|Year : 1995 | Volume
| Issue : 1 | Page : 13-15
Retinal detachment secondary to ocular perforation during retrobulbar Anaesthesia
Lingam Gopal, SS Badrinath, Sunil Parikh, Gajendra Chawla
From Vision Research Foundation, Sankara Nethralaya, 18 College Road, Madras 600 006, India
From Vision Research Foundation, Sankara Nethralaya, 18 College Road, Madras 600 006
Source of Support: None, Conflict of Interest: None
The clinical characteristics and the retinal breaks associated with rhegmatogenous retinal detachments secondary to accidental globe perforation during local infiltration anaesthesia in five highly myopic eyes are presented. Retinal detachment was total with variable proliferative vitreoretinopathy. The pattern of retinal breaks was rather typical and predictable. Management involved vitreous surgery with internal tamponade by silicone oil in four eyes and perfluoropropane gas in one eye. At the last follow-up, all eyes had attached retina. One eye did not recover useful vision due to possible concurrent optic nerve damage.
Keywords: Retinal detachment - Retrobulbar anaesthesia - Peribulbar anaesthesia -Globe perforation - Vitreous surgery.
|How to cite this article:|
Gopal L, Badrinath S S, Parikh S, Chawla G. Retinal detachment secondary to ocular perforation during retrobulbar Anaesthesia. Indian J Ophthalmol 1995;43:13-5
Accidental ocular perforation is a rare complication of retrobulbar anaesthesia. If recognized immediately, adequate treatment can be instituted to the iatrogenic retinal holes as a prophylaxis against retinal detachment. However, once retinal detachment occurs, the management almost always involves complex vitreoretinal surgery. The general pattern of retinal breaks in this situation is predictable. We discuss five cases of such retinal detachments, repaired successfully by multiple vitreoretinal surgical procedures.
| Materials and methods|| |
All the five cases involved highly myopic eyes and retrobulbar anaesthesia. Retinal perforation occurred while giving retrobulbar anaesthesia for intended extracapsular cataract extraction (ECCE) in two cases, extracapsular cataract extraction with posterior chamber intraocular lens implantation (PC IOL) in two cases and radial keratotomy in one case. All the cases were referred with total retinal detachment. In two cases, the operating surgeon was aware of the accidental perforation during the retrobulbar anaesthesia, but proceeded with ECCE with PC IOL implantation, apparently with no specific problem but for the lack of normal fundus reflex due to vitreous haemorrhage.
Four patients noticed loss of vision on the first post-operative day while one patient developed loss of vision, one year later. The latter patient underwent an unsuccessful peripheral scleral buckling under general anaesthesia elsewhere before presenting to us. In four cases, vitreous haemorrhage was noticed on the first postoperative day and hence, the time of onset of the subsequent retinal detachment went unrecognized.
The intraoperative features during the vitreoretinal surgery in all the cases were very characteristic [Figure - 1]. A break in the inferotemporal quadrant was the most common feature. The location of rest of the breaks was along a line going through the inferotemporal break and pointing towards the upper nasal quadrant. Sewing machine-type of breaks occurred in two cases (cases 3 and 5). These breaks were larger, more oblong and close to each other. Proliferative vitreoretinopathy was present in all cases: grade D3 in two cases, D2 in one case, C2 and C1 in one case each.
The surgery involved lensectomy (in the only phakic eye), and total vitrectomy including excision of the base and membrane peeling. In some cases the breaks were obscured by membranes and were identified only on membrane removal. Following fluid-air exchange, the posterior retinal breaks were treated with endolaser while the peripheral breaks were treated with transscleral cryopexy. One case had gas tamponade with 14% perfluoropropane (C3F8)-air mixture while the rest had silicone oil tamponade. One case with silicone oil had recurrence of detachment and needed a second surgical procedure. This consisted of membrane peeling under oil, endo-drainage of subretinal fluid with more silicone oil injection and endolaser photocoagulation. Of the four cases with silicone oil injection, two had silicone oil removal approximately 2 months after the last surgical procedure. The other two cases are awaiting silicone oil removal.
| Results|| |
The follow-up period ranged from 2 to 21 months (mean, 8 months). At the last follow-up evaluation, all eyes were found to have attached retina. One case with silicone oil tamponade had secondary glaucoma that was controlled with topical antiglaucoma medication. The best-corrected visual acuities postoperatively were 3/36 in two cases, 6/ 36 and 6/18 in one case each. One patient attained a visual acuity of only hand motions due to optic atrophy.
| Discussion|| |
Perforating ocular injury secondary to local anaesthesia is not an unknown complication. Schniderreported a series of seven eyes with ocular perforation. Duker et al have described 20 eyes that had accidental perforation during local anaesthesia and attempted to characterize the eyes prone to such a complication. This complication has also been described with peribulbar anaesthesia.
It is imperative to differentiate between a penetrating (single site) injury and perforating injury (entry and exit sites). With a perforating injury, any injection of anaesthetic will be extraocular thereby not contributing to the damage. With a single wound (penetrating injury), intraocular injection of anaesthetic, if done, will be detectable immediately because of significant rise in intraocular pressure. If recognised, the needle can be withdrawn and the anaesthetic solution can be injected in the proper location. The location and type of the breaks and subsequent problems that occur, are directly related to the type of perforation and whether or not the intraocular injection was given. In most cases the accidental perforation would have occurred in large myopic eyes with or without equatorial staphyloma, although the general direction of the path of the needle was considered correct. In such cases, the needle is likely to be parallel to the globe wall and cause multiple sewing machine-type of breaks that are close to each other. These breaks are relatively large and oblong in shape. In contrast, a needle that has been introduced in a wrong direction is likely to strike at a more acute angle and exit posteriorly, causing two widely separated breaks of oval shape. Depending on the direction, the posterior break can be present anywhere around the posterior pole or upper nasal quadrant. In accidental perforation during local anaesthesia, the scleral perforation is likely to be of a larger size compared to accidental perforations caused during subconjunctival/subtenon's injection wherein 26 gauge or smaller needles are used. Hence, most of these cases are recognized immediately because of the sudden softening of the eye. If recognized, the surgeon should abort the intended surgery and seek the help of a vitreoretinal surgeon for management. With rest, the vitreous haemorrhage may settle down, permitting laser photocoagulation of the breaks. In the event of non-resolution of vitreous haemorrhage within 7 to 10 days, vitrectomy combined with intraoperative treatment of breaks is advocated. This approach is quite effective in the prevention of retinal detachment.
The occurrence of retinal detachment is very frequent in those eyes that are left untreated. Perforation involving the retina, vitreous traction secondary to trauma and vitreous haemorrhage and predisposition of myopic eyes for retinal detachment are contributing factors.
In three of our cases in this series, the referring surgeon was apparently not aware of the accidental perforation during retrobulbar anaesthesia. The dense proliferative vireoretinopathy at the time of our initial evaluation precluded characterization of the breaks. But intraoperatively the clinical presentation of the breaks prompted us to look for signs of accidental perforation. Following attachment of the retina by fluid-air exchange, the choroidal scar caused by the needle track was visible within the break. In one case, even the scleral wound could be identified inferotemporally as a puckered scleral scar.
The final visual acuity in the series reported by Hay et al was 6/120 or better in two of the 14 cases that presented with retinal detachment. In this series, four of the five patients attained a visual acuity better than 3/36. One patient had only hand motions inspite of attached retina due to optic atrophy.
The visual results in this series were quite encouraging with four of the five patients having a final visual acuity of better than 3/36 and compared very favourably with earlier reports. The only case that did not have significant visual improvement had evidence of optic atrophy, the exact cause of which was unclear.
| References|| |
Schneider ME, Milstein DE, Oyakawa RT, et al. Ocular perforation from a retrobulbar injection. Am J Ophthalmol 106:35-40, 1988.
Duker JS, Belmont JB, Benson WE, et al. Inadvertent globe perforation during retrobulbar and peribulbar anaesthesia. Ophthalmology 98:519-526, 1991.
Grizzard WS, Kirk NM, Pavan PR, et al. Perforating ocular injuries caused by anaesthesia personnel. Ophthalmology 98:1011-1016, 1991.
Hay A, Flynn HW, Hoffmann JI, et al. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 98:1017-1024, 1991.
Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anaesthesia for retinal detachment surgery. Am J Ophthalmol 86:61-74, 1978.
Ginsburg RN, Duker JS. The management of globe perforation from retrobulbar and peribulbar injections. Current Opinion in Ophthalmology 111:50-55, 1993.
[Figure - 1]
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