Eye injury

Iatrogenic injury is a term broadly used to denote "harm, hurt, damage or impairment that results from the activities of a doctor" (Contractor and Hardman. Contin Educ Anaesth Crit Care Pain 6:67-70, 2006). The discussion in this chapter is limited to eye injuries, many of which are the result of human error and could be avoided through active and ongoing anticipation and high standards of care. In studies of eye injuries, ocular injury occurs during 0.1-0.5% of general anesthetics and is usually corneal in nature in patients whose eyes are taped shut during the case (Contractor and Hardman. Contin Educ Anaesth Crit Care Pain 6:67-70, 2006; Grover et al. Can J Anaesth 45:575-577, 1998). When the eyes are left untaped during general anesthesia, the incidence of ocular injury has been reported to be as high as 44% (Grover et al. Can J Anaesth 45:575-7, 1998; Kocaturk et al. J Clin Anal Med 3:163-165, 2012). General anesthesia reduces the tonic contraction of the orbicularis oculi muscle, causing lagophthalmos, a condition in which the eyelids do not close completely, in 59% of patients (Contractor and Hardman. Contin Educ Anaesth Crit Care Pain 6:67-70, 2006). Additionally, general anesthesia reduces natural tear production and tear film stability. This results in the drying of the corneal epithelium leading to reduced lysosomal protection. The protection afforded by Bell's phenomenon (in which the eyeball turns upward during sleep, protecting the cornea) is also lost during general anesthesia (Nair and White. Anaesth Intensive Care Med 15:40-43, 2014). Intraoperative eye injuries accounted for 2% of medicolegal claims in Australia and the United Kingdom (Contractor and Hardman. Contin Educ Anaesth Crit Care Pain 6:67-70, 2006; Marcucci et al. Avoiding common anesthesia errors. Philadelphia: Lippincott Williams & Wilkins; 2008) and 3% in the American Society of Anesthesiologists (ASA) Closed Claims Project (Gild et al. Anesthesiology 76(2):204-208, 1992). One subset of eye injuries was characterized by a low incidence of permanent damage. Patient movement during ophthalmic procedures resulting in blindness in all cases characterized the second subset of eye injuries. Seventy-six percent of these cases occurred during general anesthesia, and the remaining 24% occurred during monitored anesthesia care (MAC). Ensuring patient immobility during surgery, using an eye block only when necessary, and maintaining stable hemodynamic monitoring and positioning can decrease the incidence of eye injury in the operating room.