Ocular explosion after peribulbar anesthesia Gagandeep S. Brar, MD, Jagat Ram, MD, Mangat Ram Dogra, MD, Surinder Singh Pandav, MD, Ashok Sharma, MD, Sushmita Kaushik, MD, Amod Gupta, MD ABSTRACT We report 3 cases of globe rupture after peribulbar anesthesia. We discuss the predisposing factors, presenting features, and visual outcome after this complication. Globe explosion is a severe complication of inadvertent intraocular injection during peribulbar anesthesia. Visual outcome after vitrectomy is generally poor; however, cases that do not develop a retinal detachment may achieve good results. J Cataract Refract Surg 2002; 28: 556 –561 © 2002 ASCRS and ESCRS
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eriocular injections for ophthalmic anesthesia are generally considered safe and routine.1–3 Nevertheless, a variety of complications can occur after retrobulbar and peribulbar injections.4 –14 The intraocular complications of these injections may be related to the toxic drug effects, direct mechanical injury by the needle, or high intraocular pressure (IOP) induced by inadvertent intraocular injection.4,11 Globe perforations have been reported after peribulbar injections,5– 8 but they seem to be less frequent than with the retrobulbar technique.8 –10,15 Although globe penetration is a well-known complication of peribulbar anesthesia, ocular explosion and rupture after intraocular injection of anesthetic agents was reported for the first time by Magnante and coauthors in 1997.11 Since then, 7 more cases of this serious complication have been reported.11–13,16,17 We report 3 unusual cases of globe explosion after peribulbar anesthesia. One of the patients achieved a final visual acuity Accepted for publication July 9, 2001. From the Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India. Reprint requests to Jagat Ram, MD, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh160012, India. E-mail:
[email protected]. © 2002 ASCRS and ESCRS Published by Elsevier Science Inc.
of 6/9 after pars plana vitrectomy and another developed 360-degree giant retinal dialysis.
Case Reports Case 1 A 58-year-old man scheduled for cataract surgery in the right eye at a primary care hospital was administered local anesthesia. Details of the peribulbar anesthesia were obtained from the operating surgeon who referred the case. While being given the block of lidocaine hydrochloride 2% (Xylocaine威) in a 10 mL syringe with a 26-gauge, 0.75-inch needle, the patient reported severe pain. The ophthalmologist noticed a massive, dark, round swelling near the limbus nasally with 360-degree subconjunctival hemorrhage. At this point, the surgical procedure was abandoned. The visual acuity in the right eye was subsequently noted as light perception with defective projection and very low IOP that could not be recorded with an applanation tonometer. The patient was treated with topical ciprofloxacin 0.3%, cyclopentolate 1%, and oral acetazolamide 250 mg 3 times daily and diclofenac sodium 50 mg twice daily. There was no red reflex on indirect ophthalmoscopy. After 3 weeks, the patient was referred to our tertiary care center for further management. On ocular examination, visual acuity was light perception with accurate projection in the right eye and 6/18 in the left eye. Intraocular pressure by applanation tonometry was 14 mm Hg and 16 mm Hg, respectively. Anterior segment examination of the right eye revealed a nasal ciliary staphyloma with a globular mass 8.0 mm 0886-3350/02/$–see front matter PII S0886-3350(01)01034-3
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in diameter in the subconjunctival space nasally (Figure 1, top). Slitlamp examination revealed loose blood in the anterior chamber with aniridia. Nasally, the ciliary processes were visible from 2 to 4 o’clock. There was a gray vitreous hemorrhage with no view of the retina. The diagnosis was globe rupture after inadvertent intraocular injection of local anesthetic agents. An ultrasonogram revealed vitreous hemorrhage, an attached retina, and a hemorrhagic choroidal detachment extending from 7:00 to 10:30 o’clock in the temporal periphery reaching posterior to the equator. The patient was sent for pars plana vitrectomy. Intraoperatively, the lens nucleus and the iris were lying in the subconjunctival space nasally. The lens nucleus spontaneously extruded out as the conjunctival incision was performed, and the prolapsed iris tissue was abscised. The site of scleral dehiscence, which extended from 2 to 6 o’clock in the ciliary region, had healed and did not require surgical repair. The vitreous hemorrhage and lens capsule remnants were cleared. Fundus examination revealed a localized shallow choroidal detachment temporally, which was sparing the macular center. Cryoapplication was performed to
Figure 1. (Brar) Top: Right eye in Case 1 shows dark discoloration with a globular subconjunctival mass nasally (arrow). Bottom: The same eye after pars plana vitrectomy shows aniridia with persistent dark discoloration nasally. Note that the globular mass noted preoperatively has been removed.
2 equatorial retinal breaks temporally. There was no retinal detachment. After air–fluid exchange, a #240 encircling band was applied. Postoperatively, the patient had clear ocular media and a flat retina. After 6 months of follow-up, best corrected visual acuity (BCVA) was 6/9 with a clear cornea, complete aniridia (Figure 1, bottom), and an attached retina.
Case 2 A 42-year-old woman had extreme pain with sudden and profound loss of vision in the left eye while receiving a peribulbar block for phacoemulsification. The ophthalmologist suspected a globe perforation and abandoned the surgical procedure. He referred the patient to us after prescribing topical ciprofloxacin 0.3%, betamethasone 0.1%, cyclopentolate 1%, and oral acetazolamide 250 mg 3 times daily. Two weeks later, on initial presentation, BCVA was light perception with accurate projection in the left eye. The left eye was extremely hypotonus with unrecordable pressure. Anterior segment examination of the left eye revealed a clear cornea, normal anterior chamber depth, fixed dilated pupil, and a mature cataract. Ultrasonogram of the left eye revealed a dense vitreous hemorrhage and a small area of choroidal hemorrhage inferiorly at 5:30 o’clock just anterior to the equator. There were several vitreous membranes sticking to the ocular wall at the same site, suggesting this was the site of globe perforation or rupture. The patient was started on oral prednisolone 1 mg/kg body weight, and vitreous surgery was planned. While she was awaiting surgery, repeat ultrasound 1 week later produced similar results, with the additional finding of a superior retinal detachment. The patient had pars plana lensectomy with vitrectomy. Intraoperatively, a total retinal detachment with 360-degree retinal dialysis was noted. There was little vitreous in the eye. The only explanation was that it had extruded out at the time of globe rupture. Perfluorooctane was injected over the optic disc area, and all epiretinal and subretinal membranes were removed. A 360-degree endolaser was applied, and direct silicone oil and perfluorocarbon exchange was performed. During application of a #240 silicone explant, an area of scleral rupture approximately 5.0 mm long was noted just behind the insertion of the superior rectus muscle. This area showed vitreous incarceration, membrane formation, and scarring. No other site of scleral dehiscence was noted. This observation was in contradiction to the ultrasound findings that had suggested an inferior equatorial rupture. Six weeks postoperatively, visual acuity was hand motions close to the face. There was pallor of the disc, but the retina was well attached.
Case 3 A 65-year-old woman had a globe explosion during peribulbar anesthesia administered by a resident at our institution. We routinely use a 10 mL syringe with a 26-gauge,
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lateral one third of the inferior orbital rim. The resident felt unusual resistance while introducing the needle but did not suspect a globe perforation. The patient reported severe pain and tightening of the globe, and periocular ecchymosis was noticed. There was a sudden gush of fluid, blood, and vitreous from under the upper lid. On examination, a consultant made the diagnosis of globe rupture following intraocular injection of anesthetic (Figure 2, top). The patient was given intravenous mannitol 20%, and the procedure was abandoned. She was sent for examination and suturing of the rupture under general anesthesia the same day. Intraoperatively, a limbal rupture 6.0 mm long extending from 12 to 2 o’clock was noted and sutured after prolapsed uveal tissue was excised. A postoperative ultrasonogram showed a 360-degree hemorrhagic choroidal detachment and an anteriorly collapsed vitreous. There was total retinal detachment, with a crumpled retina posteriorly (Figures 3 and 4). The patient was advised to have vitreous surgery, which she refused. Eight weeks later, the periocular edema had subsided and the choroidal hemorrhage was clearing, but the patient had no perception of light (Figure 2, bottom).
Discussion
Figure 2. (Brar) Top: Left eye in Case 3 shows prolapsed uveal tissue superiorly (arrow) with surrounding dark discoloration after globe explosion. Bottom: The same eye 8 weeks postoperatively after repair of a perilimbal rupture. Note the cataract with a yellow hue.
0.75-inch needle for peribulbar blocks. A single injection of 8 mL was given at the junction of the medial two thirds and
Figure 3. (Brar) A B-scan ultrasonogram (transverse cut, nasal side anterior to equator) in Case 3 shows a large hemorrhagic choroidal detachment. 558
Globe penetration during peribulbar and retrobulbar anesthesia is a serious and well-recognized complication. Although the risk is low, with the rate being less than 0.1% in eyes with an axial length less than 26.0 mm,2,3 the potential complications are serious. Early recognition with appropriate management has been shown to yield favorable results.9,15 More serious, however, is the inability to recognize globe penetration and the subsequent intraocular injection of the anes-
Figure 4. (Brar) A B-scan ultrasonogram (transverse cut) in Case 3 shows a detached retina crumpled posteriorly (arrow).
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thetic solution with its additives. The intraocular complications of these injections range from simple globe penetration to more serious retinal vascular occlusions, retinal detachment, macular toxicity, and, in extreme cases, globe rupture or “explosion.”2,4,12 In contrast, ocular explosion is not a sequela of globe perforation, which has an anterior wound of entry and a posterior wound of exit. Even though an increasing number of globe penetrations are being recognized and documented,18 globe rupture or explosion has not been widely reported. Bullock and coauthors12 report a series of 7 patients, 2 of whom had an axial length of 26.0 mm or more; in 2 other cases, the primary surgeon continued with cataract surgery without realizing the globe rupture. Two additional cases had spontaneous lens extrusion. In experimental work reported in the same study, perilimbal and equatorial ruptures were noted in almost equal frequency after intraocular injection of saline into human cadaver eyes. Lens extrusion occurred in only 3 of 11 perilimbal ruptures, and no eye with equatorial rupture had such an outcome. Spontaneous lens extrusion has also been reported in another case of globe explosion after peribulbar injection.13 We observed a perilimbal rupture in 2 cases and an equatorial rupture near the insertion of the superior rectus muscle in 1 case. Lens expulsion into the subconjunctival space was noted in 1 case with perilimbal rupture. In their experimental analyses of ocular explosion, Bullock and coauthors12,17 give recommendations for recognizing and minimizing this event. They advocate using a larger (12 mL) syringe with a blunt needle because a smaller syringe attains rupture pressure more easily. The syringe should be wiggled slightly while the globe is observed for any movement. The plunger is aspirated before injecting to rule out intravascular injection of anesthetic agent.12,17,19 Corneal clouding during administration of a block indicates intraocular injection, and the maneuver should be discontinued. Intolerable pain should alert the ophthalmologist to the possibility of globe penetration or explosion.14 All patients in our study with globe explosion had severe pain during peribulbar anesthesia. Other indicators of globe perforation are loss of fundal glow, presence of an air bubble behind the posterior capsule, and hypotony.20,21 On the other hand, the globe may be tense if the solution has been injected intraocularly.
Although myopia is a well-known risk factor for globe penetration, with a reported incidence as high as 1 in 140 cases,9 none of the 3 cases reported here had an axial length greater than 24.5 mm. Dual peribulbar anesthesia has also been suggested as a risk factor because an inferior orbital injection displaces the globe superiorly, making it more vulnerable to penetration.22 All cases in our series and nearly all reported cases of globe explosion occurred after peribulbar injection. Although both peribulbar and retrobulbar techniques involve blind insertion of a needle into the orbit, globe explosion has been reported more often after peribulbar anesthesia because the smaller needle length makes globe penetration more likely than perforation. Also, a smaller and sharper needle requires less force for globe penetration, and scleral engagement is probably less painful than with a blunt needle, which results in the loss of an important indicator of globe penetration. Although the use of a blunt needle makes scleral penetration more difficult,23–25 it does not preclude it. Vivian and Canning23 conclude that use of a blunt needle does not afford an extra advantage as far as the risk of globe penetration is concerned. There are reports of significant numbers of penetrations with the use of blunttipped needles.26,27 Sound knowledge of the orbital anatomy and ensuring that appropriately trained personnel administer the block are vital, and one should exercise extreme caution when encountering any indication of globe penetration. The third case in our series occurred after injection by a 2nd-year resident who was administering the block without supervision. This case highlights the need for proper supervision when a relatively inexperienced person—whether resident, anesthetist, or nursing assistant—is giving the block. In general, the visual outcome after globe explosion is poor. In cases reported previously,12 final visual acuity ranged from no light perception to 20/160. Six of the 7 cases had an acuity no better than light perception, and 2 required enucleation. The poor visual outcome in 6 of the 7 cases was attributed to proliferative vitreoretinopathy and inoperable retinal detachment.12 Although anesthetic solutions have been reported to be relatively nontoxic when injected intravitreally,28,29 additives such as gentamicin are well-known toxic agents that lead to retinal infarction and necrosis.30 –32 This may be another factor in the poor visual outcome in many cases. In our series, final visual acuity was 6/9 in the first case,
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hand motions close to the face in the second, and no light perception in the third. To the best of our knowledge, the excellent visual outcome in our first case has never been reported. Although prolapse of intraocular contents, including lens, uveal, retinal, and vitreous, has been noted in previous reports, 360-degree retinal dialysis with total expulsion of vitreous, as occurred in our second case, has not been described. During pars plana vitrectomy, we noted vitreous remnants near the rupture site. There was 360-degree retinal dialysis without a trace of retinal tissue near the ora serrata. This appearance has not been noted in any previous report. In conclusion, although serious complications have been reported after peribulbar anesthesia, it is safe when performed by experienced personnel. Although newer options for ocular anesthesia such as topical anesthesia and sub-Tenon’s infusion are available,33–35 periocular injections remain the mainstay of ophthalmic regional anesthesia. Inadvertent intraocular injection of the anesthetic agent is increasingly recognized as a potential complication. A thorough knowledge of the orbital anatomy, administration of regional blocks by appropriately trained personnel, supervised injections at the learning stage, and timely recognition of scleral engagement/globe penetration will make the procedure safer and minimize the chances of severe complications such as globe rupture.
9.
10.
11.
12.
13.
14.
15.
16.
17.
References 1. Davis DB II, Mandel MR. Efficacy and complication rate of 16,224 consecutive peribulbar blocks; a prospective multicentric study. J Cataract Refract Surg 1994; 20: 327–337; erratum, 673 2. Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anesthesia for retinal detachment surgery. Am J Ophthalmol 1978; 86:61– 64 3. Schechter RJ. Management of inadvertent intraocular injections. Ann Ophthalmol 1985; 17:771–775 4. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology 1988; 95:660 – 665 5. McCombe M, Heriot W. Penetrating ocular injury following local anaesthesia. Aust NZ J Ophthalmol 1995; 23:33–36 6. Mount AM, Seward HC. Scleral perforations during peribulbar anaesthesia. Eye 1993; 7:766 –767 7. Kimble JA, Morris RE, Witherspoon CD, Feist RM. 560
8.
18.
19. 20.
21. 22. 23. 24.
Globe perforation from peribulbar injection. (letter) Arch Ophthalmol 1987; 105:749 Joseph JP, McHugh JDA, Franks WA, Chignell AH. Perforation of the globe—a complication of peribulbar anaesthesia. Br J Ophthalmol 1991; 75:504 –505 Duker JS, Belmont JB, Benson WE, et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia; patient characteristics, surgical management, and visual outcome. Ophthalmology 1991; 98:519 –526 Boniuk V, Nockowitz R. Perforation of the globe during retrobulbar injection: medicolegal aspects of four cases. Surv Ophthalmol 1994; 141–145 Magnante DO, Bullock JD, Green WR. Ocular explosion after peribulbar anesthesia; case report and experimental study. Ophthalmology 1997; 104:608 – 615 Bullock JD, Warner RE, Green WR. Ocular explosions from periocular anesthetic injections; a clinical histopathologic, experimental, and biophysical study. Ophthalmology 1999; 106:2341–2352; discussion by MS Cox, 2352–2353 Nagpal M. Lens expulsion into sub-conjunctival space following peribulbar anaesthesia. Indian J Ophthalmol 1998; 46:109 –110 Seelenfreund MH, Freilich DB. Retinal injuries associated with cataract surgery. Am J Ophthalmol 1980; 89: 654 – 658 Rinkoff JS, Doft BH, Lobes LA. Management of ocular penetration from injection of local anesthesia preceding cataract surgery. Arch Ophthalmol 1991; 109:1421– 1425 Rathi V, Basti S, Gupta S. Globe rupture during digital massage after peribulbar anesthesia. J Cataract Refract Surg 1997; 23:297–299 Bullock JD, Warwar RE, Green WR. Ocular explosion during cataract surgery: a clinical, histopathological, experimental, and biophysical study. Trans Am Ophthalmol Soc 1998; 96:243–276; discussion, 276 –281 Gillow JT, Aggarwal RK, Kirby GR. A survey of ocular perforation during ophthalmic local anaesthesia in the United Kingdom. Eye 1996; 10:537–538 Kraushar MF. Ocular explosion after peribulbar anesthesia. (letter) Ophthalmology 1997; 104:1728 Schneider ME, Milstein DE, Oyakawa RT, et al. Ocular perforation from a retrobulbar injection. Am J Ophthalmol 1988; 106:35– 40 Ram J. Reducing cataract surgery-related complications. (editorial) Indian J Ophthalmol 1999; 47:153–154 Feibel RM. Ocular explosion after peribulbar anesthesia. (letter) Ophthalmology 1997; 104:1727 Vivian AJ, Canning CR. Scleral perforation with retrobulbar needles. Eur J Implant Refract Surg 1993; 5:39 – 41 Galindo A, Keilson LR, Mondshine RB, Sawelson HI. Retro-peribulbar anesthesia; special technique and
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25.
26.
27.
28. 29.
30.
needle design. Ophthalmol Clin North Am 1990; 3(1):71– 81 Waller SG, Taboada J, O’Connor P. Retrobulbar anesthesia risk; do sharp needles really perforate the eye more easily than blunt needles? Ophthalmology 1993; 100:506–510 Hay A, Flynn HW Jr, Hoffman JI, Rivera AH. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991; 98:1017–1024 Grizzard WS, Kirk NM, Payan PR, et al. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991; 98:1011–1016 Lincoff H, Zweifach P, Brodie S, et al. Intraocular injection of lidocaine. Ophthalmology 1985; 92:1587–1591 Holekamp NM, Wax MB. Intraocular anesthetic following peribulbar anesthesia. Arch Ophthalmol 1998; 116: 380 –381 Rosenbaum JD, Krumholz DM, Metz DM. Gentamicin retinal toxicity after cataract surgery in an eye that under-
31.
32.
33.
34.
35.
went vitrectomy. Ophthalmic Surg Lasers 1997; 28:236 –238 Brown GC, Eagle RC, Shakin EP, et al. Retinal toxicity of intravitreal gentamicin. Arch Ophthalmol 1990; 108: 1740 –1744 McDonald HR, Schatz H, Allen AW, et al. Retinal toxicity secondary to intraocular gentamicin injection. Ophthalmology 1986; 93:871– 876; discussion by GA Peyman, 876 – 877 Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine to control discomfort during cataract surgery using topical anesthesia. J Cataract Refract Surg 1997; 23:545–550 Jolliffe DM, Abdel-Khalek MN, Norton AC. A comparison of topical anaesthesia and retrobulbar block for cataract surgery. Eye 1997; 11:858 – 862 Hansen EA, Mein CE, Mazzoli R. Ocular anesthesia for cataract surgery: a direct sub-Tenon’s approach. Ophthalmic Surg 1990; 21:696 – 699
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