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ARTICLES
Year : 1989  |  Volume : 37  |  Issue : 2  |  Page : 59-61

Posterior peribulbar anesthesia : An alternative to retrobulbar anesthesia


The Medical-surgical Eye center 1237 B Street Hayward, California 94541, USA

Correspondence Address:
David B Davis II
The Medical-surgical Eye center 1237 B Street Hayward, California 94541
USA
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Source of Support: None, Conflict of Interest: None


PMID: 2583779

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  Abstract 

Peribulbar anesthesia is a safe alternative to retrobulbar anesthesia for ophthalmic surgery. Because the anesthetic is deposited outside the muscle cone, the potential for intraocular or intradural injection is greatly minimized. Furthermore, intraconal hemorrhage and direct optic nerve injury is avoided. We illustrate the details of our technique for posterior peribulbar anesthesia and describe our experience in over 3,000 cases.

Keywords: cataract surgery, posterior peribulbar anes-thesia, radial keratotomy surgery, retrobulbar anesthesia.


How to cite this article:
Davis II DB, Mandel MR. Posterior peribulbar anesthesia : An alternative to retrobulbar anesthesia. Indian J Ophthalmol 1989;37:59-61

How to cite this URL:
Davis II DB, Mandel MR. Posterior peribulbar anesthesia : An alternative to retrobulbar anesthesia. Indian J Ophthalmol [serial online] 1989 [cited 2020 Jul 9];37:59-61. Available from: http://www.ijo.in/text.asp?1989/37/2/59/26092

Table 2

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Table 2

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Table 1

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Table 1

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  Introduction Top


Several one million dollar malpractice suits in the Southeastern United States has refocused attention on the potential complications of retrobulbar anesthesia. In at least one case, a young patient sustained a major loss of vision fol­lowing the retrobulbar injection of local anesthetic for radial keratotomy. The visual loss in this otherwise healthy eye will be permanent. The risk of local anesthesia for ocular surgery can be reduced by use of peribulbar injection. Peribulbar anesthesia affords a reliable alternative to retrobul­bar injection by achieving the same degree of anesthesia and akinesia while reducing or eliminating many of the complica­tions.

This procedure has been performed for many years but is not widely known by the ophthalmic profession. We are unable to locate any published reports describing the technique. Kel­man introduced the technique in the mid 1970s (personal com­munication, 1982) and various modifications are currently used by Tennant (personal communication, 1984) Thornton (personal communication, 1985), Bloomberg (1986), Weiss (1987), and many others.

We began to use peribulbar injections exclusively six years ago. In our experience with over 3,000 cases, the side effects have been mild and we have yet to encounter any significant complications. We use this technique for all of our cataract and intraocular surgeries. For the occasional difficult radial keratotomy case in whom topical anesthesia is not deemed adequate, a minor modification of the procedure is used.

Complications of retrobulbar injections are well known [Table - 1]. These are greatly minimized in peribulbar anes­thesia because the injection is deposited entirely outside the muscle cone, the muscles themselves are not engaged, and the needle is far from the globe, optic nerve, and dural sheaths. Other advantages of the peribulbar injection technique are listed in [Table - 2]. Complications of the procedure have been minor and include periorbital ecchymosis which does not cause intraoperative or post-operative problems.


  Technique Top


The first injection is performed in the lower eyelid just above the inferior orbital rim, approximately one finger breadth medial to the lateral canthus. A small skin wheal is raised using 0.5m1 of a mixture of 1% lidocaine 1 part and 9 parts BSS. An additional 0.5ml is then injected into the orbicularis oculi muscle under the skin wheal, and approximately 1.0ml is deposited just anterior to the equator. A folded 4 X 4 is placed over the injection sites for approximately thirty seconds to one minute to decrease potential ecchymosis. This first injection, developed by Robert Hustead, M.D., is essen­tially painless and prevents discomfort due to the subsequent Bupivacaine injection.

The second stage of the procedure is performed with the stand­ard blunt 7/8 inch Atkinson 23-gauge retrobulbar needle [Figure - 1],[Figure - 2] or the 23 gauge Thornton needle. Bupivacaine 0.75% 6.5 ml is mixed with 3.0 ml of lidocaine 1 % and 0.3cc hyaluronidase in a I Oml syringe to which the retrobulbar needle is attached. The needle is inserted transcutaneously just above the inferior orbital rim 1.5cm medial to the lateral canthus. Two milliliters of the anesthetic solution is deposited immediately, beneath the orbicularis oculi muscle. The needle is then advanced along the inferior orbit to the equator of the globe. After aspirating to ensure that an intravascular injection will not be given, an additional 2.Oml of solution is deposited just anterior to the equator of the globe. The barrel of the syringe is then angled over the malar eminence and the needle is advanced in a slightly su­perior direction to approximately 7/8". After aspirating, 4.Oml to 6.Om1 of the solution is deposited just posterior to the equator. During this injection, the globe moves slightly up­ward and minimally proptoses. This is evident by observing a smoothing of the upper eyelid fold. If this occurs, it is prob­able that no additional injection will be needed.

At this point, one may note that the eyelides are tense. This does not result from orbital hemorrhage but represents orbi­tal fullness from the injection. A folded 4 X 4 is placed over the closed eyelids and pressure is firmly applied to the lids for approximately one minute, although the "Super Pinkie" can be applied immediately.

Prior to cataract surgery, the "super pinkie" is applied. For radial keratotomy patients, the injection is modified so that anesthetic material is deposited beneath the orbicularis oculi muscle and at the equator of the globe only. Pressure is ap­plied to the eyelids to prevent superficial bleeding and ec­chymosis. The super pinkie is not used for radial keratotomy patients.

After approximately eight minutes the competancy of the block is evaluated. When surgeons are learning the procedure, they will not obtain complete anesthesia with the initial trial in approximately 50% of cases. However, once the technique is mastered, incomplete anesthesia occurs in less than 10% of cases. If residual motility occurs, additional anesthetic may be given. If the lateral rectus remains active, then an addition­al injection of 1-2cc can be given in the same place. If the medial and/or superior muscles remain active, a second injec­tion can be given in the inferonasal orbit. The anesthetic is deposited below the globe inferior to the lower punctum. The direction is not towards the globe, but slightly superior and posterior so as to avoid the globe.

The dilute BSS-Lidocaine mixture can be given initially, if needed, followed by the standard bupivacaine peribulbar in­jection. We usually give an additional 1/3cc at approximate­ly the equator or slightly posterior to the equator of the globe for the second injection. In the rare case where the superior muscle has not responded to either injection, a third injection can be given through the upper lid below the superior orbital notch at the level of the lid crease - following basically the same technique as detailed earlier. The needle is passed posteriorly and slightly inferiorly again avoiding the globe. Although we have had no serious case of ptosis or perforation into the ethmoid sinuses this third site is less desirable because of its potential affects.

Anesthesia does not begin as rapidly as it does following retrobulbar injection, and complete anesthesia is not obtained for at least 10 to 12 minutes. This is clinically insignificant if the surgeon plans accordingly. Following a peribulbar in­jection, the patient may complain transiently of the brightness of the operating microscope light upon initial exposure to the light. However, the patient rapidly becomes adapted, and glare throughout the surgical procedure has not been a problem. Also, for unknown reasons, minor ocular move­ments with peribulbar anesthesia do not appear to increase pressure as seen with retrobulbar injection.

[Figure - 2] illustrates the approximate location of the injection sites. The exact mechanism of anesthetic action is not known but is probably a combination of direct inhibition of neuromuscular transmission from orbital diffusion into the extraocular muscles themselves as well as diffusion into the third, fourth, fifth, and sixth cranial nerves and the ciliary ganglion.

The peribulbar injection also provides excellent lid akinesia and anesthesia and eliminates the need for Nadbath, O'Brien, Atkinson, or other seventh nerve blocks. Although the seventh nerve itself is not blocked, the lack of orbicularis function probably results from the initial intraorbicularis and suborbicularis injection with subsequent intramuscular and submuscular diffusion of anesthetic.

In addition, we have found that most problems reported by others using our technique occurred to those physicians who were not able to observe the actual technique. Also, there is a much higher risk of perforation if a thin sharp 27 gauge is utilized. We recommend only the modified 23 & 25 gauge needles. We have made available at low cost a very detailed 30-minute instruction videotape on our procedure. You may contact us for a copy.


  Summary Top


We have used the peribulbar injection for the past six years in over 3,000 cases with no apparent complications. To date, nervous system symptoms, retrobulbar haemorrhage, the need to cancel central surgery, optic atrophy, and perforation of the golobe or optic nerve have not been encountered with the use of this technique. The technique is simple and safe, and in our experience eliminates the need for standard retrobulbar injections.


    Figures

  [Figure - 1], [Figure - 2]
 
 
    Tables

  [Table - 1], [Table - 2]


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