Inadvertent globe perforation during retrobulbar injection in high myopes

Clinical Profile, Complications and Trends of Ocular Anaesthesia in a Multi-tier Ophthalmology Network in India: An Eight-Year Experience

INTRODUCTION

To describe the clinical profile, complications and trends of ocular anaesthesia in a multi-tier ophthalmology network in India.

METHODS

This retrospective hospital-based study included 417,622 patients presenting between January 2013 and December 2020. Patients who were administered either topical, local or general anaesthesia for ocular surgery in at least one eye were included as cases. The data were collected using an electronic medical record system.

RESULTS

Among the 417,622 patients, local anaesthesia was administered to 280,638, (67.2%) patients and was the most commonly administered type followed by topical anaesthesia in 84,117 (20.14%) patients. The most common complication encountered in administering local anaesthesia was retrobulbar haemorrhage in 103 (0.037%) patients followed by lid haematoma in 49 (0.017%) patients. Tooth damage occurred in 40 (0.076%) patients followed by delayed recovery in 30 (0.057%) patients during general anaesthesia. The trend of local anaesthesia decreased (83.48% vs 53.36%), whereas the trend of topical anaesthesia increased (8.61% vs 32.42%) over the study period.

CONCLUSION

There is a notable trend towards the adoption of less invasive anaesthetic methods, particularly in common surgeries such as cataract, intravitreal injection, and vitreoretinal surgery. However, despite this trend, a significant proportion of oculoplastic/orbital surgeries, trauma, and strabismus surgeries continue to be performed under general anaesthesia. These observations underscore the ongoing evolution of ocular anaesthesia practices, reflecting advancements in surgical techniques and patient preferences.

Anaesthetic considerations for the surgical management of ocular hypotony in adults

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

Cataract surgery in myopic eyes

PURPOSE OF REVIEW

We discuss the preoperative, intraoperative, and postoperative considerations for cataract surgery in eyes with high myopia. We also reviewed the recent literature on refractive outcomes and complications of cataract surgery in myopic eyes.

RECENT FINDINGS

Several novel intraocular lens (IOL) power calculation formulas have recently been developed to optimize refractive outcomes. Haigis formula is the most accurate among the third-generation IOL formulas. Novel formulas such as Barrett Universal II, Kane, and modified Wang-Koch adjustment for Holladay I formula provide a better refractive prediction compared with old formulas. Intraoperatively, the chopping technique is preferred to minimize pressure on weak zonules and reduce the incidence of posterior capsule rupture. Anterior capsular polishing is recommended to reduce the risk of postoperative capsular contraction syndrome (CCS). Postoperatively, complications such as refractive surprises, intraocular pressure spikes, and CCS remain higher in myopic eyes. Only 63% of myopic patients with axial length more than 26 mm achieve a visual acuity at least 20/40 after cataract surgery, mainly because of coexisting ocular comorbidities.

SUMMARY

There are multiple preoperative, intraoperative, and postoperative considerations when performing cataract surgery in myopic eyes. Further research is needed to optimize the refractive outcomes in these eyes and determine the best IOL formula. Surgeons should be adept and knowledgeable with different techniques to manage intraoperative complications.

Ocular complications of perioperative anesthesia: a review

Ocular complications associated with anesthesia in ocular and non-ocular surgeries are rare adverse events which may present with clinical presentations vacillating between easily treatable corneal abrasions to more serious complication such as irreversible bilateral vision loss. In this review, we outline the different techniques of anesthetic delivery in ocular surgeries and highlight the incidence and etiologies of associated injuries. The changes in vision in non-ocular surgeries are mistaken for residual sedation or anesthetics, therefore require high clinical suspicion on part of the treating ophthalmologists, to ensure early diagnosis, adequate and swift management especially in surgeries such as cardiac, spine, head and neck, and some orthopedic procedures, that have a comparatively higher incidence of ocular complications. In this article, we review the literature for reports on the clinical incidence of different ocular complications associated with anesthesia in non-ocular surgeries and outline the current understanding of pathophysiological processes associated with these adverse events.

Feasibility and safety of vitrectomy under topical anesthesia in an office-based setting

Purpose

The purpose of this study was to evaluate the feasibility and safety of office-based vitreoretinal procedures.

Methods

Patients undergoing primary elective pars plana vitrectomy were elected for surgery in an office-based setting (performed in a minor procedure room under topical anesthesia [TA] and oral anxiolysis). Rates of surgical objective achievement, surgical timing, and comfort were recorded to evaluate feasibility. Intraoperative and postoperative adverse events were assessed to evaluate safety.

Results

Office-based vitrectomy surgery was performed in 34 eyes of 30 patients. The mean surgical time was 12.351 ± 8.21 min. Surgical objectives were achieved in 100% of cases. The mean best-corrected visual acuity improvement was 9.08 letters (P < 0.0001). During most parts of the procedure, no patient reported pain or discomfort. Neither intraoperative nor postoperative adverse events were reported until the final follow-up visit.

Conclusion

Office-based vitreoretinal procedures under TA could be as feasible and as safe as vitreoretinal procedures under conventional anesthesia.

Traumatic Branch Retinal Vein Occlusion With Retinal Neovascularization Following Inadvertent Retrobulbar Needle Perforation

Retrobulbar injection of anesthesia is one of the most common procedures performed for ophthalmic surgery. Complications are rare but can be potentially serious, including retrobulbar hemorrhage, brainstem anesthesia, and inadvertent globe perforation. This is the preliminary report describing branch retinal vein occlusion (BRVO) secondary to accidental retrobulbar needle laceration with subsequent preretinal neovascularization.

A comparison of topical or retrobulbar anesthesia for 23-gauge posterior vitrectomy

Background. To compare the efficacy and safety of topical anesthesia versus retrobulbar anesthesia in 23-gauge vitreoretinal surgery. Materials and Methods. A total of 63 patients scheduled for 23 G posterior vitrectomy without scleral buckling procedures were included in the study. The patients were randomly assigned to receive either topical (Group 1, n = 31) or retrobulbar anesthesia (Group 2, n = 32). Postoperatively, patients were shown a visual analogue pain scale (VAPS) from 1 (no pain or discomfort) to 4 (severe pain or discomfort) to rate the levels of pain. Results. There was more discomfort in patients in Group 2 while anesthetic was administered (Group 1:  1.0 ± 0, Group 2: 2.3 ± 0.7, P = 0.0001). Between the two groups the level of pain during surgery (Group 1: 1.4 ± 0.5, Group 2: 1.5 ± 0.5; P = 0.85) was noted. There was also no significant difference between two groups postoperatively (Group 1: 1.2 ± 0.4, Group 2: 1.3 ± 0.4; P = 0.28). There were no complications in either group related to the anesthetic technique. No patient needed sedation or anesthesia supplement during the surgery or postoperative period. Conclusion. Topical anesthesia in posterior vitrectomy procedures is an effective and safe method that is alternative to retrobulbar anesthesia.

Management of retinal detachment in block related globe perforation with pneumatic retinopexy

Retinal detachment after ocular perforation related to local anesthesia is a common complication, which is usually associated with a poor prognosis despite complex vitreoretinal surgical procedures. We report a case of 62-year-old male with cataract surgery done 4 weeks back with nasal retinal detachment with a posterior break. Pneumatic retinopexy was performed and laser barrage of the breaks was done the next day when the retina got attached. A vision of 20/30 was achieved at the end of 2 months. To the best of our knowledge, this is a first case report in literature where pneumatic retinopexy was used to manage a retinal detachment caused by block-related perforation.

Early use of eyeglasses for myopia predicts long axial length of the eye

Patients with long axial length (AL) eyes (> 25 mm) are at increased risk of globe perforation during performance of intraconal (retrobulbar) eye block. These patients often require glasses or contact lenses for myopia (nearsightedness) as children or young adults. A history of early correction for myopia might, therefore, be a predictor of long AL eyes. One hundred one patients undergoing cataract surgery had AL measured and answered questions about their use of corrective lenses. We found that a history of correction for myopia as a child or young adult was 82% sensitive and 84% specific for having a measured AL > or = 25 mm. Patients with this history may be at increased risk for globe perforation during intraconal block.

Iatrogenic retinal traumas in ophthalmic surgery

BACKGROUND

To describe the main retinal iatrogenic traumas possibly related to ophthalmic surgery and the precautions to be adopted to avoid them.

METHODS

The article reviews the main peer-reviewed literature concerning retinal injuries caused by surgically related maneuvers. Safety measures alleged to inhibit any possible iatrogenic damage are also evaluated.

RESULTS

Photochemical damage of the retina, retinal complications after strabismus surgery, retinal complications related to local anesthesia for ophthalmic surgery, retinal damage during cataract surgery and retinal damage during vitreoretinal surgery are the most common iatrogenic retinal injuries. Their incidence is related to risk factors peculiar to each condition.

CONCLUSIONS

Ophthalmic surgeons are aware that there are a number of circumstances in which several undesirable retinal iatrogenic injuries might occur, sometimes with serious consequences. This is why surgeons should take every precaution at each surgical step to avoid any possible retinal iatrogenic damage.

Visual Outcomes and Associated Risk Factors of Cataract Surgeries in Highly Myopic Taiwanese

AIMS

The purposes of this study are to describe the visual outcome of highly myopic eyes undergoing cataract surgery, to investigate associated risk factors for poor postoperative vision and to assess the postoperative complication frequency among the myopic Taiwanese population.

METHODS

We conducted a retrospective, noncomparative case series study at the Department of Ophthalmology, Zhongxing Branch, Taipei City Hospital, Taiwan. High myopia was defined as axial length > or =26.0 mm. The main study outcomes were visual acuity for the initial 6-month postoperative period (including visual acuities and improvement of postoperative vision) and postoperative complications (including subsequent cataract formation and postoperative retinal detachment).

RESULTS

Fifty-two highly myopic eyes were enrolled between January 2002 and December 2004. The mean follow-up interval was 43.3 +/- 20.2 weeks (range 25-103). Thirty-two eyes (61.5%) had good postoperative visual improvement (> or =4 lines of Snellen chart). Thirty-seven eyes (71.2%) achieved good postoperative vision (20/40 or better). Fifteen eyes (28.8%) demonstrated poor postoperative vision. Pre-existing maculopathy was an independent risk factor for failure to achieve good postoperative vision [odds ratio (OR): 6.84, 95% confidence interval (CI): 1.12-41.8] and improvement (OR: 16.1, 95% CI: 2.2-119.9). Diabetic history was considered another independent risk factor for poor postoperative vision (OR: 15.6, 95% CI: 0.97-267.6). Six eyes (11.5%) developed subsequent posterior capsular opacification requiring Nd:YAG laser capsulotomy. Two eyes (3.8%) developed retinal detachment during follow-up.

CONCLUSIONS

Most highly myopic eyes achieved good visual improvement and good postoperative visual acuity after cataract surgery. Pre-existing maculopathy was an independent risk factor of postoperative visual improvement and status. It is crucial to examine retinal status prior to cataract surgery to prevent poor vision improvement, poor postoperative vision or retinal complications.

Anesthesia for intraocular surgery

Surgeons must decide on the type of anesthesia to use when performing cataract surgery. These "viewpoints" articles provide a well-balanced discussion offering the pros and cons of both topical anesthesia and retrobulbar/peribulbar injection. Dr. Dutton gives an overview of both techniques, focusing on relevant orbital anatomy. Drs. Hassan, Edelhauser and Kim, review the various types of topical anesthesia currently in use, and Drs. Spriggs and Broocker examine retrobulbar and peribulbar injections. Both techniques are associated with advantages and risks, so each surgeon must decide which technique is best suited for his or her own practice.