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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 203-206

Our experience with ocular perforation resulting from peribulbar anesthesia


1 Department of Ophthalmology, Adesh Medical College and Hospital, Ambala, Haryana, India
2 Department of Ophthalmology, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
3 Department of Pediatrics, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
4 Department of Surgery, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Rajwinder Kaur
Department of Ophthalmology, Gian Sagar Medical College and Hospital, Ram Nagar, Tehsil Rajpura, Patiala - 140 601, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_93_17

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  Abstract 


Purpose: The purpose of this study is to analyze the clinical presentation and outcome of treatment for globe perforation secondary to peribulbar perforation.
Materials and Methods: A total of 10 patients were included in the study, of which nine patients referred to vitreoretina unit from outside for the management and one patient, that is, eye with altered axial length (eye with previous buckle), at our setting. Three eyes were myopic. One patient underwent indirect argon laser photocoagulation to seal the retinal break, another patient underwent peripheral break sealed with cryotherapy, and six patients underwent pars plana vitrectomy with fluid gas exchange and endolaser. Two patients had sclera buckling in addition.
Results: The final visual acuity after follow-up of 1 year was better than 20/30 in two patients, between 20/30 and 20/40 in four patients, and perception of light in two patients. One eye became phthyesical due to recurrent retinal detachment.
Conclusion: If diagnosed early and treated adequately, a majority of patients with globe perforation during peribulbar anesthesia can have a good visual outcome.

Keywords: Anesthesia, globe perforation, pars plana vitrectomy, peribulbar, visual


How to cite this article:
Khan B, Kaur R, Kaur M, Singh H, Kaur K. Our experience with ocular perforation resulting from peribulbar anesthesia. Kerala J Ophthalmol 2017;29:203-6

How to cite this URL:
Khan B, Kaur R, Kaur M, Singh H, Kaur K. Our experience with ocular perforation resulting from peribulbar anesthesia. Kerala J Ophthalmol [serial online] 2017 [cited 2018 Sep 19];29:203-6. Available from: http://www.kjophthal.com/text.asp?2017/29/3/203/224304




  Introduction Top


Peribulbar anesthesia, though presumed to be safer than retrobulbar injection, is not without the risk of inadvertent globe perforation. In such cases, the incidence of proliferative vitreoretinopathy is high and further complicated by the occurrence of retinal detachment. Timely detection and management of this sight threatening complication is important. According to the international classification of ocular trauma, penetrating injury is when there is single entry wound, whereas perforation is where there are two wounds, one entry wound, and one exit wound.[1] We present this case series of ten patients who were diagnosed to have perforation following peribulbar anesthesia and were managed in the vitreoretinal unit at our hospital.


  Materials and Methods Top


This retrospective, single-institution, interventional case study was done in our Tertiary Care Referral Center in North India. Ten patients were seen in the retina clinic from January 2010 to January 2012 with a diagnosis of globe perforation during peribulbar anesthesia. Nine patients were referred from outside for the management and one patient was diagnosed at our center. All cases were reviewed and studied retrospectively. Records were retrospectively reviewed for data regarding age and sex, visual acuity (VA) on presentation, and anterior and posterior segment findings. Detailed history regarding pain at the time of injection from the patient and the person giving injection was also investigated regarding the site and the type of needle used for the block. As per record, 24G needle was used to give block in superonasal and inferotemporal quadrants by OT assistant in nine cases and by resident in one case. In cases where the fundus was not visible, a B-scan was done, and surgical details including timing, type and number of procedure, and intraoperative findings were also noted. Postoperative follow-up was included extending up to 1 year.

In cases where the fundus was visible, break was visible; it was sealed with argon laser photocoagulation. In cases where the break was peripheral, cryotherapy was done. In cases where the patient had vitreous hemorrhage, B-scan was done to rule out associated retinal detachment. In the absence of retinal detachment, 23 Gauze Pars Plana Vitrectomy (GPPV) was done with fluid gas exchange and with endolaser around the break. In the presence of retinal detachment, additional scleral buckle was placed with C3F8 or silicon oil.


  Results Top


Of the ten patients sustaining ocular perforation from local anesthesia, five (50%) were male and five were (50%) female, and nine patients underwent peribulbar blocks for cataract surgery and one patient underwent retinal surgery.

The mean age of patients was 62.6 years. One patient (10%) was in the age group 20–40 years; another patient (10%) was in the age group 40–60 years, whereas eight patients (80%) were in the age group of >60 years. Right eye was affected in 50% cases (5 eyes) and left eye in other 50% cases (5 eyes).

Time of presentation and final visual outcome at our hospital are shown in [Table 1]. One patient (10%) came to the hospital on the same day. The mean time of presentation was 15.3 days. Two patients (20%) presented within a week. Six patients (35%) came to the hospital within a month and only one patient (10%) presented late. The total number of patients who were taken up for surgery on the same day had better visual outcome.
Table 1: Time of presentation to the hospital and their visual outcome

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Presenting complaint of the patient was no improvement in the vision after the surgery. On examination, there was hyphema in two cases (20%) and posterior segment examination showed vitreous hemorrhage in nine cases (90%). When media was hazy, B-scan was done to find out the associated retinal detachment which was diagnosed in four cases (40%).

In our brief report, it was found that in five cases, the axial length found was more than 24. One patient had altered axial length because of sclera buckling. Ninety percent of patients (n = 9) presented with vitreous hemorrhage, 40% (n = 4) of patients presented with associated retinal detachment, and 20% of patients (n = 2) had hyphema. Perforation site was found to be inferotemporal in 40% cases followed by superonasal 30%. The site of perforation of various patients is shown in [Figure 1].
Figure 1: Layout of breaks

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The surgical techniques required to treat the patients varied according to the site of perforation, severity of retinal detachment, and associated proliferative vitreoretinopathy (PVR). Operative details are given in [Table 2], and in 20% cases, 360-degree belt buckle was used to reduce the incidence of postoperative retinal detachment and retinal tears were treated with endolaser. Three (30%) eyes were given internal tamponade in the form of silicon and three eyes (30%) were left under C3F8 tamponade. The second surgery was done in 30% of cases (n = 3) for silicon oil removal. One patient had phthisical eye after multiple surgeries because of recurrent retinal detachment and in one patient, media was clear and break was visible and so barrage to the break was done. All patients were followed up for at least 1 year. Retina was found to be attached in 90% cases. Hence, it was considered as successful anatomical outcome.
Table 2: Type of surgeries

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[Table 3] shows the comparison of VA at the time of presentation and final visual outcome. In seven patients, the VA was <20/200 at the time of presentation, and postoperative visual outcome was favorable in 50% cases and one patient had no light perception.
Table 3: Comparison of initial visual acuity and final visual acuity

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  Discussion Top


To reduce the complications associated with retrobulbar anesthesia, the technique of peribulbar anesthesia was introduced. The classic peribulbar technique was described by Davis and Mandel which required two injections: one at the lateral third of the lower orbital rim and the second at the medial third of the upper orbital rim. Davis and Mandel emphasized the safety of peribulbar perforation in skilled hands, and in their series of 16,224 consecutive peribulbar blocks, they reported a single globe perforation (incidence –0.006%).[2]

Davis and Mandel also recommend single inferotemporal peribulbar injections; they found that a superonasal injection was only necessary only if inadequate akinesia was achieved. Blunt needles have been recommended to decrease the chance of globe perforation when performing peribulbar and retrobulbar anesthesia. This case series report demonstrates the serious consequences of ocular perforation by the sharp needle while giving block.[3] Visual outcome was good in our case series, contrary to the previously reported series. The reasons for good visual outcome were early presentation to vitreoretinal surgeon, early and adequate management with latest equipment and location of break mostly found in periphery (sparing macula), and minimal proliferative vitreoretinal changes.

Previous studies have suggested the following risk factors for globe perforation: posterior staphloma,[4] long axial length,[5] and inexperienced personal.[6]

Budd et al. recently presented a series of 1000 consecutive peribulbar anesthetics performed using the same technique.[7] One study also proposed that the second peribulbar injection is unnecessary and may carry an increased risk of peribulbar perforation.[8]

Patient coming with vitreous hemorrhage on the 1st postoperative day is a high suspicion sign for ocular perforation. Nine patients presented with vitreous hemorrhage but in only one patient it was recognized as a diagnosis of ocular perforation on day 1 postoperatively. The delay in referral to vitreoretinal unit ranged from 1 to 36 days.

The site of perforation was a major prognostic factor in the series. In nine patients, the site of perforation was peripheral which is a favorable factor. Double perforation is known to have a worse prognosis. If the retinal break is identified and the surrounding retina remains flat, prophylactic laser photocoagulation or cryotherapy around the break is done with good visual outcome. The break identified with early shallow localized retinal detachment away from macula may have a better outcome if managed at the earliest. If the detachment is bullous and PVR supervened, it has worse prognosis.[9],[10],[11]

One eye underwent phthisis because of repeated surgery. Rest of the cases had encouraging final visual outcome. During surgery of an unusually soft eye, hyphema following anesthesia should raise suspicion of perforation.


  Conclusion Top


Watch for corresponding globe movements while performing horizontal movements of the needle following needle insertion but before injection. Ocular perforation should be suspected when fresh vitreous hemorrhage is noted on the 1st postoperative day. Close follow-up and early appropriate intervention result in best visual outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pieramici DJ, Sternberg P Jr., Aaberg TM Sr., Bridges WZ Jr., Capone A Jr., Cardillo JA, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol 1997;123:820-31.  Back to cited text no. 1
    
2.
Davis DB 2nd, Mandel MR. Posterior peribulbar anesthesia: An alternative to retrobulbar anesthesia. J Cataract Refract Surg 1986;12:182-4.  Back to cited text no. 2
    
3.
Davis DB, Mandel MR. Peribulbar anesthesia: Reducing complications. Ocul Surg News 1989;7:21, 28, 29.  Back to cited text no. 3
    
4.
Edge R, Navon S. Scleral perforation during retrobulbar and peribulbar anesthesia: Risk factors and outcome in 50,000 consecutive injections. J Cataract Refract Surg 1999;25:1237-44.  Back to cited text no. 4
    
5.
Duker JS, Belmont JB, Benson WE, Brooks HL Jr., Brown GC, Federman JL, et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia. Patient characteristics, surgical management, and visual outcome. Ophthalmology 1991;98:519-26.  Back to cited text no. 5
    
6.
Grizzard WS, Kirk NM, Pavan PR, Antworth MV, Hammer ME, Roseman RL. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991;98:1011-6.  Back to cited text no. 6
    
7.
Budd J, Hardwick M, Barber K, Prosser J. A single-centre study of 1000 consecutive peribulbar blocks. Eye (Lond) 2001;15(Pt 4):464-8.  Back to cited text no. 7
    
8.
Ball JL, Woon WH, Smith S. Globe perforation by the second peribulbar injection. Eye (Lond) 2002;16:663-5.  Back to cited text no. 8
    
9.
Kimble JA, Morris RE, Witherspoon CD, Feist RM. Globe perforation from peribulbar injection. Arch Ophthalmol 1987;105:749.  Back to cited text no. 9
    
10.
Joseph JP, McHugh JD, Franks WA, Chignell AH. Perforation of the globe – A complication of peribulbar anaesthesia. Br J Ophthalmol 1991;75:504-5.  Back to cited text no. 10
    
11.
Gillow JT, Aggarwal RK, Kirkby GR. Ocular perforation during peribulbar anaesthesia. Eye (Lond) 1996;10(Pt 5):533-6.  Back to cited text no. 11
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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