Single Injection Peribulbar Anesthesia with a Short Needle Combined with Digital Compression

Inverted ILM Flap for a Needle Injury to the Macula after Peribulbar Anaesthesia: A Case Report and Literature Review

Globe perforation following peribulbar anesthetic injection is a rare but dreaded complication that often results in poor visual outcomes. This case report is on a female patient who sustained vitreous hemorrhage, retinal detachment, and macular breaks due to a peribulbar block administered in the setting of cataract extraction. The retina was repaired with pars plana vitrectomy, endolaser of the peripheral retinal break only, and an internal limiting membrane inverted flap for the macular breaks to avoid the endolaser on the macular area, achieving stable visual outcomes. The authors discussed various modes of local anesthesia for vitreoretinal surgery, risks for globe perforations, and how to approach retinal detachment secondary to needle perforations, which are complex cases at high risk for proliferative vitreoretinopathy. Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer axial length, superior, and multiple perforations are at higher risk of developing complications such as retinal detachment and vitreous hemorrhage. Complications such as retinal detachment, macular injury, and vascular occlusion are risk factors for poor prognosis.

Three dimensional MRI study: Safety of short versus long needle peribulbar anesthesia

BACKGROUND

The standard technique of Peribulbar block is to use 25 g 25 mm needle at the junction between the lateral one third and medial two third of the lower orbital rim in the infero-temporal quadrant of the orbit. Theoretically, insertion of longer needles increases the potential of injury to important structure; however, safety of the shorter needle had never been demonstrated. This study describes the anatomy of the orbital structures with magnetic resonance imaging (MRI) using the three-dimensional constructive interference in steady state (3D CISS) sequence to present a morphological basis for needle entry at 12.5 and 25 mm lengths. Statistical comparisons were performed at the 12.5 versus 25 mm depths. Statistical significance was indicated by P < 0.05.

METHOD

Fifty patients free of orbital pathology with normal axial length were selected for MRI with the 3D CISS sequence. Original axial and multiplanar image reconstruction (MPR) images were selected for image interpretation. Orbital structures were identified at 12.5 and 25 mm depths from the orbital rim to compare significant differences in anatomy between the two imaging planes at the expected needle depth and to assess the size of the globe and the orbit.

RESULTS

The cross sectional area of the extraocular muscles were statistically significantly smaller at the 12.5 mm plane (P = 0.001). The area of inferotemporal fat was statistically significantly larger at the 12.5 mm plane (P = 0.033). There was no statistical difference in the inferonasal and superonasal fat areas at different depths (P = 0.34, P = 0.35 respectively). The size of the orbit and globe was significantly larger at 12.5 mm (P = 0.001). There was no difference between depths in the presence or absence of neurovascular bundles and supporting structures including the intramuscular septae.

CONCLUSION

There is a larger structure-free space at a depth of 12.5 mm than at 25 mm. Therefore, the inference is that a needle inserted in the infero-temporal zone to a depth of 12.5 mm is less likely to injure the eyeball or extra-ocular muscles than one advanced to 25 mm.

Periocular hematoma secondary to subperiosteal injury by a short needle

Bleeding and intraorbital hematoma is one of the most common complications of needle block for ophthalmic local anesthesia. We describe an unusual presentation of hematoma that originated in the subperiosteal space and extended to the subconjunctival and periocular area after a peribulbar block for phacoemulsification in a 55-year-old lady. It required an urgent surgical evacuation in order to reduce the intraocular pressure and save the eye. Detailed management to improve the outcome is discussed.

Anesthesia for pars plana vitrectomy with insulin needle, is it possible?

Peribulbar block is commonly used for ocular posterior segment surgery. This work aimed to compare the efficacy of using 12.5 mm to 25 mm standard needle length in performing single injection peribulbar block for retinal surgery. Peribulbar block was performed in 120 patients using either standard 25 mm or 12.5 mm 30 G needle (insulin needle). While applying digital pressure around the needle hub, 8–10 mL of local anesthetic are injected. Ocular movement was assessed at 5 and 10 min using simple akinesia score (0–8). If after 10 min score was >1, supplementary injection was given. Visual analogue scale (0–10) was used at the end of the procedure to assess surgeons' satisfaction and patients' intraoperative pain. No differences in akinesia score at 5 & 10 min (P = 0.34 and 0.36, resp.). Initial volume injected was comparable between groups (P = 0.31), however total volume of local anesthesia and supplementary injections were significantly higher in 12.5 mm group (P = 0.03 and 0.01, resp.). No difference as regard surgeons' satisfaction and patients' intraoperative pain (P = 1.0 and 0.18, resp.). Peribulbar block with 12.5 mm needle together with digital compression is a suitable alternative to the standard block with 25 mm needle length for retinal surgery.

Comparison of levobupivacaine 0.5% or bupivacaine 0.5% both in a mixture with lidocaine 2% for superficial extraconal blockade

PURPOSE

To evaluate the quality and efficacy of Peribulbar blockade for superficial extraconal anesthesia with levobupivacaine 0.5% versus bupivacaine 0.5%, both combined with lidocaine 2% for patients undergoing phacoemulsification.

MATERIALS AND METHODS

In this prospective, double blind study, 150 patients were randomly divided into two groups: group-1 received a Peribulbar block (PB) with a mixture of evobupivacaine 0.5% and lidocaine 2% while group-2 received a PB with a mixture of bupivacaine 0.5% and lidocaine 2%. The block was performed by insertion of a short needle (15 mm) in infra-temporal space just above inferior orbital notch. An initial volume of 6 9 ml of either mixture was injected until total upper eyelid drop. Akinesia score was assessed at 2, 5, and 10 min after the block. The degree of pain was assessed by a verbal rating scale immediately after block, at the end of surgery and 4 h postoperatively. The patients and surgeons were asked to rate their satisfaction level of the quality of block postoperatively. Data were analyzed with the unpaired, two-tailed t-test and the Chi-square test as appropriate. P < 0.05 was considered statistically significant.

RESULTS

There were no significant differences between groups with respect to the akinesia score (P = 0.2) at 2, 5, and 10 min, the number of supplementary injections (P = 0.84) and initial and total required volume of local anesthetics (P = 0.80 and 0.81, respectively). There was no significant difference between the groups regarding surgeon and patient satisfaction (P = 0.53 and P = 0.74, respectively). Similarly the verbal rating scales assessed at three different occasions were not significantly different between the groups (P > 0.05 all cases). The need for additional intra-operative topical anesthetic was also similar between the groups. (P = 0.69).

CONCLUSIONS

Superficial extra-conal block with a mixture of levobupivicaine 0.5% and lidocaine 2% or bupivicaine 0.5% and lidocaine 2% provides similar block quality and efficacy.

Comparison between single-injection inferomedial and inferotemporal peribulbar blockades before cataract surgery

PURPOSE

To compare the efficacy and safety of single-injection inferomedial (IM) and conventional inferotemporal (IT) peribulbar blockades.

PATIENTS AND METHODS

This prospective randomized study included 200 patients who were randomly allocated into two equal groups (n = 100 patients); in the first group, patients received IM peribulbar injection (IM group), while IT peribulbar injection was performed for the second group (IT group). The measurement data were patient characteristics, number of patients who required supplementations, total anesthetic volume injected, surgeon's experience and any recordable complications.

RESULTS

The number of patients who required supplemental anesthetics due to inadequate block was significantly higher in the IT group (15 patients, 15%, vs. no patients, 0%, in the IM group). The total anesthetic volume injected was significantly lower in the IM group (5.6 ± 0.8 vs. 9.8 ± 0.7 ml in the IT group). Surgeon's satisfaction was significantly higher in the IM group (100 vs. 22% in the IT group). The incidences of complications were not significantly different between the two groups.

CONCLUSION

It is safe and effective to conduct single-injection IM peribulbar blockade using a small needle size and low anesthetic volume.

Needle-based blocks for the 21st century ophthalmology

PURPOSE

This paper reviews history of the needle orbital blocks used in the earlier centuries and how they have evolved towards safer anaesthesia in the modern clinical practice.

METHODS

Material is derived from literature searches from major ophthalmic and anaesthetic journals on the use of orbital needle blocks over earlier centuries.

RESULTS

Needle-based anaesthetic techniques were described shortly after the invention of reliable medical needles. Atkinson popularized the classical retrobulbar block in a series of papers published in the early 20th century. This technique,which utilises a relatively long needle inserted towards the apex of the muscle cone behind the globe, has been criticized by some as unsuitable for modern 21st century ophthalmic surgery because of the extremely rare potential for serious complications. Satisfactory anaesthesia and akinesia can be obtained with short sharp or dull needles with slightly higher volumes of local anaesthetic agent placed in the farthest inferotemporal quadrant.

CONCLUSION

Aside from relative safety, modern needle blocks offer the advantage of lid akinesia without a need for a second injection for the seventh nerve that is often performed con-comitantly with retrobulbar block.