Newsletter 5, October 2001 - British Ophthalmic Anaesthesia Society

44 Pages·2002·1.57 MB·English

by  Chandra Kumar

Ophthalmic Anaesthesia News
The Official Newsletter of the British Ophthalmic Anaesthesia Society
Issue 5, October 2001

An update : Anaesthesia for Strabismus surgery
Page - Contents
Dr. P.A. Guise, FRCA, FANZCA

1 An update : Anaesthesia for
Specialist Anaesthetist, Auckland hospital, New Zealand
Strabismus surgery

6.BOAS 2001 meeting Report
8 OAS 2001 Meeting Report
13 An update : sub-Tenon’s Block Introduction
19 A Device for Inhalational

Anaesthesia in Children
Strabismus surgery involves altering the direction of gaze by detaching
20.Sub-Tenon’s Anaesthesia for
one or more extraocular muscles from its insertion on the globe and
Cataract Surgery Using a Plastic
Cannula repositioning it to effectively shorten the muscle (resection) or to
22 News and Information lengthen it (recession).
27 BOAS membership application The key anaesthetic implications of this procedure are:
form
1. Nausea and vomiting
31 Recent publications of interest
2. The oculo-cardiac reflex (OCR)
43 Members list
3. Adequate postoperative analgesia
BOAS Registered Office 4. It is most commonly performed on the paediatric population.
Department of Anaesthesia
5. Associated conditions
South Cleveland Hospital
6. It is usually a Day-stay or almost an out-patient procedure.
Middlesbrough TS4 3BW UK
7. The Forced Duction test (FDT)
Tel [phone]
Fax [phone]. Choice of anaesthetic technique.
Email: [email protected]
Website: www.boas.org
Nausea and Vomiting.
Ophthalmic Anaesthesia News
Editor:
Dr Chandra Kumar The incidence of nausea and vomiting (PONV) in the first 24 hrs after
Associate Editors strabismus surgery has been found to be as high as 72% in some
Mr David Smerdon studies1. There are several possible reasons for this2. Firstly, during
Dr Sean Tighe
surgery, impulses from the extra-ocular muscles are relayed to the
Dr Stephen Mather
vestibular nuclei III, IV and V of the medial longitudinal fasciculi,

The Society can’t be held which lie in the brainstem reticular formation. These nuclei lie in close
responsible for the statements or anatomical proximity to the vomiting centre and impulses in the
views of the contributors. No part of former may stimulate the vomiting centre. Support for this theory
this Newsletter may be reproduced
comes from the fact that there is an association between the
without prior permission.
oculocardiac reflex (OCR) and subsequent PONV3 such that children
Articles of interest for future issue
or correspondence should be sent by who had demonstrated an oculocardiac response intra-operatively were
post, disk or email: 2.6 times more likely to vomit postoperatively than those who had not.
Dr Chandra Kumar
Secondly, alteration of the direction of gaze is thought to produce a
Secretary, BOAS
conflict in the CNS processing of positional information from vision
South Cleveland Hospital
and that from the vestibular apparatus in the inner ear leading to a
Middlesbrough
TS4 3BW “travel sickness” effect commonly termed the “oculokinetic reflex”.
[email protected]
[email protected]

Ophthalmic Anaesthesia News, Issue 5, October 2001
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This effect lasts for several hours rises in a temporal relation to the offset of the
postoperatively until the brain readjusts to the block.
altered proprioceptive information it is
receiving. Furthermore, children are also more Oculocardiac reflex (OCR)
prone to nausea and vomiting4. Anaesthetic The OCR is a Trigemino-Vagal reflex 13 and is
technique plays a significant part (see later): produced by traction on the extraocular
the use of opiates significantly increases the muscles during surgery. (Fig 1.) Reproduced
incidence 1 and the use of prophylactic anti- with permission).
emetics lowers it. The afferent pathway is via the long and short
The choice of which anti-emetic is most ciliary nerves to the ciliary ganglion and thence
suitable is unclear. However, ondansetron 0.15 to the main sensory nucleus of the trigeminal
mg/kg appears to be more effective than nerve via the Gasserian ganglion and the
metoclopramide 5 droperidol appears to be as ophthalmic branch of V. Short internuncial
effective as ondansetron 6,7 but is not the most fibres in the reticular formation link with the
suitable anti-emetic for day stay procedures motor nucleus of the vagus, which lies slightly
because of the dysphoria that affects up to 29% further down the brainstem. Efferent fibres
of patients over the first 24 hrs. postoperatively then pass via X to the heart.
even at doses as low as 10mcg/kg 8.
Since the receptors involved in the vomiting
pathway include D2, 5HT-3, H1, and ACh,
theoretically administration of a combination
of anti-emetics such as metoclopramide (D2),
ondansetron (5HT-3) and prochlorperazine (H1
and ACh) to block all the above receptors may
be more effective than a single agent.

In high risk or refractory cases, dexamethasone
0.15 mg/kg 9 may enhance the effect of other
anti-emetics. Oral clonidine 4mcg/kg 90min.
pre-operatively 10 or lignocaine 2 mg/kg
intravenously at induction of anaesthesia 2
could also be considered.

Insertion of a sub-Tenon’s block prior to
closure of the conjunctiva appears to
significantly reduce the incidence of
PONV11,12. The exact mechanism of this is
unclear but may be due to the blockage of
proprioceptive impulses from the operated eye
The reflex has several features:
preventing the “oculokinetic reflex”. Bearing in
a) It is fatigueable: repeated traction
mind the association of PONV and the
produces progressively less effect.
occurrence of the OCR, the insertion of a sub-
b) It is produced to an equal extent
Tenon’s block before muscle traction to block
from all extaocular muscles.
the OCR may be of additional benefit. This
However, because of its
technique also makes it unnecessary to
fatigueability, the first muscle to be
administer any opiates to these patients.
pulled produces the biggest
Modification of anaesthetic technique (see
response.
below) can reduce the incidence of PONV to
c) It may be more common in the
less than 6% in the immediate postoperative
presence of a high PaCO2 (>40
period although the incidence of late PONV
mmHg)
Ophthalmic Anaesthesia News, Issue 5, Octoberl 2001 2
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d) It is more common if there is acute A history of any bleeding disorders should
(square-wave) and aggressive also be sought as well as current medications
traction on the EOM. and allergies. It is now uncommon, but
e) It is not reliably prevented by occasionally phospholine iodide (ecothiopate
anticholinergic premedication 14. iodide) may be used in the management of
strabismus. This drug blocks
There is little value in pre-treating with IV pseudocholinesterase and therefore prolongs
anticholinergics at induction. If the reflex the effects of succinylcholine and ester-type
becomes clinically significant despite careful local anaesthetics.
surgical traction, complete cessation of traction Other medical conditions that may be
and the administration of anticholinergic associated with strabismus in children are
(Eg.atropine 10 mcg/kg) is all that is required. summarised in table 1.
Medical Anaesthetic implications
Adequate postoperative analgesia condition
Traditionally, many of these children would be Down syndrome Atlanto-axial instability,
given narcotic analgesics during or cardiac defects,
immediately after surgery, which greatly macroglossia,
increases the incidence of PONV in this group. sub-glottic stenosis,
Modification of the anaesthetic technique (see tonsillar hypertrophy,
below) makes the use of narcotic analgesics hypothyroidism
unnecessary. Cerebral palsy Seizures, gastroesophageal
reflux, joint contractures.
Paediatric and Associated conditions
Detailed accounts of the specific aspects of Congenital heart May require SBE
anaesthetising children are out of the scope of disease prophylaxis
this review, but several points are worth
emphasising. These children are usually Table 1. Other medical conditions associated
otherwise fit and well. However, there appears with strabismus
to be an association between strabismus and
neuromuscular disease such as muscular Day-stay considerations
dystrophy 15 and malignant hyperthermia (MH) Unless indicated by an associated medical
particularly if there is associated ptosis16,17. It condition, apart from a FBC in females 16-60
is therefore important to ascertain if there is yrs., no preoperative laboratory tests are
any family history of anaesthetic problems. required.
However, it is important to note that a history The optimal duration of preoperative fasting is
of a previous uneventful anaesthetic does not not unanimously agreed. However, in this
exclude susceptibility to MH even if known institution there is restriction of solids for 6hrs.
trigger agents had been administered. and clear fluids for 2hrs. in children and adults,
and 4hrs for breast and bottle-fed infants.
Because nausea and vomiting are a significant Patients having strabismus surgery are usually
concern with strabismus surgery, a history of ready for discharge within 2 - 4hrs.
PONV or motion sickness should be noted. postoperatively, and therefore sedative
Strabismus surgery is an elective procedure premedication is usually omitted. However,
and this must be taken into account if the child paediatric patients routinely receive 30mg/kg
presents with an upper respiratory tract oral paracetamol on arrival (about 60 min.
infection (URTI). The presence of an URTI preoperatively). A 250mg/5ml strength syrup is
increases the risk of a perioperative respiratory used to decrease the volume of fluid given.
complication four- to sevenfold19. The Anticholinergic premedication is not routinely
complication risk is particularly high in employed since it is unreliable at preventing
children under 1yr. And these should definitely the oculo-cardiac reflex [14], and drying of
be deferred. In older children the risk/benefit secretions is not required.
ratio needs to be considered on an individual
basis.
Ophthalmic Anaesthesia News, Issue 5, October 2001 3
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4
Forced Duction Test (FDT) from a surgical and anaesthetic management
This is a manoeuvre performed by the surgeon aspects. Traditionally these children would
after induction of anaesthesia to check for free spend at least most of the day if not a night in
passive movement of the eye in order to hospital after surgery. Strabismus surgery has
differentiate between a paretic muscle and a been associated with one of the highest
physical restriction impeding ocular incidences of PONV of any surgical procedure.
movement. Some authors19 recommend non- Also, these patients were routinely intubated,
depolarising neuromuscular block as well as with all the associated problems that that may
avoiding succinylcholine so that muscle tone is cause in day-stay patients.
absent permitting a more “accurate” FDT. The
paediatric ophthalmologists in this institution Understanding the mechanisms behind many of
are of the firm opinion that although avoiding the postoperative problems has led to
succinylcholine is desirable, it is unnecessary significant improvements in the way these
to produce neuromuscular block in order to children are managed for their anaesthetic with
accurately perform the FDT. a corresponding reduction in postoperative
morbidity. This has contributed to a reduction
Choice of Anaesthetic Technique in time spent in hospital such that most
At Auckland hospital, the following technique children are now ready for discharge within 2
is used: oral preoperative Paracetamol hours after surgery
30mg/kg, spontaneous respiration on a References
laryngeal mask with Oxygen/Nitrous 1. Mendel HG et al. ketorolac vs fentanyl on
oxide/Sevoflurane, avoiding narcotics and postoperative vomiting and analgesic
performing a sub-Tenon’s block using a requirements. Anes. Analg. 1995:80:1129-
lignocaine/bupivacaine mix at the end of 33.
surgery. A randomised, prospective double- 2. Warner LO, Rogeres MD et al. Intravenous
blind trial11 of 70 children employing this lignocaine reduces the incidence of
technique with and without ondansetron 0.1 vomiting in children after strabismus
mg/kg, was associated with minimal surgery. Anesthesiology 1988:68:618-21.
postoperative discomfort and a PONV 3. Allen L, Sudesh S, et al. Th association
incidence of less than 6% in the first two hours between the oculocardiac reflex and post-
postoperatively. PONV in the subsequent 24 operative vomiting in children undergoing
hrs. (when the sub-Tenon’s block would have strabismus surgery. Eye 1998:12:193-6.
worn off) was higher, but still less than 20%. 4. Kenny GN. Risk factors in postoperative
Interestingly, the incidence of PONV was not nausea and vomiting. Anaesthesia 1994
reduced by addition of ondansetron. No (Jan):49 Suppl.6-10.
patients required admission overnight and no 5. Rose JB, Martin JM, Corddry DH et al.
narcotic analgesia was required Ondansetron reduces the incidence and
postoperatively. severity of poststrabismus repair vomiting
A previous study by Fry and Walker12 on 45 in children. Anes.Analg. 1994:79(3):486-9.
patients using a similar technique but with 6. Tang J, Watcha M, White P. A comparison
routine use of ondansetron and of costs and efficacy of ondansetron and
prochlorperazine was associated with a zero droperidol as prophylactic antiemetics.
incidence of PONV in the first 24hrs. Anesth.Analg. 1996:83:304-313.
postoperatively.
7. Klockgether-Radtke A, et al. Ondansetron,
The inclusion of a non-steroidal anti-
droperidol and their combination for the
inflammatory agent such as Voltaren 1.5 mg/kg
prevention of post-operative vomiting in
could also be considered, although it is
children. Eur.J.Anaesthesiol. 1997:14:362-7.
uncertain as to whether this improves overall
pain scores. 8. Lim BS, Pavy TJ, Lumsden G. The
antiemetic and dysphoric effects of
Summary droperidol in the day surgery patient.
The management of children having strabismus Anaesth.Int.Care 1999:27:4:371-4.
surgery has changed over recent years both
Ophthalmic Anaesthesia News, Issue 5, October 2001 4
Email: [email protected] Website http://www.boas.org
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9. Splinter W, Rhine E. Low-dose ondansetron undergoing squint surgery.
with dexamethasone more effectively Br.J.Anaes.1982:54:1059-63.
decreases vomiting after strabismus surgery 15 Lewandowsi KB. Strabismus as a possible
in children than does high-dose sign of muscular dystrophy and malignant
ondansetron. Anesthesiology 1998:88:72-5. hyperthermia. Can.An.Soc.J. 1982:29:372-
10 Mikawa K, Nishina K, et al. Oral clonidine 6.
premedication reduces vomiting in children 16 King JO, Denborough MA. Anaesthetic
after strabismus surgery. Can. J. An. 1995 induced malignant hyperthermia in children.
Nov 42 (11): 977-81. J.Peadiatr. 1973:81:37-40.
11 Fry R, Guise P. A comparison of 17 Smith R.J. Preoperative assessment of risk
Ondansetron vs. placebo on postoperative factors for malignant hyperthermia.
nausea and vomiting following squint Br.J.Anaes. 1988:60:317-9.
surgery in children. (Work in progress). 18 Cohen MM Cameron CB. Should you
12 Fry R, Walker M. Can vomiting after cancel the operation when a child has an
squint surgery be prevented? (Letter) upper respiratory tract infection?
Anaesth.Int.Care 1997:25:94-5. Anesth.Analg. 1991:72 (3):282-8.
13 Blanc V. et al. The oculo-cardiac reflex: an 19 Dell R, Williams B. Anaesthesia for
analysis in infants and children. Can.J.An. strabismus surgery: a regional survey.
1983:30:360-9. Br.J.Anaes. 1999:82:5:761-3.
14 Mirakhur RK, Jones CJ, et al. IM or IV
atropine or glycopyrrolate for the prevention
of the oculo-cardiac reflex in children

Ophthalmic Anaesthesia News, Issue 5, October 2001 5
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BOAS Meeting Report
Middlesbrough
30TH-31ST AUGUST, 2001

After the unfortunate cancellation of the 3rd previous sharp needle techniques. They
Annual meeting of the Society in London, the concluded that Sub-Tenons should be the
fate of BOAS 2001 was uncertain. However method of choice for eye surgery.
due to the hard work and enthusiasm of Dr Sean Tighe ended the first session with a
Chandra Kumar, we need not have worried. comparison of Sub-Tenons and Topical Local
BOAS 2001 WOULD happen and WOULD be Anaesthesia in respect of their complications
a success. and efficacy, concluding that Sub-Tenons was
Tall Trees Conference Centre again proved probably superior. He also tackled the cost
itself to be an excellent venue for the meeting issue of including an Anaesthetist, and
with its unique blend of high quality concluded that since they contributed greatly to
accommodation and sports facilities in a rather efficiency and provided the necessary ALS
“Out of Town” environment. back up, that their expense was justified!
Despite the organisers’ short time scale, the After Coffee the Free paper session contained
meeting attracted speakers from as far as Egypt six excellent presentations where again the
and New Zealand, as well as 92 delegates from most frequent subject was that of Sub-Tenons.
all corners of the UK and Portugal. Mr H Ruschen presented four case reports of
The meeting commenced on the afternoon of complications following Sub-Tenons; two
Thursday 30th with a series of workshops on patients developed hyphaemas, one a central
such topics as Peribulbar/Retrobulbar blocks, retinal artery occlusion and the fourth vitreous
Sub-Tenons block, Orbital Anatomy and Fast haemorrhages from a presumed globe
Track Cataract Surgery. Due to popular perforation. This served as a warning to all that
demand each workshop was run twice, giving Sub-Tenons may not be as free from
both presenters and delegates a very busy complications as we imagine.
afternoon. Chandra Kumar presented the results of a study
Professor Chris Dodds, the President of BOAS in Middlesbrough using a short (6 mm) metal
welcomed delegates to the meeting at the start cannula. This proved to be equally as effective
of proceedings on Friday morning, which was as standard Cannulae and may reduce the risk
well attended despite the excellent dinner and of complications.
wine the previous evening. The next paper, also from Middlesbrough
The first Scientific Session began with Monica described the results of an audit comparing 3
Hardwick presenting a summary of the recently commonly used Sub-Tenons Cannulae. All
published, Joint Colleges Guidelines on Local three Cannulae gave good results but the deep
Anaesthesia for Intraocular Surgery. This plastic cannula was more effective than the
provoked a few comments from delegates on anterior one, and was equal or better than the
the more controversial issues, but generally it metal cannula.
appears that these guidelines have been well The third paper from Middlesbrough given by
received, unlike their predecessors! Mr N Prasad described the fascinating
The remainder of the first session was devoted subjective visual experiences described by
mainly to the technique of Sub-Tenons block, patients undergoing phacoemulsification
which seems to be rapidly gaining in cataract surgery under Sub-Tenons anaesthesia.
popularity. Chandra Kumar gave a fact-filled On a different subject, Dr Andy Mitchell
presentation on the history of the technique presented a study, which he carried out in
along with illustrations of the various Cannulae Worcester, looking at postoperative morbidity
used, possible drug mixtures and after cataract surgery under three different local
complications. block techniques. Although there was no
Phil Guise presented the results of a large serious morbidity reported after any of the
prospective study carried out in his unit in techniques, it was surprising to note the high
Auckland, which compared efficacy and incidence of minor morbidity such as a “blood-
complications of Sub-Tenons with their
Ophthalmic Anaesthesia News, Issue 5, October 2001 6
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shot“ eye, double vision, periorbital numbness surgical techniques used, and how they affect
and post op pain. the anaesthetist – this was “all you ever wanted
The second paper on a subject other than Sub- to know about vitreoretinal surgery but were
Tenons, was given by Prof S Aziz from Cairo, afraid to ask (…a surgeon)!”
and looked at the use of deep topical fornix The third presentation was by Ken Barber from
nerve block as an aid to the one step adjustable Worcester who gave a colourfully illustrated
suture technique for horizontal strabismus practical guide to dealing with problem
surgery. They concluded that this was an patients presenting for cataract surgery under
effective method of performing this technique local anaesthesia. These included the very
without the need for general anaesthesia. anxious, those with a marked tremor, COPD,
The last scientific session of the morning or an inability to lie flat. Various methods were
included two National Survey reports. suggested to alleviate what are very common
The first was an excellent presentation by Ed problems for surgeons and anaesthetists.
Morris from Bristol on the National Survey of A Case discussion was the next item on the
Fasting in Ophthalmic Regional Anaesthesia, programme, and this was presented by Robert
which was published recently in Anaesthesia. Boyce from Middlesbrough, who described
The second Survey report was that of current two patients that developed acute orbital
cataract practise in the UK by UKISCRS inflammation after cataract surgery. The local
members, presented by David Smerdon from anaesthetic techniques were different, but
Middlesborough. The questionnaires of which hyalase was used in both cases. The discussion
79% were returned, asked numerous questions revolved around the causes of orbital
on surgical technique, biometry formulae and inflammation and whether these were cases of
recording outcomes. There were also questions pseudotumour induced by hyalase. Delegates
on Anaesthesia, including techniques, who were asked to report any similar cases in their
gave the anaesthetic and methods of practice to BOAS.
monitoring. The final presentation of the day was the guest
At the Annual General Meeting of the Society lecture sponsored by Abbot Laboratories and
Prof Chris Dodds officially took over as the speaker was Dr Graem McLeod from
President of BOAS and thanked his Dundee. Dr McLeod’s presentation was
predecessor Rob Johnson for getting the entitled Levobupivacaine- improved safety for
society off to such a good start. Two new Regional Anaesthesia? In which he eloquently
council members were approved – Dr Steve reviewed the preclinical, human toxicity,
Mather and Dr Gurvinder Thind, and details potency and clinical data for Levobupivacaine.
were announced of forthcoming meetings, He provided evidence from large studies that
particularly that in Birmingham in June 2002. Levobupivacaine is consistently less toxic than
After lunch the first scientific session of the Bupivacaine, and has been used effectively in
afternoon included three papers on more central and peripheral blocks including
practical issues of patient management for ophthalmic blocks.
various types of ophthalmic surgery. The meeting closed with a vote of thanks from
The first was by Jonathan Lord from Prof Chris Dodds to the organisers of an
Moorfields on General Anaesthesia for excellent meeting, namely Chandra Kumar and
Paediatric Glaucoma. Although Paediatric his team from Middlesbrough, including the
Glaucoma is very much a specialist area many stalwart conference secretary Pat McSorley.
of the principles outlined in Dr Lord’s All those present; Council members, faculty
presentation would be equally applicable to and delegates had enjoyed an entertaining and
children undergoing other types of ophthalmic informative meeting which would ensure the
surgery. continuing success of the British Ophthalmic
Dr Rob Johnson gave an illuminating Anaesthesia Society.
presentation on General and Local Anaesthesia
for Vitreoretinal Surgery. He also included Dr Monica Hardwick, Worcester, UK
some fascinating and useful background to the

Ophthalmic Anaesthesia News, Issue 5, October 2001 7
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OAS Meeting, Chicago 2001 challenges from both surgical and an
anaesthetic view.
The annual scientific meeting of the American We were treated to two excellent workshops.
Ophthalmic Anesthesia Society took place in Dr Gary Fanning presented a master class on
Chicago from the 5th to the 7th of October. It orbital anatomy and the virtues of using a
was a very successful meeting and well SHORT needle in the correct place. Dr Scott
attended by North American members as well Greenbaum ran a master class on sub-tenon's
as by 5 members of BOAS despite everyone's anaesthesia with a very balanced view of the
concern with air travel after September the alternative techniques and their respective
11th. merits - or otherwise.

The quality of the scientific programme was of
a uniformly high standard and it covered areas
of interest to all delegates. Indeed there
appeared to have been a move to reduce the
UK questions (usually - why not give a GA?)
by providing expert discussion of points raised
in the lectures.

I will hint at the flavour of the meeting by
mentioning just a few of the presentations, not
because of lack of merit in those missed out,

but because a comprehensive listing can be
found on the OAS website ([email protected]). Three wise monkeys (from left to right Prof
There were anaesthetically orientated topics Chris Dodds, Gary Fanning and Chandra
such as a fascinating review of the history of Kumar)
ophthalmic anaesthesia by Warren Hill, another
on the impact of coagulopathy on ophthalmic
anaesthesia from Marc Feldman, and the
cluster of diplopia following regional orbital
anaesthesia without bovine hyaluronidase from
Sandra Brown. There was an update on the
American Resuscitation guidelines from Len
Romanowski that reinforced some of the
differences in practice across the Atlantic. How
many of us are aware of the changes
recommended in February this year by the
European Resuscitation Council, or have
actually been re-certified as an ACLS
provider?

The ophthalmic surgical perspective was clear Ladies had wonderful time too (from left to
and incisive - just as we would expect! The right Mrs Arline Fanning, Dr Ann Dodds,
lecture by Steve Charles on the anaesthetic and Mrs Suchi Kumar and Mrs Ursula Johnson)
surgical interface for V-R surgery was
grounded in both clear expertise and great Socially, (I have no doubt the BOAS website
common sense. Those who care for these will testify to this!) we had a great time but it
patients all learnt from the lecture and those played havoc with our diets. It was so good
who didn't were even more determined not to that several airlines reduced the number of
get involved. Steven Gayer gave a masterly passengers to maintain a safe weight of cargo
review of intraocular melanoma and the for the return trip. Even staunch trenchermen
Ophthalmic Anaesthesia News, Issue 5, October 2001 8
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9
like Chandra Kumar failed to complete at the
Eire Café, although Bob Johnson and another
did manage to order and eat pudding.

Dr Gary Fanning entertaining BOAS
representatives and their wives (from left
Ursula Johnson, Bob Johnson, Arline
Fanning, Gary Fanning, Chandra Kumar
and Chris Dodds)

All in all it was a great meeting and one that
we would encourage more members of BOAS
to include in their CEPD list of places to go.
Certainly they were very interested in the next
BOAS meeting in Birmingham next June.

Chris Dodds, President, BOAS
Ophthalmic Anaesthesia News, Issue 5, October 2001 9
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BOAS is grateful to
Abbott Laboratories
for sponsoring the
printing of this
Newsletter
We hope to receive
future support

Ophthalmic Anaesthesia News, Issue 5, October 2001 10
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