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 Table of Contents    
LETTER TO THE EDITOR
Year : 2021  |  Volume : 53  |  Issue : 2  |  Page : 178-179
 

Modified drug regimen for ophthalmic anesthesia during COVID-19 pandemic: Revisiting pharmacological concepts


1 Cataract, Cornea and Refractive Services, Cataract, Pediatric Ophthalmology, Aravind Eye Hospital Post Graduate Institute of Ophthalmology, Puducherry, India
2 Strabismus Services, Aravind Eye Hospital Post Graduate Institute of Ophthalmology, Puducherry, India

Date of Submission31-Jan-2021
Date of Decision05-Mar-2021
Date of Acceptance26-Apr-2021
Date of Web Publication26-May-2021

Correspondence Address:
Dr. Bharat Gurnani
Cataract, Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry 605 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijp.ijp_89_21

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How to cite this article:
Gurnani B, Kaur K. Modified drug regimen for ophthalmic anesthesia during COVID-19 pandemic: Revisiting pharmacological concepts. Indian J Pharmacol 2021;53:178-9

How to cite this URL:
Gurnani B, Kaur K. Modified drug regimen for ophthalmic anesthesia during COVID-19 pandemic: Revisiting pharmacological concepts. Indian J Pharmacol [serial online] 2021 [cited 2021 Jun 15];53:178-9. Available from: https://www.ijp-online.com/text.asp?2021/53/2/178/316957




Sir,

The pandemic caused by novel COVID-19 has disrupted all the global sectors as well as the healthcare services.[1] This has forced us to modify and adopt new norms for better patient care and safety. Ophthalmologists, anesthesiologists, ENT surgeons, and those involved in critical care are the worst affected and some have even lost their lives.[2] New ophthalmic surgery and anesthesia guidelines were formulated for surgical management of patients during the lockdown.[3] As the cases are exponentially increasing the guidelines continue to evolve. Here, we will discuss a few of the vital changes adopted during ophthalmic anesthesia and important precautions taken during ophthalmic surgery at most of the tertiary eye care centers across the country.

The aerosol-generating procedures are being avoided as they involve cauterizing the bleeders and droplet spread during the saline flush.[4] Only emergency surgeries are undertaken like open globe injuries, lasers for retinopathy of prematurity, phacolytic/phacomorphic glaucoma, and endophthalmitis. The important precautions are mandatory masks for patients, extra drapes over the eye, viscoelastic application at the phacoemulsification entry wound, extra plastic sheets over the microscope, air conditioners, and ventilators. A definitive COVID-19 consent is taken from all patients either by using hospital-based forms or forms proposed by the All India Ophthalmic Society.[5] To ensure early and safe procedures, most of the surgeries are being performed by senior surgeons. Only three people are allowed inside the operating room beside the patient-the surgeon, assisting nurse, and a running nurse. Most of the hospitals are performing COVID-19 testing for elective surgery only for patients with symptoms such as cough, fever, and breathlessness. Some are opting for reverse transcription-polymerase chain reaction, chest X-ray, or high-resolution computed tomography. In case tested positive, patients are referred to COVID designated hospitals.

The anesthesia team and surgeon have resorted to precautions such as wearing the mask, face shield, gloves, shoes, and hand sanitization. Many hospitals are using aerosol box or plastic sheets while administering anesthesia. During all the ophthalmic procedures, local anesthesia is preferred over general anesthesia. During general anesthesia, for induction and daycare anesthesia Glycopyrrolate to reduce secretions and Propofol are used, preoxygenation with an aerosol box or plastic sheet, disposable Heat and Moisture Exchanger (HME) filters through the mask at the endotracheal tube, closed circuit with disposable filters at the expiratory limb, analgesics like Fentanyl and Tramadol, muscle relaxant Rocuronium is preferred over Atracurium due to early onset of action and shorter acting. Airway management is usually performed by the senior-most experienced anesthetist. Airway instrumentation is also minimized due to the risk of aerosol spread. Tracheal intubation rather than the use of a laryngeal mask is favored. Intraoperatively Dexmetrophene is used to reduce postoperative cough and secretions. Extubation is done with normal norms. A minimum of 12 air pressure exchange is preferred. The guidelines suggest an interval of 20 min between two patients at the majority of the centers in our country. In some international countries like Australia and England, the interval is around 2 h.

For local anesthesia-the block is administered by a senior resident. Use of long-acting Bupivacaine is preferred over Lignocaine and Proparacaine. At most of the centers, in COVID-19 negative patients subtenons anesthesia is preferred due to the risk of aerosol spread while administering peribulbar and retrobulbar block and also because subtenons anesthesia is administered after cleaning the conjunctival sac with povidone-iodine which is expected to safeguard against the Coronavirus. Local anesthesia, also reduces the risk of nausea, vomiting, and cough, and aerosol spread. In COVID-19-positive patients, peribulbar and retrobulbar anesthesia are preferred since 5% of them can have Coronavirus in tears. The best option is topical anesthesia for phacoemulsification.

For pediatric anesthesia oral and intravenous premedication has been preferred to the nasal route. In pediatric cases, preferred practices include intravenous anesthesia over the inhalational, closed circuit with deep neuromuscular blockade, double hand low-tidal volume for ventilation. Use of plastic tent at various centers for induction, and video laryngoscopy.

For postoperative management, post anesthesia care unit precautions have been undertaken at most of the centers. We believe that these modifications and changes in practice patterns will also help pharmacologists, anesthetists, and ophthalmologists at all centers to work in collaboration with confidence for better patient management and outcomes.

Acknowledgments

Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Odor PM, Neun M, Bampoe S, Clark S, Heaton D, Hoogenboom EM, et al. Anaesthesia and COVID-19: Infection control. Br J Anaesth 2020;125:16-24.  Back to cited text no. 1
    
2.
Verma R, Mohan B, Attri JP, Chatrath V, Bala A, Singh M. Anesthesiologist: The silent force behind the scene. Anesth Essays Res 2015;9:293-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ahmad N, Zahoor A, Ahmad AE, El Dawlatly A. Anesthesia management of ophthalmic surgery for patient with suspected/confirmed COVID-19 - Saudi Anesthesia Society guidelines. Saudi J Anaesth 2020;14:355-8.  Back to cited text no. 3
  [Full text]  
4.
Khamar P, Shetty R, Balakrishnan N, Kabi P, Roy D, Basu S, et al. Quantitative shadowgraphy of aerosol and droplet creation during oscillatory motion of the microkeratome amid COVID-19 and other infectious diseases. J Cataract Refract Surg 2020;46:1416-21.  Back to cited text no. 4
    
5.
Sengupta S, Honavar SG, Sachdev MS, Sharma N, Kumar A, Ram J, et al. All India Ophthalmological Society - Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic. Indian J Ophthalmol 2020;68:711-24.  Back to cited text no. 5
[PUBMED]  [Full text]  




 

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