|Year : 1988 | Volume
| Issue : 3 | Page : 128-130
Orbital haemorrhage following retrobulbar injection
Nikhil C Kaushik
Senior Registrar, Manchester Royal Eye Hospital, Oxford Road, Manchester, M 13 9WH, United Kingdom
Nikhil C Kaushik
Senior Registrar, Manchester Royal Eye Hospital, Oxford Road, Manchester, M 13 9WH
Between April 1981 and March 1983, retrobulbar anaesthetic drugs; were injected on 3,453 eyes in preparation for ocular surgery. The incidence of retrobulbar orbital haemorrhage was ©.75% (26 of 3,453 eyes). This complication forced the postponement of surgical procedure to a later date. In 65% (17 of 26 eyes) surgery was carried out within six weeks, while in other cases the interval was longer. This complication of local anaesthesia did not have any adverse effect on the long term management of these cases., except for the temporary setback to their surgical schedule.
|How to cite this article:|
Kaushik NC. Orbital haemorrhage following retrobulbar injection. Indian J Ophthalmol 1988;36:128-30
| Introduction|| |
Local anaesthesia for surgical procedures is a time honoured practice. Almost all ophthalmic procedures can be safely performed under a local anaesthetic, and its relative safety and economy is highly rewarding for the ophthalmic profession. Local anaesthesia combined with mild sedation bypasses the need for a potentially harmful general anaesthetic in the elderly, who by and large form the major workload of ophthalmic surgeons the world over.
Injection of an anaesthetic drug in the retrobulbar space provides akinesia and analgesia to the eye. Rarely this procedure is complicated by the development of a retrobulbar orbital hemorrhage.
It is believed that an accidental damage to one of the small blood vessels in the orbit, by the sharp end of the injection needle leads to collection of the blood behind the globe. This results in an acutely tense orbit combined with a variable degree of proptosis. Seepage of blood anterior to the globe can result in periorbital skin bruising and the subconjunctival collection of blood.
This is a report of the experience of the occurence of orbital haemorrhage at the Manchester Royal Eye Hospital as a complication of retrobulbar injections of anaesthetic.
| Material and Methods|| |
The operation records of patients undergoing eye surgery at the Manchester Royal Eye Hospital in the two year period between 1st April 1981 and 31st March 1983 were studied. Patients scheduled to have their operations under local anaesthesia involving retrobulbar injection of anaesthetic drug were included in this study. Such injections were made on 3,453 occassions during the above period, by the medical staff of this hospital. The following standard technique of injection was followed in most cases:
3 to 4 mls. of Marcaine or Lingnocaine in which 1000 units of Hyaluronidase were dissolved, were injected using a 25 gauge, 1.5 inch long needle. The needle was inserted rather parallel to the floor of the orbit initially and then directed towards the apex. During injections the eye was directed up and inwards (Supra-adducted).
A total of 26 eyes developed a retrobulbar orbital haemorrhage which was identified by the development of an acutely tense orbit together with periorbital skin bruising. In all these cases surgery was postponed, an eye pad and bandage were applied and the patient returned to the ward. In none of these cases was it felt necessary to perform a canthotomy, or to undertake a haematoma evacuation procedure.
The case records of these 26 patients were studied further:
| Results|| |
Of the above 26 cases 2 were scheduled for peripheral iridectomy for narrow angle glaucomoa, 1 was scheduled for cataract extraction with an iris clip lens implant, while the remaining 23 cases were scheduled for plain cataract extraction.
Of the 26 patients developing a retrobulbar orbital hemorrhage 54% [14 ] were aged between 70 and 79 years, 19%  were aged between 80 and 90 years, another 19%  were aged between 60 and 69 years: while the remaining 8%  were between the ages of 50 and 59 years.
Of these 26 patients,38%  were males, while 62%16 were females. The left eye was involved in 42% , while the right eye was involved in 58%  patients.
Most patients expressed disappointment at cancellation of their operation, but were prepared to have surgery at a later date as advised by their surgeons. 58%  patients accepted a repeat local anaesthetic, 27%  patients preferred a general anaesthetic, 11%  patients declined any further surgery; and 4%  patients were lost to follow up.
The time interval between retrobulbar orbital haemorrhage and further surgery was variable. The surgeons used the following criteria to consider a patient ready for further surgery.:
1-When there was no clinical proptosis.
2-When there was no significant lid swelling.
3-When the patient was mentally prepared to face another operation.
Surgery was performed uneventfully in all patients, usually within two weeks when general anesthesia was used and within six weeks when repeat local anesthesia was used.
Of the seven patients who had a general anasthetic, 2 were able to have their operation within a week, while the other 5 requested a time delay.
Of the 15 patients who had a repeat local anaesthetic, 12 had their operation within 6 weeks from their retrobulbar orbital haemorrhage.
Except for three , cases who were disappointed by their retrobulbar haemorrhage, and declined any further surgery, and the one lost to follow up, the remaining 22 patients attained satisfactory results. Of the 21 cases undergoing cataract extraction, 16 attained a visual acuity of 6/18 or better; while in the remaining 5 patients the visual acuity was less than 6/24. [Table - 1].
| Discussion|| |
Orbital haemorrhage following injection of an anaesthetic drug is a rare complication. The incidence, based on this survey, is 0.75 percent. The retrobulbar space is a potential site for collection of blood or inflammatory exudates, and under these circumstances proptosis of the globe may occur. Collection of exudates in the retrobulbar and periocular spaces is responsible for the proptosis that accompanies conditions such as orbital cellulitis.
In cases of dysthyroid. eye disease the increased bulk of retrobulbar and periocular tissues results in a proptosed eye.
Retrobulbar haemorrhage occurs rarely following trauma involving fractures of the facial bones ,, following plastic reconstructive Surgery  and following injection of retrobulbar drugs . This results from an injury to one of the blood vessels in the highly vascular orbital fat, or to one of the extraocular muscles . Spontaneous retrobulbar haemorrhage has been known although reports of such cases are rare. Such cases probably result from a congenital vascular malformation in the orbit, particularly in a state of increased vascular congestion ,.
Due to limitation of space in the orbit, the rising pressure acts as an occuler on the leaking vessel, and active leakage soon stops with the development of a tense orbit. Resolution of orbital swelling usually is observed in a short span of time, and does not commonly leave any permanent ill effect on the eye .
However if the pressure behind the eye continues to remain high, as may occur when a retrobulbar haemorrhage is accompanied with an inflammatory response, i.e., in cases of trauma, or excessive soft tissue manipulation in cosmetic blepharoplasty, then a prolonged compression of the globe and the intraorbital portion of the optic nerve may result in devastating effects on the visual performance of the eye.
Accidental involvement of important vessels during retrobulbar and periocular injections have been known to cause visual disasters ,. Injection of a drug into the retinal circulation has been reported . Similarly a case has been reported were the meningeal sheaths of the optic nerve were pierced resulting in the injection of drug into the subarachnoid space. But reports of such cases are indeed rare.
| Conclusion|| |
This study confirms the comparatively benign course of orbital haemorrhage complicating a retrobulbar injection of anaesthetic drugs, but it should be remembered that the sharp end of the injection needle can inflict potentially serious injuries to the delicate tissues in the orbit.
| Acknowledgement|| |
I am grateful to the Consultants at the Manchester Royal Eye Hospital for allowing me to study patients under their care and to Mr. M.F. Raines for his help during the preparation of this paper.
| References|| |
|1.||Ord, R.A., El-Attar. A.: Acute retrobulbar haemorrhage complicating malar fracture. J. Oral. Maxillofac. Surg, 40:234-6, 1982. |
|2.||Ord, R.A.: Post-operative retrobulbar haemorrhage and blindness complicating trauma surgery. Br. J. Oral. Surg. 19:202-7, 1981. |
|3.||Hodes, B.L., Edelman, D.: Central retinal ortery occlusion after facial trauma. Opthalmic Sirg. 10:21-3, 1979. |
|4.||Heinze, J.B., Hueston, J.T.: Blindness after blepharoplasty: mechanism and early reversal. Plast. Reconstr. Surg. 61:347-54, 1978. |
|5.||Putterman, A.M.: Temporary blindness after cosmetic blepharoplasty. Am. J.Ophthalmol. 80:1081-3, 1975. |
|6.||Hartley, J.H., Lester, J.C., Schatten, W.E.: Acute retrobulbar hemorrhage during elective blepharoplasty. Its pathophysiology and management. Plast, Reconstr. Surg. 52:8-15, 1973. |
|7.||Huang, T.T., Horwitz, B., Lewis, S.R.: Retrobular hemorrhage. Plast. Reconstr. Surg. 59:39-44, 1977. |
|8.||Weiss, I.S.: Retrobulbar haemorrhage occuring after placement of superior rectus suture. Am.J. Ophthalmol. 80:153-4, 1975. |
|9.||Law, F.W.: Spontaneous orbital haemorrhage. Br. J. Ophthalmol. 55:556-8, 1971. |
|10.||Katz, B., Carmody, R.: Subperiosteal orbital haematoma induced by valsalva maneuver. Am. J. Ophthalmol. 100:617-8, 1985. |
|11.||Fry, H.J.: Reversible visual loss after proptosis from retrobulbar heamorrhage. Reproduction of the syndrome in Cynomolgus monkey, Plast. Reconstr. Surg. 44:480-3, 1969. |
|12.||Goldsmith, M.O.: Occlusion of the central retinal artery following retrobulbar haemorrhage. Ophthalmologica. 153:191-6, 1967. |
|13.||Klein, M.L., Jampol, C.M., Condon, P.1., Rice, T.A., Serjeant, G.R.: Central retinal artery occlusion without retrobulbar haemorrhage after retrobulbar anaesthesia. Am. J. Ophthalmol. 93:573-7, 1982. |
|14.||Ellis, - P.P.: Occlusion of the central retinal artery after retrobulbar contricosteroid injection. Am. J. Ophthalmo. 85:352-6, 1978. |
|15.||Meyers, E.F., Ramirez, R.C., Boniuk, I.: Grandmal seizures after retrobulbar block, Arch. Ophthalmol. 96:847, 1978. |
[Table - 1]