Hello and welcome back to ACRAC. I'm Jed Wolpa and I am thrilled to have back with me the one and only Dr. Jillian Isaac for another key word episode. It's been a little while. So we thought it was time. We are going today to talk about some stuff to do with the eye. It won't cover the entire eye, but we'll do some important.

High yield board stuff with the eye in terms of retro bulb or blocks and then the ocular cardiac reflex and we'll revisit more to do with the eye another day. Jillian welcome back to the show.

Thank you. Yes. So I started this. I was telling Dr. Wolpa before we started recording that I started thinking I'm just going to do all the ice stuff. I'm going to bang out all the ice stuff and ended up being much more than I realize. And I guess it's probably because I don't do a lot of ophthalmic anesthesia anymore and full disclosure.

When I was a resident at Columbia, God bless Columbia, but I hated the I institute and Wilmer is not much better. That's the I institute at Hopkins. It's not my favorite thing to do.

But you have to know it and it is important. And as Dr. Wolpa said, these are two very high yield subjects almost guaranteed. You're going to get a question on this on either an ITE or written exam.

I would say it probably falls under both the basic and the advanced advanced because it is a subspecialty but basic because there isn't fair amount of anatomy associated with these questions.

So if you are interested, not that you are. If you went to the ASA website and you looked at the content outline, you'll find this on page 43.

It's under clinical subspecialty is ophthalmic anesthesia and the board wants you to know about retro bulbor and peri bulbor blocks. I again will do open eye injuries and interact with pressure on another day and then the ocular cardio reflex. So that's where we're going to go through today.

So in terms of retro bulbor and peri bulbor blocks, what is on the test and just to reiterate, I go to this website called open anesthesia. I don't know how they know, but if you type in keywords, they'll tell you when they were tested and it's based on the ITE.

So they're testing hemodynamic effect that was tested in 2010 and 2013 risk factors that was tested in 2021 complications that was tested in 2020 and then the difference between a retro bulbor and a peri bulbor block and that was tested in 2008, 2011, 2016 and 2019.

So I just want to review quickly a retro bulbor block and then go through questions. So this is, again, for whoever wrote this in open anesthesia, I want to give them credit.

This is directly from the open anesthesia, which is a free open website where I got this information. So a retro bulbor block is frequently used for various ophthalmologic procedures, including surgeries of the cornea, anterior chamber and lens.

The local anesthetic is injected into the cone formed by the four rectus muscles of the eye, they're providing a canusia and anesthesia to ocular and extracurricular muscles with the exception of the ubiquitous ocular of the eyelid, the superior oblique muscle also has extracurricular innovation and can become incompletely anesthetized with the block.

So complications of this block include orbital perforation or ischemia, vascular injury causing retro bulbor hemorrhage, brainstem anesthesia and activation of the ocular cardiac reflex of those hands down the most common complications, the ocular cardio reflex.

And we will cover that more in depth as the next topic. Okay.

So these are the type of questions you're going to see. And again, super high yield almost guaranteed you're going to see a question like this or one of these, I think we have six or seven of them on a test. Okay.

So the first one is a 70 year old man with stable angina is scheduled for cataract or removal with a retro bulbor block.

After injection of five amel of 0.75% bupivocane, his heart rate decreases from 90 to 55 beats per minute, and he has frequent premature ventricular contractions on his EKG.

These changes are most likely caused by so one trick that I teach my residents who kind of struggle with standardized testing is before you look at the answer choices, cover them up and try to answer in your head.

Because if you actually know it, you're much more likely to answer it correctly, and it helps you not get distracted by the wrong answer choices. But these are the answer choices a

intravascular injection of bupivocane, the subarachnoid injection of bupivocane, see myocardial ischemia, deocular cardiac reflex, eat retro bulbor hemorrhage.

Right. And you know, hopefully looking at this stem, like you said, if you don't even look at the answers, you think to yourself, all right, this is something being injected behind the eye, causing some pressure, the heart rate is the main thing that we're seeing here. Yes, there's some PVC's, but mainly we're seeing braid a cardiac.

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