mivacurium (Chiu et al 1998) have been suggested to minimize suxamethonium ocular pressure effects on the eye.

Recommendations for use in open globe (after Chidiac 2004)

1. If intubation is easy, avoid using suxamethonium chloride. 2. If intubation is difficult, ask if eye is viable or not:

a.If eye is viable then use suxamethonium

b.If eye not viable then use fiber optic laryngoscopy.

References and Further Reading

Brinkley JR, Henrick A. Role of extraocular pressure in open globe injury. Anesthesiology 100: 1036, 2004.

Chidiac EJ. Succinylcholine and the open globe: Question unanswered. Anesthesiology 100: 1035–1036, 2004.

Chiu CL, Lang CC, Wong PK, et al. The effect of mivacurium pretreatment on intraocular pressure changes induced by suxamethonium. Anaesthesia 53(5): 501–505, 1998.

Cook JH. The effect of suxamethonium on intraocular pressure. Anaesthesia 36: 359, 1981.

Eldor J, Admoni M. Acute glaucoma following nonophthalmic surgery. Isr J Med Sci 25: 293–294, 1989.

France NK, et al. Succinylcholine alteration of the forced duction test. Ophthalmology 87: 1282, 1980.

Goldstein JH, Gupta MK, Shah MD. Comparison of intramuscular and intravenous succinylcholine on intraocular pressure. Ann Ophthalmol 13: 173, 1981.

Indu B, et al. Nifedipine attenuates the intraocular pressure response to intubation following succinylcholine. Can J Anesthesiol 36: 269–272, 1989.

Kelly RE, et al. Succinylcholine increases intraocular pressure in the human eye with the extraocular muscles detached. Anesthesiology 79: 948, 1993.

Lingua RW, Feuer W. Intraoperative succinylcholine and the postopera­ tive eye alignment. J Pediatr Ophthalmol Strabismus 29(3): 167–170, 1992.

McGoldrick KE. The open globe: is an alternative to succinylcholine necessary? J Clin Anesthesia 5(1): 1–4, 1993.

Metz HS, Venkatesh B. Succinylcholine and intraocular pressure. J Pediatr Ophthalmol Strabismus 18: 12, 1981.

Meyers EF, Singer P, Otto A. A controlled study of the effect of succinylcholine self-taming on intraocular pressure. Anesthesiology 53: 72, 1980.

Mindel JS, et al. Succinylcholine-induced return of the eyes to the basic deviation. Ophthalmology 87: 1288, 1980.

Moreno RJ, et al. Effect of succinylcholine on the intraocular contents of open globes. Ophthalmology 98: 636–638, 1991.

Nelson LB, Wagner RS, Harley RD. Prolonged apnea caused by inherited cholinesterase deficiency after strabismus surgery. Am J Ophthalmol 96: 392, 1983.

Polarz H, Bohrer H, Fleischer F, et al. Effects of thiopentone/suxamethonium on intraocular pressure after pretreatment with alfentanil. Eur J Clin Pharmacol 43(3): 311–313, 1992.

Polarz H, Bohrer H, Martin E, et al. Oral clonidine premedication prevents the rise in intraocular pressure following succinylcholine administration. Germ J Ophthalmol 2(2): 97–99, 1993.

Robinson R, White M, et al. Effect of anaesthesia on intraocular blood flow. Br J Ophthalmol 75: 92–93, 1991.

Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe. Anesthesiology 99: 220–223, 2003.

Ocular side effects

Systemic administration

Certain

1. Pupils – dependent on plane of anesthesia

a.Mydriasis – reactive to light (initial)

b.Miosis – reactive to light (deep level of anesthesia)

c.Mydriasis – non-reactive to light (coma)

2. Extraocular muscles – dependent on plane of anesthesia

a.Slow oscillations (initial)

b.Eccentric placement of globes (initial)

c.Concentric placement of globes (coma) 3. Non-specific ocular irritation

4. Conjunctival hyperemia

5. Lacrimal secretion – dependent on plane of anesthesia

a.Increased (initial)

b.Decreased (coma)

c.Abolished (coma)

6. Decreased intraocular pressure

7. Decreased vision

8. Cortical blindness

Inadvertent ocular exposure

Certain

1. Irritation

a.Hyperemia

b.Edema

2. Punctate keratitis

3. Corneal opacities

Clinical significance

Adverse ocular reactions due to ether are common, reversible and seldom of clinical importance other than in the determination of the plane of anesthesia. Ether decreases intraocular pressure, probably on the basis of increasing outflow facility. Ether vapor is an irritant to all mucous membranes, including the conjunctiva. In addition, either vapor has a vasodilator property. Permanent corneal opacities have been reported due to direct contact of liquid ether with the cornea. Blindness after induction of general anesthesia is probably due to asphyxic cerebral cortical damage.

References and Further Reading

Gilman AG, Goodman LS, Gilman A (eds). The Pharmacological Basis of Therapeutics, 6th edn, Macmillan, New York, p 291, 1980.

Murphy DF. Anesthesia and intraocular pressure. Anesth Analg 64: 520, 1985. Smith MB. Handbook of Ocular Toxicology, Publishing Sciences Group,

Acton, pp 356–357, 1976.

Sweetman SC (ed). Martindale: The Complete Drug Reference, 34th edn, Pharmaceutical Press, London, pp 1298–1299, 2004.

Tripathi RC, Tripathi BC. The Eye. Riddell RH (ed), Pathology of DrugInduced­ and Toxic Diseases, Churchill Livingstone, New York,

pp 377–450, 1982.

Class: General Anesthesia

Generic name: Ether (anesthetic ether).

Proprietary names: None.

Primary use

This potent inhalation anesthetic, analgesic and muscle relaxant is used during induction of general anesthesia.

Generic name: Ketamine hydrochloride.

Proprietary name: Ketalar.

Primary use

This intravenous non-barbiturate anesthetic is used for shortterm diagnostic or surgical procedures. It may also be used as an adjunct to anesthesia.