Complications of Ophthalmic Regional Blocks: Their Treatment and Prevention

Kumar, Chandra M.; Dowd, T C

doi:10.1159/000090570

Cited by 71 publications

(67 citation statements)

References 115 publications

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“…7 Topical anaesthesia with local anaesthetic drops or gel Here, local anaesthetic eye drops or gel is applied to the surface of the eye for anaesthesia. Rectus muscles are therefore not affected; anaesthesia is never complete and there is no akinesia.…”

Section: Sub-tenon's Blockmentioning

confidence: 99%

“…Eyes with an axial length of more than 26 mm are more prone to globe damage (perforation and penetration); the risk of damage to the globe and optic nerve is also greater when the globe is rotated during injection. 7 It is therefore safer to introduce a needle as far laterally as possible because, if it is introduced at the junction of the medial two-thirds and lateral one-third of the inferior orbital rim, the inferior rectus, the inferior oblique muscles and their nerves may be damaged. 14 Needle blocks are generally avoided in patients receiving anticoagulants and sub-Tenon's block; in such cases, topical anaesthesia is preferred.…”

Section: Assessment and Preparation Of Patients Before Loco-regional mentioning

confidence: 99%

“…Both retrobulbar and facial nerve blocks were associated with significant reported complications and the technique has undergone recent changes. 7 In modern retrobulbar block, the globe is kept in the neutral gaze position and a shorter needle (< 31 mm) is inserted as far as possible in the extreme inferonasal quadrant either perconjunctivally or percutaneously. Surface anaesthesia (oxybuprocaine or a similar eye drop) is essential for perconjunctival insertion.…”

Section: Introductionmentioning

confidence: 99%

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Ophthalmic loco-regional anaesthesia: Reducing discomfort during injection

Zundert

Kumar

2008

Southern African Journal of Anaesthesia and Analgesia

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Loco-regional anaesthesia is commonly used for both intraocular and extraocular surgical procedures, although the provision and use of the anaesthetic technique varies worldwide. Injection techniques (retrobulbar, peribulbar and sub-Tenon's blocks) are associated with significant pain; indeed, many patients have a fear of pain. Discomfort during injection can, however, be reduced and patients can be made comfortable through reassurance, careful performance of the technique and the provision of sedation and/or analgesia. In this article, the authors describe common loco-regional anaesthetic techniques and measures to reduce discomfort during injection, thus improving patient satisfaction.

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Section: Sub-tenon's Blockmentioning

confidence: 99%

Section: Assessment and Preparation Of Patients Before Loco-regional mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Ophthalmic loco-regional anaesthesia: Reducing discomfort during injection

Zundert

Kumar

2008

Southern African Journal of Anaesthesia and Analgesia

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“…With no evidence for intravascular injection, the lack of structural brain abnormalities, and the most striking feature on post mortem examination being severe triple vessel coronary artery disease, it was concluded that this was primarily cardiac in origin; however, the possibility of brainstem anaesthesia should also be considered. The use of sub-Tenon's block for cataract surgery is becoming increasingly popular in the UK and it is felt to be a safer alternative to other anaesthetic techniques, despite the lack of a randomised double-blind study to validate conclusions regarding its relative safety [1]. 'Brainstem anaesthesia' is a complex phenomenon which may result from local anaesthesia entering the central nervous system, and it is a recognised complication of ophthalmic regional blocks, with various postulated and debated mechanisms and variable presentation [2].…”

mentioning

confidence: 99%

“…The use of sub-Tenon's block for cataract surgery is becoming increasingly popular in the UK and it is felt to be a safer alternative to other anaesthetic techniques, despite the lack of a randomised double-blind study to validate conclusions regarding its relative safety [1]. 'Brainstem anaesthesia' is a complex phenomenon which may result from local anaesthesia entering the central nervous system, and it is a recognised complication of ophthalmic regional blocks, with various postulated and debated mechanisms and variable presentation [2].…”

mentioning

confidence: 99%

Death potentially secondary to sub‐Tenon's block

Quantock¹,

Goswami

2006

Anaesthesia

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SummaryAn 82-year-old ASA 2 patient underwent routine sub-Tenon's block for cataract surgery. One minute after injection of the local anaesthetic, the patient had a generalised tonic-clonic seizure and developed refractory ventricular fibrillation; subsequent resuscitation was unsuccessful. With no evidence for intravascular injection, the lack of structural brain abnormalities, and the most striking feature on post mortem examination being severe triple vessel coronary artery disease, it was concluded that this was primarily cardiac in origin; however, the possibility of brainstem anaesthesia should also be considered. The use of sub-Tenon's block for cataract surgery is becoming increasingly popular in the UK and it is felt to be a safer alternative to other anaesthetic techniques, despite the lack of a randomised double-blind study to validate conclusions regarding its relative safety [1]. 'Brainstem anaesthesia' is a complex phenomenon which may result from local anaesthesia entering the central nervous system, and it is a recognised complication of ophthalmic regional blocks, with various postulated and debated mechanisms and variable presentation [2]. To date there have been no reported deaths in connection with a sub-Tenon's block. The following is a case report of a death potentially secondary to inadvertent subarachnoid injection. Case historyAn 82-year-old female presented for an elective cataract operation. On a routine pre-operative visit she was found to be a known hypertensive on 2.5 mg bendrofluazide once daily. She denied having any history of myocardial infarction, angina, epilepsy or allergic reactions. Her blood pressure was 178 ⁄ 94 mmHg and her pulse rate 76 beats.min . She had undergone general anaesthesia previously, but she had not had cataract surgery. Her left axial globe length was 25.83 mm. No pre-operative ECG was performed.In the anaesthetic room she was calm and was happy to proceed with the sub-Tenon's block.She was monitored using pulse oximetry and electrocardiography, and following venous cannulation with a 22G cannula in her left hand, 1% amethocaine was instilled followed by 5% povidine eye drops.A 19G 25-mm (1-inch) sub-Tenon's metal cannula was used to perform a left sub-Tenon's block in the inferior nasal quadrant. After a negative aspiration, 3 ml of the injectate, which contained 750 IU hyalase in a 50 : 50 mix of 2% lidocaine and 0.5% bupivacaine, was injected over 3-4 min. She complained of a little discomfort, but no change in heart rate was noted.Within 1 min of performing the sub-Tenon's block, in mid sentence, the patient stopped talking and had a generalised tonic-clonic seizure.She was immediately turned to her right, ventilated with 100% oxygen via a Bain's circuit and given 2 mg midazolam intravenously. She was then discovered to have no pulse and to be in ventricular fibrillation.Adrenaline 1 mg was administered intravenously whilst the paddles of the defibrillator were attached, and three stacked shocks were administered: 200 J, 200 J, 360 J. She remained in ...

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Surgical Techniques for Orbital Tumors

Karcioglu

2019

Surgical Ophthalmic Oncology

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Many mid and deep orbital surgeries in adults and virtually all procedures in children are performed under general anesthesia; however, anterior orbit explorations and/or simple biopsies in adults can be performed with local anesthesia and intravenous sedation [1]. The administration of regional anesthetics, even when general anesthesia is used, containing epinephrine about 5-15 min prior to incision into the soft tissues of the surgical field contributes to vasoconstriction significantly. If nasal or sinus involvement is anticipated during the orbital exploration, it may be helpful to use a vasoconstrictive nasal spray and pack the nose with halfinch gauze-strip, soaked in Neosynephrine or another vasoconstrictive agent [2]. All local anesthetic solutions are prepared as weak hydrochloride salts to extend their shelf lives and to stabilize added vasoconstrictors. However, this weak acid assembly delays their onset of action and makes them painful on injection. Lidocaine (1% or 2%) is the most widely used local anesthetic and produces the least amount of pain on injection. Anesthetics commonly utilized can be generally ordered on a scale from least to most painful for injection: lidocaine 1%, procaine 2%, bupivacaine 0.5%, and etidocaine 1%. Pain during injection varies with pH of solution, osmolality, lipid solubility, temperature, the speed of injection, size of needle, as well as other environmental and emotional patient-related factors [3, 4]. Addition of epinephrine (1:100,000, 1:200,000, 1:400,000) for vasoconstriction decreases the absorption rate, prolongs the action, but increases the pain of local anesthetics at injection. At the incision site, lidocaine with epinephrine is usually injected subcutaneously into deeper soft tissues. The use of a long-acting local anesthetic, administration of an IV steroid to minimize inflammation and utilization of a nonsteroidal anti-inflammatory drug on a regular basis will minimize the need for postoperative opioids, and this works well in ASA I and II patients. The effect of local anesthetics begins approximately 5 and 4 min after injection without and with epinephrine respectively. The duration of the effect ranges from 1 to 2 h. The maximum recommended dose is 4.4 mg/kg without epinephrine and 7.0 mg/kg with epinephrine. Lidocaine, like all other local anesthetics, may lead to systemic toxicity with increased BP and heart rate, arrhythmias, dysrhythmias, and CNS signs and symptoms of drowsiness, seizures, and

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Complications of Ophthalmic Regional Blocks: Their Treatment and Prevention

Cited by 71 publications

References 115 publications

Ophthalmic loco-regional anaesthesia: Reducing discomfort during injection

Ophthalmic loco-regional anaesthesia: Reducing discomfort during injection

Death potentially secondary to sub‐Tenon's block

Surgical Techniques for Orbital Tumors

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