Eye injuries during general anaesthesia are reasonably common if care is not taken to prevent them.

Incidence of eye injuries

The incidence of eye injuries during general anaesthesia has been studied, and different methods of eye protection have been compared. When eyes are untaped during general anaesthesia, the incidence of ocular injury has been reported to be as high as 44%.C Marcucci, NA Cohen, DG Metro & JR Kirsch 2008, ''Avoiding Common Anesthesia Errors'', Lippincott Williams & Wilkins, Philadelphia PA USA.Kocaturk, O, Kocaturk, T, Kaan, N & Dayanir V 2012 'The Comparison of Four Different Methods of Perioperative Eye Protection under General Anesthesia in Prone Position', ''Journal of Clinical and Analytical Medicine'', vol. 3, no. 2, pp. 163-
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/ref> If tape is used to hold the eyes closed, ocular injury occurs during 0.1-0.5% of

general anaesthetic General anaesthetics (or anesthetics, see spelling differences) are often defined as compounds that induce a loss of consciousness in humans or loss of righting reflex in animals. Clinical definitions are also extended to include an induced com ...

s, and is usually

cornea The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical ...

l in nature.S Contractor & JG Hardman 2006, 'Injury During Anaesthesia', ''Continuing Education in Anaesthesia, Critical Care & Pain'', vol. 6, no. 2, pp. 67-70
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/ref>VK Grover, KV Kumar, S Sharma & SP Grewal 1998, 'Comparison of Methods of Eye Protection under General Anaesthesia', ''Canadian Journal of Anesthesia'', vol. 45, no. 6, pp. 575-7
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/ref> Intraoperative eye injuries account for 2% of medico-legal claims against

anaesthetist Anesthesiology, anaesthesiology, or anaesthesia is the medical specialty concerned with the total perioperative care of patients before, during and after surgery. It encompasses anesthesia, intensive care medicine, critical emergency medicine ...

s in Australia and United Kingdom, and 3% in the USA.J Anson, 'Perioperative Corneal Abrasions: Etiology, Prevention, and Management', ''Pennsylvania Society of Anesthesiologists''
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Effect of general anaesthesia on eyes

General anaesthesia reduces the tonic contraction of the orbicularis oculi muscle, causing lagophthalmos i.e. the eyelids do not close fully in 59% of patients. In addition, general anaesthesia reduces tear production and tear-film stability, resulting in corneal epithelial drying and reduced lysosomal protection. The protection afforded by Bell's phenomenon (in which the eyeball turns upwards during sleep, protecting the cornea) is also lost during general anaesthesia.PN Nair & E White 2014, 'Care of the Eye During Anaesthesia and Intensive Care', ''Anaesthesia and Intensive Care Medicine'', vol. 15, no. 1, pp. 40-43
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Mechanism of injury

Corneal abrasion Corneal abrasion is a scratch to the surface of the cornea of the eye. Symptoms include pain, redness, light sensitivity, and a feeling like a foreign body is in the eye. Most people recover completely within three days. Most cases are due to ...

s are the most common injury; they are caused by direct trauma, exposure keratopathy/

keratitis Keratitis is a condition in which the eye's cornea, the clear dome on the front surface of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves any of the following symptoms: pain, impaired e ...

E White 2004, 'Care of the eye during anaesthesia', ''Anaesthesia and Intensive Care Medicine'', vol. 5, pp. 302-
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K Zheng, CG Guta, V Kulkarni & J Brock-Utne 2009, 'Prevention of Corneal Abrasions in Patients with Autoimmune Dry Eyes', ''Anaesthesia and Analgesia'', vol. 108, no. 1, pp. 385-6
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/ref> or chemical injury.A Grixti, M Sadri & MT Watts 2013, 'Corneal Protection during General Anesthesia for Nonocular Surgery', ''The Ocular Surface'', vol. 11, no. 2, pp. 109-18
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/ref> An open eye increases the vulnerability of the cornea to direct trauma from objects such as face masks, laryngoscopes, identification badges, stethoscopes, surgical instruments, anaesthetic circuits, and drapes. Exposure keratopathy/keratitis refers to the drying of the cornea with subsequent epithelial breakdown.NJ Friedman & PK Kaiser 2007, ''Essentials of Ophthalmology'', Elsevier Health Sciences, Philadelphia PA USA. When the cornea dries out it may stick to the eyelid and cause an abrasion when the eye reopens.N Tarmey & LA White 2009, 'Section 5: Damage to the eye during General Anaesthesia', ''Risk Associated with your Anaesthetic'', Royal College of Anaesthetists website
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Clare-314

Chemical injury can occur if cleaning solutions such as

povidone-iodine Povidone-iodine (PVP-I), also known as iodopovidone, is an antiseptic used for skin disinfection before and after surgery. It may be used both to disinfect the hands of healthcare providers and the skin of the person they are caring for. It may ...

(Betadine),

chlorhexidine Chlorhexidine (CHX) (commonly known by the salt forms chlorhexidine gluconate and chlorhexidine digluconate (CHG) or chlorhexidine acetate) is a disinfectant and antiseptic that is used for skin disinfection before surgery and to sterilize surgi ...

or alcohol are inadvertently spilt into the eye, for example when the face, neck or shoulder is being prepped for surgery. Therefore, the anaesthetist ensures that the eyes are fully closed and remain closed throughout the procedure. Seemingly trivial contact can result in

corneal abrasion Corneal abrasion is a scratch to the surface of the cornea of the eye. Symptoms include pain, redness, light sensitivity, and a feeling like a foreign body is in the eye. Most people recover completely within three days. Most cases are due to ...

s and the risk of this occurring is markedly increased if exposure keratopathy is already present. Corneal abrasions can be excruciatingly painful in the postoperative period, may hamper postoperative rehabilitation and may require ongoing ophthalmological review and after care. In extreme cases there may be partial or complete visual loss.

Iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 ...

injury of the eyelids is also common. Bruising (frequently) and tearing (rarely) of the eyelid can occur when the adhesive dressing used to hold the eye closed is removed. Removal of eyelashes can also occur.

Methods available for eye injury prevention

Methods to prevent intraoperative corneal injuries include * simple manual closure of the eyelids * holding the eyelids shut with tape or a general purpose adhesive dressing * use of a specially designed eyelid occlusion dressing * use of eye ointment (although this is controversial, see below) * bio-occlusive dressings * suture

tarsorrhaphy Tarsorrhaphy is a surgical procedure in which the eyelids are partially sewn together to narrow the eyelid opening. It may be done to protect the cornea in cases of corneal exposure, as a treatment for Graves' ophthalmopathy, Möbius syndrome or ...

However, none of the protective strategies are completely effective; vigilance is always required i.e. the eyes need to be inspected regularly throughout surgery to check they are closed.

Discussion of methods

The most commonly employed method is to use tape or a general purpose adhesive dressing. Unfortunately the adhesive used on the tape or dressing will generally be inappropriate for this use. The adhesive strength may change when reaching body temperature, or over time.AN Gent 1996, 'Adhesion and strength of viscoelastic solids. Is there a relationship between adhesion and bulk properties?', ''Langmuir'', vol. 12, no. 19, pp. 4492-96
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As the operation progresses this can cause the adhesive to stop working and become gooey, allowing the eyelids to move apart, and leaving behind a sticky residue. This leaves the cornea exposed to epithelial drying and/or abrasions, sometimes caused by the tape that was originally applied to protect the cornea. Alternatively, the adhesive strength may increase, which upon removal can result in eyelid bruising, tears, or eyelash removal. Tape removal

Rolls of tapes are often “laying around” the operating theatre or kept in health care workers' pockets. Tape on scrubs

Therefore, they can be a source of

hospital-acquired infection A hospital-acquired infection, also known as a nosocomial infection (from the Greek , meaning "hospital"), is an infection that is acquired in a hospital or other health care facility. To emphasize both hospital and nonhospital settings, it is so ...

s (HAI's) such as

Methicillin-resistant Staphylococcus aureus Methicillin-resistant ''Staphylococcus aureus'' (MRSA) is a group of Gram-positive bacteria that are genetically distinct from other strains of '' Staphylococcus aureus''. MRSA is responsible for several difficult-to-treat infections in human ...

(MRSA) &

Vancomycin-resistant Enterococcus Vancomycin-resistant ''Enterococcus'', or vancomycin-resistant enterococci (VRE), are bacterial strains of the genus ''Enterococcus'' that are resistant to the antibiotic vancomycin. Mechanism of acquired resistance Six different types of vanc ...

(VRE), with a 2010 study showing that 50% of partially used tape rolls tested positive for

MRSA Methicillin-resistant ''Staphylococcus aureus'' (MRSA) is a group of Gram-positive bacteria that are genetically distinct from other strains of ''Staphylococcus aureus''. MRSA is responsible for several difficult-to-treat infections in humans. ...

, VRE or both.Clinical and Laboratory Standards Institute 2010, 'Performance Standards for Antimicrobial Susceptibility testing: Twentieth Informational Supplement', ''CLSI Document M100-S20
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Most tapes and dressings are non-transparent and so it is not possible to see if the patient’s eyes are opened or closed throughout the case. It is not uncommon for the eyelids to move open as the case progresses, even with adhesive tapes stuck onto them. In a practical sense, these medical tapes/dressings may be difficult to remove from a patient because their ends can become stuck flush with the skin. The possibility of tape removal causing trauma is also significantly increased in older people, people with sensitive skin, dermatitis, dehydration or side effects of medications.C Konya, H Sanada, J Sugama, M Okuwa, Y Kamatani, G Nakagami & K Sakaki 2010, 'Skin Injuries Caused by Medical Adhesive Tape in Older People and Associated Factors', ''Journal of Clinical Nursing'', vol. 19, no. 9-10, pp. 1236-124
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As noted above, there have been several studies looking at the efficacy and safety of eye ointments/lubricants as adjuncts with tape or as a stand-alone management for intra-operative eye closure. Unfortunately many in common use have problems. Petroleum gel is flammable and is best avoided when

electrocautery Cauterization (or cauterisation, or cautery) is a medical practice or technique of burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, o ...

and open oxygen are to be used around the face. Preservative-free eye ointment is preferred, as preservative can cause corneal epithelial sloughing and

conjunctival hyperemia Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The ...

. They have been implicated in blurred vision in up to 75% of patients and they do not protect from direct trauma.M Weed & N Syed 2012, 'Perioperative Corneal Abrasions: Systems-based review and analysis', EyeRounds.org
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Specially made eyelid occlusion dressings are available commercially, such as EyeGard (manufactured in the USA by KMI Surgical and marketed by Sharn Anesthesia), EyePro (Innovgas Pty Ltd, Australia) and Anesthesia-Aid (Sperian Protection). These dressings overcome most of the problems associated with tape or general purpose dressings.

Adverse outcomes associated with intra-operative eye injuries

Some of the adverse outcomes associated with intra-operative injuries include: * Increased length of stay. This is due to

ophthalmology Ophthalmology ( ) is a surgical subspecialty within medicine that deals with the diagnosis and treatment of eye disorders. An ophthalmologist is a physician who undergoes subspecialty training in medical and surgical eye care. Following a medic ...

consults required, associated infections and treatment. * Increased costs. This is due to increased length of stay, cost of treating the complications.S Prakash 2013, 'Perioperative Eye Protection under General Anaesthesia', ''Journal of Anaesthesiology Clinical Pharmacology'', vol. 29, no. 1, pp. 138-13
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* Pain and discomfort for the patient.

s are extremely painful for the patient and the treatment consists of drops and ointments applied in the eye which may cause further discomfort for the patient.

References

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