Inadvertent Globe Perforation
during Retrobulbar and Peri bulbar. Anesthesia
Patient Characteristics, Surgical Management, and Visual Outcome JAYS. DUKER, MD/ JONATHAN B. BELMONT, MD/ WILLIAM E. BENSON, MD/ H. LOGAN BROOKS, Jr., MD, 3 GARY C. BROWN, MD/ JAY L. FEDERMAN, MD, 2 DAVID H. FISCHER, MD/ WILLIAMS. TASMAN, MD 2
Abstract: The authors report a series of 20 eyes from 20 patients in whom inadvertent perforation of the globe occurred during local anesthesia for ocular surgery. Perforation resulted from retrobulbar anesthesia in 18 eyes and from peribulbar anesthesia in 2 eyes. Nine (45%) of 20 eyes had an axial length greater than or equal to 26.00 mm. Combining this figure with axial length data for the general population and estimates for the risk of globe perforation during local anesthesia yields an approximate incidence of perforation in eyes with axial length greater than or equal to 26.00 mm of 1 in 140 injections. Proliferative vitreoretinopathy (PVR) developed in 8 of the 20 eyes (40%) in this series. Overall, 15 (75%) of the 20 eyes were successfully repaired, and, in five eyes (25%), the final visual acuity was 20/70 or better. Ophthalmology 1991; 98:519-526
Local anesthesia for ocular surgery in the form of a retrobulbar injection was first described by Knapp in 1884. 1 Since an optimal anesthetic agent that combined Originally received: September 25, 1990. Revision accepted: November 29, 1990. 1
Retina Associates, Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. 2 Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia. 3 Tallahassee Regional Medical Center, Tallahassee. Presented at the American Academy of Ophthalmology Annual Meeting, Atlanta, OclfNov 1990 Supported in part by the Heed/Knapp Foundation, Chicago, Illinois (Dr. Duker), the Retina Research and Development Fund, Philadelphia, Pennsylvania, and Research to Prevent Blindness, Inc, New York, New York. Reprint requests to Jay S. Duker, MD, Eye Research Institute Library, 20 Staniford St, Boston, MA 02114.
safety with efficacy was not widely available until the early part of the 20th century, retrobulbar anesthesia did not become generally accepted until the 19 30s. 2•3 At the present time, the administration of local anesthesia during ocular surgery is an extremely common procedure. In excess of l ,000,000 retrobulbar anesthetic injections are delivered yearly in the United States alone. The majority of these injections are without complication, although vision-threatening and even life-threatening side effects of retrobulbar anesthesia can occur. In an effort to reduce the risks of local anesthesia for ocular surgery, the peribulbar technique was introduced in the United States during the mid-1970s. 4•5 Peribulbar anesthesia consists of one or more injections of local anesthetic around the globe but not directly into the muscle cone. Because the injections are not applied as obliquely to the visual axis or as deeply into the orbit as with retrobulbar anesthesia, theoretically, peribulbar anesthesia 519
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carries less risk of inadvertently penetrating vital structures. There appears to be no appreciable loss of efficacy, although multiple injections may be necessary and a delay in onset is common. 4•6 •7 Potential side effects of both retrobulbar and peribulbar techniques include retrobulbar hemorrhage, respiratory depression, central nervous system depression, seizures, contralateral amaurosis, direct optic nerve damage, central retinal artery obstruction, combined central retinal artery and central retinal vein obstruction, and perforation of the globe. 3•8 We report on a series of 20 eyes of 20 consecutive patients who were referred to a single center for management of globe perforation associated with intraocular hemorrhage that occurred during local anesthesia for ocular surgery. The clinical characteristics, techniques of surgical repair, and visual outcome for the affected patients are described.
PATIENTS AND METHODS We retrospectively surveyed the charts and operative reports of patients who were seen on the Retina Service at Wills Eye Hospital from January 1, 1984 to December 31, 1989 with the diagnosis of perforated or penetrated globe secondary to retrobulbar or peribulbar anesthesia. During this 6-year period, 20 patients with this diagnosis were evaluated and treated. . In each instance, the patient's chart was examined with particular attention to the length of time between globe perforation and subsequent referral, initial visual acuity, final visual acuity, follow-up interval, ultrasonography results, presence of a retinal detachment on initial examination and on final follow-up examination, and the number and types of surgical procedures performed. Whenever possible, the referring surgeon was queried concerning the preoperative axial lengths of the affected eyes, the type oflocal anesthesia given (retrobulbar versus peribulbar), the type of needle used, and whether the presence of a perforation was suspected at the time of surgery. All patients underwent a comprehensive preoperative ocular examination including visual acuity, intraocular tension, slit-lamp examination, and dilated fundus examination. In any case in which opaque media precluded an adequate view of the posterior segment via indirect ophthalmoscopy, B-scan ultrasonography was obtained. Axial length data were derived from either the referring surgeon's record or from the ultrasonography examination performed before surgical repair of the perforation. In the single patient who did not undergo an ultrasound examination, axial length was grossly estimated from the refractive error. In patients requiring pars plana vitrectomy with silicone oil injection, a special informed consent form was signed, which was approved by the Wills Eye Hospital Institutional Review Board. All pars plana vitrectomies were performed using a standard three-port technique. General anesthesia was used in all cases. 520
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RESULTS Of the 20 patients in the study, 7 were male and 13 were female. Fifteen right eyes and five left eyes were involved. The median age of the patients was 68.9 years (range, 40-84 years). All patients were white. The followup interval, measured from the time of initial attempt at surgical repair of the perforation(s) by the retina specialist to the last examination by either the retina specialist or the referring physician, ranged from 6 months to 4 years (mean, 12.6 months). In 18 of the patients, the referring physician reported that the type of anesthesia injection attempted was retrobulbar. Two of the affected eyes were perforated during attempted peribulbar anesthesia. Both of the peribulbar injections and 17 of the retrobulbar injections were performed by ophthalmologists. The remaining retrobulbar perforation occurred during an injection by an anesthesiologist. To the best of the referring physicians' knowledge, none of the perforations resulted in anesthetic injection into the vitreous cavity. Eighteen of the patients were referred to the Retina Service at Wills Eye Hospital for evaluation and treatment of vitreous hemorrhage after local anesthesia for ocular surgery. One patient was referred for an iridodialysis with vitreous hemorrhage and another patient for subretinal hemorrhage. Eighteen of the 20 patients were scheduled for cataract extraction using planned extracapsular or phacoemulsification technique at the time the perforation occurred. One patient was scheduled to undergo a combined extracapsular cataract extraction and trabeculectomy. The final patient had age-related macular degeneration; this patient's globe was perforated while receiving a retrobulbar block before a krypton laser treatment for a juxtafoveal subretinal neovascular membrane. The operating surgeon did not suspect that a perforation had occurred in 10 (50%) of the 20 cases. In 13 of the 19 cases that involved planned cataract surgery, the initially scheduled surgical procedure was completed, including 3 cases in which a perforation was suspected after the block. Despite the presence of a globe perforation, in none of the 13 cases in which the planned surgery was completed was there any further surgical complication such as loss of vitreous, capsular rupture, or expulsive choroidal hemorrhage. In 1 of the 13 patients, the surgeon elected not to place an intraocular lens (IOL). All of the other 12 cases had IOLs placed. In the case of the macular laser treatment associated with a perforation, the laser treatment to the subretinal neovascular membrane was successfully completed. There were six cases in which the surgery was canceled because of suspected perforation. After repair of the posterior segment trauma, three of these eyes underwent successful cataract extraction with placement of an IOL at a later date. The cataract extractions were subsequently performed under general anesthesia, one 5 months, one 6 months, and the other 8 months after globe perforation. In the other three postponed cases, a lensectomy was performed using pars plana vitrectomy at the time of the
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Table 1. Clinical Characteristics of Group 1 Patients* Patient No.
Age (yrs)/ Sex
Eye
Typet
Axial Length
Initial Visual Acuity
Final Visual Acuity
Status
1 2 3 4 5 6 7 8 9 10 11
67/F 58/M 68/F 76/F 67/F 52/F 67/M 81/F 81/F 65/M 60/F
OD OD OD OD OD OD OD OD OD OD OD
Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Peribulbar Peribulbar Retrobulbar Retrobulbar Retrobulbar
23.98 29.91 26.60 22.12 24.45 26.77 26.51 22.23 22.83 21.64 26.29
HM LP HM LP LP HM LP HM HM LP LP
LP CFi HM LP LP CF LP LP NLP CF LP
Detached Attached Attached Detached Detached Attached Attached Detached Detached§ Attached Attached
OD = right eye; HM = hand movements; LP = light perception; CF = counting fingers; NLP = no light perception. * Retinal detachment present at the time of initial referral. t Method of local anesthesia attempted. t Visual acuity 4 months after the retinal detachment repair was 20/80. A subfoveal subretinal neovascular membrane probably related to high myopia subsequently developed and reduced the final visual acuity to this level. §Enucleated.
attempted repair with vitrectomy surgery. No IOL was placed in any of these three eyes. The initial visual acuity at the time of referral was 20/ 200 in one patient, counting fingers in four patients, hand motions in eight patients, and light perception in seven patients. All20 eyes showed vitreous hemorrhage of varying degrees. Hypotony, defined as an intraocular pressure less than or equal to 8 mmHg was present in six (30%) eyes, whereas in two (I 0%) eyes, the intraocular pressure was abnormally elevated above 22 mmHg. Eleven (55%) of the 20 patients had a detached retina at the time of initial evaluation. This was diagnosed with ophthalmoscopy and/or ultrasonography and confirmed at the time of surgery in all 11 eyes. In only 4 of 20 eyes, none of which had a retinal detachment, was the media clear enough that the perforation sites could be identified with indirect ophthalmoscopy. At the time of surgical repair, in I8 (90%) of 20 eyes, two definite retinal perforation sites were identified (double scleral perforating injuries). In the other two eyes, only one site was confirmed (i.e., probable globe penetration). Since an immediate rise in intraocular pressure did not occur at the time of injection in the two instances of probable single perforation, it is likely that the surgeon withdrew the needle without intraocular delivery of the anesthetic agent. In none of the 20 eyes was an attempt made to surgically repair either the anterior or posterior external scleral perforation sites. The presence or absence of a retinal detachment before the initial surgical repair of the perforations appears to have prognostic significance. With respect to this finding, these 20 cases may be divided into two groups. Group 1 consists of the 11 eyes in patients who presented to the retinal consultant with a retinal detachment. The mean time between occurrence of the perforation and subsequent referral to a retinal specialist for this group was 19.4 days (range, 5 hours-56 days). All 11 of these eyes underwent initial repair attempts with surgical procedures including pars plana vitrectomy with air-fluid exchange
and injection of a long-acting gas (nine eyes) or silicone oil (two eyes). Eight of the eyes also had a scleral buckle placed at the time of the initial retinal surgery. Eight eyes in Group I required a second operation because of redetachment, and in seven eyes, proliferative vitreoretinopathy (PVR) played a role in the redetachment. In five of the eight eyes that redetached, silicone oil was used for long-term tamponade. At the last examination, six of the eyes in Group I remained attached; final visual acuity in the eyes in Group 1 was 20/400 in one eye, counting fingers in three eyes, hand motions in one eye, light perception in five eyes, and no light perception in one eye. The eye with no light perception eventually underwent enucleation for pain relief. The clinical characteristics of the Group 1 patients are listed in Table I. Group 2 consists of the nine eyes that had no retinal detachment at the time of their initial referral for retinal evaluation. The mean time between occurrence of the perforation and subsequent referral to a retinal special for this group was 7.1 days (range, immediate to 35 days). Five eyes in Group 2 underwent pars plana vitrectomy, air-fluid exchange, and gas injection as an initial repair procedure. In none of these eyes was silicone oil used primarily. Two of these five eyes also had a prophylactic scleral buckle placed to relieve traction on anterior retinal breaks as well as the vitreous base. As previously mentioned, four of the eyes without retinal detachment had media clear enough so that the retinal specialist could identify the perforation sites with indirect ophthalmoscopy. Three of the eyes with clear media and no retinal detachment underwent outpatient laser photocoagulation around the retinal perforations, while the other such eye received outpatient transscleral cryotherapy. In none of these four eyes did a retinal detachment develop. Of the nine eyes in Group 2, a retinal detachment eventually developed in only one. It was associated with PVR and successfully reattached with silicone oil tamponade. The clinical characteristics and final visual acuities of the eyes 521
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Table 2. Clinical Characteristics of Group 2 Patients* Patient No.
Age (yrs)/ Sex
Eye
Typet
1
84/F 40/M 79/M 72/M 73/F 79/F 74/F 65/M 67/F
00 00 00 OS 00 OS OS OS OS
Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar
2 3 4 5 6 7 8 9
Axial Length
Initial Visual Acuity
Final Visual Acuity
Status
28.90 26.00 23.99
HM 20/200 HM CF CF CF CF HM LP
CF 20/40 20/200 20/400 CF 20/50 20/70 20/25 20/25
Attached Attached Attached Attached Attached Attached Attached Attached Attached
t
24.4 27.80 24.84 26.65 22.46
00 = right eye; HM = hand movements; CF = counting fingers; OS = left eye; LP = light perception. * No retinal detachment at the time of referral. t Method of local anesthesia attempted. t Axial length data unavailable. Since the spherical equivalent of the patient's refraction was +2.00 0, the likelihood that the axial length was ;;::26.00 mm is extremely remote. 23
in Group 2 are listed in Table 2. The following case report summarizes the successful management of a perforation secondary to local anesthesia.
CASE REPORT Case 2. A 67-year-old woman (patient 9 in Group 2) with no significant past ocular or medical history was scheduled for a planned extracapsular cataract extraction. Preoperative axial length was 22.46 mm and visual acuity was 20/80. Immediately after a single retrobulbar injection, given with a 25-gauge sharp needle inferotemporal to the globe, a moderate amount of subconjunctival hemorrhage was noted (Fig 1). Surgery was postponed due to assumed retrobulbar hemorrhage, however results of indirect ophthalmoscopy showed a dense vitreous hemorrhage and the patient was immediately referred to the Wills Eye Hospital Retina Service. On examination approximately 5 hours later, visual acuity was bare light perception and there was no view of the posterior segment. B-scan ultrasonography showed a dense vitreous hemorrhage but no retinal detachment (Fig 2). The following day, a pars plana vitrectomy was performed. Adequate visualization of the posterior segment through the cataractous lens was obtained, and, therefore, a lensectomy was not performed. Two perforation sites were detected, one in the inferotemporal quadrant near the vitreous base, and the second just inferior to the inferior arcade vessels. A posterior vitreous detachment was present. The posterior perforation was treated with endolaser. The anterior perforation was treated with transscleral cryotherapy and then supported on a radial sponge along with an encircling scleral buckle. A complete air-fluid exchange and injection of 20% sulfur hexafluoride gas was performed. After 2 months, the visual acuity returned to the preperforation level of 20/80 with the retina fully attached (Fig 3). Cataract extraction via phacoemulsification under general anesthesia was performed without complication 5 months after globe perforation, and the visual acuity subsequently improved to 20/25.
DISCUSSION Perforation of the globe with the local anesthetic needle represents one of the most dreaded complications of ocu522
lar surgery. With the assistance of a computerized literature search, we identified 18 previously published, welldocumented case reports of eyes treated for inadvertent perforation secondary to local anesthesia injection. Seventeen cases of globe perforation occurred during retrobulbar anesthesia, 9 - 15 while one was associated with peribulbar anesthesia. 8 These 18 cases are summarized in Table 3. Other instances of globe perforation secondary to either retrobulbar or peribulbar anesthesia are mentioned in the literature, with few or no clinical details revealed. 16- 20 Instances of globe perforation occurring during attempted periocular or retrobulbar delivery of corticosteroids, some of which resulted in intraocular injection of the corticosteroid preparation: have been reported as well. 9 •21 - 24 With the exception of the rare instances in which retinal toxicity apparently occurred secondary to the osmolality of the solution or the associated vehicle, such cases do not differ significantly in terms of prognosis or methods of surgical repair from the perforations associated with local anesthesia. Clinical experiences and experimental data indicate that intraocularly injected local anesthetics do not have long-term toxic effects on the retina. 3•13 •25 •26 To prevent globe perforation, some investigators strongly advocate the use of blunt needles for the delivery of local anesthesia? 1•27 Blunt needles, however, do not invariably prevent globe perforation. Seelenfreund and Freilich 10 reported on two cases in which double perforation occurred despite the use of a blunt, Atkinson-type needle. Additionally, at least one of the cases reported by Schneider and associates9 involved a perforation with a blunt needle. To the best of our knowledge, none of the 20 perforations in the present series occurred with a blunt needle; however, in over half the cases, we were unable to ascertain the type of needle used. The use of peribulbar anesthesia also has been advocated to reduce the risk of globe perforation. 4 •6 •20 Zaturansky and Hyams 12 state that peribulbar anesthesia "minimizes and perhaps eliminates" the risk of globe perforation. Although the risk of perforation may be less than with the retrobulbar technique, surgeons who use peri-
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Fig 1. Top left, group 2, case 9. View of the anterior segment about 6 hours after retrobulbar perforation. The amount of subconjunctival hemorrhage simulates a retrobulbar hemorrhage. Fig 2. Top right, group 2, case 9. B scan ultrasonogram shows vitreous hemorrhage with a posterior vitreous separation. No retinal detachment is present, however the posterior perforation site inferior to the optic disc is detectable (arrow). Fig 3. Second row left, group 2, case 9. Three months after PPV and repair of retinal perforations. Shows the area of the posterior perforation site, which is surrounded by endolaser (arrow). The retina is attached. Visual acuity has returned to pre-perforation levels (20/80). After cataract extraction, visual acuity improved to 20/25. Fig 4. Second row right, group 2, case 8. Follow-up appearance after PPV with prophylactic scleral buckle. Notice the posterior perforation site inferior to inferior arcade vessels with surrounding endolaser (arrow). Visual acuity is 20/25. Fig 5. Bottom, group 2, case 3. A retinal detachment secondary to PVR has developed despite the absence of a retinal detachment initially. Notice the posterior perforation site just superonasal to the fovea. The retina was successfully reattached using silicone oil.
bulbar anesthesia must be aware that globe perforation can still occur. Kimble and co-workers8 were the first to report such an occurrence, and other examples also have been recognized. 19 •20 The current series adds to the liter-
ature two more cases of globe perforation secondary to peribulbar anesthesia. Previous investigators undertook studies to estimate the overall risk of perforation of the globe during retrobulbar 523
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Table 3. Summary of the Previously Published Well-documented Cases of Globe Perforation Secondary to Local Anesthesia Injection During Ocular Surgery
Schneider et al
Seelenfreund et al Ramsay et al Zaturansky et al Kimble et al Lincoff et al (Patient 2) Haul et al O'Connor et al
Age (yrs)/ Sex
Eye
65/M 72/F 78/F 66/F 76/F 48/M 66/F 32/M 21/F 32/F 58/M 84/F 82/Mt
OD OD OS OD OS OD OS OS OS OD OD OS OS
?
79/F 71/F 44/M 62/F
?
OD OD
? ?
Axial Length or Refraction
Detached Retina
Proliferative Vitreoretinopathy
Final Visual Acuity
24.8 mm 23.5 mm 21.43 mm 28.46 mm 22.14 mm 26.83 mm
+ + +
+ + +
-14.00D -19.50D -9.00 D -9.00 D
+ +* +* +*
HM HM LP 20/40 20/30 20/200 20/30 20/25 20/400 20/20 20/20 20/60 20/40
?
? ?
+
?
+*
? ?
+t +
Emmetropic Emmetropic
20/40 20/60 20/30 +
? ?
OD = right eye; HM = hand movements; OS = left eye; LP = light perception; D = diopters. * Retinal detachment was present before the perforation. t Peribulbar anesthesia.
and peribulbar anesthesia. Cibis, 16 in 1965, reported the results of 1000 consecutive cases of retinal surgery performed under local anesthesia. He encountered one instance of globe perforation, yielding an overall incidence of 0.1 %. In 1978, Ramsay and Knobloch 11 reported on three cases of globe perforation out of 4000 consecutive patients undergoing local anesthesia for retinal detachment surgery. Their incidence of0.075% is quite similar to that calculated by Cibis. More recently, a single occurrence of globe perforation secondary to peribulbar anesthesia was encountered out of 4200 consecutive patients (0.024%) receiving peribulbar injections by a single anesthesiologist. 8 In contrast, another series of consecutive peribulbar injections found no incidence of perforation in 2000 injections. 4 Since the series reported by both Cibis and Ramsay were derived solely from patients undergoing retinal detachment surgery, it is reasonable to assume that there was a higher-than-normal incidence of axial myopia among these patients. In light of this, the rate of occurrence of globe perforation during local anesthesia for ophthalmic surgery performed on a general population (e.g., cataract surgery patients) is probably somewhat lower than the approximately 1 in 1000 injections estimated by the retinal surgery-derived series. In previous reports, certain risk factors for globe perforation during local anesthesia for ocular surgery were suggested, although none were conclusively proven in a controlled fashion. 8- 16 These risk factors include axial myopia, the presence of a posterior or inferior staphyloma, the use of multiple injections, a history of a previous scleral buckling procedure, and enophthalmos. The present study gives strong support to the hypothesis that axial myopia is a definite risk factor for globe perforation. Nine (45%) 524
of 20 affected eyes in this series had an axial length of 26.00 mm or greater. Coupling this percentage with the estimate that approximately 1.5% of the general population has an axial length greater than 26.00 mm 28 - 30 yields a relative risk of perforation in these large eyes of approximately 30 times greater than the normal population (i.e., 45/1.5 = 30). By using the most conservative estimate for the incidence of globe perforations derived from the series limited to peribulbar blocks ( 1 of 4200 injections), 8 an estimate for the overall risk for eyes with axial lengths greater than 26.00 mm can be calculated. This risk is approximately 1 globe perforation for every 140 injections (4200/30 = 140). In light of these data, extreme caution should be used during the administration of local anesthesia in any patient undergoing ocular surgery who has a long axial length. In addition, axial length in and of itself should be a factor when preoperatively determining the most appropriate type of anesthesia for ocular surgery. Compared with a vision-threatening complication rate of at least 1 in 140, the increased systemic complication rate associated with general anesthesia appears justifiable for patients whose axial length is greater than 26 mm. The final outcome of the eyes suffering inadvertent globe perforation with respect to the anatomic status of the retina as well as the visual acuity appears to be greatly dependent on the presence or absence of a retinal detachment. In this series, if no retinal detachment was present at the time of referral (Group 2 eyes), then the incidence of subsequent retinal detachment was only 11% ( 1 of 9 eyes). The long-term retinal attachment rate in this group was 100%. Additionally, 5 (56%) of 9 eyes in Group 2 achieved a final visual acuity of 20/70 or better. Conversely, if a retinal detachment was present (Group 1 eyes),
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then the long-term reattachment rate was reduced to 64% (6 of 11). None of the patients with a retinal detachment maintained a long-term final visual acuity better than 20/ 200. One patient in Group 1 had a visual acuity of 20/ 80 in the immediate follow-up period, only to have the central acuity reduced to counting fingers from an apparently unrelated subfoveal neovascular membrane. The major reason that the eyes in this series did not do well either anatomically or visually was the development of PVR with resultant redetachment of the retina. Proliferative vitreoretinopathy developed in 40% of the eyes overall, but the rate of PVR in eyes-in Group 1 was 64% (7 of 11). None of the eight eyes that developed PVR in this series completed the study with a visual acuity better than 20/200. The previous report of Schneider and coworkers9 found a similar overall rate of PVR as 3 (43%) of 7 eyes with retrobulbar perforations in their series developed PVR. None of the three eyes with PVR in their series achieved a final visual acuity better than hand motions. Perforation through the fovea or optic nerve may account for decreased visual acuity in some of these eyes also, as was the case in at least two patients in Group 2. However, the most common posterior perforation site seems to be inferior to the fovea (Figs 4, 5). 9 It has been suggested that in cases of suspected retrobulbarjperibulbar globe perforation during cataract surgery, two options for immediate management exist. 3 If the media remain clear enough to visualize the perforation sites with indirect ophthalmoscopy, then the anterior segment surgery should be aborted and prompt arrangements made for laser or cryotherapy retinopexy to the perforation sites. Conversely, ifthe cataract itself precludes adequate visualization of the posterior segment, then the anterior segment surgeon may consider proceeding with lens removal, provided adequate anesthesia and akinesia are present and the eye is not hypotonus. This will give the posterior segment surgeon better visualization during the subsequent vitrectomy and retinal repair, if it is necessary. More importantly, after removing the cataract, the media may prove clear enough that laser photocoagulation to the perforation sites becomes an option, thereby saving the patient from a more invasive procedure. Some may claim that the placement of an IOL in such a case might interfere with visualization of the posterior segment during vitrectomy. Others have not experienced this difficulty when an IOL with a 7-mm optic is used. 31 Another objection to continuation with the cataract surgery is that there may be an increased potential for further surgical complications. However, in none of the cases in this present series in which the cataract surgery was completed did the presence of a globe perforation appear to interfere with the technical outcome of the anterior segment procedure. The best techniques for repairing the posterior segment trauma in these cases remain to be fully defined. If the media is clear and no retinal detachment is present, then transscleral cryotherapy alone, as initially reported by Seelenfreund and Freilich, 10 may be successful. Alternatively, in these instances, laser retinopexy may be performed with a good outcome. 14 The role of prophylactic scleral buckling in cases of retinal perforation with no
retinal detachment is not clear. In most cases of double perforation, the posterior site can be placed on a scleral buckle only with great difficulty and risk. From examples derived from this series, and by extrapolation from vitrectomy surgery involving a deliberate posterior retinotomy, one may conclude that if sufficient removal of vitreous traction, good retinopexy, and an adequate gas tamponade are obtained, then scleral buckling of posterior breaks is unnecessary. In contrast, if, at the time of initial repair, a retinal detachment is present in conjunction with a double perforation, then the risk of developing PVR with subsequent redetachment appears to be alarmingly high. Under these circumstances, most surgeons would elect to use an encircling scleral buckle and some advocate the use of silicone oil tamponade as part of the primary procedure as well. There probably exist some cases of globe perforation secondary to local anesthesia featuring clear media, no retinal detachment, and self-sealing retinal perforation sites in which only observation is indicated. No such examples were included in this present series. This report's bias toward more severely affected eyes may be attributable to two factors. Since a retrospective mechanism was used to recall these cases, less severely affected eyes and those that required no intervention may have been overlooked in the process. Secondly, the patient population under consideration consisted of only those whose ocular problem was deemed severe enough to warrant referral to a tertiary care center. The findings of this series of 20 instances of globe perforation secondary to local anesthesia during ocular surgery allow for some generalizations to be made. In suspected cases featuring moderate to dense vitreous hemorrhage, immediate B-scan ultrasonography and consideration for early vitrectomy surgery is strongly recommended. When dense media opacity but no retinal detachment is present, prompt removal of the vitreous hemorrhage in conjunction with laser or cryotherapy to the perforation sites may prevent subsequent retinal detachment secondary to vitreous traction and PVR. The difference in referral times between eyes in Group 1 and Group 2 support this contention. When confronted with a possible globe perforation in an eye with a dense cataract that, in itself, precludes a view of the posterior segment, the anterior segment surgeon may consider finishing the procedure, provided the anesthesia is adequate and the eye is not hypotonus. Although peribulbar anesthesia may lessen the likelihood of inadvertent globe perforation, this report, like others before it, shows that the risk is not completely eliminated by the peribulbar technique. In addition, since axial myopia appears to be a strong risk factor for perforation, general anesthesia should be considered in eyes with a long axial length. Finally, if a macula-involving retinal detachment, foveal injury, or optic nerve trauma does not result from the globe perforation, a satisfactory visual result may be obtainable in these cases.
REFERENCES 1. Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol1884; 13:402-48.
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2. Russell DA Jr, Guyton JS. Retrobulbar injection of lidocaine (Xylocaine) for anesthesia and akinesia. Am J Ophthalmol 1954; 38:78-84. 3. Feibel RM. Current concepts in retrobulbar anesthesia. Surv Ophthalmol1985; 30:102-10. 4. Davis DB II, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986; 12:182-4. 5. Davis DB II. Retrobulbar and facial nerve block? No; peribulbar? Yes. [Letter] Ophthalmic Surg 1985; 16:604. 6. Bloomberg LB. Administration of periocular anesthesia. J Cataract Refract Surg 1986; 12:677-9. 7. Weiss JL, Deichman CB. A comparison of retrobulbar and periocular anesthesia for cataract surgery. Arch Ophthalmol1989; 107:96-8. 8. Kimble JA, Morris RE, Witherspoon CD, Feist RM. Globe perforation from peribulbar injection. Arch Ophthalmol1987; 105:749. 9. Schneider ME, Milstein DE, Oyakawa RT, et al. Ocular perforation from a retrobulbar injection. Am J Ophthalmol1988; 106:35-40. 10. Seelenfreund MH, Freilich DB. Retinal injuries associated with cataract surgery. Am J Ophthalmol 1980; 89:654-8. 11. Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anesthesia for retinal detachment surgery. Am J Ophthalmol 1978; 86:61-4. 12. Zaturansky B, Hyams S. Perforation of the globe during the injection of local anesthesia. Ophthalmic Surg 1987; 18:585-8. 13. Lincoff H, Zweifach P, Brodie S, et al. Intraocular injection of lidocaine. Ophthalmology 1985; 92:1587-91. 14. Haut J, Monin C, Renard Y, Tazartes M. Perforation du globe au cours de l'anesthesie retrobulbaire. Bull Soc Opht France 1989; 89:783-6. 15. O'Connor PR, MacDonald R. Retinal damage during ocular surgery. Ann Ophthalmol1971; 3:1118-21. 16. Cibis PA. General discussion: opening remarks. In: Schepens CL, Regan CDJ, eds. Controversial Aspects of the Management of Retinal Detachments. Boston: Little, Brown, 1965;222. 17. Rosen DA. Anaesthesia in ophthalmology. Can Anaesth Soc J 1962; 9:545-9.
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18. Bettman JW. A retrospective look at twenty-two medicolegal claims. How they might have been avoided. Surv Ophthalmol 1983; 28:5560. 19. Straus JG. A new retrobulbar needle and injection technique. Ophthalmic Surg 1988; 19:134-9. 20. Davis DB, Mandel MR. Peribulbar anesthesia. A review of technique and complications. Ophthalmol Clin N Am 1990; 3:101-10. 21. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology 1988; 95:660-5. 22. Schlaegel TF, Wilson FM. Accidental intraocular injection of depot corticosteroids. Trans Am Acad Ophthalmol and Otolaryngol 1974; 78:847-55. 23. Giles CL. Bulbar perforation during periocular injection of corticosteroids. Am J Ophthalmol1974; 77:438-41. 24. Hida T, Chandler D, Arena JE, Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol 1986; 101 :190-5. 25. Stangos N, Rey P, Leuenberger P, Korol S. The effect of xylocaine injections on the rabbit's retina: Averaged ERG and electron microscopy. Vision Res 1971; 11:1208-9. 26. Schechter RJ. Management of inadvertent intraocular injections. Ann Ophthalmol1985; 17:771-5. 27. Atkinson WS. Retrobulbar injection of anesthetic within the muscle cone (cone injection). Arch Ophthalmol1936; 16:494-503. 28. Hoffer KJ. Biometry of 7,500 cataractous eyes. Am J Ophthalmol 1980; 90:360-8. 29. Yu CS, Kao D, Chang CT. Measurement of the length of the visual axis by ultrasonography in 1, 789 eyes. Chin J Ophthalmol 1979; 15: 45-7. 30. Sorsby A. Epidemiology of refraction.lnt Ophthalrnol Clin 1971; 11(1): 1-18. 31. Benson WE, Brown GC, Tasman WS, McNamara JA. Extracapsular cataract extraction, posterior chamber lens insertion, and pars plana vitrectomy in one operation. Ophthalmology 1990; 97:918-21.
during Retrobulbar and Peri bulbar. Anesthesia
Patient Characteristics, Surgical Management, and Visual Outcome JAYS. DUKER, MD/ JONATHAN B. BELMONT, MD/ WILLIAM E. BENSON, MD/ H. LOGAN BROOKS, Jr., MD, 3 GARY C. BROWN, MD/ JAY L. FEDERMAN, MD, 2 DAVID H. FISCHER, MD/ WILLIAMS. TASMAN, MD 2
Abstract: The authors report a series of 20 eyes from 20 patients in whom inadvertent perforation of the globe occurred during local anesthesia for ocular surgery. Perforation resulted from retrobulbar anesthesia in 18 eyes and from peribulbar anesthesia in 2 eyes. Nine (45%) of 20 eyes had an axial length greater than or equal to 26.00 mm. Combining this figure with axial length data for the general population and estimates for the risk of globe perforation during local anesthesia yields an approximate incidence of perforation in eyes with axial length greater than or equal to 26.00 mm of 1 in 140 injections. Proliferative vitreoretinopathy (PVR) developed in 8 of the 20 eyes (40%) in this series. Overall, 15 (75%) of the 20 eyes were successfully repaired, and, in five eyes (25%), the final visual acuity was 20/70 or better. Ophthalmology 1991; 98:519-526
Local anesthesia for ocular surgery in the form of a retrobulbar injection was first described by Knapp in 1884. 1 Since an optimal anesthetic agent that combined Originally received: September 25, 1990. Revision accepted: November 29, 1990. 1
Retina Associates, Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. 2 Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia. 3 Tallahassee Regional Medical Center, Tallahassee. Presented at the American Academy of Ophthalmology Annual Meeting, Atlanta, OclfNov 1990 Supported in part by the Heed/Knapp Foundation, Chicago, Illinois (Dr. Duker), the Retina Research and Development Fund, Philadelphia, Pennsylvania, and Research to Prevent Blindness, Inc, New York, New York. Reprint requests to Jay S. Duker, MD, Eye Research Institute Library, 20 Staniford St, Boston, MA 02114.
safety with efficacy was not widely available until the early part of the 20th century, retrobulbar anesthesia did not become generally accepted until the 19 30s. 2•3 At the present time, the administration of local anesthesia during ocular surgery is an extremely common procedure. In excess of l ,000,000 retrobulbar anesthetic injections are delivered yearly in the United States alone. The majority of these injections are without complication, although vision-threatening and even life-threatening side effects of retrobulbar anesthesia can occur. In an effort to reduce the risks of local anesthesia for ocular surgery, the peribulbar technique was introduced in the United States during the mid-1970s. 4•5 Peribulbar anesthesia consists of one or more injections of local anesthetic around the globe but not directly into the muscle cone. Because the injections are not applied as obliquely to the visual axis or as deeply into the orbit as with retrobulbar anesthesia, theoretically, peribulbar anesthesia 519
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carries less risk of inadvertently penetrating vital structures. There appears to be no appreciable loss of efficacy, although multiple injections may be necessary and a delay in onset is common. 4•6 •7 Potential side effects of both retrobulbar and peribulbar techniques include retrobulbar hemorrhage, respiratory depression, central nervous system depression, seizures, contralateral amaurosis, direct optic nerve damage, central retinal artery obstruction, combined central retinal artery and central retinal vein obstruction, and perforation of the globe. 3•8 We report on a series of 20 eyes of 20 consecutive patients who were referred to a single center for management of globe perforation associated with intraocular hemorrhage that occurred during local anesthesia for ocular surgery. The clinical characteristics, techniques of surgical repair, and visual outcome for the affected patients are described.
PATIENTS AND METHODS We retrospectively surveyed the charts and operative reports of patients who were seen on the Retina Service at Wills Eye Hospital from January 1, 1984 to December 31, 1989 with the diagnosis of perforated or penetrated globe secondary to retrobulbar or peribulbar anesthesia. During this 6-year period, 20 patients with this diagnosis were evaluated and treated. . In each instance, the patient's chart was examined with particular attention to the length of time between globe perforation and subsequent referral, initial visual acuity, final visual acuity, follow-up interval, ultrasonography results, presence of a retinal detachment on initial examination and on final follow-up examination, and the number and types of surgical procedures performed. Whenever possible, the referring surgeon was queried concerning the preoperative axial lengths of the affected eyes, the type oflocal anesthesia given (retrobulbar versus peribulbar), the type of needle used, and whether the presence of a perforation was suspected at the time of surgery. All patients underwent a comprehensive preoperative ocular examination including visual acuity, intraocular tension, slit-lamp examination, and dilated fundus examination. In any case in which opaque media precluded an adequate view of the posterior segment via indirect ophthalmoscopy, B-scan ultrasonography was obtained. Axial length data were derived from either the referring surgeon's record or from the ultrasonography examination performed before surgical repair of the perforation. In the single patient who did not undergo an ultrasound examination, axial length was grossly estimated from the refractive error. In patients requiring pars plana vitrectomy with silicone oil injection, a special informed consent form was signed, which was approved by the Wills Eye Hospital Institutional Review Board. All pars plana vitrectomies were performed using a standard three-port technique. General anesthesia was used in all cases. 520
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RESULTS Of the 20 patients in the study, 7 were male and 13 were female. Fifteen right eyes and five left eyes were involved. The median age of the patients was 68.9 years (range, 40-84 years). All patients were white. The followup interval, measured from the time of initial attempt at surgical repair of the perforation(s) by the retina specialist to the last examination by either the retina specialist or the referring physician, ranged from 6 months to 4 years (mean, 12.6 months). In 18 of the patients, the referring physician reported that the type of anesthesia injection attempted was retrobulbar. Two of the affected eyes were perforated during attempted peribulbar anesthesia. Both of the peribulbar injections and 17 of the retrobulbar injections were performed by ophthalmologists. The remaining retrobulbar perforation occurred during an injection by an anesthesiologist. To the best of the referring physicians' knowledge, none of the perforations resulted in anesthetic injection into the vitreous cavity. Eighteen of the patients were referred to the Retina Service at Wills Eye Hospital for evaluation and treatment of vitreous hemorrhage after local anesthesia for ocular surgery. One patient was referred for an iridodialysis with vitreous hemorrhage and another patient for subretinal hemorrhage. Eighteen of the 20 patients were scheduled for cataract extraction using planned extracapsular or phacoemulsification technique at the time the perforation occurred. One patient was scheduled to undergo a combined extracapsular cataract extraction and trabeculectomy. The final patient had age-related macular degeneration; this patient's globe was perforated while receiving a retrobulbar block before a krypton laser treatment for a juxtafoveal subretinal neovascular membrane. The operating surgeon did not suspect that a perforation had occurred in 10 (50%) of the 20 cases. In 13 of the 19 cases that involved planned cataract surgery, the initially scheduled surgical procedure was completed, including 3 cases in which a perforation was suspected after the block. Despite the presence of a globe perforation, in none of the 13 cases in which the planned surgery was completed was there any further surgical complication such as loss of vitreous, capsular rupture, or expulsive choroidal hemorrhage. In 1 of the 13 patients, the surgeon elected not to place an intraocular lens (IOL). All of the other 12 cases had IOLs placed. In the case of the macular laser treatment associated with a perforation, the laser treatment to the subretinal neovascular membrane was successfully completed. There were six cases in which the surgery was canceled because of suspected perforation. After repair of the posterior segment trauma, three of these eyes underwent successful cataract extraction with placement of an IOL at a later date. The cataract extractions were subsequently performed under general anesthesia, one 5 months, one 6 months, and the other 8 months after globe perforation. In the other three postponed cases, a lensectomy was performed using pars plana vitrectomy at the time of the
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Table 1. Clinical Characteristics of Group 1 Patients* Patient No.
Age (yrs)/ Sex
Eye
Typet
Axial Length
Initial Visual Acuity
Final Visual Acuity
Status
1 2 3 4 5 6 7 8 9 10 11
67/F 58/M 68/F 76/F 67/F 52/F 67/M 81/F 81/F 65/M 60/F
OD OD OD OD OD OD OD OD OD OD OD
Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Peribulbar Peribulbar Retrobulbar Retrobulbar Retrobulbar
23.98 29.91 26.60 22.12 24.45 26.77 26.51 22.23 22.83 21.64 26.29
HM LP HM LP LP HM LP HM HM LP LP
LP CFi HM LP LP CF LP LP NLP CF LP
Detached Attached Attached Detached Detached Attached Attached Detached Detached§ Attached Attached
OD = right eye; HM = hand movements; LP = light perception; CF = counting fingers; NLP = no light perception. * Retinal detachment present at the time of initial referral. t Method of local anesthesia attempted. t Visual acuity 4 months after the retinal detachment repair was 20/80. A subfoveal subretinal neovascular membrane probably related to high myopia subsequently developed and reduced the final visual acuity to this level. §Enucleated.
attempted repair with vitrectomy surgery. No IOL was placed in any of these three eyes. The initial visual acuity at the time of referral was 20/ 200 in one patient, counting fingers in four patients, hand motions in eight patients, and light perception in seven patients. All20 eyes showed vitreous hemorrhage of varying degrees. Hypotony, defined as an intraocular pressure less than or equal to 8 mmHg was present in six (30%) eyes, whereas in two (I 0%) eyes, the intraocular pressure was abnormally elevated above 22 mmHg. Eleven (55%) of the 20 patients had a detached retina at the time of initial evaluation. This was diagnosed with ophthalmoscopy and/or ultrasonography and confirmed at the time of surgery in all 11 eyes. In only 4 of 20 eyes, none of which had a retinal detachment, was the media clear enough that the perforation sites could be identified with indirect ophthalmoscopy. At the time of surgical repair, in I8 (90%) of 20 eyes, two definite retinal perforation sites were identified (double scleral perforating injuries). In the other two eyes, only one site was confirmed (i.e., probable globe penetration). Since an immediate rise in intraocular pressure did not occur at the time of injection in the two instances of probable single perforation, it is likely that the surgeon withdrew the needle without intraocular delivery of the anesthetic agent. In none of the 20 eyes was an attempt made to surgically repair either the anterior or posterior external scleral perforation sites. The presence or absence of a retinal detachment before the initial surgical repair of the perforations appears to have prognostic significance. With respect to this finding, these 20 cases may be divided into two groups. Group 1 consists of the 11 eyes in patients who presented to the retinal consultant with a retinal detachment. The mean time between occurrence of the perforation and subsequent referral to a retinal specialist for this group was 19.4 days (range, 5 hours-56 days). All 11 of these eyes underwent initial repair attempts with surgical procedures including pars plana vitrectomy with air-fluid exchange
and injection of a long-acting gas (nine eyes) or silicone oil (two eyes). Eight of the eyes also had a scleral buckle placed at the time of the initial retinal surgery. Eight eyes in Group I required a second operation because of redetachment, and in seven eyes, proliferative vitreoretinopathy (PVR) played a role in the redetachment. In five of the eight eyes that redetached, silicone oil was used for long-term tamponade. At the last examination, six of the eyes in Group I remained attached; final visual acuity in the eyes in Group 1 was 20/400 in one eye, counting fingers in three eyes, hand motions in one eye, light perception in five eyes, and no light perception in one eye. The eye with no light perception eventually underwent enucleation for pain relief. The clinical characteristics of the Group 1 patients are listed in Table I. Group 2 consists of the nine eyes that had no retinal detachment at the time of their initial referral for retinal evaluation. The mean time between occurrence of the perforation and subsequent referral to a retinal special for this group was 7.1 days (range, immediate to 35 days). Five eyes in Group 2 underwent pars plana vitrectomy, air-fluid exchange, and gas injection as an initial repair procedure. In none of these eyes was silicone oil used primarily. Two of these five eyes also had a prophylactic scleral buckle placed to relieve traction on anterior retinal breaks as well as the vitreous base. As previously mentioned, four of the eyes without retinal detachment had media clear enough so that the retinal specialist could identify the perforation sites with indirect ophthalmoscopy. Three of the eyes with clear media and no retinal detachment underwent outpatient laser photocoagulation around the retinal perforations, while the other such eye received outpatient transscleral cryotherapy. In none of these four eyes did a retinal detachment develop. Of the nine eyes in Group 2, a retinal detachment eventually developed in only one. It was associated with PVR and successfully reattached with silicone oil tamponade. The clinical characteristics and final visual acuities of the eyes 521
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Table 2. Clinical Characteristics of Group 2 Patients* Patient No.
Age (yrs)/ Sex
Eye
Typet
1
84/F 40/M 79/M 72/M 73/F 79/F 74/F 65/M 67/F
00 00 00 OS 00 OS OS OS OS
Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar Retrobulbar
2 3 4 5 6 7 8 9
Axial Length
Initial Visual Acuity
Final Visual Acuity
Status
28.90 26.00 23.99
HM 20/200 HM CF CF CF CF HM LP
CF 20/40 20/200 20/400 CF 20/50 20/70 20/25 20/25
Attached Attached Attached Attached Attached Attached Attached Attached Attached
t
24.4 27.80 24.84 26.65 22.46
00 = right eye; HM = hand movements; CF = counting fingers; OS = left eye; LP = light perception. * No retinal detachment at the time of referral. t Method of local anesthesia attempted. t Axial length data unavailable. Since the spherical equivalent of the patient's refraction was +2.00 0, the likelihood that the axial length was ;;::26.00 mm is extremely remote. 23
in Group 2 are listed in Table 2. The following case report summarizes the successful management of a perforation secondary to local anesthesia.
CASE REPORT Case 2. A 67-year-old woman (patient 9 in Group 2) with no significant past ocular or medical history was scheduled for a planned extracapsular cataract extraction. Preoperative axial length was 22.46 mm and visual acuity was 20/80. Immediately after a single retrobulbar injection, given with a 25-gauge sharp needle inferotemporal to the globe, a moderate amount of subconjunctival hemorrhage was noted (Fig 1). Surgery was postponed due to assumed retrobulbar hemorrhage, however results of indirect ophthalmoscopy showed a dense vitreous hemorrhage and the patient was immediately referred to the Wills Eye Hospital Retina Service. On examination approximately 5 hours later, visual acuity was bare light perception and there was no view of the posterior segment. B-scan ultrasonography showed a dense vitreous hemorrhage but no retinal detachment (Fig 2). The following day, a pars plana vitrectomy was performed. Adequate visualization of the posterior segment through the cataractous lens was obtained, and, therefore, a lensectomy was not performed. Two perforation sites were detected, one in the inferotemporal quadrant near the vitreous base, and the second just inferior to the inferior arcade vessels. A posterior vitreous detachment was present. The posterior perforation was treated with endolaser. The anterior perforation was treated with transscleral cryotherapy and then supported on a radial sponge along with an encircling scleral buckle. A complete air-fluid exchange and injection of 20% sulfur hexafluoride gas was performed. After 2 months, the visual acuity returned to the preperforation level of 20/80 with the retina fully attached (Fig 3). Cataract extraction via phacoemulsification under general anesthesia was performed without complication 5 months after globe perforation, and the visual acuity subsequently improved to 20/25.
DISCUSSION Perforation of the globe with the local anesthetic needle represents one of the most dreaded complications of ocu522
lar surgery. With the assistance of a computerized literature search, we identified 18 previously published, welldocumented case reports of eyes treated for inadvertent perforation secondary to local anesthesia injection. Seventeen cases of globe perforation occurred during retrobulbar anesthesia, 9 - 15 while one was associated with peribulbar anesthesia. 8 These 18 cases are summarized in Table 3. Other instances of globe perforation secondary to either retrobulbar or peribulbar anesthesia are mentioned in the literature, with few or no clinical details revealed. 16- 20 Instances of globe perforation occurring during attempted periocular or retrobulbar delivery of corticosteroids, some of which resulted in intraocular injection of the corticosteroid preparation: have been reported as well. 9 •21 - 24 With the exception of the rare instances in which retinal toxicity apparently occurred secondary to the osmolality of the solution or the associated vehicle, such cases do not differ significantly in terms of prognosis or methods of surgical repair from the perforations associated with local anesthesia. Clinical experiences and experimental data indicate that intraocularly injected local anesthetics do not have long-term toxic effects on the retina. 3•13 •25 •26 To prevent globe perforation, some investigators strongly advocate the use of blunt needles for the delivery of local anesthesia? 1•27 Blunt needles, however, do not invariably prevent globe perforation. Seelenfreund and Freilich 10 reported on two cases in which double perforation occurred despite the use of a blunt, Atkinson-type needle. Additionally, at least one of the cases reported by Schneider and associates9 involved a perforation with a blunt needle. To the best of our knowledge, none of the 20 perforations in the present series occurred with a blunt needle; however, in over half the cases, we were unable to ascertain the type of needle used. The use of peribulbar anesthesia also has been advocated to reduce the risk of globe perforation. 4 •6 •20 Zaturansky and Hyams 12 state that peribulbar anesthesia "minimizes and perhaps eliminates" the risk of globe perforation. Although the risk of perforation may be less than with the retrobulbar technique, surgeons who use peri-
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Fig 1. Top left, group 2, case 9. View of the anterior segment about 6 hours after retrobulbar perforation. The amount of subconjunctival hemorrhage simulates a retrobulbar hemorrhage. Fig 2. Top right, group 2, case 9. B scan ultrasonogram shows vitreous hemorrhage with a posterior vitreous separation. No retinal detachment is present, however the posterior perforation site inferior to the optic disc is detectable (arrow). Fig 3. Second row left, group 2, case 9. Three months after PPV and repair of retinal perforations. Shows the area of the posterior perforation site, which is surrounded by endolaser (arrow). The retina is attached. Visual acuity has returned to pre-perforation levels (20/80). After cataract extraction, visual acuity improved to 20/25. Fig 4. Second row right, group 2, case 8. Follow-up appearance after PPV with prophylactic scleral buckle. Notice the posterior perforation site inferior to inferior arcade vessels with surrounding endolaser (arrow). Visual acuity is 20/25. Fig 5. Bottom, group 2, case 3. A retinal detachment secondary to PVR has developed despite the absence of a retinal detachment initially. Notice the posterior perforation site just superonasal to the fovea. The retina was successfully reattached using silicone oil.
bulbar anesthesia must be aware that globe perforation can still occur. Kimble and co-workers8 were the first to report such an occurrence, and other examples also have been recognized. 19 •20 The current series adds to the liter-
ature two more cases of globe perforation secondary to peribulbar anesthesia. Previous investigators undertook studies to estimate the overall risk of perforation of the globe during retrobulbar 523
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Table 3. Summary of the Previously Published Well-documented Cases of Globe Perforation Secondary to Local Anesthesia Injection During Ocular Surgery
Schneider et al
Seelenfreund et al Ramsay et al Zaturansky et al Kimble et al Lincoff et al (Patient 2) Haul et al O'Connor et al
Age (yrs)/ Sex
Eye
65/M 72/F 78/F 66/F 76/F 48/M 66/F 32/M 21/F 32/F 58/M 84/F 82/Mt
OD OD OS OD OS OD OS OS OS OD OD OS OS
?
79/F 71/F 44/M 62/F
?
OD OD
? ?
Axial Length or Refraction
Detached Retina
Proliferative Vitreoretinopathy
Final Visual Acuity
24.8 mm 23.5 mm 21.43 mm 28.46 mm 22.14 mm 26.83 mm
+ + +
+ + +
-14.00D -19.50D -9.00 D -9.00 D
+ +* +* +*
HM HM LP 20/40 20/30 20/200 20/30 20/25 20/400 20/20 20/20 20/60 20/40
?
? ?
+
?
+*
? ?
+t +
Emmetropic Emmetropic
20/40 20/60 20/30 +
? ?
OD = right eye; HM = hand movements; OS = left eye; LP = light perception; D = diopters. * Retinal detachment was present before the perforation. t Peribulbar anesthesia.
and peribulbar anesthesia. Cibis, 16 in 1965, reported the results of 1000 consecutive cases of retinal surgery performed under local anesthesia. He encountered one instance of globe perforation, yielding an overall incidence of 0.1 %. In 1978, Ramsay and Knobloch 11 reported on three cases of globe perforation out of 4000 consecutive patients undergoing local anesthesia for retinal detachment surgery. Their incidence of0.075% is quite similar to that calculated by Cibis. More recently, a single occurrence of globe perforation secondary to peribulbar anesthesia was encountered out of 4200 consecutive patients (0.024%) receiving peribulbar injections by a single anesthesiologist. 8 In contrast, another series of consecutive peribulbar injections found no incidence of perforation in 2000 injections. 4 Since the series reported by both Cibis and Ramsay were derived solely from patients undergoing retinal detachment surgery, it is reasonable to assume that there was a higher-than-normal incidence of axial myopia among these patients. In light of this, the rate of occurrence of globe perforation during local anesthesia for ophthalmic surgery performed on a general population (e.g., cataract surgery patients) is probably somewhat lower than the approximately 1 in 1000 injections estimated by the retinal surgery-derived series. In previous reports, certain risk factors for globe perforation during local anesthesia for ocular surgery were suggested, although none were conclusively proven in a controlled fashion. 8- 16 These risk factors include axial myopia, the presence of a posterior or inferior staphyloma, the use of multiple injections, a history of a previous scleral buckling procedure, and enophthalmos. The present study gives strong support to the hypothesis that axial myopia is a definite risk factor for globe perforation. Nine (45%) 524
of 20 affected eyes in this series had an axial length of 26.00 mm or greater. Coupling this percentage with the estimate that approximately 1.5% of the general population has an axial length greater than 26.00 mm 28 - 30 yields a relative risk of perforation in these large eyes of approximately 30 times greater than the normal population (i.e., 45/1.5 = 30). By using the most conservative estimate for the incidence of globe perforations derived from the series limited to peribulbar blocks ( 1 of 4200 injections), 8 an estimate for the overall risk for eyes with axial lengths greater than 26.00 mm can be calculated. This risk is approximately 1 globe perforation for every 140 injections (4200/30 = 140). In light of these data, extreme caution should be used during the administration of local anesthesia in any patient undergoing ocular surgery who has a long axial length. In addition, axial length in and of itself should be a factor when preoperatively determining the most appropriate type of anesthesia for ocular surgery. Compared with a vision-threatening complication rate of at least 1 in 140, the increased systemic complication rate associated with general anesthesia appears justifiable for patients whose axial length is greater than 26 mm. The final outcome of the eyes suffering inadvertent globe perforation with respect to the anatomic status of the retina as well as the visual acuity appears to be greatly dependent on the presence or absence of a retinal detachment. In this series, if no retinal detachment was present at the time of referral (Group 2 eyes), then the incidence of subsequent retinal detachment was only 11% ( 1 of 9 eyes). The long-term retinal attachment rate in this group was 100%. Additionally, 5 (56%) of 9 eyes in Group 2 achieved a final visual acuity of 20/70 or better. Conversely, if a retinal detachment was present (Group 1 eyes),
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then the long-term reattachment rate was reduced to 64% (6 of 11). None of the patients with a retinal detachment maintained a long-term final visual acuity better than 20/ 200. One patient in Group 1 had a visual acuity of 20/ 80 in the immediate follow-up period, only to have the central acuity reduced to counting fingers from an apparently unrelated subfoveal neovascular membrane. The major reason that the eyes in this series did not do well either anatomically or visually was the development of PVR with resultant redetachment of the retina. Proliferative vitreoretinopathy developed in 40% of the eyes overall, but the rate of PVR in eyes-in Group 1 was 64% (7 of 11). None of the eight eyes that developed PVR in this series completed the study with a visual acuity better than 20/200. The previous report of Schneider and coworkers9 found a similar overall rate of PVR as 3 (43%) of 7 eyes with retrobulbar perforations in their series developed PVR. None of the three eyes with PVR in their series achieved a final visual acuity better than hand motions. Perforation through the fovea or optic nerve may account for decreased visual acuity in some of these eyes also, as was the case in at least two patients in Group 2. However, the most common posterior perforation site seems to be inferior to the fovea (Figs 4, 5). 9 It has been suggested that in cases of suspected retrobulbarjperibulbar globe perforation during cataract surgery, two options for immediate management exist. 3 If the media remain clear enough to visualize the perforation sites with indirect ophthalmoscopy, then the anterior segment surgery should be aborted and prompt arrangements made for laser or cryotherapy retinopexy to the perforation sites. Conversely, ifthe cataract itself precludes adequate visualization of the posterior segment, then the anterior segment surgeon may consider proceeding with lens removal, provided adequate anesthesia and akinesia are present and the eye is not hypotonus. This will give the posterior segment surgeon better visualization during the subsequent vitrectomy and retinal repair, if it is necessary. More importantly, after removing the cataract, the media may prove clear enough that laser photocoagulation to the perforation sites becomes an option, thereby saving the patient from a more invasive procedure. Some may claim that the placement of an IOL in such a case might interfere with visualization of the posterior segment during vitrectomy. Others have not experienced this difficulty when an IOL with a 7-mm optic is used. 31 Another objection to continuation with the cataract surgery is that there may be an increased potential for further surgical complications. However, in none of the cases in this present series in which the cataract surgery was completed did the presence of a globe perforation appear to interfere with the technical outcome of the anterior segment procedure. The best techniques for repairing the posterior segment trauma in these cases remain to be fully defined. If the media is clear and no retinal detachment is present, then transscleral cryotherapy alone, as initially reported by Seelenfreund and Freilich, 10 may be successful. Alternatively, in these instances, laser retinopexy may be performed with a good outcome. 14 The role of prophylactic scleral buckling in cases of retinal perforation with no
retinal detachment is not clear. In most cases of double perforation, the posterior site can be placed on a scleral buckle only with great difficulty and risk. From examples derived from this series, and by extrapolation from vitrectomy surgery involving a deliberate posterior retinotomy, one may conclude that if sufficient removal of vitreous traction, good retinopexy, and an adequate gas tamponade are obtained, then scleral buckling of posterior breaks is unnecessary. In contrast, if, at the time of initial repair, a retinal detachment is present in conjunction with a double perforation, then the risk of developing PVR with subsequent redetachment appears to be alarmingly high. Under these circumstances, most surgeons would elect to use an encircling scleral buckle and some advocate the use of silicone oil tamponade as part of the primary procedure as well. There probably exist some cases of globe perforation secondary to local anesthesia featuring clear media, no retinal detachment, and self-sealing retinal perforation sites in which only observation is indicated. No such examples were included in this present series. This report's bias toward more severely affected eyes may be attributable to two factors. Since a retrospective mechanism was used to recall these cases, less severely affected eyes and those that required no intervention may have been overlooked in the process. Secondly, the patient population under consideration consisted of only those whose ocular problem was deemed severe enough to warrant referral to a tertiary care center. The findings of this series of 20 instances of globe perforation secondary to local anesthesia during ocular surgery allow for some generalizations to be made. In suspected cases featuring moderate to dense vitreous hemorrhage, immediate B-scan ultrasonography and consideration for early vitrectomy surgery is strongly recommended. When dense media opacity but no retinal detachment is present, prompt removal of the vitreous hemorrhage in conjunction with laser or cryotherapy to the perforation sites may prevent subsequent retinal detachment secondary to vitreous traction and PVR. The difference in referral times between eyes in Group 1 and Group 2 support this contention. When confronted with a possible globe perforation in an eye with a dense cataract that, in itself, precludes a view of the posterior segment, the anterior segment surgeon may consider finishing the procedure, provided the anesthesia is adequate and the eye is not hypotonus. Although peribulbar anesthesia may lessen the likelihood of inadvertent globe perforation, this report, like others before it, shows that the risk is not completely eliminated by the peribulbar technique. In addition, since axial myopia appears to be a strong risk factor for perforation, general anesthesia should be considered in eyes with a long axial length. Finally, if a macula-involving retinal detachment, foveal injury, or optic nerve trauma does not result from the globe perforation, a satisfactory visual result may be obtainable in these cases.
REFERENCES 1. Knapp H. On cocaine and its use in ophthalmic and general surgery. Arch Ophthalmol1884; 13:402-48.
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2. Russell DA Jr, Guyton JS. Retrobulbar injection of lidocaine (Xylocaine) for anesthesia and akinesia. Am J Ophthalmol 1954; 38:78-84. 3. Feibel RM. Current concepts in retrobulbar anesthesia. Surv Ophthalmol1985; 30:102-10. 4. Davis DB II, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986; 12:182-4. 5. Davis DB II. Retrobulbar and facial nerve block? No; peribulbar? Yes. [Letter] Ophthalmic Surg 1985; 16:604. 6. Bloomberg LB. Administration of periocular anesthesia. J Cataract Refract Surg 1986; 12:677-9. 7. Weiss JL, Deichman CB. A comparison of retrobulbar and periocular anesthesia for cataract surgery. Arch Ophthalmol1989; 107:96-8. 8. Kimble JA, Morris RE, Witherspoon CD, Feist RM. Globe perforation from peribulbar injection. Arch Ophthalmol1987; 105:749. 9. Schneider ME, Milstein DE, Oyakawa RT, et al. Ocular perforation from a retrobulbar injection. Am J Ophthalmol1988; 106:35-40. 10. Seelenfreund MH, Freilich DB. Retinal injuries associated with cataract surgery. Am J Ophthalmol 1980; 89:654-8. 11. Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anesthesia for retinal detachment surgery. Am J Ophthalmol 1978; 86:61-4. 12. Zaturansky B, Hyams S. Perforation of the globe during the injection of local anesthesia. Ophthalmic Surg 1987; 18:585-8. 13. Lincoff H, Zweifach P, Brodie S, et al. Intraocular injection of lidocaine. Ophthalmology 1985; 92:1587-91. 14. Haut J, Monin C, Renard Y, Tazartes M. Perforation du globe au cours de l'anesthesie retrobulbaire. Bull Soc Opht France 1989; 89:783-6. 15. O'Connor PR, MacDonald R. Retinal damage during ocular surgery. Ann Ophthalmol1971; 3:1118-21. 16. Cibis PA. General discussion: opening remarks. In: Schepens CL, Regan CDJ, eds. Controversial Aspects of the Management of Retinal Detachments. Boston: Little, Brown, 1965;222. 17. Rosen DA. Anaesthesia in ophthalmology. Can Anaesth Soc J 1962; 9:545-9.
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18. Bettman JW. A retrospective look at twenty-two medicolegal claims. How they might have been avoided. Surv Ophthalmol 1983; 28:5560. 19. Straus JG. A new retrobulbar needle and injection technique. Ophthalmic Surg 1988; 19:134-9. 20. Davis DB, Mandel MR. Peribulbar anesthesia. A review of technique and complications. Ophthalmol Clin N Am 1990; 3:101-10. 21. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections. Ophthalmology 1988; 95:660-5. 22. Schlaegel TF, Wilson FM. Accidental intraocular injection of depot corticosteroids. Trans Am Acad Ophthalmol and Otolaryngol 1974; 78:847-55. 23. Giles CL. Bulbar perforation during periocular injection of corticosteroids. Am J Ophthalmol1974; 77:438-41. 24. Hida T, Chandler D, Arena JE, Machemer R. Experimental and clinical observations of the intraocular toxicity of commercial corticosteroid preparations. Am J Ophthalmol 1986; 101 :190-5. 25. Stangos N, Rey P, Leuenberger P, Korol S. The effect of xylocaine injections on the rabbit's retina: Averaged ERG and electron microscopy. Vision Res 1971; 11:1208-9. 26. Schechter RJ. Management of inadvertent intraocular injections. Ann Ophthalmol1985; 17:771-5. 27. Atkinson WS. Retrobulbar injection of anesthetic within the muscle cone (cone injection). Arch Ophthalmol1936; 16:494-503. 28. Hoffer KJ. Biometry of 7,500 cataractous eyes. Am J Ophthalmol 1980; 90:360-8. 29. Yu CS, Kao D, Chang CT. Measurement of the length of the visual axis by ultrasonography in 1, 789 eyes. Chin J Ophthalmol 1979; 15: 45-7. 30. Sorsby A. Epidemiology of refraction.lnt Ophthalrnol Clin 1971; 11(1): 1-18. 31. Benson WE, Brown GC, Tasman WS, McNamara JA. Extracapsular cataract extraction, posterior chamber lens insertion, and pars plana vitrectomy in one operation. Ophthalmology 1990; 97:918-21.
