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      Do we need ophthalmic anesthesia as a subspecialty?

      editorial
      Journal of Anaesthesiology, Clinical Pharmacology
      Wolters Kluwer - Medknow

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          Abstract

          The American Heart Association categorizes ophthalmic surgeries as low-risk surgeries due to less stress response, hemodynamic variation, minimal blood loss, minimal requirement of invasive monitoring, mild to moderate perioperative pain, etc.[1] Patients requiring ophthalmic procedures belong to variable age groups ranging from infants being operated for retinopathy of prematurity, congenital cataract, and congenital glaucoma to elderly patients for cataract or malignancy. Many ophthalmic pathologies require urgent attention and early surgery to provide vision. Anesthesia for ophthalmic procedures poses unique challenges like providing ocular akinesia, prevention of patient movement, control of intraocular pressure, minimizing oculo-cardiac reflex, and prevention and treatment of postoperative nausea and vomiting. Ocular pathology may be associated with a number of syndromes with difficult airway and cardiorespiratory and neurological disorders. Moreover, given the short duration of procedures, an overwhelming number of ophthalmic procedures and examinations are performed under general anesthesia daily in the tertiary care centers. A large number of patients requiring ophthalmic surgeries are from the pediatric age group. So, an anesthesiologist should have expertise in dealing with difficult airway as well as pediatric anesthesia. In the current issue, Prajapati and Nanda[2] successfully used Blockbuster laryngeal mask airway in a preterm infant weighing 1.6 kg for lower eye lid swelling. Most of the ophthalmic procedures in adults can be performed under regional or topical anesthesia. Some elderly patients requiring ophthalmic surgeries may have various comorbidities like diabetes, hypertension, coronary artery disease, and chronic obstructive pulmonary disease, making the knowledge of their management a matter of utmost importance for anesthesiologist. Surgeries in these sets of patients are usually done under regional anesthesia with monitored anesthesia care, with or without anxiolysis and sedation. Hence, anesthesiologists should also be familiar with all aspects of geriatric along with locoregional anesthesia. In the current issue, Upadhyay et al.[3] have given an insight of recent trends of use of anesthetic agents and techniques for anesthesia in ophthalmic surgeries. They have discussed newer sedative agents, various positionings during surgery, Valsalva retinopathy, neuromonitoring intraocular pressure changes, ultrasound for ophthalmic blocks, and local anesthetic agents. Saad et al.[4] studied about the effect of 0.5 μg/kg dexmedetomidine as an adjuvant to sub-tenon’s block and as intravenous sedation in patients undergoing cataract surgery. They concluded that dexmedetomidine decreases the onset time of block as well as prolongs the duration of block with significant reduction in postoperative pain. Intravenous dexmedetomidine also reduces pain at the time of administration of block and results in sedation. There is continuous advancement of technology in the surgical field and ophthalmology is no exception. With advanced microscopes, 3D monitors, and imaging, complicated cases are being operated in a more precise way using techniques like Descemet’s stripping endothelial keratoplasty, deep anterior lamellar keratoplasty, and Descemet membrane endothelial keratoplasty to provide better vision. Hence, the question arises, do we need ophthalmic anesthesia as a subspecialty? Subspecialities are created to have extra knowledge and command in a particular field to provide better patient care. Cambridge dictionary defines subspecialty as a subject that someone knows a lot about, within a larger subject, particularly in medicine. As per definition, ophthalmic anesthesia may qualify as a subspecialty. Presently, dedicated scientific societies and associations like British Ophthalmic Anaesthesia Society and Association of Indian Ophthalmic Anaesthesiologists conduct educational activities, and focused research is being published in ophthalmic anesthesia journals to improve patient care and safety. However, the essence of anesthesia like drugs, induction and maintenance of anesthesia, airway management, extubation, and regional blocks will remain the same for each case, with variation according to the requirement of a particular surgical specialty like ophthalmic, bariatric, ENT, urology, etc. This holds true even within a subspecialty like pediatric anesthesia as goals of tracheoesophageal fistula repair will be different from those of a hernia surgery or of Wilm’s tumor resection due to specific surgical requirements. This gives way to the following questions: do we need a separate ophthalmic anesthesia department or unit in a teaching institute or do we need a DM course or fellowship in ophthalmic anesthesia subspecialty? A dedicated department or unit will need DM or fellowship courses to function independently. DM course in ophthalmic anesthesia is not a good option as ophthalmic surgeries are low-risk surgeries and 60%–70% cases are done under regional blocks, with minimal hemodynamic variations, blood loss, or critical incidents. The trainee will face limited scope due to lack of experience in critical care management, emergency management, invasive procedures, pain management, and administration of neuraxial blocks and other regional blocks. A competent anesthesiologist should be able to manage a wide variety of cases but working only in ophthalmic theater for 3 years during postgraduation will restrict overall skill and expertise in the other surgical anesthesia fields. Post MD ophthalmic anesthesia fellowship for 3–6 months, however, is an option for interested residents who are not exposed to ophthalmic theater during their MD course or who want to pursue ophthalmic anesthesia in their future practice. They can learn and refine their skills of administration of ophthalmic blocks, sedation, and tailored general anesthesia techniques for ophthalmic surgeries during fellowship to improve patient safety. One should also think about the job perspectives after ophthalmic anesthesia fellowship. There are very few teaching hospitals with dedicated ophthalmic centers, and most of them have post MD program with rotation to ophthalmic theater for experience in ophthalmic anesthesia. As such, DM and fellowship in pediatric anesthesia include pediatric ophthalmic anesthesia training in many institutes. Three years of MD anesthesia training provides enough experience to manage adult patients requiring general anesthesia or monitored anesthesia care with sedation for ophthalmic surgery. Most of the big eye hospitals are standalone private hospitals and anesthesiologist works as full time or part time. Most of the hospitals do not have dedicated intensive care unit (ICU) for pediatric and adult patients due to cost versus benefit ratio. Patients are shifted to nearby hospitals for ICU care in case of complication. Admission of patients with multiple comorbidities requiring postoperative ICU care is limited in private standalone hospitals, and these patients are usually referred to a tertiary care institute. In conclusion, ophthalmic anesthesia appears to be an attractive subspecialty, but it might end up restricting trainees with limited options of work, that is, only in ophthalmic centers, unlike pediatric anesthesia subspecialty. I am afraid that dividing anesthesia to different miniscule parts will take away the shine of a competent anesthesiologist as the well-known multitasking Octopus depiction. Keeping in mind coronavirus disease 2019 (COVID-19)-like pandemic, an anesthesiologist should keep all his/her arms and skills in a working condition and, perhaps, strive to strengthen one particular arm a tad bit more.

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          Most cited references4

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          ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.

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            • Record: found
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            • Article: not found

            Blockbuster laryngeal mask airway as a boon in neonate undergoing ophthalmic surgery

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              • Record: found
              • Abstract: not found
              • Article: not found

              Recent trends in anesthetic agents and techniques for ophthalmic anesthesia

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                Author and article information

                Journal
                J Anaesthesiol Clin Pharmacol
                J Anaesthesiol Clin Pharmacol
                JOACP
                J Anaesthesiol Clin Pharmacol
                Journal of Anaesthesiology, Clinical Pharmacology
                Wolters Kluwer - Medknow (India )
                0970-9185
                2231-2730
                Jul-Sep 2023
                29 September 2023
                : 39
                : 3
                : 341-342
                Affiliations
                [1]Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
                Author notes
                Address for correspondence: Dr. Renu Sinha, R.N. 376, RP Centre, AIIMS, New Delhi, 110 029, India. E-mail: renusinha@ 123456aiims.edu
                Article
                JOACP-39-341
                10.4103/joacp.joacp_410_23
                10661614
                df693b6a-1da5-41aa-ad52-92ab8f31ecdf
                Copyright: © 2023 Journal of Anaesthesiology Clinical Pharmacology

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 10 September 2023
                : 11 September 2023
                Categories
                Editorial

                Anesthesiology & Pain management
                Anesthesiology & Pain management

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