Changes in intraocular pressure and optic nerve sheath diameter in patients undergoing robotic-assisted laparoscopic prostatectomy in steep 45° Trendelenburg position

Sebastian Blecha, Marion Harth, Felix Schlachetzki, Florian Zeman, Christiane Blecha, Pierre Flora, Maximilian Burger, Stefan Denzinger, Bernhard M Graf, Horst Helbig, Michael T Pawlik, Sebastian Blecha, Marion Harth, Felix Schlachetzki, Florian Zeman, Christiane Blecha, Pierre Flora, Maximilian Burger, Stefan Denzinger, Bernhard M Graf, Horst Helbig, Michael T Pawlik

Abstract

Background: To evaluate changes in intraocular pressure (IOP) and intracerebral pressure (ICP) reflected by the optic nerve sheath diameter (ONSD) in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) in permanent 45° steep Trendelenburg position (STP).

Methods: Fifty-one patients undergoing RALP under a standardised anaesthesia. IOP was perioperatively measured in awake patients (T0) and IOP and ONSD 20 min after induction of anaesthesia (T1), after insufflation of the abdomen in supine position (T2), after 30 min in STP (T3), when controlling Santorini's plexus in STP (T4) and before awakening while supine (T5). We investigated the influence of respiratory and circulatory parameters as well as patient-specific and time-dependent factors on IOP and ONSD.

Results: Average IOP values (mmHg) were T0 = 19.9, T1 = 15.9, T2 = 20.1, T3 = 30.7, T4 = 33.9 and T5 = 21.8. IOP was 14.0 ± 7.47 mmHg (mean ± SD) higher at T4 than T0 (p = 0.013). Univariate mixed effects models showed peak inspiratory pressure (PIP) and mean arterial blood pressure (MAP) to be significant predictors for IOP increase. Mean ONSD values (mm) were T1 = 5.88, T2 = 6.08, T3 = 6.07, T4 = 6.04 and T5 = 5.96. The ONSD remained permanently >6.0 mm during RALP. Patients aged <63 years showed a 0.21 mm wider ONSD on average (p = 0.017) and greater variations in diameter than older patients.

Conclusions: The combination of STP and capnoperitoneum during RALP has a pronounced influence on IOP and, to a lesser degree, on ICP. IOP is directly correlated with increasing PIP and MAP. IOP doubled and the ONSD rose to values indicating increased intracranial pressure. Differences in the ONSD were age-related, showing higher output values as well as better autoregulation and compliance in STP for patients aged <63 years. Despite several ocular changes during RALP, visual function was not significantly impaired postoperatively.

Trial registration: Z-2014-0387-6 . Registered 8 July 2014.

Keywords: Intraocular pressure; Optic nerve sheath diameter; Robotic-assisted laparoscopic prostatectomy; steep Trendelenburg position.

Figures

Fig. 1
Fig. 1
Preparation and test of 45° Trendelenburg position before start of RALP
Fig. 2
Fig. 2
Measurement of the optic nerve sheath diameter
Fig. 3
Fig. 3
Mean IOP for each time point (±SD)
Fig. 4
Fig. 4
Mean PIP for each time point (±SD)
Fig. 5
Fig. 5
Mean MAP for each time point (±SD)
Fig. 6
Fig. 6
Mean ONSD for each time point all patients (±SD)
Fig. 7
Fig. 7
Age differences of changes in the ONSD (±SD)

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