April 2020 · Vol. 51, No. 4 249 The Cutting Edge Edited by Yoshihiro Yonekawa, MD, and Peter H. Tang, MD, PhD The authors present a case of retinal detachment (RD) re- pair after inadvertent perfora- tion from a retrobulbar block needle. One of the key features of this video is the decision to perform a sub-Tenon’s block in which a conjunctival and Tenon’s capsule cutdown is created followed by advance- ment of a blunt-tipped cannula into the retrobulbar space and injection of the an- esthetic. Compared to a peribulbar or retrobulbar block, there is almost no risk of globe perforation or retrobulbar hemorrhage. At the same time, a sub-Tenon’s block offers the same advantages with excellent analgesia and akinesia. The down- side is primarily cosmetic, with development of subconjunctival hemorrhage, though it typically resolves within a week. Sometimes, if the cannu- la is not through Tenon’s capsule or if too much anesthetic is injected, there can be ballooning of the conjunctiva. Risk factors for perforation with retrobulbar and peribulbar blocks include a long axial length, as seen in high myopes, and associated presence of a posterior staphyloma. Although retrobulbar blocks rarely lead to complications, when they do, they can be devastating. Few cases of scleral perfo- ration after blocks have been published; however, the outcomes tend to vary, though few appear to regain reading vision. In this case, the steps for surgical repair of the detachment from the multiple needle perforations are excellent. Using triamcinolone to visualize the hyaloid and ensure posterior vitreous separation is crucial, as residual adherent vitreous may act as a scaffold for proliferative vitreoretinopathy (PVR). When separating the hyaloid in the presence of a RD, there is also a risk of incarcerating the retina in the cutter’s mouth, particularly if high suction is used. A bubble of perfluorocarbon liquid once the hyaloid is off the macula can sometimes be helpful in stabilizing the retina to avoid this complication. Also, one can use just enough suction to engage the gel into the mouth of the cutter then come off the foot pedal and just mechanically elevate the hyaloid with very little or no suction. Finally, the traumatic nature of this detachment with associ- ated vitreous and subretinal hemorrhage places this patient at a high risk for PVR. Therefore, the decision to use silicone oil primarily was a good idea beyond the stated benefits of decreased need for postoperative positioning and earlier recovery of some functional vision. Jason Hsu, MD Retina Service of Wills Eye Hospital Thomas Jefferson University Hospital Mid Atlantic Retina Philadelphia, PA Repair of Rhegmatogenous Retinal Detachment Following Globe Perforation by Retrobulbar Anesthesia Nicolas A. Yannuzzi, MD; Swarup S. Swaminathan, MD; Rehan Hussain, MD; Jayanth Sridhar, MD ABSTRACT: Globe perforation following retrobulbar or peribulbar anesthetic injection is a rare but dreaded complication that often results in suboptimal visual outcomes. This video describes a 72-year-old woman who sustained a globe perforation during retrobulbar block in the setting of cataract extraction and later developed a retinal detachment. The retina was re- paired with pars plana vitrectomy and silicone oil, resulting in a favorable visual outcome. The authors discuss various modes of local anesthesia for vitreo- retinal surgery, risks for globe perforations, and how to approach retinal detachment secondary to needle perforations, which are complex cases at high risk for proliferative vitreoretinopathy. Jason Hsu, MD
Transcript
April 2020 · Vol. 51, No. 4 249
The Cutting EdgeEdited by Yoshihiro Yonekawa, MD, and Peter H. Tang, MD, PhD
The authors present a case of retinal detachment (RD) re-pair after inadvertent perfora-tion from a retrobulbar block needle. One of the key features of this video is the decision to perform a sub-Tenon’s block in which a conjunctival and Tenon’s capsule cutdown is created followed by advance-
ment of a blunt-tipped cannula into the retrobulbar space and injection of the an-esthetic. Compared to a peribulbar or retrobulbar block, there is almost no risk of globe perforation or retrobulbar hemorrhage. At the same time, a sub-Tenon’s block offers the same advantages with excellent analgesia and akinesia. The down-side is primarily cosmetic, with development of subconjunctival hemorrhage, though it typically resolves within a week. Sometimes, if the cannu-la is not through Tenon’s capsule or if too much anesthetic is injected, there can be ballooning of the conjunctiva.
Risk factors for perforation with retrobulbar and peribulbar blocks include a long axial length, as seen in high myopes, and associated presence of a posterior staphyloma. Although retrobulbar blocks rarely lead to complications, when they do, they can be devastating. Few cases of scleral perfo-ration after blocks have been published; however,
the outcomes tend to vary, though few appear to regain reading vision.
In this case, the steps for surgical repair of the detachment from the multiple needle perforations are excellent. Using triamcinolone to visualize the hyaloid and ensure posterior vitreous separation is crucial, as residual adherent vitreous may act as a scaffold for proliferative vitreoretinopathy (PVR). When separating the hyaloid in the presence of a RD, there is also a risk of incarcerating the retina in the cutter’s mouth, particularly if high suction is used. A bubble of perfluorocarbon liquid once the hyaloid is off the macula can sometimes be helpful in stabilizing the retina to avoid this complication. Also, one can use just enough suction to engage the gel into the mouth of the cutter then come off the foot pedal and just mechanically elevate the hyaloid with very little or no suction. Finally, the traumatic nature of this detachment with associ-ated vitreous and subretinal hemorrhage places this patient at a high risk for PVR. Therefore, the decision to use silicone oil primarily was a good idea beyond the stated benefits of decreased need for postoperative positioning and earlier recovery of some functional vision.
Jason Hsu, MDRetina Service of Wills Eye HospitalThomas Jefferson University HospitalMid Atlantic RetinaPhiladelphia, PA
Repair of Rhegmatogenous Retinal Detachment Following Globe Perforation by Retrobulbar AnesthesiaNicolas A. Yannuzzi, MD; Swarup S. Swaminathan, MD; Rehan Hussain, MD; Jayanth Sridhar, MD
ABSTRACT: Globe perforation following retrobulbar or peribulbar anesthetic injection is a rare but dreaded complication that often results in suboptimal visual outcomes. This video describes a 72-year-old woman who sustained a globe perforation during retrobulbar block in the setting of cataract extraction and later developed a retinal detachment. The retina was re-
paired with pars plana vitrectomy and silicone oil, resulting in a favorable visual outcome. The authors discuss various modes of local anesthesia for vitreo-retinal surgery, risks for globe perforations, and how to approach retinal detachment secondary to needle perforations, which are complex cases at high risk for proliferative vitreoretinopathy.
The Cutting EdgeSurgical video section with expert commentary
A woman in her 70s with a history of a dense nucle-ar sclerotic cataract with
best-correct visual acuity (BCVA) of 20/200 underwent retrobulbar block prior to cataract surgery due to language barriers. Intraoperative-ly, the eye was felt to be soft and the anterior chamber shallow; an
intraocular lens was placed into the capsular bag un-eventfully. On postoperative Day 1, the vision was mea-sured to be hand motions, and the fundus examination disclosed inferior subretinal hemorrhage, which pro-gressed to vitreous hemorrhage (VH) with a macula-in-volving 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 encroach-ing into the inferior macula. Subretinal hemorrhage was present along the inferotemporal arcade vessels, along with multiple retinal breaks in a linear fashion extend-ing from nasally adjacent to the optic nerve toward the inferotemporal quadrant (Figure 1C). A total of six reti-nal breaks were found. A PPV with depressed shaving
Figure 1. Repair of retinal detachment in a woman with retrobulbar anesthesia globe perforation. (A) B-scan ultrasonography shows a retinal detachment with vitreous hemorrhage. (B) Intraoperative view of sub-Tenon’s anesthesia administration with a conjunctival cut down. (C) Intraoperative view during pars plana vitrectomy shows multiple retinal breaks and subretinal hemorrhage. (D) At postoperative Month 6, the retina was attached under fluid.
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Rehan Hussain
Jayanth Sridhar
Swarup S. Swaminathan
Nicolas A. Yannuzzi
April 2020 · Vol. 51, No. 4 251
The Cutting Edge
was completed with the assistance of dilute triamcino-lone acetonide. A complete fluid-air exchange was per-formed 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 un-der 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 (Figure 1D).
Safe delivery of ophthalmic anesthesia is a crucial aspect of ophthalmic surgery. Although many ophthal-mologists administer their own regional anesthetics for procedures, a recent survey of vitreoretinal surgeons found that the majority of patients undergoing vitreo-retinal surgical cases receive local anesthesia from anes-thesiologists.1 This trend was observed in anterior seg-ment surgery, as well.2 A concern is that only a fraction of anesthesiologists receive reginal ophthalmic anesthe-sia training during their residency,3 and this experience is not required for accreditation.4
Regional blocks include a number of potential com-plications. Adverse events may be systemic, such as sei-zure 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 inci-dence 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 perfo-ration 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 read-ing ability.10 Another series identified risk factors such as high myopia, previous placement of a scleral buckle, poor cooperation during injection, or an anesthesiolo-gist delivering the block.11 Furthermore, it differenti-ated early complications (retinal breaks or hemorrhage, VH, RD, and choroidal hemorrhage from late complica-tions (epiretinal membrane, optic atrophy, and recur-rent 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 prolifera-tive vitreoretinopathy (PVR).11
In summary, repair of RD following globe perfora-tion during regional anesthesia placement may be chal-lenging. We recommend consideration of PPV with sili-cone oil, as many of these patients are at high risk for developing PVR.
REFERENCES
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Nicolas A. Yannuzzi, MD, can be reached at the Department of Ophthal-mology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136; email: [email protected].
Swarup S. Swaminathan, MD, can be reached at the Department of Oph-thalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136; email: [email protected] Hussain, MD, can be reached at the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136; email: [email protected] Hsu, MD, can be reached at the Retina Service of Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, Suite 1020, Philadelphia, PA, 19107; email: [email protected] Sridhar, MD, can be reached at the Department of Ophthalmol-ogy, Bascom Palmer Eye Institute, University of Miami Miller School of Medi-cine, 900 NW 17th Street, Miami, FL 33136; email: [email protected].
Disclosures: Dr. Sridhar has received honoraria from Alcon, Alimera, and Thrombogenics. The remaining authors report no relevant financial disclosures.
