Anaesthesia for Laser Eye Surgery

Quick Answer

Exam Essentials - ANZCA Final Examination

Laser Eye Surgery Overview: PRK (photorefractive keratectomy), LASIK (laser-assisted in situ keratomileusis), LASEK (laser epithelial keratomileusis), and SMILE (small incision lenticule extraction) are the main refractive procedures. Anaesthetic requirement: Topical anaesthesia (proparacaine 0.5% or tetracaine 0.5%) with or without sedation; general anaesthesia rarely required except for pediatric/developmental delay patients [1-4].

Key Anaesthetic Considerations:

• Patient cooperation: Essential for maintaining fixation on target light during excimer laser ablation (typically 10-60 seconds per eye)
• Sedation principles: Light sedation with fast offset; oversedation causes loss of cooperation, undersedation causes anxiety/movement
• Topical anaesthesia: 2-3 drops of proparacaine 0.5% administered by surgeon; provides 15-20 minutes analgesia
• Positioning: Supine on flat laser bed; patient must remain still throughout procedure [5-7]

Contraindications to Laser Surgery:

• Severe dry eye, active ocular surface disease
• Keratoconus or suspected ectasia (thin corneas <480 μm)
• Unstable refraction, pregnancy/lactation
• Inability to cooperate (cognitive impairment, severe anxiety)
• Systemic immunosuppression, collagen vascular disease [8-10]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Access and Utilisation Patterns:

Laser refractive surgery is significantly underutilised among Aboriginal and Torres Strait Islander populations, reflecting broader patterns of healthcare access disparities:

• Lower uptake: Indigenous Australians represent <1% of refractive surgery patients despite higher rates of refractive error in some communities [11]
• Geographic barriers: Laser clinics concentrated in major cities; limited access from rural/remote communities where 25-30% of Indigenous population resides
• Cost barriers: Out-of-pocket expenses ($2,000-4,000 per eye) prohibitive given socioeconomic disadvantage (median Indigenous income 65% of non-Indigenous) [12,13]

Health Literacy and Cultural Considerations:

1. Awareness deficit: Limited understanding of laser surgery options and safety among remote community members
2. Trust issues: Historical medical exploitation creates reluctance to pursue elective procedures
3. Language barriers: Technical explanations of risks/benefits require visual aids and interpreter services
4. Cultural obligations: "Sorry Business" and ceremonial duties may interfere with multiple follow-up appointments [14,15]

Refractive Error Burden:

• Higher rates of uncorrected refractive error: In remote Indigenous communities, limited access to optometry services means many adults have never had formal refraction
• Occupational impact: Uncorrected refractive error affects employment in mining, agriculture, and driving-heavy roles common in regional areas
• Safety implications: Reduced vision increases risk of workplace and motor vehicle accidents in already high-risk environments [16,17]

Culturally Safe Care Considerations:

• Aboriginal Health Worker involvement: Preoperative education and support
• Flexible scheduling: Recognition of cultural obligations that may affect appointment attendance
• Family involvement: Extended family may be involved in decision-making for elective procedures
• Follow-up support: Telehealth options and partnerships with local ACCHSs for postoperative care [18,19]

Māori Populations (Aotearoa New Zealand)

Utilisation and Equity Issues:

Māori experience similar barriers to accessing laser refractive surgery:

• Lower procedure rates: Māori represent disproportionately low percentage of laser vision correction patients relative to population prevalence of refractive error [20]
• Cost as primary barrier: 35% of Māori report cost as main barrier to elective eye procedures vs 15% of European New Zealanders [21]
• Geographic distribution: Limited laser clinic presence in regions with high Māori population (Northland, Tairāwhiti, Midland) [22]

Te Tiriti o Waitangi Considerations:

Equitable access to refractive surgery services requires addressing structural barriers:

1. Active offer: Information about laser options proactively offered to Māori patients with refractive error
2. Whānau-centred approach: Family involvement in decision-making and support throughout process
3. Cultural navigator: Māori Health Worker support for clinic navigation and communication
4. Data sovereignty: Māori-led research on refractive surgery outcomes and access barriers [23,24]

Rural and Regional Considerations:

• Northland and Bay of Plenty: High Māori populations with limited local laser services requiring travel to Auckland
• Follow-up logistics: Postoperative day 1 and week 1 reviews challenging for rural patients
• Workforce implications: Shift work in agriculture/manufacturing creates scheduling conflicts with laser clinic hours [25,26]

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Epidemiology and Types of Laser Surgery

Global Burden of Refractive Error

Refractive errors (myopia, hyperopia, astigmatism) represent the most common ophthalmic condition worldwide:

Prevalence:

• Myopia: 27-34% of global population (estimated 2.6 billion people, 2020) [27]
• High myopia (>-5.00 D): 4-5% of population; major cause of visual impairment [28]
• Hyperopia: 5-10% of young adults, increasing with age (presbyopia affects 100% by age 50) [29]
• Astigmatism: 15-30% have >0.75 D of astigmatism [30]

Economic Impact:

• Annual global spending on spectacles and contact lenses: $50-60 billion USD [31]
• Lost productivity from uncorrected refractive error: $270 billion USD annually [32]
• Laser vision correction market: $2-3 billion USD annually [33]

Australian and New Zealand Context:

• Laser surgery rates: 15-20,000 procedures annually in Australia; 3-5,000 in New Zealand [34]
• Myopia epidemic: East Asian populations (significant migration to Australia/NZ) show 80-90% myopia rates in young adults [35]
• Access disparities: Rural/regional populations have 50-60% lower rates of refractive surgery [36]

Types of Laser Refractive Surgery

Patient Selection Criteria

Ideal Candidate Characteristics:

• Age ≥18 years (≥21 preferred for LASIK)
• Stable refraction for ≥12 months (change <0.50 D)
• Corneal thickness ≥480-500 μm for LASIK (depends on ablation depth)
• Normal corneal topography (no keratoconus or forme fruste)
• Realistic expectations
• Ability to follow postoperative instructions [41,42]

Contraindications:

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Anaesthetic Considerations

Topical Anaesthesia

Agents Used:

Administration:

• 2-3 drops instilled 2-3 minutes before procedure
• Repeat drops every 10-15 minutes if prolonged procedure
• Excessive use (>4-5 drops) can delay epithelial healing and cause toxic keratopathy [45,46]

Complications of Topical Anaesthesia:

• Toxic keratopathy: Epithelial defects, delayed healing from excessive use
• Allergic reaction: Rare with proparacaine
• Incomplete anaesthesia: Supplemental drops as needed [47]

Sedation for Laser Surgery

Principles:

• Goal: Anxiolysis, not anaesthesia
• Patient must maintain consciousness and ability to follow commands
• Cooperation and fixation critical for surgical success
• Fast offset essential (procedure typically 10-15 minutes total) [48,49]

Sedation Options:

Recommended Sedation Protocol:

For anxious patients:

1. Preoperative: Oral diazepam 5-10 mg 30-60 min before (if no IV access)
2. Intraoperative: Midazolam 0.5-1 mg IV titrated to effect ± fentanyl 25-50 mcg
3. Monitoring: Continuous pulse oximetry, NIBP every 5 minutes
4. Oxygen: Nasal cannula 2-4 L/min
5. Reversal: Flumazenil 0.2-0.5 mg IV available if needed [54,55]

Monitoring Requirements:

Patient Cooperation and Fixation

Critical Requirements:

During excimer laser ablation, the patient must:

1. Maintain steady gaze at fixation target (red or green light)
2. Suppress blink reflex (eyelid speculum used)
3. Remain absolutely still (no head movement)
4. Continue cooperation for duration of ablation (typically 10-60 seconds per eye)

Factors Affecting Cooperation:

Suction Ring Application (LASIK/SMILE):

• Intraocular pressure rises to 60-80 mmHg during suction (required for flap/lenticule creation)
• Patient experiences pressure sensation and temporary vision blackout (10-20 seconds)
• Advance warning essential: "You will feel pressure and your vision will go dark for a few seconds. This is normal."
• Patient must maintain position despite discomfort [60,61]

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Surgical Technique and Anaesthetic Implications

LASIK Procedure Steps

PRK/LASEK Procedure Steps

Key Differences from LASIK:

• No suction required (no pressure sensation/blackout)
• Surface ablation (more discomfort postoperatively)
• Slower visual recovery [64,65]

Complications During Surgery

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Postoperative Considerations

Immediate Postoperative Care

Recovery Requirements:

• Observation period: 30-60 minutes before discharge
• Visual assessment: Document unaided visual acuity
• Slit-lamp examination: Confirm flap position (LASIK), no debris
• Discharge criteria: Stable vision, comfortable, escort available [69,70]

Common Immediate Symptoms:

Analgesia Requirements

LASIK:

• Minimal postoperative pain (surface intact)
• Paracetamol 1 g q6h PRN usually sufficient
• Topical lubricating drops (preservative-free) every 1-2 hours initially [72]

PRK/LASEK:

• Significant pain for 48-72 hours (epithelial defect)
• Multimodal analgesia:
  • Topical NSAIDs (ketorolac, diclofenac) - 4× daily for 3 days
  • Oral NSAIDs (ibuprofen 400 mg q6-8h)
  • Paracetamol-codeine if needed
  • Oral gabapentin 300 mg TDS for severe pain [73,74]

Postoperative Instructions

Critical Instructions (Patient Education):

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SAQ Practice Questions

SAQ 1: Sedation for Laser Eye Surgery (20 marks)

Scenario: A 32-year-old woman is scheduled for LASIK surgery. She is extremely anxious about the procedure and requests sedation. She is otherwise healthy (ASA I) and has fasted for 6 hours.

Questions:

a) What are the goals of sedation for laser eye surgery? (5 marks)

b) Outline your sedation plan, including drug choices, doses, and monitoring. (8 marks)

c) What are the risks of over-sedation in this setting? (7 marks)

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Model Answer:

a) Goals of sedation (5 marks):

• Anxiolysis: Reduce anxiety to acceptable level for awake procedure (1 mark)
• Maintain consciousness: Patient must follow commands and maintain fixation (1 mark)
• Preserve cooperation: Ability to remain still during critical laser ablation phase (1 mark)
• Amnesia: Desirable but not essential; reduce memory of procedure (1 mark)
• Rapid offset: Fast recovery to allow same-day discharge (1 mark)

b) Sedation plan (8 marks):

• Monitoring: Continuous pulse oximetry, NIBP every 5 min, continuous observation (2 marks)
• Oxygen: Nasal cannula 2-4 L/min throughout procedure (1 mark)
• Midazolam: 0.5-1 mg IV titrated slowly to effect; goal is calm, responsive patient (2 marks)
• Adjuncts: Fentanyl 25-50 mcg IV for pressure sensation during suction ring (1 mark)
• Reversal agent: Flumazenil 0.2-0.4 mg IV available if over-sedation (1 mark)
• Postoperative: 30-60 min observation before discharge with escort (1 mark)

c) Risks of over-sedation (7 marks):

• Loss of cooperation: Patient unable to maintain fixation or follow commands → decentered ablation (2 marks)
• Respiratory depression: Hypoventilation, hypoxaemia, airway obstruction (1 mark)
• Airway compromise: May require intervention in laser suite (limited access to patient) (1 mark)
• Cardiovascular instability: Hypotension, bradycardia (1 mark)
• Prolonged recovery: Delayed discharge, requires longer observation (1 mark)
• Disinhibition: Paradoxical agitation with midazolam (1 mark)

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SAQ 2: Topical Anaesthesia in PRK (20 marks)

Scenario: A 28-year-old man is undergoing PRK for myopia. The surgeon plans to use topical proparacaine 0.5% for anaesthesia. The procedure is expected to take 15 minutes per eye.

Questions:

a) Describe the pharmacology of proparacaine and its advantages for laser surgery. (6 marks)

b) What is the maximum recommended dose and duration of topical anaesthesia for this procedure? (6 marks)

c) What are the complications of excessive topical anaesthetic use? (8 marks)

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Model Answer:

a) Proparacaine pharmacology (6 marks):

• Class: Ester-type local anaesthetic (related to procaine, tetracaine) (1 mark)
• Mechanism: Blocks voltage-gated sodium channels → prevents nerve depolarisation (1 mark)
• Onset: Rapid (10-20 seconds) (1 mark)
• Duration: 15-20 minutes (sufficient for laser procedure) (1 mark)
• Advantages: Minimal stinging on instillation (vs tetracaine), rapid onset, adequate duration, good patient tolerance (2 marks)

b) Dosing and duration (6 marks):

• Initial dosing: 2-3 drops instilled 2-3 minutes before procedure (2 marks)
• Repeat dosing: 1-2 drops every 10-15 minutes if prolonged procedure (1 mark)
• Maximum total: Generally 4-5 drops per eye over 30-60 minutes (1 mark)
• Duration: Should not exceed 60-90 minutes of continuous anaesthesia (1 mark)
• Rationale: Minimises toxicity while maintaining comfort (1 mark)

c) Complications of excessive use (8 marks):

• Toxic keratopathy: Epithelial defects, punctate erosions, delayed healing (2 marks)
• Corneal epithelial toxicity: Direct cellular toxicity from repeated applications (1 mark)
• Endothelial damage: Rare with excessive dosing (1 mark)
• Delayed wound healing: PRK epithelial healing compromised (2 marks)
• Persistent epithelial defects: May require bandage contact lens extension (1 mark)
• Allergic reactions: Rare with proparacaine but possible (1 mark)

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SAQ 3: Intraoperative Complications (20 marks)

Scenario: During LASIK surgery on a 35-year-old man, the patient moves suddenly during the excimer laser ablation phase. The eye tracking system pauses the laser, but the patient is now distressed and requests that the procedure be stopped.

Questions:

a) What are the immediate management steps? (6 marks)

b) How would you manage the patient's anxiety to allow completion of the procedure? (7 marks)

c) What are the potential consequences of patient movement during ablation, and how are they prevented? (7 marks)

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Model Answer:

a) Immediate management (6 marks):

• Stop procedure: Pause laser immediately (already occurred) (1 mark)
• Assess patient: Check vital signs, level of distress, reasons for movement (1 mark)
• Reassurance: Calm, clear explanation that no damage occurred (1 mark)
• Evaluate surgical field: Surgeon checks for flap displacement or debris (1 mark)
• Decision point: Determine if can continue or need to abort and reschedule (1 mark)
• Support: Provide physical and emotional support, hand-holding if helpful (1 mark)

b) Managing anxiety for completion (7 marks):

• Communication: Explain exactly what will happen next and how long remaining (1 mark)
• Repositioning: Ensure patient comfortable, adjust head position (1 mark)
• Sedation adjustment: If under-sedated, additional midazolam 0.5 mg IV (2 marks)
• Verbal coaching: Continuous guidance: "Look at the green light... you're doing well... almost done" (2 marks)
• Break if needed: Short pause to allow patient to compose before resuming (1 mark)

c) Consequences and prevention (7 marks):

• Decentered ablation: Optical zone not centred on pupil → irregular astigmatism, visual symptoms (2 marks)
• Incomplete ablation: Uneven tissue removal → irregular corneal surface (1 mark)
• Flap complications: Movement during flap manipulation → striae, displacement (1 mark)
• Prevention strategies:
  • Modern eye-tracking systems (pupil tracking, active tracking) (1 mark)
  • Thorough preoperative counselling and preparation (1 mark)
  • Appropriate sedation level (1 mark)

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ANZCA Exam Focus

Viva Voce Preparation

Scenario 1: Sedation for Anxious Patient

"You are asked to provide sedation for a patient undergoing LASIK. The patient is very anxious. How do you approach this?"

Key points:

• Goal: Anxiolysis, not general anaesthesia
• Light, titrated sedation (midazolam 0.5-1 mg IV)
• Patient must remain conscious and cooperative
• Monitoring requirements
• Risks of over-sedation

Scenario 2: Topical vs General Anaesthesia

"A patient with severe claustrophobia is scheduled for laser eye surgery. Discuss the anaesthetic options."

Key points:

• Standard: Topical ± light sedation
• Claustrophobia may preclude laser bed positioning
• General anaesthesia rarely indicated
• Consider alternative procedures (ICL, PRK under GA if absolutely necessary)
• Risks of GA for elective refractive surgery

Scenario 3: Intraoperative Crisis

"During PRK, the patient suddenly sits up and grabs their eye. What is your response?"

Key points:

• Immediately protect surgical field
• Assess for injury (corneal abrasion, flap displacement if LASIK)
• Manage patient distress
• Surgical review before continuing
• Documentation and follow-up

Written Exam High-Yield Topics

ANZCA Professional Standards

PS07: Guidelines for Perioperative Care

• Sedation monitoring standards apply
• Documentation of drugs, doses, patient response
• Discharge criteria must be met before release

PG67(G): End-of-Life Care

• Not directly applicable but principles of informed consent relevant
• Realistic expectation setting for elective procedures

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This document was created for educational purposes for ANZCA Fellowship examination preparation. All citations are from peer-reviewed literature. Last updated: 2026-02-03