Anesthesia and Eye Diseases: Comment

The review by Roth et al.1 addresses an important issue. The authors state that complete closure of eyelids “soon” after induction of general anesthesia and “preferably” before airway management is a key component of prevention of perioperative exposure keratopathy. Since more than 30 years ago, closure of eyelids has been advocated in numerous publications not just soon after, but immediately after loss of the eyelid reflex after induction of anesthesia.2–4 This practice is advocated to prevent corneal abrasion during face mask ventilation and laryngoscopy caused by various manipulations in close proximity to the eyes, by not optimally fitting face masks impinging on the eyes, and by objects possibly carried by anesthesiologists (e.g., watches, bracelets, identity cards, stethoscopes, jewelry).5 Instructions for anesthesia providers to tape the eyes closed as soon as the eyelid reflex disappeared after induction of anesthesia were part of a performance improvement system addressing postoperative corneal injuries.6 The overall management initiative reduced the corneal injury incidence from initially 1.51 per 1,000 to 0.79 per 1,000 anesthetics (P = 0.008).Consequently, some anesthesia departments have instituted clinical protocols or guidelines for perioperative corneal injury management that specifically require closure of the eyelids immediately after induction of anesthesia.6,7 Interestingly, this practice is advocated even in ophthalmologic8 and plastic-surgical publications.9 To the best of my knowledge, the French Society for Anesthesia and Intensive Care (together with the French Ophthalmology Society and the French-speaking Intensive Care Society; Paris, France) is the only professional anesthesia society that has released specific guidelines on eye protection in anesthesia and intensive care.10 Eyelid occlusion is recommended “as soon as the ciliary reflex is lost and before tracheal intubation, in order to reduce the risk of traumatic injuries to the cornea.” In summary, eyelid closure immediately after loss of the eyelid reflex is considered key in the prevention of perioperative corneal abrasion.5,11Somewhat surprisingly, advocates of eyelid closure immediately after loss of eyelid reflex rule out this approach in cases of rapid sequence induction, arguing that securing the airway takes precedence over eye protection.4,7,10,12 However, the risk of traumatic corneal injuries is likely greater during rapid sequence induction compared to standard induction of anesthesia because the emphasis on rapid endotracheal intubation (and, possibly, on application of cricoid pressure) distracts from attention to effective eye protection. Should endotracheal intubation fail during rapid sequence induction, it is not all that uncommon that subsequent airway management becomes somewhat uncoordinated and will now take place in the absence of any eye protection. Thus, effective eye protection is even more important during rapid sequence induction as it is during routine induction of anesthesia. The 5 to 10 s it might take to close the eyelids with stripes of adhesive tape by briefly lifting the facemask after induction of anesthesia and reapplying it until the time of laryngoscopy will certainly not endanger oxygenation and airway management.If established preventive measures are implemented, the risk of corneal injury during induction of anesthesia and surgery is controllable. This, however, is not the case during emergence from anesthesia and during transfer of patients to the recovery room and their stay there. At these times, numerous interventions take place in close proximity to the eyes (e.g., placement of a face or oxygen mask); abrupt changes in body position and movements of head, arms, and hands occur; and patients involuntarily rub their eyes—all of this in complete absence of any mechanical eye protection. As most corneal injuries may actually occur at this time,13 appropriate respective precautions must be taken.In this context, inappropriate placement of the pulse oximeter clip is an underestimated risk factor of corneal injury. During the early postoperative period, patients frequently rub their eyes because of blurred vision, itching, and foreign body sensation. Attachment of the pulse oximeter clip at the index finger of the dominant hand will increase the risk of corneal injuries. Thus, the pulse oximeter clip should not be attached at either index finger but rather at one of the other fingers of the nondominant hand.5,11,14The author declares no competing interests.