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   Table of Contents      
ORIGINAL ARTICLE
Year : 1999  |  Volume : 47  |  Issue : 3  |  Page : 181-183

Management of ocular perforations resulting from peribulbar anaesthesia


Department of Ophthalmology, Southport General Infirmary, UK

Correspondence Address:
P Puri
Department of Ophthalmology, Southport General Infirmary, UK

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Source of Support: None, Conflict of Interest: None


PMID: 10858774

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  Abstract 

Purpose: To analyse the clinical presentation and outcome of treatment for globe perforation secondary to peribulbar anaesthesia.
Methods: Eight patients (3 females and 5 males) aged 66-84 years were included in the study. Ocular perforations were suspected in 3 cases before or during surgery, in 4 cases diagnosis was established within one week and in one case at 3 weeks. Three patients underwent indirect argon laser photocoagulation to seal the retinal break, one patient had cryotherapy, 3 patients underwent a pars plana vitrectomy with fluid gas exchange and endolaser; and one patient refused any further treatment. Results: The final visual acuity after a mean follow up of 14 months was better than 6/9 in 2 patients, between 6/9-6/12 in 4 patients, and perception of light in 2 patients. Conclusion: If diagnosed early and treated adequately, a majority of patients with globe perforation during periocular anaesthetic could be saved

Keywords: Peribulbar anaesthesia, perforation, vitrectomy, photocoagulation, cryotherapy


How to cite this article:
Puri P, Verma D, McKibbin M. Management of ocular perforations resulting from peribulbar anaesthesia. Indian J Ophthalmol 1999;47:181-3

How to cite this URL:
Puri P, Verma D, McKibbin M. Management of ocular perforations resulting from peribulbar anaesthesia. Indian J Ophthalmol [serial online] 1999 [cited 2019 Sep 23];47:181-3. Available from: http://www.ijo.in/text.asp?1999/47/3/181/14919

PPV IS PARS PLANA VITRECTOMY; EL IS ENDOLASER; FGE IS FLUID GAS EXCHANGE.

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PPV IS PARS PLANA VITRECTOMY; EL IS ENDOLASER; FGE IS FLUID GAS EXCHANGE.

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Ocular perforation during peribulbar anaesthesia is a recognized but uncommon complication. Visual prognosis in these patients depends on early diagnosis and subsequent management. We present a series of 8 patients who were diagnosed to have ocular perforations following peribulbar anaesthesia and were managed in the vitreoretinal unit at our infirmary.

According to the International Classification of ocular trauma (Pieramisi)[1] a single entry site is termed as penetration whereas one entry site with one exit site is termed as perforation. Keeping this in mind, however, the term perforation in the article has been interchangeably used with penetration.


  Materials and Methods Top


Eight patients undergoing conventional cataract extraction with intraocular lens (IOL) implantation under peribulbar anaesthesia diagnosed with ocular perforation during the procedures, over a period of 2 years, were included in the study. Anaesthetists performed all the procedures. Details of the anaesthetic technique used were obtained in all cases. A two-needle injection peribulbar technique was used. The first injection was given at the lateral third of the lower orbital rim by a transcutaneous or a transconjunctival approach and the second either at the medial third of the upper orbital rim through the upper lid (5 cases) or at the inner canthus (3 cases). A sharp 25mm 25 G needle was used in 6 cases, and in 2 cases a 38mm 25G needle was used.


  Results Top


Eight patients (3 females and 5 males) 66-84 years were included in the study [Table - 1]. All the patients were scheduled for extracapsular cataract extraction with IOL implantation. The axial length of the operated eyes was normal (range 22.06-23.48mm). There were no cases of high myopia, abnormally long eyes or patients with scleral buckling. However, one case had deep-set eyes with prominent eyebrows.

In contrast to some of the earlier series,[2][3][4][5] peribulbar anaesthesia in all cases was administered by anaesthetists.

No penetration was noticed at the time of administration of local anaesthesia. The possibility of perforation was entertained before or during surgery in 3 cases. Of these, one was noted to have hyphaema before surgery, another had a very soft eye, while in the third no red reflex was present after lens expression.

Surgery was postponed in one case which developed hyphaema and an unusually soft eye following anesthesia. The diagnosis of the perforation was made within a week in 7 of the 8 patients, all of whom had vitreous haemorrhage. Four perforations were detected in the superior or superonasal quadrant, one in the nasal quadrant, 2 in inferotemporal quadrant and in one case the exact site was not clear. Media was sufficiently clear in 7 cases while in one case the diagnosis of retinal detachment was confirmed on B-scan ultrasonography. The surgical technique required to treat the patients varied according to the site of perforation, presence of retinal detachment, and associated proliferative vitreoretinopathy (PVR).

Three patients underwent indirect argon laser photocoagulation to seal the retinal breaks, while one patient had cryotherapy. Pars plana vitrectomy with fluid gas exchange and endolaser photocoagulation was performed in 3 patients who presented with retinal detachment and one patient refused any further treatment. Patients were followed up for a period of 3 months to 2 years (Mean follow up 11 months). Final visual acuity was better than 6/9 in 2 cases, between 6/9-6/18 in 4 cases, but was reduced to perception of light in 2 cases, of which one had presented with total retinal detachment with proliferative vitreoretinopathy (PVR).


  Discussion Top


The technique of peribulbar anaesthesia described by Davis and Mendal[2] was an attempt to reduce the complications associated with retrobulbar anaesthesia.[3],[4] This two-injection technique included an injection at the lateral third of the lower orbital rim and the second at medial third of the upper orbital rim. While their series reported ocular perforations in 0.006 % of cases,[5] there has subsequently been an increase in the reported incidence of ocular perforations as a result of peribulbar block.[6][7][8] In the study centre the incidence of peribulbar anaesthesia-related ocular perforation is 0.47% (8/1,700 consecutive cataract extraction).

In contrast to the earlier report,[9] a possibility of ocular perforation was considered in 7 of the 8 cases. In 3 cases, diagnosis was made within 48 hours, while in 4 cases the diagnosis was established within 7 days. One patient was diagnosed at 3 weeks. A delay in visual recovery combined with a hazy vitreous prompted the clinician to look for posterior segment pathology in this case. The average delay between perforation and diagnosis was 3.6 days in 7 out of 8 cases.

At diagnosis, 3 patients had retinal breaks with vitreous haemorrhage, 2 had breaks with a surrounding cuff of subretinal fluid (SRF) while 3 had total retinal detachments, with PVR in 2 cases. Two patients with retinal detachments and one with vitreous haemorrhage underwent pars plana vitrectomy, with fluid gas exchange and endolaser. In 3 patients, media was clear enough to perform indirect argon laser photocoagulation to seal the break while in one patient cryotherapy was performed. A similar treatment plan has been suggested for the management of retinal detachment as a result of peribulbar block.[10] Interval between initial surgery and final management was 1-28 days ( mean 6 days). All the breaks found in the series were located anteriorly and the majority of them were seen in the superonasal quadrant. No cases of perforation were recorded. One case had two entry sites. Final visual prognosis was quite encouraging. At an average follow up of 14 months, anatomical attachment of the retina was achieved in all cases which had surgical intervention. The presence of macular scarring in one case prevented any visual improvement.

In patients undergoing surgery under peribulbar anaesthesia the possibility of ocular perforation should be considered before the surgery, particularly if they develop hyphaema or an unusually soft eye following anaesthesia.

During surgery an unusually soft eye accompanying absence or loss of red reflex should be considered highly suspicious and a thorough ocular examination should be performed to rule out perforation. Presence of unexplained vitreous haemorrhage at postoperative ocular evaluation should be thoroughly investigated. If a retinal break is identified and the surrounding retina is flat, prophylactic laser photocoagulation or cryotherapy gives good results.[7][8][9] Timely surgical intervention bears a good visual prognosis in cases with retinal detachment associated with peripheral breaks and absence of proliferative vitreous retinopathy.[10] Cases with double perforations, with posterior breaks or those associated with retinal detachment with PVR require complex surgical procedures and thus have poor visual prognosis. Early diagnosis and timely management of these cases appear to be the key factors in good visual recovery. The anterior location of breaks and absence of double perforations also contributed to the good visual outcome in our series of patients.

In conclusion, it is evident that although ocular perforation is a serious complication of peribulbar anaesthesia, early diagnosis and management seems to hold the key to good visual recovery.

 
  References Top

1.
Pieramisi DJ, Steenberg P, Aaberg TM, Bridges Jr WZ, Caponne Jr A, Kuhn F, et al. A system of classifying mechanical injuries of the eye (globe). Am J Ophthalmol 1997;123:820-31.  Back to cited text no. 1
    
2.
Davis DB, Mandel MR. Posterior peribulbar anesthesia:Alternative to retrobulbar anesthesia. J Cat Ref Surg 1986;12:182-84.  Back to cited text no. 2
    
3.
Duker JS, Belmount JB, Benson WE, Brooks HL Jr, Federman JL, Fischer DM, et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia. Ophthalmology 1991;98:519-26.  Back to cited text no. 3
    
4.
Bonuik V, Nockowitz R. Perforation of the globe during retrobulbar injection:Medicolegal aspects of four cases. Surv Ophthalmol 1994;39:141-15.  Back to cited text no. 4
    
5.
Davis DB, Mandel MR. Efficacy and complication rate of 16,224 consecutive peribulbar blocks:A prospective multicentric study. J Cat Ref Surg l994;20:323-27.  Back to cited text no. 5
    
6.
Mount AM, Seward HC. Scleral perforations during peribulbar anesthesia. Eye 1993;7:766-67.  Back to cited text no. 6
[PUBMED]    
7.
Kimble JA, Morris RE, Witherspoon CE, Friest RM. Globe perforation from peribulbar anesthesia. Arch Ophthalmol 1987:105;749.  Back to cited text no. 7
    
8.
Joseph JP, McHugh JD, Franks WA, Chignell AH. Perforation of the globe:a complication of peribulbar anesthesia. Br J Ophthalmol 1991;75:504-45.  Back to cited text no. 8
[PUBMED]    
9.
Gillow JT, Aggarwal RK, Kirby GR. Ocular perforation during peribulbar anesthesia. Eye 1996; 10:533-36.  Back to cited text no. 9
    
10.
Gopal L, Badrinath SS, Parikh S, Chawla G. Retinal detatchment secondary to ocular perforation during retrobulbar anaesthesia. Indian J Ophthalmol 1995;43:3-5.  Back to cited text no. 10
    



 
 
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