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Beitragstitel A case series of elderly patients with aortic stenosis (AS) undergoing awake glaucoma surgery in sub-Tenon’s or subconjunctival anaesthesia
Beitragscode P96
Autor:innen
  1. Friedrich Lersch Inselspital - Universitätsspital Bern Präsentierende:r
Präsentationsform ePoster
Themengebiete
  • Glaucoma
Abstract-Text Abstract: With swelling ranks of octogenarians scheduled for glaucoma surgery, more present with aortic sclerosis graded median or severe as part of their list of systemic disease. This presents a specific conundrum for anaesthesiologist and eye-surgeons alike: while surgeons will ask that arterial pressures be reduced to maximal degree for fear of expulsive suprachoroidal bleeding, anaesthesiologists will fear shock from decompensated AS should pressure be over-eagerly reduced by sedation or anti-hypertensive drugs.
As many of these patients seek treatment at an aggravated stage of their glaucoma, cancelling and postponing of these cases is often not a viable strategy.

Case vignettes: We report 4 cases of patients 78 years or older, classified as ASA 3 systemic disease patients, scheduled on one morning for glaucoma surgery with 2 classified as severe and 2 as moderate aortic stenosis patients. All presented with hypertensive pressure ( range systoly 160-180 mmHg, range diastole 90-110 mm Hg) notwithstanding regular intake of their morning medication on the day of surgery. All 4 patients received small boluses of sedation (8 ug of dexmedethomidine iv, 10 mg propofol iv and 2/4 patients received 25 ug fentanyl) following which arterial pressures remitted to high normal pressures. The first patient presenting with the most severe AS was administrated sub-Tenon’s block for trabeculectomy. Patients 2 and 3 were “downgraded” from TE to preserflow-procedures, Patient 4 underwent TE in awake analgo-sedation with the surgeon administrating subconjunctival local anaesthesia. During surgery, pressure rose to hypertensive values and local anaesthesia had to be repeated due to patient’s discomfort in spite of the anaesthetist’ efforts of improve analgosedation. Towards the end of surgery a localized a delineated temporal choroidal bleeding was remarked, intra-cameral pressure stabilized and mannitol administered systemically. Follow-up was complicated by exorbitant intraocular pressure swings and a secondary localized choroidal bleeding after one suture was severed for IOC-relieve 10 days after surgery. Improvements in the patients eye during follow-up were steady but slow.
Discussion.
As exemplified in these cases the contradicting haemodynamic demands of aortic stenosis versus glaucoma surgery situation are challenging. Both anaesthetist and surgeon have to attune their strategy to provide optimal transmural pressu