Nicolas A. Yannuzzi
Swarup S. Swaminathan
A woman in her 70s with a history of a dense nuclear sclerotic cataract with best-correct visual acuity (BCVA) of 20/200 underwent retrobulbar block prior to cataract surgery due to language barriers. Intraoperatively, the eye was felt to be soft and the anterior chamber shallow; an intraocular lens was placed into the capsular bag uneventfully. On postoperative Day 1, the vision was measured to be hand motions, and the fundus examination disclosed inferior subretinal hemorrhage, which progressed to vitreous hemorrhage (VH) with a macula-involving retinal detachment (RD) by postoperative Week 1 (Panel A). She was brought back to the operating room the following day for a pars plana vitrectomy (PPV).
For our surgery, local anesthesia was achieved with a sub-Tenon's block after inferior conjunctival cut down (Figure 1B). A posterior vitreous detachment was noted along with a rhegmatogenous RD extending from 1-o'clock to 7:30-o'clock inferior-temporally encroaching into the inferior macula. Subretinal hemorrhage was present along the inferotemporal arcade vessels, along with multiple retinal breaks in a linear fashion extending from nasally adjacent to the optic nerve toward the inferotemporal quadrant (Figure 1C). A total of six retinal breaks were found. A PPV with depressed shaving was completed with the assistance of dilute triamcinolone acetonide. A complete fluid-air exchange was performed to drain subretinal hemorrhage and fluid from the most posterior retinal break. Endolaser was then applied to surround each retinal break, and the air was completely exchanged for 1,000 centistoke silicone oil. At postoperative Month 1, the retina was attached under oil, and the decision was later made to remove the oil at postoperative Month 3. Six months following her initial surgery, the retina is still attached with a BCVA of 20/60 (See Video below).
Safe delivery of ophthalmic anesthesia is a crucial aspect of ophthalmic surgery. Although many ophthalmologists administer their own regional anesthetics for procedures, a recent survey of vitreoretinal surgeons found that the majority of patients undergoing vitreoretinal surgical cases receive local anesthesia from anesthesiologists.1 This trend was observed in anterior segment surgery, as well.2 A concern is that only a fraction of anesthesiologists receive reginal ophthalmic anesthesia training during their residency,3 and this experience is not required for accreditation.4
Regional blocks include a number of potential complications. Adverse events may be systemic, such as seizure and cardiorespiratory arrest, or limited to the globe and ocular adnexa. Ophthalmic complications include those localized to the orbit (retrobulbar hematoma), muscles and cranial nerves (ptosis, diplopia, restrictive strabismus), posterior segment (retinal vein occlusion,5 retinal artery occlusion,6 retinal tear or RD), and optic nerve (traumatic optic neuropathy). The reported incidence of direct globe trauma ranges from 1:10,0007 to 1:40,0008 and is estimated to be 1:140 in eyes with an axial length greater than 26 mm.9
Retrospective case series of eyes with scleral perforation during peribulbar or retrobulbar anesthesia have shown unfavorable results. One study of nine cases over 17 years found that six had ambulatory vision only, one was no light perception, and only two recovered reading ability.10 Another series identified risk factors such as high myopia, previous placement of a scleral buckle, poor cooperation during injection, or an anesthesiologist delivering the block.11 Furthermore, it differentiated early complications (retinal breaks or hemorrhage, VH, RD, and choroidal hemorrhage from late complications (epiretinal membrane, optic atrophy, and recurrent RD, and hypotony). In one large series, the rate of RD following globe perforation was over 50%.12 These complications are frequently associated with VH and subretinal hemorrhage and have a high rate of proliferative vitreoretinopathy (PVR).11
In summary, repair of RD following globe perforation during regional anesthesia placement may be challenging. We recommend consideration of PPV with silicone oil, as many of these patients are at high risk for developing PVR.
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