Ophthalmic drugs with systemic effects for the anaesthetist

Also known as Ophthalmic drugs with systemic effects for the anaesthetist · Eye drop systemic toxicity · Timolol phenylephrine echothiophate

Exam-exhaustive systemic effects of ophthalmic medications for ANZCA Final: absorption via the nasolacrimal route, timolol beta-blockade, phenylephrine hypertensive crisis, echothiophate-suxamethonium interaction, acetazolamide acid-base effects, mydriatic delirium, and anaesthetic decision rules.

high10 referencesUpdated 26 July 20268 min readVerification in progress

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10 MCQs

The one-line answer

Eye drops are systemic drugs in disguise. Salminen's review found eyedrops absorb rapidly into systemic circulation, with lower plasma levels when punctal occlusion is applied.^[4] Four agents own this topic: timolol beta-blocks (Ostergaard: FEV1 −56% + bradycardia after 0.25% drops^[6]; Nanda: systemic absorption/CNS penetration well-studied with bradycardia/bronchospasm/fatigue/confusion^[7]), phenylephrine drives hypertensive/pulmonary complications (Sbaraglia: 4/187 paediatric, 2.1% major^[9]; Bhatia: 10% drops mostly no significant rise, severe 1/34 hypertensive^[8]), echothiophate with anticholinesterase drops prolongs suxamethonium apnoea (Gesztes^[3]), and acetazolamide causes metabolic acidosis causally linked to ocular hypotension (Bietti^[10]). Take an ophthalmic drug history on every eye-list patient.

Meet the patient

A 78-year-old man on timolol drops and oral bisoprolol arrives for cataract extraction under sub-Tenon block with light sedation. After the midazolam his heart rate is 42 and his blood pressure 88 over 50 — a stacked beta-blockade pattern consistent with Ostergaard's timolol bradycardia provocation and Nanda's common bradycardia list.^[6]^[7]

The two questions that decide his next five minutes are the two that decide every ophthalmic drug crisis: what is on this eye, and when was the last dose? Hold those two and the four-drug map below slots into place (taught history craft; Salminen lists the absorbed agents that make history matter).^[4]

References10Show

[1]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial Lancet, 2008.PMID 18479744
[2]Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Circulation, 1999.PMID 10477528
[3]Gesztes T Prolonged apnoea after suxamethonium injection associated with eye drops containing an anticholinesterase agent. British Journal of Anaesthesia, 1966.PMID 5939140
[4]Salminen L Review: systemic absorption of topically applied ocular drugs in humans. Journal of Ocular Pharmacology, 1990.PMID 2290070
[5]Müller L, Jensen BP, Bachmann LM, Wong D, Wells AP New technique to reduce systemic side effects of timolol eye drops: The tissue press method-Cross-over clinical trial. Clinical and Experimental Ophthalmology, 2020.PMID 31525271
[6]Ostergaard Laursen S, Bjerrum P Timolol eyedrop-induced severe bronchospasm. Acta Medica Scandinavica, 1982.PMID 7113767
[7]Nanda T, Rasool N, Callahan AB, Stamper RL, Odel JG Ophthalmic Timolol Hallucinations: A Case Series and Review of the Literature. Journal of Glaucoma, 2017.PMID 28671925
[8]Bhatia J, Varghese M, Bhatia A Effect of 10% phenylephrine eye drops on systemic blood pressure in normotensive & hypertensive patient. Oman Medical Journal, 2009.PMID 22303506
[9]Sbaraglia F, Mores N, Garra R, Giuratrabocchetta G, Lepore D, Molle F Phenylephrine eye drops in pediatric patients undergoing ophthalmic surgery: incidence, presentation, and management of complications during general anesthesia. Paediatric Anaesthesia, 2014.PMID 24354865
[10]Bietti G, Virno M, Pecori-Giraldi J Acetazolamide, metabolic acidosis, and intraocular pressure. American Journal of Ophthalmology, 1975.PMID 1163584