofknowledge associatedtothese(i.e.infiltration oflocal anesthetics, sedation). This mysticism of anesthesia is alsoexemplified byanesthetics andanesthesiologist being wrongfullyaccusedfor post-operativecomplicationswhich cannotbeexplainedotherwise.
A healthy 55-year-old female presented for anterior-chamber phakic intraocular-lens placementfor correction of myopia of the lefteye. The same procedure was per-formed on the right eye using retrobulbar anesthesia a fewweeksprioruneventfully.StandardAmericanSocietyof Anesthesiologists(ASA)monitorswere placed,the patient was pre-medicated with 2mg of intravenous midazolam, afterwhich a retrobulbar block wasperformed. Withthe ocularglobe inprimarypositiona 23G 31mm needlewas insertedthroughtheskinoftheinfero-temporalorbitalrim. The needle was advanced 15mm tangentially and subse-quentlyre-directedupwardsandinwardstoreachproximity tothemusclecone.Withpriornegativeaspiration,3mlof 0.75%bupivacainewere injected.After5minutesinternal andexternalophthalmoplegia,aswellasocularanesthesia wereachievedandthesurgeryproceededuneventfully.
Onpost-operativedayonethepatientreferred7/10pain (onan 11-point visual analog scale, (VAS), anchored with 0=nopainand10=worstpaineverexperienced)totheleft eye, withassociatedfixed mydriasis,and extraocular eye movementswerepreserved.Thepatientwasevaluatedby theophthalmologist,andthefindingsweredeemedas resid-ual anesthetic block and analgesics wereprescribed. The patientwasre-evaluated3dayslaterwithpersistent symp-toms;increasedintraocularpressurewasnotedandtreated
bytheophthalmologist,whoagaindeemedthefindings sec-ondarytoanesthesia;andwassubsequentlydiscussedwith theanesthesiologist.
Ananatomic review yieldedthe ciliary ganglion asthe onlystructureintheneedle’spathwhichwhencompromised could prompt cycloplegia.2 A thorough literature review
showed no reported cases of ciliary ganglion injuries or long-term cycloplegia following retrobulbar blocks. How-ever two similar cases were described following phakic intraocular lens placement,3,4 yielding the diagnosis of
Urrets-Zavalia Syndrome, a rare post-operative compli-cation, usually present after penetrating keratoplasty.3---5
Delayedfillingoftheiriscapillariesanddecreasedperfusion wereobservedbyirisfluoresceinangiographyconfirmingthe diagnosis.
Twolessonscanbedrawnfromtheabove:Urrets-Zavalia is a rare complication following phakic intraocular-lens surgery which anesthesiologists performing ocular blocks needtorealize,andtheimportanceofavailableliterature toclarifyundueallegationsbasedonthemystiqueof anes-thesia.
References
1.McKayRE.Inhaledanesthetics.In:MillerRD,PardoMC,editors. Basicsofanesthesia.6thed.Philadelphia:Elsevier;2011.p.82.
2.PutzR,PabstR.AtlasdeAnatomiaHumanaSobotta,vol.1,21st ed.Madrid:Panamericana;2001.p.377.
3.ParkSH,KimSY,KimHI,etal.Urrets-Zavaliasyndrome follow-ingiris-clawphakicintraocularlensimplantation.JRefractSurg. 2008;24:959---61.
4.YuzbasiogluE,HelvaciogluF,SencanS.Fixed,dilatedpupilafter phakicintraocularlens implantation.J CataractRefractSurg. 2006;32:174---6.
5.UrretsZavaliaJrA. Fixed,dilatedpupil,irisatrophy and sec-ondaryglaucoma.AmJOphthalmol.1963;56:257---65.
JuanA.Ramos
DepartmentofAnesthesiology,UniversidaddeCarabobo,
Valencia,Venezuela
E-mail:[email protected](J.A.Ramos).
Availableonline12March2014
http://dx.doi.org/10.1016/j.bjane.2014.02.010
