What the Anesthesiologist Should Know before the Operative Procedure
Lacrimal apparatus dysfunction can be present in up to 60% to 70% of infants at birth but is only symptomatic in 5% to 6%. However, spontaneous resolution occurs by 1 year of age in 96% of cases. Initial primary treatment involves observation, lacrimal massage, and topical antibiotics. If persistent, primary surgical intervention involves simple nasolacrimal duct probing. Success rate of primary probing ranges from 70% to 97%. Further procedures to establish patency include duct stenting, balloon dilatation, nasal endoscopy, and dacryocystorhinostomy. The majority of cases in children are congenital. Acquired cases can be associated with trauma, viral conjunctivitis, acute dacryocystitis, and the use of topical antiviral medications. Urgency may depend on the etiology of the lacrimal duct obstruction.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Emergent: Not applicable
Urgent: Related to acute dacrocystitis in neonates, although low risk of delay if need preoperative evaluation
Elective: Most common
2. Preoperative evaluation
The majority of cases are spontaneous in otherwise healthy children. Preoperative evaluation should include thorough assessment of patient’s history including cardiovascular, respiratory, and neurologic systems, specifically a history of prematurity or other conditions associated with prematurity. Family history of complications with anesthesia should also be reviewed.
Known medical conditions that are associated with lacrimal duct obstruction include children with craniosynostosis, Down syndrome, Goldenhar syndrome, clefting syndromes, hemifacial microsomia, or any midline facial defect. Knowledge of the presence of these conditions is important in determining anesthetic plan and overall risk.
Medically unstable conditions warranting further evaluation include associated congenital heart disease that is unevaluated.
Delaying surgery may be indicated if presence of acute upper respiratory tract infection or history and physical examination indicate possible presence of above medical conditions without thorough preoperative evaluation
3. What are the implications of co-existing disease on perioperative care?
Medical conditions, specifically congenital syndromes, associated with lacrimal duct obstruction should be evaluated preoperatively. Depending on the disorder or syndrome, there are different anesthetic concerns that arise.
Perioperative evaluation: No specific requirements since most cases are in otherwise healthy children. Evaluation should depend on the presence of coexisting disease discovered on history and physical examination.
Perioperative risk reduction strategies: Presence of any of the known congenital conditions associated with lacrimal duct obstruction as listed above should be noted and evaluated.
b. Cardiovascular system
Congenital heart disease: Uncorrected or unstable congenital heart defects should be considered in children with Down syndrome or Goldenhar syndrome. Evaluation should include a pediatric cardiologist and echocardiography.
URI: Children with recent upper respiratory symptoms are at increased risk of pulmonary complication in the perioperative period and elective surgery should be postponed.
Reactive airway disease (Asthma): Presence of any active symptoms should cause postponement of surgery until symptoms have resolved and patient is medically stable.
Difficult airway:Children with midline facial defects, clefting, Down syndrome, or Goldenhar syndrome may have airway collapse or obstruction and should be considered a potential difficult mask and intubation. Downs and Goldenhar syndrome patients may also have cervical spine abnormalities that might alter the approach to securing the airway.
No specific disorders involving the renal or gastrointestinal system are known to be associated with lacrimal duct obstruction.
Acute issues: Goldenhar syndrome can be associated with hydrocephalus. Evidence of hydrocephalus without preexisting medical/surgical correction should be managed prior to lacrimal duct probing. Patients with associated congenital syndromes may also have developmental delay.
Chronic disease: Patients with associated congenital syndromes may also have developmental delay.
No specific disorders involving the endocrine system are known to be associated with lacrimal duct obstruction.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
Presence of additional existing ocular pathology should be reviewed.
4. What are the patient's medications and how should they be managed in the perioperative period?
No specific medications are used to manage this disorder. Medications will be specific to other comorbid diseases.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
There are none.
i. What should be recommended with regard to continuation of medications taken chronically?
Most chronic medications can be continued in the perioperative period.
j. How To modify care for patients with known allergies –
Avoid known agents that cause allergic reactions.
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
m. Does the patient have a history of allergy to anesthesia?
Most children presenting for this surgery will not have undergone anesthesia prior to this. Family history of problems with anesthesia should be reviewed for those at risk of developing malignant hyperthermia (MH).
Malignant hyperthermia (MH)
Documented: Avoid all trigger agents such as succinylcholine and inhalational agents. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Ensure an MH cart is available [MH protocol].
Family history or risk factors for MH
Local anesthetics/muscle relaxants: Although still very rare, muscle relaxants are the leading cause of anaphylaxis related to medicines given in the operating room. This procedure does not necessitate the use of muscle relaxants. Local anesthetics, specifically ester local anesthetics, can very rarely cause allergic reactions.
5. What laboratory tests should be obtained and has everything been reviewed?
No specific laboratory tests need to be obtained unless coexisting diseases necessitate it.
Common laboratory normal values will be same for all procedures, with a difference by age and gender.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Anesthetic management may depend on extent of probing and presence of irrigation. Nasolacrimal duct probing for patency can be done in an office or require general anesthesia depending on the age and cooperation of the patient. A simple probing can take 5 to 10 minutes and be done under mask general anesthesia without the absolute necessity of intravenous access. However, irrigation with saline or fluorescein to determine patency of the lacrimal system may contribute to pooling of liquid in the airway and be better managed with a laryngeal mask airway (LMA) or endotracheal tube.
a. Regional anesthesia:
generally not indicated for this procedure
b. General Anesthesia
Benefits: Helpful in children who are uncooperative with office exam and probing.
Drawbacks: Manipulation of airway for relatively minor and quick procedure.
Other issue: Pain associated with procedure is relatively minor.
Airway concerns: Lacrimal duct obstruction is associated with syndromes known for potential difficult airways. Mask anesthesia can be utilized during short procedures. Presence of irrigation may necessitate endotracheal tube placement to prevent potential pooling of fluids and subsequent airway irritation, laryngospasm, or aspiration.
Monitored Anesthesia Care
Benefits: Does not require manipulation of airway
Drawbacks: Usually not an option in children who would not cooperate with preoperative IV placement.
6. What is the author's preferred method of anesthesia technique and why?
For simple probing, general anesthesia via inhalational induction with IV access and proceeding with either mask airway or LMA with spontaneous respiration would be preferred. If indicated, children should receive premedication with oral midazolam 0.5 to 1 mg/kg preoperatively.
What prophylactic antibiotics should be administered?
There are none.
What do I need to know about the surgical technique to optimize my anesthetic care?
Expected duration of probing as well as potential use of irrigation would be helpful in determining which airway technique to utilize.
What are the most common intraoperative complications and how can they be avoided/treated?
Most common intraoperative complications include nasal bleeding and bradycardia or arrhythmia secondary to the oculocardiac reflex with eye manipulation. The manifestations associated with the oculocardiac reflex can be treated initially by stopping surgical stimulation and administering an anticholinergic medicine such as atropine at 0.02 mg/kg. Maneuvers such as hyperventilation and deepening anesthetic level can also be utilized.
Cardiac: Bradycardia or other dysrhythmias such as junctional bradycardia, ventricular bigeminy, and sinus arrest may occur with stimulation of the eye leading to the oculocardiac reflex.
Pulmonary: Children, especially young children, are at risk of airway obstruction and laryngospasm during manipulation of the airway. Children younger than 44 weeks post conceptual age and otherwise healthy should be monitored overnight in the hospital after anesthesia due to the risk of post operative apnea.
b. If the patient is intubated, are there any special criteria for extubation?
Control of nasal bleeding if present and careful suctioning of any excess irrigation or secretions.
c. Postoperative management
What analgesic modalities can I implement?
This procedure has minimal analgesic requirements. If required, rectal acetaminophen (30 mg/kg) or IV fentanyl (1 mcg/kg) can be administered.
What level bed acuity is appropriate?
Usually an ambulatory procedure unless <44 weeks postconceptual age for term children.
What are common postoperative complications, and ways to prevent and treat them?
Minimal complications. Most common complication is postoperative nausea/vomiting in older children. Treatment should involve hydration and medications including 5HT3 receptor antagonists such as ondansetron (50-200 mcg/kg).
What's the Evidence?
Lad, EM, Egbert, PR, Moshfeghi, DM, Jaffe, RA, Jaffe, RA, Samuels, SI. “Ophthalmicsurgery”. Anesthesiologist's Manual ofSurgical Procedures. 2009. pp. 139-172. (This chapter provides a comprehensive guide to anesthetic and surgical perspectives pertaining to ophthalmic surgery including anesthetic technique and details affecting preoperative, intraoperative, and postoperative care.)
Hauser, MW, Valley, RD, Bailey, AG, Motoyama, EK, Davis, PJ. “Anesthesia for Ophthalmic Surgery”. Smith's Anesthesia for Infants and Children. 2006. (This chapter provides an updated review of pediatric ophthalmologic anatomy, physiology, and diseases as well as discussion of specific anesthetic and surgical considerations in lacrimal duct apparatus dysfunction.)
Weaver, RG, Tobin, JR, Cote, CJ, Lerman, J, Todres, ID. “Ophthalmology”. A Practice of Anesthesia for Infants and Children. 2009. pp. 685-699. (This chapter provides an updated review of common pediatric ophthalmologic diagnoses/conditions presenting for surgery including discussion of ophthalmologic physiology, pharmacology, procedures, and anesthetic care specific to the pediatric patient population.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?