Summer 2023 Issue

Greetings OAS Members! 2023 has been a year of excitement.  Next year we are hosting the 37th Annual OAS Scientific Meeting in Houston, Texas on February 9-10, 2024.  The society first met in Houston, so this journey has brought us full circle to where it all began.  As the fourth largest city in the US, Houston is a fantastic city to get to know.  We have a wealth of academic support from our partners in the Texas Medical Center - the largest medical center in the world!!  We are hoping that a central location will appeal to our bicoastal colleagues and with two airports, there are many options to get here.   Our society is also working on increasing our international footprint with involvement from our colleagues in the British and Indian Ophthalmic Anesthesia Organizations.  The OAS continues it’s tradition of being an organization that brings together ophthalmologists, anesthesiologists, registered nurse anesthetists and other clinicians to improve the quality of care for our patients. Can’t wait to see you in Houston! Maggie Jeffries, MD President, Ophthalmic Anesthesia Society

The OAS Annual Scientific Meetings are held each year and feature scientific programs designed to feature the latest education, techniques, and research in the realm of ophthalmic surgery and anesthesia. We look forward to meeting you in Houston, February 9-10, 2024.  ·        Hands-on workshops with certificates of attendance ·        Exclusive lectures from anesthesia, ophthalmology and surgery experts  ·        Round table events with other physicians and registered nurses   ·        Valuable networking opportunities ·        Slides and notes from speakers at all presentations Whether you are an anesthesiologist, CRNA, ophthalmologist, nurse, resident or student, there is something for everyone at the OAS Annual Scientific Meeting.

Find out more

Budget now to renew your membership for next year and benefit from reduced registration at the conference. Membership Categories Annual Rate   CRNA/ AA $395   Physician $395   Associates (RN, PA, Surgical Techs) $100   Resident/ Fellow $50 OAS Members enjoy exclusive benefits:         OASIS Newsletter Archives         OAS Member Directory         OAS Program Archive         Scientific Forum No formal gatherings are scheduled for the current year. However, we encourage you to avail yourself of a comprehensive array of resources, including last year's presentations and an extensive repository of information accessible via past newsletters. These invaluable assets facilitate engagement with the scientific community, fostering collaborative opportunities among peers. Anticipate forthcoming dynamic updates on society initiatives that promise enhanced interactivity and engagement.

FDA warns consumers not to purchase or use certain methylsulfonylmethane (MSM) eye drops due to contamination Turning medicine caps into mosaic

Meet the OAS Board

President        Maggie Jeffries, MD, Avanti Anesthesia President-Elect/VP   Jefferson Doyle, MD, Johns Hopkins Immediate Past-President    George Dumas, MD, University of Alabama Birmingham Secretary        Kay Phelan, CRNA, Connecticut Eye Surgery Center Treasurer       Robert Gauvin, CRNA, Anesthesia Professionals Directors                  Eric Fry, MD, Fry Eye Associates, P.A. Pete Spitellie, MD, JJM Medical Services Elaine Liew, MD, University of California, Los Angeles Tina Tran, MD, Johns Hopkins Brenton Rains, CRNA, Center for Sight  Scientific Advisory Chair                 Randolf Harvey, CRNA, Florida Eye Clinic / ASC At-Large Director                 Vinodkumar Singh, MD, University of Alabama Birmingham

Repository

Take a survey for a chance to win $250 AMAZON Card OAS President, Dr. Maggie Jeffries, recently published a paper regarding opiate use in cataract surgery. Below is a follow up survey she helped design to gain even more information to share with the ophthalmic anesthesia industry. Please take a few minutes to complete the survey, results will be shared later this year in a recap from Dr. Jeffries. A randomly selected winner will receive an electronic $250 Amazon Card. Be sure to fill out the survey for a chance to win!

Take the survey now

GLP-1 receptor agonists and sedation for Ophthalmic surgery Many of us are now aware of the reports of retained gastric contents in patients take glucagon-like peptide-1 (GLP-1) receptor agonists despite being appropriately NPO.  These medications work by the inhibition of gastric emptying and stimulation of insulin production and reduction in glucagon secretion leading to lower insulin levels.   The delayed gastric emptying reduces hunger, leading to a reduction in food intake and subsequent weight loss.  It is advisable to familiarize yourself with the generic and brand names of these medication and ensure that your preoperative staff is educated as well.  There are various routes of administration such as oral pills and subcutaneous injections and administration could be daily or weekly.  As of publication of this article, the current FDA approved GLP-1 medications are: Dulaglutide (trulicity) Exenatide (Bydureon, Byetta) Semaglutide (Ozempic, Wegovy, Rybelsus) Liraglutide (Victoza, Saxenda) Lixisenatide (Adlyxin) Tirzapatide (Mounjaro) If the patient has GI symptoms such as nausea, vomiting, dyspepsia and abdominal distention, current evidence indicates there is an increased likelihood of retained gastric contents.2 Because of concerns over an increased risk of aspiration associated with GLP-1 agonists, the ASA Task Force on Preoperative Fasting reviewed the limited existing literature and compiled the following recommendations for elective procedures.3 This is taken directly from their statement which is linked in the references below.  “Day or week prior to the procedure: ·        Hold GLP-1 agonists on the day of the procedure/surgery for patients who take the medication daily. ·        Hold GLP-1 agonists a week prior to the procedure/surgery for patients who take the medication weekly. ·        Consider consulting with an endocrinologist for guidance in patients who are taking GLP-1 agonists for diabetes management to help control their condition and prevent hyperglycemia (high blood sugar). Day of the Procedure: ·        Consider delaying the procedure if the patient is experiencing GI symptoms such as severe nausea/vomiting/retching, abdominal bloating or abdominal pain and discuss the concerns of potential risk of regurgitation and aspiration with the proceduralist or surgeon and the patient. ·        Continue with the procedure if the patient has no GI symptoms and the GLP-1 agonist medications have been held as advised. ·        If the patient has no GI symptoms, but the GLP-1 agonist medications were not held, use precautions based on the assumption the patient has a “full stomach” or consider using ultrasound to evaluate the stomach contents. If the stomach is empty, proceed as usual. If the stomach is full or if the gastric ultrasound is inconclusive or not possible, consider delaying the procedure or proceed using full stomach precautions. Discuss the potential risk of regurgitation and aspiration of gastric contents with the proceduralist or surgeon and the patient. ·        Full stomach precautions should be used in patients who need urgent or emergency surgery.” This is all well and good for general anesthetics, but what about procedures/surgery under light sedation such as cataract surgery?  These medications are being prescribed in ever increasing amounts and not always by legitimate health care providers.  Compounding pharmacies are now offering these medications as well as online websites.  Further concerning is that patients may not disclose taking these medications as they don’t see it as a “medication.” The Ophthalmic Anesthesia Society has received numerous inquiries as to what guidance, if any, we can provide.  We recommend that patients be specifically asked if they are taking any GLP-1 medications, in what dose and delivery form, for what indication, and if they are having any GI side effects.  Preferably this occurs at the surgeon’s office so that an intervention in dosing might be made.  At the very least, sedation should be tailored to keep these patients as awake as possible.  As sedation is a spectrum from light to deep, the final decision on how to proceed remains with the anesthesia provider and should be influenced by both patient and surgical factors.  The OAS will continue to monitor the available evidence which will continue to evolve as more research is performed.  It is our expectation to perform a survey of our members regarding their anesthesia practices related to GLP-1 medications and present the data at our annual meeting.  There will be a lecture and further discussion regarding this important subject.  See you there!! References: Klein SR, Hobai IA. Semaglutide, delayed gastric emptying, and intraoperative pulmonary aspiration: A case report. Can J Anesth. 2023. DOI: 10.1007/s12630-023-02440-3. Silveira SQ, da Silva LM, Abib ACV et al. Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth. 2023; 87: 111091. Powell K. Did you know that the ASA has offered guidance on preoperative management of patients on glucagon-like peptide-1 (GLP-1) receptor agonists for elective procedures?  Online, August 2, 2023.

Meet the OAS Board of Directors

• George Dumas, MD
• Maggie Jeffries, MD
• David Markoff, MD
• Kay Phelan, CRNA 
• Chris Bender, CRNA 
• Eric Fry, MD
• Pete Spitellie, MD 
• Elaine Liew, MD 
• Tina Tran, MD 
• Brenton Rains, CRNA 
• Elaine Chiewlin Liew, MD
• Randolf Harvey, CRNA
• Alan Zamora, CRNA

Higher incidence of retinal vascular occlusion after COVID-19 infection 

With COVID-19 known to cause vascular damage and induction of a prothrombotic state, investigators examined the risk of retinal vascular occlusions in patients with COVID-19 infections. This cohort study of 432,515 patients diagnosed with COVID-19 found that the incidence of retinal vein occlusions, but not retinal artery occlusions, appeared to increase in the 6 months after COVID-19 diagnosis. Patients with COVID-19 infection may have an increased risk of retinal vein occlusion in the 6 months after infection, similar to the increased risk of systemic vascular damage associated with COVID-19, and clinicians need to consider this factor when evaluating these patients. Read the full study at JAMA Ophthalmology.

Register Today for the 2022 Annual OAS Scientific Meeting   

The OAS Annual Scientific Meetings are held each year in September and feature scientific programs designed to feature the latest education, techniques, and research in the field of ophthalmic surgery and anesthesia. We look forward to meeting you in Baltimore this year, September 9-11, 2022.

Register before July 15, 2022 to secure early-bird rates! 

The meeting will be held in person at the Lord Baltimore Hotel in downtown Baltimore, MD. Discounted hotel registration is available for OAS attendees --  book your room at the Lord Baltimore Hotel's website.

Virtual attendance is also available and Zoom details will be shared with attendees if you cannot travel this year. 

Scientific content includes:

• Fire Safety in the OR

• Acute MI at the Ambulatory Surgery Center

• Safe Ophthalmic Anesthesia: A Broad Review

• How Not to Get Your Case Canceled! And Other Pearls for Cataract Surgery

• Practice Updates Post-COVID 19

• Special Cases: Diabetes, Pregnancy, or Pediatric Considerations

• Hands-on Workshops! Learn Orbital Anatomy, Sub-Tenon Blocks & Orbital Blocks

• Round table events with board members and experienced clinicians

• Valuable networking opportunities

• Engaging and interactive sessions

• Hands-on eye block workshop with certificate options

• Poster Session – Submit Your Abstract Here

Currently there is a backlog of surgical procedures that have been delayed but are necessary to improve the health and quality of life of our patients. Although there is increasing information to address the timing of surgery after COVID-19 infection, studies continue to lag behind the emerging variants and the likelihood that vaccinated patients have a lower a risk of postoperative complications as compared to unvaccinated patients. Almost all available data come from study periods with zero to low prevalence of vaccination. Read the full article at apsf.org.

Interval Between COVID Diagnosis and Surgery	30-day Mortality Rate for Elective Patients (%, CI)**
No COVID Diagnosis	0.62 (0.57-0.67)
0-2 weeks	3.09 (1.64-4.54)
3-4 weeks	2.29 (1.06-3.53)
5-6 weeks	2.39 (0.87-3.91)
≥7 weeks	0.64 (0.20-1.07)

Greetings OAS Members!

2022 is an exciting time to be a member. Our growing organization has over 100 members and we are proud to be the only organization where anesthesiologists, ophthalmologists, registered nurse anesthetists and other clinicians can come together to improve the quality of care for our patients.

This year we are hosting the 36th Annual OAS Scientific Meeting in Baltimore Maryland – and offering online access for those who cannot travel. It’s a vibrant, new city for OAS members with a wealth of academic support from our partners on the East coast. Can’t wait to see you there!

Michael Morley, MD, ScM ¹, Anne M. Menke, RN, PhD², Karen C. Nanji, MD, MPH³

¹ Ophthalmic Consultants of Boston, Harvard Medical School, Boston, MA
² Ophthalmic Mutual Insurance Company, San Francisco, CA 
³ Massachusetts General Hospital, Harvard Medical School, Boston, MA

DOI: https://doi.org/10.1016/j.ophtha.2019.12.019

Publication date: December 25, 2019
Ophthalmology Journal - a publication of the American Academy of Ophthalmology

PurposeTo evaluate the types of anesthesia-related closed claims and their contributing factors, using data from the Ophthalmic Mutual Insurance Company (OMIC).

Design
Retrospective analysis of preexisting data.

Participants
Plaintiffs who filed a professional liability claim or suit (written demand for money) against OMIC-insured ophthalmologists, ophthalmic practices, or surgicenters in which the surgical case occurred.

Methods
Plaintiff claims were collected from the OMIC database from 2008 to 2018 using search queries for terms associated with known complications of ophthalmic anesthesia.

Main Outcome Measures
Number and types of anesthesia-related injuries and claims, who administered the anesthesia, the outcomes of the claim or suit, cost to defend, and payments made to plaintiffs.

Results
Sixty-three anesthesia-related claims or suits were filed by 50 plaintiffs. Anesthesia-related injuries included globe perforation (n = 17), death (n = 13), retrobulbar hemorrhage (n = 7), optic nerve damage (n = 4), vascular occlusions (n = 2), pain (n = 2), eye or head movement resulting in injury (n = 2), and 1 case each for numbness, diplopia, and tooth loss during intubation. All but 1 patient who died had preexisting, significant comorbidities. Two deaths were related to brainstem anesthesia. Regarding the type of anesthesia in the closed claims, retrobulbar and peribulbar anesthesia were the most common types (n = 16 each), followed by local infiltration around the lids and facial nerve (n = 6), topical anesthesia (n = 5), and general anesthesia (n = 5). In 2 cases, the exact type of anesthesia was unknown but not general. The 5 topical with sedation anesthesia-related claims were due to inadequate pain control (n = 2), ocular movement resulting in capsular rupture (n = 2), or death (n = 1) allegedly related to excessive or inadequate monitoring of sedation. There were 5 claims related to general anesthesia including 4 deaths and 1 tooth loss during intubation. Sedation was alleged to be a factor in 5 cases resulting in death. Anticoagulants were a factor in 3 retrobulbar hemorrhage cases.

Conclusions
Although claims and suits were infrequent given the large number of insured ophthalmologists and the large number of surgical cases requiring various types of anesthesia performed over the 10.5-year study period, severe injuries can occur

A Single-Center, Retrospective Records Review of 130,775 Patients, 1999-2015

Vinodkumar Singh, MD¹,Ayesha S. Bryant, MSPH, MD¹, Matthew Hull, MD¹, Jason Skelley, MD¹, Robin Walters, MD² , R. Clark Cross, MD¹, Marc A. Rozner, MD³ , and Gwendolyn L. Boyd, MD¹

¹ Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
² Department of Anesthesiology, University of Kansas Medical Center, Kansas City, MO, USA
³ Baylor College of Medicine Education at The University of Texas MD Anderson Cancer Center, Houston, TX, USA 

Abstract 

Purpose: The most recent study of ophthalmic surgery morbidity and mortality was published in 1995, with a patient study population from 1977 to 1988. The present study reports surgical outcomes from a single-center, retrospective analysis of patient records from 1999 to 2015. Methods: Three International Classification of Diseases–9-CM codes for cardiorespiratory events were searched in the discharge diagnoses in an eye hospital over a 16-year period. The overall mortality and preoperative risk factors were analyzed, including the type of anesthetic, type of surgery, medical comorbidities, and bradycardia preceding the cardiac events. Results: Between February 1, 1999 and October 1, 2015, a total of 130 775 patients presented for ophthalmic surgery. Fifty-nine patients (0.45 per 1000) experienced a cardiorespiratory event. Of the 59 patients, 14 patients had a cardiorespiratory arrest, 9 of whom died during the perioperative period. Of the remaining 45 patients, 29 had significant adverse events needing some form of advanced monitoring, evaluation, and/or intervention. There was a significantly greater prevalence of diabetes among patients who had a cardiorespiratory event (P < .001). Conclusions: The major risk factor associated with ophthalmic surgery morbidity and mortality was diabetes with its associated complications of autonomic neuropathy, nephropathy, and retinopathy. Of the 9 patients who died, 8 were diabetic with proliferative diabetic retinopathy and renal  insufficiency/failure. The ninth mortality was secondary to a venous air embolism during ocular air infusion. The adage that “the eye is the window to our overall health” seems to be correct.

Click here to read the full paper. 

Howard Palte, MBChB
University of Miami System of Health 

Ocular trauma is common arising secondary to sports injury, road accidents, assault and leisure. The quoted incidence is imprecise because estimates are retrospective and drawn from hospital records and population surveys. However, the World Health Organization (WHO) estimates there are 55 million injuries globally with more than 2.5 million occurring in the United States, alone. The majority (90%) occur in males, particularly those in the 15-24-year age group.

The Ocular Trauma Study Group divides eye trauma into open and closed globe injury with further classification according to type, grade, pupil response and zone of injury (Table 1). Moreover, the area affected is divided into three zones, viz. zone I (limited to the cornea and limbus), zone II (< 5mm posterior to limbus) and zone III ( > 5mm posterior to limbus).

The primary considerations in the management of eye trauma are control of intraocular pressure (IOP) and preservation of ocular integrity by preventing extrusion of ocular contents. In brief, the primary factors affecting IOP are changes in intraocular volume (blood and aqueous humor), orbit compliance and external compressive forces. Intraoperative coughing, straining and retching result in massive increases in IOP and pose significant threat to visual outcome.

Anesthesia management of ocular trauma extends beyond the eye., The preoperative evaluation is important because there may be additional factors that modify the anesthesia plan. The provider should determine the mechanism of injury and examine for associated injuries, especially head trauma. In certain instances, additional investigations  such as, CT scan orbit and head and metabolic panel may be warranted.

For decades, general anesthesia (GA) has been preferred for repair of open globe injuries (OGI) because it provides ocular akinesia, lowered IOP, airway control and eliminates the peril of unexpected patient movement. Anecdotal reports, dating back to the 1950s, stressed avoidance of succinylcholine because of elevations in IOP and extrusion of ocular contents. However, succinylcholine  may be considered in select OGI when airway control or aspiration is of concern because it produces moderate and transient increases in IOP (9mmHg), and not an implicated precursor of vitreous expulsion. The drawbacks of GA  include risk of regurgitation, increased nausea and vomiting and significant increases in IOP with coughing and bucking.

Regional anesthesia (RA) with monitored anesthesia care (MAC) is an alternative option in select open globe injuries. A retrospective review at a leading eye institute examined outcomes of eye injuries managed under RA + MAC in terms of  long-term visual acuity. It found that anterior (Zone I & II) injuries and intraocular foreign bodies (IOFB) managed under RA & MAC resulted in reduced operative times, and no statistical difference in visual acuity at 2-month follow-up.

The regional anesthesia technique used in open globe injuries requires modification in order to prevent fluctuations in IOP. Eyelid squeezing causes massive increases in IOP and is attenuated by performance of a facial nerve (VII) block, commonly adopting a modified van Lint approach. The subsequent extraconal (peribulbar) block is performed using a restricted volume (5-6 ml) of LA injected in small aliquots over 2-3 minutes (limiting external compressive forces on the globe).

Eye injuries in children require operative repair under GA. It is estimated that 90% of these injuries are preventable because the majority occur at home when there is no parental supervision.  The mechanism varies with age with cleaning products injuring toddlers and older children more likely to sustain sports and projectile insults.

Primary closure of open globe injuries is optimally achieved within 24 hours. Long-term visual outcomes are determined by initial visual acuity . The US Eye Injury Register indicates that long-term visual acuity is determined by presenting light perception. Ultimately, 3 /4 patients retain a degree of vision and 20% regain normal light perception. 

First off, I would like to sincerely thank the Board of Directors and all the members of the Ophthalmic Anesthesia Society for your trust and support in nominating me as this year’s president. I will do my best to fulfill my duties and responsibilities, but I will need your help - I want to hear your ideas, feedback, and suggestions to help our society develop a strong voice for patient care, patient safety, and operating room business in ophthalmic surgery and anesthesia.

Membership is very crucial for the survival of any organization, and I believe that the value of the membership is a very important factor in retaining existing members and attracting new members. Therefore, improving the value of our membership will continue to be my main focus of the OAS business in the upcoming year.

The OAS annual scientific meeting has been a great platform for all our members to come together face to face to exchange updated information, discuss new founded theories, and practice ophthalmic surgery and anesthesia. I want to enhance the educational value of the 34th Annual Scientific Meeting and start the planning of the 34th annual scientific meeting early in order to invite valuable speakers, to advertise the benefits of the meeting, and attract new members to our society while gaining new attendees.

Many of our members are already experts in the practice of ophthalmic surgery and anesthesia. Their publications, including papers, articles, abstracts, practice protocols, institutional policies, and letters to editors are very valuable to showcase to our members and the international ophthalmic society as well. Four years ago, during my first term of presidency, I wanted to create an online repository to host all the publications from our members, however, the project was delayed due to technical difficulty so I would like to try to implement this one again in the upcoming year. In addition to post your work, the repository will also house guidelines from centers across the country to help in building consensus statements on key issues in the specialty. I will need each of you to send all of your publications to Lori and Melissa as the first step of this exciting project.

The OAS newsletter has been getting better and better in the last several years thanks to the hard work of the OAS Scientific Advisory Panel, but we need help from every member to participate and make a contribution to the newsletter to make it more meaningful and educational. Please send your suggestions to Lori, Melissa, the board members, and myself included.

The online discussion forum has also been a great success in the last several years by being more simple, effective, and accessible. If you have questions or have answers to the questions other members posted, we encourage you to participate as this is can be a great learning experience for you and your peers. Our small society is advantageous for us to get to know each other, so I hope the improvement of the online discussion forum can further develop the communication between our members.

In addition to improving the value of membership, I am also asking every member to help our society grow by reaching out to our surgical and anesthesia colleagues and encouraging them to become new members and participate in this wonderful community that we have built.

If you have any questions, comments, or concerns, please don’t hesitate to reach out to me. I am very excited for the new business year of the Ophthalmic Anesthesia Society and am looking forward to working with every member closely for the bright future of our society.

Respectfully submitted, 

Zhuang T. Fang, M.D., MSPH, FASA
Clinical Professor
David Geffen School of Medicine at UCLA
Department of Anesthesiology and Perioperative Medicine
Associate Director, Wasserman Stein Operating Service