What is the optimal anesthesia management for a patient with a prior central retinal vein occlusion, including preservation of ocular perfusion, avoidance of intra‑ocular pressure rise, maintenance of hemodynamic stability, and handling of antiplatelet or anticoagulant therapy?

Anesthesia Management for Patients with History of Central Retinal Vein Occlusion

Primary Anesthetic Goal

The primary anesthetic objective is to maintain stable ocular perfusion pressure by avoiding hypotension, hypertension, and elevated intraocular pressure, while ensuring optimal hemodynamic stability throughout the perioperative period. 1

Preoperative Assessment

Critical History Elements

• Document cardiovascular risk factors including systemic hypertension, diabetes mellitus, hyperlipidemia, cardiovascular disease, sleep apnea, and coagulopathies, as these are strongly associated with CRVO 1, 2
• Review current antiplatelet or anticoagulant therapy and coordinate with the ophthalmologist and primary care physician regarding perioperative management 1, 2
• Assess for glaucoma history and current intraocular pressure status, as CRVO is often associated with elevated IOP 1
• Determine if the patient has ischemic versus non-ischemic CRVO, as ischemic CRVO carries higher risk of neovascular complications 3

Preoperative Optimization

• Ensure blood pressure is well-controlled but avoid aggressive reduction that could compromise ocular perfusion 1
• Optimize glycemic control in diabetic patients to reduce perioperative complications 1, 2
• Continue antiplatelet therapy unless the surgical bleeding risk is prohibitive, as these patients have elevated cardiovascular and cerebrovascular risk 4, 2

Intraoperative Management

Hemodynamic Goals

• Maintain mean arterial pressure within 20% of baseline to preserve ocular perfusion pressure, as hypotension can worsen retinal ischemia 1, 2
• Avoid hypertensive episodes that could increase intraocular pressure or precipitate further vascular complications 1
• Target normocapnia (PaCO2 35-40 mmHg), as hypercapnia increases intraocular pressure and hyperventilation may reduce ocular blood flow 1

Intraocular Pressure Management

• Avoid maneuvers that increase IOP including:
  • Trendelenburg positioning (use reverse Trendelenburg or flat positioning when possible) 1
  • Tight face masks or excessive airway manipulation 1
  • Coughing, straining, or Valsalva during emergence 1
  • Succinylcholine (increases IOP by 5-10 mmHg transiently) 1
• Use non-depolarizing neuromuscular blockers for intubation if muscle relaxation is required 1
• Ensure adequate depth of anesthesia before laryngoscopy to prevent hypertensive response 1

Anesthetic Technique Selection

• Regional anesthesia is preferred when feasible (neuraxial or peripheral nerve blocks) as it provides superior hemodynamic stability and avoids airway manipulation 1
• If general anesthesia is required, use a balanced technique with:
  • Smooth induction avoiding hemodynamic swings 1
  • Maintenance with volatile anesthetics or total intravenous anesthesia 1
  • Adequate analgesia to prevent hypertensive responses 1
  • Deep extubation or awake extubation with excellent cough suppression 1

Fluid and Perfusion Management

• Maintain euvolemia to optimize cardiac output and ocular perfusion 2
• Avoid excessive crystalloid administration that could worsen macular edema 1
• Monitor for and treat anemia as it reduces oxygen delivery to already compromised retinal tissue 1, 2

Anticoagulation Management

Decision Algorithm

• For patients on antiplatelet therapy alone (aspirin, clopidogrel):

  • Continue therapy for low-bleeding-risk procedures 4, 2
  • For high-bleeding-risk surgery, discuss with surgeon and cardiologist regarding temporary cessation 2
  • Remember these patients have elevated cardiovascular risk requiring careful risk-benefit analysis 4

• For patients on anticoagulation (warfarin, DOACs):

  • Coordinate with hematology/cardiology regarding bridging strategy 2
  • Consider the indication for anticoagulation (atrial fibrillation, mechanical valve, VTE) in decision-making 2
  • Resume anticoagulation as soon as surgical hemostasis permits 4, 2

Postoperative Management

Immediate Recovery

• Maintain hemodynamic stability during emergence with smooth extubation technique 1
• Provide adequate analgesia to prevent hypertensive responses from pain 1
• Avoid postoperative nausea and vomiting which increases IOP through straining; use multimodal prophylaxis 1
• Position patient with head elevated 15-30 degrees when appropriate to reduce IOP 1

Monitoring and Follow-up

• Monitor blood pressure closely in the recovery period, treating hypertension or hypotension promptly 1, 2
• Ensure ophthalmology follow-up is scheduled, as patients with CRVO require ongoing monitoring for neovascular complications 1, 2
• Communicate with primary care physician regarding perioperative course and need for continued cardiovascular risk factor optimization 1, 4, 2

Critical Pitfalls to Avoid

• Do not assume CRVO is a stable condition: These patients have 10-20% risk of developing neovascular glaucoma, particularly with ischemic CRVO 1
• Do not discontinue antiplatelet therapy without careful consideration: Patients with CRVO have significantly elevated risk of cardiovascular and cerebrovascular events 4, 2
• Do not allow prolonged hypotension: Even brief periods of hypotension can worsen retinal ischemia in already compromised tissue 1, 2
• Do not forget the fellow eye is at risk: Approximately 10% of patients develop CRVO in the contralateral eye 4
• Do not overlook systemic disease optimization: CRVO is often a manifestation of systemic vascular disease requiring comprehensive management 1, 2