Anaesthetic management of a parturient with advanced Congenital Glaucoma presenting for Caesarean section: A case report
Abstract Number: 40
Abstract Type: Case Report/Case Series
Glaucoma is a disease of optic nerve involving loss of retinal ganglion cells.
Mechanical compression by raised intra ocular pressure and decreased blood flow of the optic nerve can lead to worsening of glaucoma.
The optimal management strategy for treating glaucoma in pregnancy is uncertain(1).
A 31 year old Caucasian multiparous woman with advanced congenital glaucoma presented for a semi emergency caesarean section. There was a history of enucleation of right eye in childhood and another eye surgery for glaucoma 14 years back, she was otherwise generally fit and well.
The preoperative BP was 110/60 mmHg. A Combined Spinal Epidural was done with 12mg of hyperbaric Bupivacaine and 20mcg Fentanyl. The level of block was T4. Soon after the induction of Spinal anaesthetic, Phenylephrine infusion was started at 16.6mcg/min(20ml/hr of 50mcg/ml) and titrated to maintain the blood pressure to near preoperative baseline levels. Continuous Non-invasive Blood pressure monitoring was used to help with the real-time titration of Phenylephrine infusion. There was one episode where the systolic BP decreased below 100mmHg which was treated immediately with a bolus of Ephedrine (6mg). The bradycardia which occurred was effectively treated with Glycopyrrolate 0.2mg. The Phenylephrine infusion was gradually weaned off in the postoperative period when the BP was stabilised to preoperative levels. Estimated blood loss was 900ml and patient was transfused 120ml of autologus blood through cell salvage and 1 unit of packed red cells besides 1.5 litres of crystalloids. Ondansetron 4mg and Cyclizine 50mg was given pre-emptively to avoid postoperative nausea and vomiting. Patient made an uneventful recovery and was discharged home on 3rd postoperative day without any change in her vision.
Congenital glaucoma is a rare condition arising from improper development of eye's drainage channels, the trabecular meshwork.
The published data on the management of anaesthesia for caesarean section with coexisting glaucoma is limited.
The factors that can worsen glaucoma during regional anaesthesia are decreased blood supply to the optic nerve and raised intraocular pressure.
Maintenance of blood pressure is of paramount importance as hypotension can result in decreased blood supply to the optic nerve and can also cause nausea and vomiting(2) which can in turn increase the intraocular pressure. Continuous non-invasive blood pressure monitoring is a useful tool in real-time titration of vasopressors to maintain stable haemodynamics.
Atropine can cause cyclopegia, mydriasis and increase in Intra Ocular Pressure, Glycopyrrolate is better tolerated than Atropine.
1. Glaucoma management in pregnancy: A questionnaire survey. Vaideanu D & Fraser S, Eye 2007; vol.21:341-3
2.Intraoperative nausea and vomiting during cesarean section under regional anesthesia. Balki M & Carvalho JC, Int J Obstet Anesth 2005; vol.14:230-41