Clinical Presentation and Management of Eyes with Globe Perforation during Peribulbar and Retrobulbar Anesthesia: A Retrospective Case Series

Abstract

Purpose: To evaluate the clinical presentation, management, and outcome of eyes with an inadvertent globe perforation during peribulbar or retrobulbar block.Methods: This retrospective study evaluated the eyes which had an accidental globe perforation during local ocular anesthesia from 2012 to 2020. The patients were divided into three groups: group 1, Clear media with no rhegmatogenous retinal detachment (RRD); group 2, significant vitreous hemorrhage (VH) precluding the retinal view without RRD; and group 3, RRD with/without VH.Results: Twenty-five patients were included in the study. The mean axial length (AL) was 24.7 ± 2.7 mm (range, 20.9–31.2 mm). The most common presenting feature was VH (n = 14). The treatment included retinal laser barrage (n = 7) and vitrectomy (n = 17). Retinal breaks were identified in all the eyes (total breaks = 37). The mean presenting best-corrected visual acuity in groups 1, 2, and 3 were logarithm of the minimum angle of resolution 0.79 ± 0.73, 1.82 ± 0.78, and 2.13 ± 0.59 respectively. All the treated patients had an attached retina at the last follow-up. The mean final best-corrected visual acuity for each group was logarithm of the minimum angle of resolution 0.59 ± 0.79, 0.48 ± 0.26, and 1.25 ± 0.64, respectively (p = 0.006). The development of RRD was associated with a larger AL (p = 0.015); while the development of significant VH associated with the superior location of the perforation (p = 0.015), late recognition of the perforation (p = 0.004), and multiple perforations (p = 0.015).Conclusions: Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer AL, superior, and multiple perforations are at higher risk of developing complications like RRD and VH. Complications like RRD, macular injury, and vascular occlusion are risk factors for poor prognosis.

Globe penetration during loco-regional anesthesia: prevalence and review of cases

“…Some anaesthetists use 30 G needles, but many find them too flexible [47] . Regarding the described prognosis factors, outcomes were related to: 1) early recognition, 2) absence of RD, and 3) site of penetration [12,32,[50][51][52][53] . In the present study, Case 1 had the worst outcome and developed a severe proliferative vitreoretinopathy (PVR) with resultant re-detachment of the retina, probably due to the presence of subretinal hemorrhage and the intensity of the laser that we had to apply around the iatrogenic rupture, which could induce more inflammation and a PVR that evolved to form a contraction star.…”

“…Described risk factors for globe penetration are posterior staphyloma, long axial length, inexperienced personnel. The use of sharp long needles and the use of multiple injections [12] . This study analyses the prevalence of inadvertent penetration of the globe during intraorbital injections of local anesthesia over five years at Centro de Oftalmología Barraquer and details the clinical features, management and subsequent course of four cases that suffered it.…”

Inverted ILM Flap for a Needle Injury to the Macula after Peribulbar Anaesthesia: A Case Report and Literature Review

“…Described risk factors for globe penetration include posterior staphyloma [ 4 ], long axial length [ 5 ], inexperienced personnel [ 6 ], uncooperative patients [ 7 ], the use of sharp long needles, and the use of multiple injections [ 8 ]. The risk of perforation is 10 to 30 times higher in highly myopic eyes with axial lengths ≥ 26.0 mm that are otherwise normal [ 11 ].…”

“…Wearne et al [ 25 ] reported that 78% of patients had poorer BCVA than counting fingers with RD. Babu et al [ 8 ] reported that 40% of patients with BCVA > 20/200 had RD.…”

Commentary: Scleral penetration or perforation during strabismus surgery

“…[ 1 ] However, unlike inadvertent perforation during peribulbar anesthesia, the incidence of sight-threatening consequences after strabismus surgery is usually low. [ 4 ] This may be because of superficial penetration limited to the choroid or formed vitreous, which tamponades the retinal breaks. [ 1 ]…”