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| BRIEF REPORT |
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| Year : 1999 | Volume
: 47
| Issue : 4 | Page : 247-248 |
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Bisected macula following retrobulbar steroid injection
S Parikh, MP Shanmugam, J Biswas
Medical and Vision Research Foundation, Chennai, India
Correspondence Address:
S Parikh
Medical and Vision Research Foundation, Chennai
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 10892482 
How to cite this article:
Parikh S, Shanmugam M P, Biswas J. Bisected macula following retrobulbar steroid injection. Indian J Ophthalmol 1999;47:247-8 |
A case of bilateral accidental globe penetration during administration of retrobulbar steroid for bilateral optic neuritis is discussed. One eye with bisected macula was managed successfully by vitrectomy, internal gas tamponade, and postoperative laser to the edges of the retinal tear. The fellow eye was blind due to central retinal artery occlusion.
Periocular injection of corticosteroids is considered a common modality of therapy for intermediate uveitis, severe anterior uveitis, panuveitis, optic neuritis, pseudotumour of the orbit, and endocrine exophthalmos.[1] The obvious advantage of such a therapy comes from placing a high concentration of depot corticosteroid in the posterior part of the globe and avoiding systemic administration that has attendant side effects. This has resulted in widespread clinical acceptance of periocular injection as an important modality of therapy in such cases. However, the most serious risk in such a procedure is globe perforation. Axial myopia, multiple injections, traditional superonasal gaze position, previous retinal buckling procedure, and endophthalmitis have been found to be risk factors for globe perforation.[2] If recognised immediately, adequate treatment can be provided to the iatrogenic retinal holes as a prophylaxis against retinal detachment. However, once retinal detachment occurs, the management almost always involves a complex vitreoretinal surgery[3] Vitrectomy has been found to be beneficial in cases of accidental intraocular steroid injection.4 We report a case that presented to us with globe perforation in the right eye and penetration in the left eye following simultaneous retrobulbar injection of dexamethasone in both the eyes. The right eye had no light perception because of central retinal artery occlusion and therefore no treatment could be offered. The left eye is the subject of this presentation.
| Case Report | |  |
A 32-year-old male was given a retrobulbar injection of dexamethasone by his ophthalmologist in December 1994, following a diagnosis of retrobulbar neuritis, first in the right eye and then in the left at the same visit. Half an hour after the injection, when the patch was removed, the patient complained of profound loss of vision in both eyes. He was diagnosed to have scleral perforation with vitreous haemorrhage in both the eyes and was referred to us for further management.
On examination at the institute 2 days after the event, his visual acuity in the right eye was no perception of light and in the left eye, counting fingers close to face. Externally the right eye had a subconjunctival haemorrhage and a relative afferent pupillary defect. The intraocular pressure (IOP) was normal in both eyes. Fundus examination of the right eye revealed a cherry red spot in the macula, retrohyaloid haemorrhage in the inferior fundus and attenuated arterioles - findings suggestive of central retinal artery occlusion. The entry wound was seen at the equatorial region in the lower temporal quadrant and a exit perforation site was seen 2 disc diameters below, temporal to the fovea. The retina was completely attached. The left eye revealed vitreous haemorrhage covering the disc and macula. An entry wound was seen at the 5'o clock meridian outside the vascular arcade.
No treatment was offered to the right eye. A standard three-port pars plana vitrectomy was done in the left eye. Posterior hyaloid separation was done. The upper temporal arteriole was found torn and the retina was ischemic distal to it. A vertical retinal tear was seen extending from a point in the upper nasal quadrant towards the lower temporal quadrant bisecting the macula area. A nonexpansile concentration of sulphur hexafluoride (20%) was used for internal tamponade. The patient was advised to remain prone for 10 days. After 12 days, argon laser photocoagulation was done to the edges of retinal tear with the slitlamp delivery system.
Eight weeks later, visual acuity in the left eye was 6/24. Fundus examination of the left eye revealed a satisfactorily attached retina, and a few retinal haemorrhages in upper temporal quadrant at the site of injury. Field examination with Krakau perimeter (Digilab 350 Mass, USA) revealed scotoma inferonasally corresponding to the superotemporal arteriolar occlusion. The electroretinogram of the left eye revealed normal response for scotopic and photopic white flash and blue flash. After 4 months the left eye developed a retinal hole in the upper temporal (previously ischaemic) area of the retina. Argon laser photocoagulation was done using a laser indirect ophthalmoscope. After 12 months, visual acuity was maintained at 6/24 in the left eye and the fundus showed attached retina with pigmented chorioretinal scar at the site of the retinal tear Figure.
| Discussion | | |
Globe perforation secondary to retrobulbar injection for local anaesthesia is a well-known complication. Schneider et al[2] reported a series of 7 eyes with ocular perforation following peribulbar injection. Direct macular injury and macular pucker each occurred in two cases in their series. Accidental globe perforation can occur following retrobulbar and peribulbar anaesthesia as also during posterior subtenon steroid injection. Posterior retinal and optic nerve damage occur generally during local anaesthetic injection due to the use of relatively long needles. In general, subtenon's steroid injection is administered with short needles that can perforate the globe only once. In the present case, the steroid was administered as a retrobulbar injection for suspected optic neuritis. Hence a long needle was probably used, resulting in the damage noted. The damage to the right eye did not permit any corrective measures. The left eye sustained a rather unique form of retinal damage. The needle, after having penetrated the globe, sliced the macula vertically and snipped off the upper temporal arteriole. This situation made it difficult for us to decide on the retinopexy intraoperatively around the vertical retinal tear. We decided to treat the tear postoperatively with slitlamp laser delivery to enable controlled application of small laser burns after flattening the edges of the tear with gas tamponade. Since the retina was not detached at the time of surgery, the postponement of retinopexy by 12 days postoperatively did not significantly increase the risk of retinal detachment. As the tear was close to the fovea, we felt that the controlled postoperative laser to the break near the fovea helped us preserve maximum functional retina, as evidenced by recovery of 6/24 vision.
The patient developed an atrophic retinal hole in the area of the branch arteriolar occlusion 4 months after the event. Such a retinal break can be a late complication in ischemic retina and should be carefully looked for. This case emphasizes the dangers of periocular injection and the diversity of presentation of complications associated with accidental globe perforation[4].
| References | | |
| 1. | Giles CL. Bulbar perforation during periocular injection of corticosteroids. Am J Ophthalmol 1974;77:438-41.  [ PUBMED] |
| 2. | Schneider ME, Milstein DE, Oyakawa RT, Oher RR, Campo R. Ocular perforation from peribulbar injection. Am J Oplithatmol 1988;106:35-40. |
| 3. | Gopal L, Badrinath SS, Parikh S, Chawla G. Retinal detachment secondary to ocular perforation during retrobulbar anaesthesia. Indian J Ophthalmol 1995;43:13-15. [ PUBMED] |
| 4. | Gopal L, Bhende M, Sharma T. Vitrectomy for accidental intraocular steroid injection. Retina 1995;15:295-99. [ PUBMED] |
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