Open globe injury with a full stomach
Stem
A 24-year-old man, 80 kg, was struck in the right eye by a metal fragment while grinding at work three hours ago. He ate a large meal an hour before the injury. He has a corneoscleral laceration with uveal prolapse and hand-motion vision; the eye is shielded. He is healthy with a reassuring airway examination, and ophthalmology wants to repair the eye tonight. Gastric ultrasound shows a distended antrum full of bright, heterogeneous material.
Question
How will you induce anesthesia?
Ideal answer
HeadlineAspiration and globe pressure both matter, but aspiration kills: rapid sequence induction with rocuronium 1.2 mg/kg, deep enough that he never coughs.
- Calm him; shield on, no pressure on the eye. Squeezing raises intraocular pressure up to 70 mmHg and coughing up to 40.1
- Propofol with lidocaine or remifentanil, because laryngoscopy adds 10–15 mmHg and these blunt it.1,2
- Rocuronium 1.2 mg/kg; sugammadex 16 mg/kg ready. Rocuronium leaves intraocular pressure unchanged, and sugammadex at that dose reverses it soon after.3,4
- Laryngoscopy only when fully relaxed, confirmed by train-of-four, because a cough on the tube is the real hazard.
- Antiemetics, stomach tube, then extubate awake, smoothed with lidocaine or remifentanil.3,2
Watch for: bradycardia when the surgeon handles the globe or muscles.
Breaking down the answer
- Succinylcholine is not forbidden — it raises intraocular pressure 5–10 mmHg briefly,3 comparable to laryngoscopy itself.1 Changes if: a difficult airway is predicted or rocuronium is unavailable; then succinylcholine after an adequate induction dose is defensible.
- Agent effects — volatiles, propofol and benzodiazepines lower intraocular pressure, nitrous oxide is neutral, opioids and nondepolarizers do not change it, and ketamine raises it above 5 mg/kg.3
- Why not a block — peribulbar injection transiently raises pressure; in 100 limited anterior injuries, vitreous prolapsed in 20% with peribulbar versus 6% with topical, intracameral and facial nerve block.5 Posterior or large wounds need general anesthesia.
- Why tonight — waiting to empty the stomach trades against endophthalmitis and extrusion of contents, so repair is almost always an emergency.3
- Ultrasound changed the risk, not the plan — solid antral content confirms the full stomach that his history already declared.
- Oculocardiac reflex — general anesthesia does not suppress it: stop traction, give an anticholinergic.3
Follow-up question
After rocuronium you see only the epiglottis, a second attempt with a bougie fails, and his saturation is 88% and falling. What do you do?
Follow-up answer
HeadlineUnanticipated cannot-intubate; oxygenation outranks the eye, and I call for help.
I place a second-generation supraglottic airway and ventilate with 100% oxygen, keeping any mask pressure off the shielded eye. If he oxygenates, I wake him: sugammadex 16 mg/kg reverses rocuronium soon after a 1.2 mg/kg dose,4 then an awake flexible scope intubation with topical anesthesia. If neither mask nor supraglottic airway works, I go straight to a scalpel cricothyroidotomy. Then I discuss timing with the surgeon and reassess.
Pitfalls that cost points
- Assuming a few hours of waiting empties his stomach: pain, opioids and trauma delay gastric emptying, so he stays a full stomach.
- A deep extubation to avoid coughing in a patient whose stomach is still full.3
Rapid-fire
Q: What is normal intraocular pressure? A: 16 ± 5 mmHg; above 21 is pathological.1
Q: How much does a blink raise it? A: Up to 5 mmHg.1
Q: Which antiemetics for a child having globe repair? A: Dexamethasone 0.15 mg/kg and ondansetron 0.1–0.15 mg/kg; avoid nitrous oxide and limit opioids.3
Q: Who has the strongest oculocardiac reflex? A: Children; it lessens with age.3
Q: What sugammadex dose reverses a moderate rocuronium block? A: 2 mg/kg at reappearance of the second twitch; 4 mg/kg for a deep block.4
Numbers to know
| Item | Value |
|---|---|
| Normal intraocular pressure | 16 ± 5 mmHg1 |
| Succinylcholine | +5–10 mmHg, transient3 |
| Laryngoscopy and intubation | +10–15 mmHg1 |
| Coughing / forced eye closure | Up to 40 / 70 mmHg1 |
| Rocuronium for RSI | 1.2 mg/kg3 |
| Sugammadex, immediate reversal | 16 mg/kg4 |
Links
- Rapid sequence induction and full stomach, Ophthalmic surgery and the oculocardiac reflex, succinylcholine, sugammadex, aspiration
- Atlas: Abdominal free fluid and gastric ultrasound
- Difficult Airway Society guideline for unanticipated difficult intubation (2015)
Sources
- 1.Use of suxamethonium in open eye injuries: a dilemma with explosive consequences · British Journal of Hospital Medicine, 2014 · storage.imrpress.comArunakirinathan M, Papamichael E, Hacking R. Br J Hosp Med 2014;75(7):418.
- 2.Anesthesia for Ruptured Globe Repair · EyeWiki (American Academy of Ophthalmology) · eyewiki.org
- 3.Ruptured Globe Repair (SPA case guide) · Society for Pediatric Anesthesia, 2025 · www2.pedsanesthesia.orgWang M, Lee A. Created April 2025.
- 4.Bridion (sugammadex) prescribing information · FDA labeling (Drugs.com) · drugs.com
- 5.Regional anaesthesia for surgical repair in selected open globe injuries in adults · Saudi Journal of Ophthalmology, 2013 · pmc.ncbi.nlm.nih.govChakraborty A, et al. Saudi J Ophthalmol 2013;27(1):37-40. 100 patients.
Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.