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Year : 1988  |  Volume : 36  |  Issue : 3  |  Page : 128-130

Orbital haemorrhage following retrobulbar injection

Senior Registrar, Manchester Royal Eye Hospital, Oxford Road, Manchester, M 13 9WH, United Kingdom

Correspondence Address:
Nikhil C Kaushik
Senior Registrar, Manchester Royal Eye Hospital, Oxford Road, Manchester, M 13 9WH
United Kingdom
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Source of Support: None, Conflict of Interest: None

PMID: 3255702

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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

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Kaushik NC. Orbital haemorrhage following retrobulbar injection. Indian J Ophthalmol [serial online] 1988 [cited 2023 Apr 1];36:128-30. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1988/36/3/128/26130

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  Introduction Top

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 Top

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 Top

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% [5] were aged between 80 and 90 years, another 19% [5] were aged between 60 and 69 years: while the remaining 8% [2] were between the ages of 50 and 59 years.

Of these 26 patients,38% [10] were males, while 62%16 were females. The left eye was involved in 42% [11], while the right eye was involved in 58% [15] 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% [15] patients accepted a repeat local anaesthetic, 27% [7] patients preferred a general anaesthetic, 11% [3] patients declined any further surgery; and 4% [1] 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 Top

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 [1],[2],[3] following plastic reconstructive Surgery [4][5][6] and follow­ing injection of retrobulbar drugs [7]. This results from an injury to one of the blood vessels in the highly vascular orbital fat, or to one of the extraocular muscles [8]. 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 [9],[10].

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 [11].

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 [12],[13]. Injection of a drug into the retinal circulation has been reported [14]. 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[15]. But reports of such cases are indeed rare.

  Conclusion Top

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 Top

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 Top

Ord, R.A., El-Attar. A.: Acute retrobulbar haemorrhage complicating malar fracture. J. Oral. Maxillofac. Surg, 40:234-6, 1982.  Back to cited text no. 1
Ord, R.A.: Post-operative retrobulbar haemorrhage and blindness com­plicating trauma surgery. Br. J. Oral. Surg. 19:202-7, 1981.  Back to cited text no. 2
Hodes, B.L., Edelman, D.: Central retinal ortery occlusion after facial trauma. Opthalmic Sirg. 10:21-3, 1979.  Back to cited text no. 3
Heinze, J.B., Hueston, J.T.: Blindness after blepharoplasty: mechanism and early reversal. Plast. Reconstr. Surg. 61:347-54, 1978.  Back to cited text no. 4
Putterman, A.M.: Temporary blindness after cosmetic blepharoplasty. Am. J.Ophthalmol. 80:1081-3, 1975.  Back to cited text no. 5
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.  Back to cited text no. 6
Huang, T.T., Horwitz, B., Lewis, S.R.: Retrobular hemorrhage. Plast. Reconstr. Surg. 59:39-44, 1977.  Back to cited text no. 7
Weiss, I.S.: Retrobulbar haemorrhage occuring after placement of superior rectus suture. Am.J. Ophthalmol. 80:153-4, 1975.  Back to cited text no. 8
Law, F.W.: Spontaneous orbital haemorrhage. Br. J. Ophthalmol. 55:556-8, 1971.  Back to cited text no. 9
Katz, B., Carmody, R.: Subperiosteal orbital haematoma induced by valsalva maneuver. Am. J. Ophthalmol. 100:617-8, 1985.  Back to cited text no. 10
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.  Back to cited text no. 11
Goldsmith, M.O.: Occlusion of the central retinal artery following retrobulbar haemorrhage. Ophthalmologica. 153:191-6, 1967.  Back to cited text no. 12
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.  Back to cited text no. 13
Ellis, - P.P.: Occlusion of the central retinal artery after retrobulbar contricosteroid injection. Am. J. Ophthalmo. 85:352-6, 1978.  Back to cited text no. 14
Meyers, E.F., Ramirez, R.C., Boniuk, I.: Grandmal seizures after retrobulbar block, Arch. Ophthalmol. 96:847, 1978.  Back to cited text no. 15


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