Anesthetic Management of Patients With Advanced Carotid Artery Disease Undergoing Ophthalmic Surgery: Implications for Cerebral Perfusion and Visual Outcomes

Carotid artery disease represents a significant clinical challenge in patients undergoing ophthalmic surgery due to its direct impact on cerebral and ocular perfusion. Its prevalence increases with age and is strongly associated with cardiovascular risk factors such as hypertension, diabetes mellitus, dyslipidemia, and smoking. These patients often present with impaired cerebral autoregulation, making cerebral blood flow highly dependent on systemic blood pressure. Consequently, even minor hemodynamic fluctuations during the perioperative period may precipitate ischemic complications. The pathophysiology involves both hypoperfusion and embolic mechanisms. Reduced cerebral blood flow, compounded by limited collateral circulation through the Circle of Willis, increases the risk of neurological injury. Simultaneously, embolization of atherosclerotic plaques may lead to acute cerebral or ocular events, including retinal artery occlusion and ischemic optic neuropathy. These risks highlight the importance of maintaining stable systemic and ocular perfusion throughout the surgical process. Preoperative evaluation requires a comprehensive neurological, cardiovascular, and imaging assessment to stratify risk and guide management. Intraoperatively, the primary objective is to preserve cerebral perfusion by maintaining stable mean arterial pressure and avoiding both hypotension and excessive hypertension. This is achieved through careful titration of anesthetic agents, appropriate fluid therapy, and the use of vasopressors when necessary. The choice of anesthetic technique should prioritize hemodynamic stability, with regional anesthesia and monitored sedation often preferred. Pharmacological management, including the selective continuation or withholding of medications, further contributes to optimizing outcomes. Overall, a tailored, multidisciplinary approach is essential to minimize perioperative complications and ensure patient safety.