Management of macular epiretinal membrane secondary to accidental globe perforation during retrobulbar anesthesia

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.

Clinical presentation and management of eyes with globe perforation during peribulbar and retrobulbar anesthesia: A retrospective case series

Aim

To evaluate the clinical presentation, management, and outcome of eyes with an inadvertent globe perforation during peribulbar or retrobulbar block.

Methods

This retrospective study evaluated the eyes which had an accidental globe perforation during local ocular anesthesia from 2012 to 2020. The patients were divided into three groups; Group 1: Clear media with no rhegmatogenous retinal detachment (RRD); Group 2: significant vitreous hemorrhage (VH) precluding the retinal view without RRD; and Group 3: RRD with/without VH.

Results

Twenty-five patients (25 eyes) were included in the study. The mean axial length (AL) was 24.7±2.7mm (Range, 20.9-31.2mm). Eleven eyes (45.8%) had an AL≥24mm. The most common presenting features were VH (n=14), hypotony (n=7), and RRD (n=7). The treatment included retinal laser barrage (n=7) and vitrectomy (n=17). Retinal breaks were identified in all the eyes (total breaks=37). Other complications included full-thickness macular hole (n=5), subretinal hemorrhage (n=4), and retinal vascular occlusion (n=4). The mean presenting best-corrected visual acuity (BCVA) in groups 1,2 and 3 were logMAR 0.79±0.73, 1.82±0.78, and 2.13±0.59 respectively. All the patients, except the one who did not undergo surgery, had an attached retina at the time of the last follow-up. The mean final BCVA for each group was logMAR 0.59±0.79, 0.48±0.26, and 1.25±0.64 respectively (p=0.006). The development of RRD was associated with a larger AL (p=0.015); while the development of significant VH precluding the retinal view was associated with the superior location of the perforation (p=0.015), late recognition of the perforation (p=0.004), and multiple perforations (p=0.015).

Conclusion

Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer AL, superior, and multiple perforations are at higher risk of developing complications like RRD and VH. Complications like RRD, macular injury, and vascular occlusion are risk factors for poor prognosis.