Ocular perforation following retrobulbar anesthesia for retinal detachment surgery

Vitreoretinal surgery after inadvertent globe penetration during local ocular anesthesia

OBJECTIVE

This study aimed to review visual morbidity resulting from inadvertent globe penetration during administration of local anesthetic and to identify the most appropriate management.

DESIGN

The records of 20 consecutive patients referred to a specialist vitreoretinal unit over a 2-year period were reviewed.

PARTICIPANTS

Twenty eyes of 20 consecutive patients were included.

INTERVENTION

Observations included type of local anesthetic administered (e.g., retrobulbar or peribulbar), level of training of person administering the block, type of needle used for the block, and findings at presentation to the vitreoretinal unit. The authors also observed results of B-scan ultrasound evaluation of the retina, interval between the recognition of the complication and referral, as well as nature and timing of subsequent surgical intervention.

MAIN OUTCOME MEASURES

Final visual acuity and retinal status (attached versus detached) were measured.

RESULTS

The most common presentation was vitreous hemorrhage observed from the first postoperative day. Ten eyes were found to have an associated retinal detachment on initial assessment in the vitreoretinal unit. These eyes generally had a poor visual outcome despite vitrectomy with long-acting gas or silicone oil tamponade. Seven (70%) of the remaining eyes with attached retina at the time of presentation achieved good visual recovery after vitrectomy.

CONCLUSIONS

The authors recommend prompt referral for consideration of early vitrectomy in eyes with dense vitreous hemorrhage after inadvertent globe penetration. This management may improve the overall visual prognosis by preventing subsequent retinal detachment.

Ocular explosion after peribulbar anesthesia: case report and experimental study

PURPOSE

A peribulbar anesthetic injection for cataract surgery produced a 10.5-mm scleral laceration and lens extrusion. This study sought to recreate this unfortunate clinical situation.

METHODS

Twenty-one human eye bank eyes were ruptured by intraocular injection of saline through Atkinson needles. The hydrostatic pressure required for globe rupture was measured by three different techniques in seven globes.

RESULTS

Forty-eight percent of the scleral lacerations were equatorial and 52% were perilimbal. Lens extrusion occurred with three of the perilimbal lacerations. Rupture pressures by each technique averaged 3065, 4972, and 5648 mmHg.

CONCLUSION

Peribulbar injection can produce inadvertent ocular explosion.

Parabulbar anesthesia for primary vitreoretinal surgery

PURPOSE

The efficacy and safety of parabulbar anesthesia was investigated prospectively in 100 patients undergoing primary vitreoretinal surgery.

METHODS

The technique involved three steps: (1) orbicularis oculi injection, (2) subconjunctival injection, and (3) sub-Tenon irrigation. The effect of anesthesia was graded 0 to 5 depending on inadequate anesthesia-akinesia with or without local supplementation. Ninety-three patients underwent vitrectomy without buckling and 4 with an encircling band; 3 had scleral buckling. Mean duration of surgery was 89.38 minutes.

RESULTS

In 69% of patients (grades 4 and 5), no supplementation was required and in 31% (grades 1-3), local supplementation was needed for inadequate anesthesia or akinesia or both. No ocular or systemic complication occurred. Early onset of anesthesia correlated with adequate anesthesia throughout the procedure (P < 0.04).

CONCLUSIONS

Parabulbar anesthesia is a safe and effective technique of local anesthesia in patients undergoing primary vitreoretinal surgery.

Cataract surgery in a Swedish population: observations and complications

PURPOSE

To describe relevant clinical conditions at cataract surgery in a defined Swedish population, examine variables and their influence on the operative procedure, and estimate the risk of complications at surgery.

SETTING

Department of Ophthalmology, Lund University Hospital, Sweden.

METHODS

Using the Cataract Analysis System, data were prospectively collected on 5878 consecutive cataract surgeries performed in a single Swedish health care district from 1986 to 1990. Patients younger than 15 years were not included. The study population was complete enough to represent all cataract surgeries in the referral region of the Lund Health Care District during this period. The incidence of zonular or lens capsule rupture at surgery was used as a measure of surgical complications and assessed as a function of other preoperative and surgical parameters. A logistic regression model was used to assess the probability of complications at surgery.

RESULTS

Glaucoma was the highest statistically significant preoperative risk factor for capsular or zonular rupture at surgery, with or without vitreous loss, with a relative risk of 2.7 (i.e., a 2.7-fold increase in risk over patients without glaucoma). Surgeons performing fewer than 40 operations in 5 years had a relative risk of zonular or capsular rupture of approximately 2.9 (i.e., a 2.9-fold increase in risk over high-volume surgeons). The overall risk was 2.5%.

CONCLUSION

Cataract patients with glaucoma have an increased risk of complications at surgery. Surgeons performing few operations tended to have more capsular or zonular ruptures.

A survey of ocular perforation during ophthalmic local anaesthesia in the United Kingdom

A survey of local anaesthetic related ocular perforation in the United Kingdom is reported. A total of 531 consultant ophthalmologists were sent a postal questionnaire and there was a 71% response rate. Thirty respondents reported 39 perforations occurring under their care during the previous year. Details of the cases are presented. The rate of local anaesthetic related ocular perforation is higher than in previous reported series. Efforts to reduce the incidence will require consideration of alternative techniques, audit, and training.

A standardized classification of ocular trauma

BACKGROUND

No internationally standardized classification of ocular trauma terminology has existed previously. Despite a growing interest in eye injuries, the absence of a common language continues to impede both clinical care and research.

METHODS

A classification has been developed initially based on the authors' extensive personal experience. It then has undergone repeated reviews over a 3-year period by international ophthalmic audiences, incorporating suggestions from respondents in 13 countries and selected ocular trauma experts.

RESULTS

By always using the entire globe as the tissue of reference, the new classification is unambiguous, consistent, and simple. It provides definitions for the commonly used eye trauma terms within the framework of a comprehensive system.

CONCLUSION

The new classification has been endorse by the Board of Directors of the International Society of Ocular Trauma, the United States Eye Injury Registry, the Hungarian Eye Injury Registry, the Vitreous Society, the Retina Society, and the American Academy of Ophthalmology. It can be reasonable expected that the system eventually will become the standardized international language of ocular trauma. The authors urge ophthalmologists to begin using this terminology in both clinical practice and research.

Sutureless scleral tunnel cataract surgery using topical and low dose perilimbal anesthesia

Because of risks and complications inherent to retrobulbar anesthesia, alternative techniques such as peribulbar and topical approaches have been devised. These also have associated problems. We have developed a technique that combines a single, minimal volume, perilimbal injection with topical anesthesia. It provides sutureless scleral tunnel cataract surgery without the risks of retrobulbar or peribulbar anesthesia, maximizing patient comfort and allowing immediate return of vision postoperatively.

Deep, topical, nerve-block anesthesia

Retrobulbar anesthesia produces profound anesthesia but involves risks such as hemorrhage and ocular tissue damage. Simple topical anesthesia is safer but does not produce the same depth of anesthesia. I have developed a technique that places a lidocaine-soaked sponge deep in the conjunctival fornices. This deep, topical, "nerve-block" technique produces a level of anesthesia previously seen only with injection techniques. I present the results of using this technique in 81 cataract extraction and intraocular lens implantation procedures. Supplemental injection was used in only two patients. The technique has advantages over injection and topical methods of anesthesia and is applicable to a variety of surgical procedures.

Regional ophthalmic anesthesia: safe techniques and avoidance of complications

In the last decade, anesthesiologists have become increasingly involved in administering regional eye blocks, while providing care for patients undergoing ophthalmic surgery. This article describes the two major approaches to regional eye block, namely retrobulbar and peribulbar, with special consideration given to relevant orbital anatomy and technical guidelines. Potential complications, ocular and systemic, with their risk factors, are reviewed. Anesthesiologists wishing to acquire skill in administering safe regional blockade are encouraged to familiarize themselves with regional anatomy and specific guidelines suggested herein.

The effects of lidocaine and bupivacaine on the rabbit retina

The toxic action of two commercial anesthetics, lidocaine and bupivacaine, on the functional and morphologic integrity of the retina was investigated in albino and pigmented rabbits. The experimental drug was injected into the vitreous of one eye, while saline solution was injected into the fellow eye. Retinal function was assessed from the electroretinogram and the visual evoked potential. Retinal structure was examined at the light microscopic level. Ten milligrams of lidocaine did not affect the electroretinogram and the visual evoked potential responses, though structural damage could be detected close to the site of injection. A lower dose of 5 mg did not produce any detectable physiologic or morphologic damage. The only dose of bupivacaine used, 0.5 mg, was not toxic to the albino and pigmented rabbit retinas, as assessed by the electroretinogram, visual evoked potential, and light microscopy. The results of this study demonstrate that lidocaine and bupivacaine are nontoxic to the rabbit retina at concentrations that are effective for retrobulbar anesthesia.

Perforation of the globe during retrobulbar injection: medicolegal aspects of four cases

Perforation or penetration of the globe is a risk of retrobulbar injection of anesthetic. Visual outcome following this complication depends on the severity of injury to the retina and on the physician's ability to promptly recognize and treat it. Four cases are presented to illustrate factors that contribute to proper management of this complication as well as to a favorable medicolegal position for the physician.

Pinpoint anesthesia: a new approach to local ocular anesthesia

Current methods of local ocular anesthesia, including retrobulbar, peribulbar, and topical anesthesia, have distinct limitations and many possible, potentially serious complications. We present a new technique that provides rapid, thorough local ocular anesthesia and eliminates these potential complications.

Efficacy and complication rate of 16,224 consecutive peribulbar blocks. A prospective multicenter study

Although usually safe, retrobulbar anesthesia and peribulbar anesthesia have potentially sight- and life-threatening complications. Although it has been suggested that peribulbar anesthesia is as effective and safer than retrobulbar anesthesia, no large study has addressed the true rate of complications. To determine the efficacy and safety of peribulbar anesthesia, this study prospectively examined 16,224 consecutive peribulbar blocks. Twelve centers in the United States, Germany, and Chile participated in the study. After a peribulbar block was administered, the degree of akinesia, amaurosis, percentage of supplemental blocks required, and side effects and complications occurring after the block and for six weeks were recorded. Perioperative and late optic nerve complications were included. To approximate a real-life situation, ophthalmologists, anesthesiologists, and certified registered nurse anesthetists performed the blocks. Ninety-five percent of patients achieved a 95% or greater degree of akinesia. The incidence of complications in the consecutive cases was low. Orbital hemorrhage occurred in 12 cases (0.74%). There was one globe perforation (0.006%), two expulsive hemorrhages (0.013%), one grand mal seizure (0.006%), and no cases of cardiac or respiratory depression or deaths. Peribulbar is as effective as retrobulbar anesthesia and appears to lead to fewer sight- and life-threatening complications, even when slightly different peribulbar techniques are used. This is especially true when the anesthetic is administered with a 1 1/4-inch or shorter needle with the eye in the primary position, followed by ten to 15 minutes of ocular compression.

Single injection, low volume periocular anesthesia in 1,000 cases

Periocular anesthesia is a proven alternative to retrobulbar anesthesia. A prospective evaluation of 1,000 cases was done to study the advantages of single point, low volume periocular anesthesia. This method is efficacious and has an excellent safety profile. The small needle length and the low volume of injected anesthetic enhance the safety. Supplemental anesthesia was needed in only 0.2% of cases. Chemosis was noted in 12.7%. In no case did surgery have to be postponed because of anesthesia-related complications. We believe this method is superior to other multipoint high volume methods of periocular anesthesia.

Visual acuity and pupillary reactions after peribulbar anaesthesia

The effect of peribulbar anaesthesia on optic nerve function in 20 patients, before and after cataract surgery, was measured. All the patients had decreased visual acuity. Five (25%) had no perception of light. Seventeen (85%) developed a relative afferent pupil defect (RAPD). No patients saw the operating instruments. Seven (35%) had improved visual acuity immediately postoperatively. Patients should be warned that they may lose vision completely on being given a peribulbar anaesthetic; however their vision will improve, but not necessarily immediately, postoperatively. Examination for an RAPD is a good method of providing reassurance that the operating instruments will not be seen.

Scleral perforations during peribulbar anaesthesia

Scleral perforation is a recognised but uncommon complication of retrobulbar and peribulbar anaesthesia; most of the reported cases have required further intervention. We report 5 cases from our department that occurred between October 1991 and June 1992. Surgery was performed in all 5 cases without complications. Vitreous haemorrhage was noted on the first post-operative day in all patients; none of the patients required further intervention. Four of 5 patients achieved a final visual acuity of 6/9 and the fifth case was an amblyopic eye with a final acuity of 6/18.

Efficacy and timed sequence analyses of modified single-injection peribulbar anesthesia

This study evaluated a modified single-injection technique of administering peribulbar anesthesia. All 150 eyes achieved complete lid anesthesia; 49 eyes (32.7%) demonstrating exophthalmos after injection achieved excellent (grade 1) instantaneous ocular akinesia. Sequence of timed events after injection included lid anesthesia (60.2 +/- 15.33 seconds), lid akinesia (75.18 +/- 15.33), lateral rectus akinesia (90.19 +/- 2.13), inferior rectus akinesia (140.44 +/- 17.51), superior rectus akinesia (229.60 +/- 15.23), and medial rectus akinesia (250.42 +/- 18.99). Peribulbar anesthesia, when successful, achieved complete akinesia in fewer than five minutes. In 12 eyes (8%), the peribulbar injection had to be repeated. For routine intraocular surgery, we recommend this efficacious, safe technique without the use of a separate facial block.

Regional anaesthesia for intraocular surgery

The role of anaesthetists in providing local anaesthesia for intraocular surgery has changed over the past decade. No longer confined to the interested few, more and more anaesthetists are involved in monitored care and/or are performing eye block anaesthesia. This review summarizes the information related to eye block anaesthesia. The salient features of the orbital anatomy important for safe conduct of eye block anaesthesia are described. The techniques for retrobulbar and peribulbar anaesthesia, including facial nerve blocks, anaesthetic mixture, types of needles, and softening the eye are presented. Complications such as retrobulbar haemorrhage, globe penetration/perforation, visual impairment, brainstem anaesthesia, muscle injury, and oculocardiac reflex are explored. The implications of anticoagulant therapy are examined. The choice between retrobulbar and peribulbar blocks and the role of anaesthetists are discussed.

A modified retrobulbar block for eye surgery

A modified retrobulbar block (MRB) using a single superomedial injection was compared with the classical retrobulbar block (RB) and peribulbar block (PB) in a randomized, prospective, surgeon-blinded study involving 150 patients undergoing cataract surgery. No serious complication occurred in any of the patients. The MRB produced higher rates of total akinesia in the orbicularis and all the extraocular muscles, which were statistically significant for the orbicularis, superior, inferior and lateral rectus and oblique muscles when compared with RB, and for the superior rectus and oblique muscles when compared with PB. MRB required less supplemental blocks, provided good operating conditions for the surgeon, and achieved high patient acceptance. It is concluded that MRB is a useful alternative method of ocular block for cataract surgery.

The metabolic and hormonal response to cataract surgery. A comparison between retrobulbar and peribulbar blockade

We studied the metabolic and hormonal responses of 30 elderly patients undergoing routine cataract surgery who were allocated randomly to receive either general anaesthesia, or local anaesthesia by means of either retrobulbar or peribulbar blockade. Both forms of local anaesthesia successfully prevented the increases in circulating cortisol and glucose concentrations seen in those patients who received general anaesthesia, there being no significant differences between retrobulbar and peribulbar blockade. The results show that the newer, and now more commonly performed peribulbar block, confers the same metabolic and hormonal stability as seen with the more traditional retrobulbar block.

The incidence of complications associated with retrobulbar injection of anaesthetic for ophthalmic surgery

A retrospective study of the incidence of complications associated with the use of retrobulbar injections was carried out on a sample of 1083 consecutive patients. The overall incidence of retrobulbar haemorrhage (1.3%) compared favourably with previous reports, but was found to be related to the experience of the surgeon. None of the more serious ocular complications of retrobulbar injection occurred in this sample. The relative safety of this technique is discussed.

Four-quadrant local anaesthesia technique for vitreoretinal surgery

We report our experience of a recently described local anaesthetic technique which seeks to avoid risk of perforation of the globe, damage to the optic nerve, or injection into the subarachnoid space, whilst providing prolonged and reliable anaesthesia. A prospective series of 19 patients who underwent vitreoretinal surgery using this technique were compared with 19 patients who had retrobulbar anaesthesia for cataract extraction. The vitreoretinal group had excellent akinesia and very good anaesthesia, allowing prolonged retinal reattachment surgery lasting up to 3 hours. Patient evaluation of discomfort or pain experienced in the two groups was assessed using a visual analogue pain score chart. The pain scores for the two groups were not significantly different (p = 0.03) and 16 of 19 patients in each group (84%) experienced only slight pain or less. Satisfaction with local anaesthesia, in both groups, was also assessed by asking patients which method of anaesthesia they would prefer if future surgery were to be performed. In the vitreoretinal group, 18 of 19 patients expressed a preference for local anaesthesia and in the cataract group 17 ot 19 also favoured local anaesthesia. The vitreoretinal patients' median pain score was 0 compared with 1 for the cataract patients. This study demonstrates that local anaesthesia provides pain relief for vitreoretinal surgery which is comparable to the experience of patients undergoing cataract surgery by retrobulbar anaesthesia. The technique described can provide successful local anaesthesia for vitreoretinal procedures. The success of this technique for pain relief and akinesia calls for a reappraisal of the number of patients suitable for vitreoretinal surgery under local anaesthesia.

Current practice of cataract extraction and anaesthesia

A questionnaire regarding preferred methods of cataract extraction and anaesthesia was sent to 456 consultant ophthalmologists in England and Wales. Replies were received from 86% (n = 392), 83% (n = 380) having completed the questionnaire in full. The most frequently employed surgical approach was non-automated extracapsular cataract extraction. Only 2% of surgeons (n = 8) used phacoemulsification routinely and 2% (n = 7) used intracapsular extraction. Intraocular lens implantation was the standard practice of 99% of surgeons (n = 376). There has been a dramatic increase in the popularity of local anaesthesia, which was employed routinely (in more than three-quarters of their cases) by 20% of surgeons (n = 76). Retrobulbar infiltration remains the most common method of administration. Sedation was given routinely by 45% of surgeons (n = 171) when using local anaesthesia. Medical contraindications and patient preference were considered the most important reasons for selecting local anaesthesia rather than general. The exclusive use of general anaesthesia in cataract surgery appears to be diminishing.

Neuroleptanalgesia and extracapsular cataract extraction

Peribulbar and retrobulbar anaesthesia are commonly used techniques in cataract extraction. They offer satisfactory analgesia and akinesia but serious complications although uncommon are consistently reported. Intravenous sedation combined with a facial nerve block offers an alternative method of anaesthesia. This is a retrospective study of patients who underwent extracapsular cataract extraction using this technique between 1 January 1986 and 1 September 1990. The operating conditions were judged to be very suitable with minimal peroperative complications. The postoperative ocular complication rate was low (minimum follow-up 3 months) and no serious medical complications were noted: 93.8% of patients achieved 6/12 vision or better. This study demonstrates that it is possible to achieve satisfactory ocular analgesia and akinesia during cataract extraction under local anaesthesia without the use of a periocular injection.

Perforation of the globe--a complication of peribulbar anaesthesia

Peribulbar anaesthesia has been recommended as a safer alternative to retrobulbar anaesthesia. We report a case of perforation of the globe sustained during peribulbar anaesthesia which resulted in blindness. Orbital injections are potentially dangerous, be they peribulbar or retrobulbar. To minimise the risk, short, blunt needles are advocated for the peribulbar route.

Perforating ocular injuries caused by anesthesia personnel

Between February 1988 and May 1990, the authors treated 12 perforating ocular injuries caused by anesthetic injections around the eye. All 12 injections were performed by nonophthalmologists. Eleven were performed by anesthesiologists and one by a certified nurse anesthetist. Five were caused by blunt needles and seven by sharp needles. Two of the eyes had multiple posterior exit wounds. The five eyes that had sharp needle, single perforations (i.e., one entrance wound and one exit wound) were easily managed with cryopexy, laser, or observation. All five of these eyes have a visual acuity of 20/40 or better. Six vitrectomies were performed on the five patients with single perforations caused by blunt needles; three of these eyes have a visual acuity of counting fingers or worse. The two patients who had multiple posterior exit wounds required a total of four procedures. The visual acuity in these eyes is 20/400 and light perception. Anesthesia personnel should be well trained before attempting ocular anesthesia. The use of blunt needles does not prevent ocular penetration.

Peribulbar anesthesia and optic nerve conduction

Serial recordings of distance visual acuity and visually evoked potentials (VEPs) after peribulbar anesthesia in three patients are reported. Visual acuity was not markedly affected but the latency and amplitude of VEPs were. This study concludes that optic nerve conduction is not significantly affected by peribulbar anesthesia.

Needle penetration of the globe during retrobulbar and peribulbar injections

The charts of 23 patients with needle penetration of the globe during retrobulbar or peribulbar injections between January 1980 and May 1990 were reviewed. Possible needle penetration risk factors included high myopia, previous scleral buckling procedures, injection by nonophthalmologists, and poor patient cooperation during the injection. Of the 23 cases of ocular penetration, 16 (70%) were from sharp (22-, 23-, and 25-gauge) needles, and 7 (30%) were from blunt (23- and 25-gauge) needles. Management options depended on the severity of the intraocular injury. Retinal breaks without retinal detachment were treated by laser photocoagulation (four cases) or cryopexy (one case) and were observed in three cases. More advanced complications (retinal detachment and vitreous hemorrhage) were usually treated by pars plana vitrectomy with or without a scleral buckle (12 of 14 cases). The final visual acuity was 20/400 or better in only 2 of the 14 retinal detachment cases. In cases without retinal detachment, the final visual acuity was 20/50 or better in 7 of 9 cases.