Two Case Reports of a Purtscher-like Retinopathy Occurring after Retrobulbar Anesthesia

PURPOSE: Although there are significant risks, retrobulbar anesthesia is commonly used for eye surgery. We report two cases of Purtscher-like retinopathy, a rare complication. CASE SUMMARY: (Case 1) A 76-year-old female visited our hospital because of decreased vision. She underwent right cataract surgery with retrobulbar anesthesia. After 7 days, she had decreased visual acuity (VA) and a constricted visual field. Multiple white spots and cotton wool spots around the optic nerve and post pole, macular edema (ME), and subretinal fluid (SRF) were found using a fundus examination. A non-perfusion area and staining of the vascular wall were seen using fluorescence angiography. Although carotid arterial angiography, thrombolysis, and intravenous injection of high-dose steroids were performed, the ME and SRF persisted. After intravitreal aflibercept was injected twice (2-month interval), the ME and SRF decreased and remained stable. (Case 2) A 61-year-old male underwent left cataract surgery with retrobulbar anesthesia. After anesthesia, the VA of the left eye was 10 cm finger count. The fundus examination showed multiple hemorrhage blots and retinal hemorrhages, and hyperfluorescence around the optic nerve and post pole; vascular wall staining revealed a Purtscher-like retinopathy. Left carotid arterial angiography, thrombolysis, and intravenous injection of high-dose steroids were then performed. After treatment, the VA of the left eye, ME, and SRF were improved at the 4-month follow-up. CONCLUSIONS: We report rare complications of retrobulbar anesthesia, with active and timely treatment having a positive impact on the visual prognosis.

Influence of retrobulbar anesthesia or atropine pretreatment before strabismus surgery for oculocardiac reflex in children / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To assess the effect of applying retrobulbar anesthesia or atropine pretreatment as an available method to prevent oculocardiac reflex(OCR). <p>METHODS:A total of 92 pediatric patients(166 eyes)aged 5-13 years old who underwent elective strabismus surgery from March 2015 to March 2016 were enrolled and randomly assigned into three groups. Traditional anesthesia(TA)group was intravenously injected with propofol 2 mg/kg, fentanyl 1 mg/kg and atracurium 0.5mg/kg. Retrobulbar anesthesia(RA)group received both traditional anesthesia and retrobulbar injection of 2% lidocaine 2mL. Atropine pretreatment(AP)group received both traditional anesthesia and intravenous injection of atropine 0.15 mg/kg before surgery. The heart rate decreased by over 10% from the baseline value was considered as OCR positive. The anesthesia time, operation time, the baseline value of heart rate and the muscles induced OCR were recorded and analyzed. <p>RESULTS:The incidence of intraoperative OCR was 20% in RA group, 22% in AP group and 58% in TA group. There was no significant difference in anesthesia time, operation time, the baseline value of heart rate and corrective rate of postoperative eye position among three groups(<i>P></i>0.05). <p>CONCLUSION: Retrobulbar anesthesia and atropine pretreatment both effectively reduced the incidence of OCR in children's strabismus surgery, which could be potentially effective methods to prevent OCR and further provide more operation security for children with strabismus.

Large exotropia after retrobulbar anesthesia.

A 67‑year‑old woman complained of horizontal diplopia shortly following bilateral cataract surgery with intraocular lens implantation performed under retrobulbar anesthesia. Retrobulbar anesthesia was administered at an inferotemporal injection site using 1 cc lidocaine hydrochloride 2% mixed with bupivacaine hydrochloride 0.5%. The initial ophthalmologic evaluation showed a 12‑prism diopter (PD) exotropia, and ocular motility evaluation revealed marked limitation of adduction without vertical limitation. One year after cataract surgery, the exodeviation increased up to 60 PD. The patient underwent an 8.0‑mm recession of the right lateral rectus and a 6.0‑mm recession of the left lateral rectus. Both lateral rectus muscles were biopsied, and biopsy revealed dense fibrous connective tissue without viable muscular cells. The lateral rectus muscle might be injured by retrobulbar anesthesia, and it could induce large exotropia.

Iatrogenic Central Retinal Artery Occlusion Following Retrobulbar Anesthesia for Intraocular Surgery

PURPOSE: To present clinical features of central retinal artery occlusion (CRAO) following retrobulbar anesthesia for intraocular surgery. METHODS: This observational case series describes 5 consecutive patients with acute CRAO following retrobulbar anesthesia for intraocular surgery. Data collected for this study included subject characteristics, retrobulbar anesthesia technique, treatment type, initial and final best-corrected visual acuity, and other ophthalmologic examinations. RESULTS: Mean subject age was 67.0 +/- 8.2 years (range, 53 to 72 years). All patients had one or more vascular risk factors (e.g., hypertension, cerebral infarction, carotid artery stenosis) and presented with acute vision loss 1 day after uneventful intraocular surgery (cataract surgery in 2 eyes and vitrectomy in 3 eyes). All 5 patients received retrobulbar anesthesia during surgery, 4 of which involved the use of a sharp needle. No immediate complications were noted during intraocular surgery. Final visual prognosis was poor (from finger count to no light perception) although intraocular thrombolysis was attempted in 3 patients. CONCLUSIONS: Iatrogenic CRAO is a potential complication of retrobulbar anesthesia for intraocular surgery in elderly patients with vascular risk factors. Unfortunately, this complication can lead to severe vision loss. We conclude that retrobulbar anesthesia for intraocular surgery should be performed with great care and special consideration for elderly patients with vascular risk factors.

Bloqueo retrobulbar guiado por ultrasonido: ¿es posible? / Ultrasound-guided retrobulbar blockade

Introducción: La anestesia retrobulbar proporciona excelentes condiciones para la cirugía de cataratas, sin embargo conlleva riesgo de grave daño sobre estructuras nobles. La siguiente serie de casos tiene por objetivo describir el uso de ultrasonografía como guía imagenológica en el bloqueo retrobulbar, para facoeresis e implante de lente intraocular. Método: Se llevó a cabo una serie de 4 casos, en que se utilizó ultrasonido con un transductor lineal de alta frecuencia, para mapeo e inserción de aguja de bloqueo retrobulbar bajo visión ecográfica en tiempo real. Resultados: Se obtuvo visión de la aguja y posicionamiento de ella en el cono muscular retrobulbar e infi ltración con anestésico local en los cuatro pacientes, logrando anestesia total en todos los casos, aquinesia total en tres y parcial en uno. No hubocomplicaciones atribuibles al procedimiento. Conclusión: Creemos que la ultrasonografía no es sólo factible, sino que podría ser un verdadero aporte en la seguridad de la anestesia ocular.

Background: Retrobulbar anesthesia provides excellent surgical conditions for cataract surgery. However, it conveys the risk of serious damage to fragile structures. The aim of this study is to describe the use of ultrasonography as a guide for retrobulbar blockade in surgical cataract patients. Methods: A series offour cases was selected and a high frequency linear ultrasound transducer was used for initial scanning andperforming of a real-time ultrasound-guided retrobulbar blockade. Results: Ultrasound images were used for needle positioning in the muscular cone of the eye and local anesthetic infiltration was performed in four patients. Complete anesthesia was achieved in all cases and complete akinesia was obtained in three, with partial akinesia in the remaining case. There were no complications in this series. Conclusion: We believe that ultrasound guided retrobulbar blockade is a feasible technique and it could be a real improvement on the safety of ophthalmic anesthesia.

Combined Central Retinal Vein and Artery Occlusion After Retrobulbar Anesthesia: A Case Report

PURPOSE: To report central retinal vein and artery occlusion after retrobulbar anesthesia for a cataract operation. CASE SUMMARY: A 65-year-old woman was transferred to our facility 4 days after she had undergone cataract extraction with IOL implantation. She could count fingers and had a relative afferent papillary defect in her left eye. As seen upon fundus examination, dot-shaped, circular-shaped irregular, and partially linear-shaped retinal hemorrhages were evident. Fluorescein angiography revealed that branch arteries around the nasal and temporal areas were not filled, and that the filling of veins was delayed. After two weeks, the patient was only able to recognize hand motion, and her intraocular pressure was 10 mmHg. According to a fundus examination, the size and quantity of retinal hemorrhages increased, and a pale, macular edema was observed. Following fluorescein angiography, the filling defect of branch vessels on the nasal and temporal areas was still evident, and the blocked fluorescence of capillaries on the fundus was prominent. After two months, she could still only recognize hand motion, and her intraocular pressure had increased to 35 mmHg; we therefore diagnosed a neovascular glaucoma. CONCLUSIONS: A patient experienced a serious central retinal vessel occlusion after retrobulbar anesthesia for cataract extraction. Retrobulbar injections should therefore be administered with great caution to prevent this outcome.

Etiological Factors of the Ptosis After Cataract Surgery

To investigate the change in upper eye lid position after cataract operation with retrobulbar anesthesia and bridle suture, we studied 60 eyes of 60 patients randomized into 3 groups, group I received retrobulbar anesthesia and bridle suture, group II received retrobulbar anesthesia and group III received topical anesthesia.The measurement of interpalpebral fissure, levator function were taken at pre-op, post-op 1 week, post-op 4 weeks.The post operative mean palpebral fissure height and mean levator function decreased compared with those of the preoperative state but there were improvement of their ptosis with times.The incidence of ptosis at post operative 4 weeks was highest in group I with both retrobulbar anesthesia and bridle suture and lowest in group III with topical anesthesia (p=0.035).The result of this study indicate that ptosis after cataract surgery can be induced by various our operative techniques including retrobulbar anesthesia and bridle suture.We found there'll be many other causes of ptosis from the result of variant ptosis in group III with topical anesthesia.

A Case of Severe Neurological Damage and Blindness after Infection of Lidocaine for Cataract Operation

At the present time, lidocaine is commonly used in ophthalmic surgery as a local anesthetic. Although it is safer than general anesthesia, visionthreatening and even life-threatening side effect can occur rarely. We report one case of visual loss combined with severe neurologic damage after local injection of lidocaine. Fifty-year-old male patient underwent phacoemulsification and IOL transscleral implantation with unplanned anterior vitrectomy after Nadbath-Ellis akinesia and retrobulbar anesthesia with lidocaine with 1:100,000 epinephrine. After operation, the patient had visual loss, facial palsy, total ophthalmoplegia, severe proptosis and submandibular swelling. There were no evidences of eyeball perforation, retrobulbar hemorrhage, and direct nerve injury. Although the mechanism of nerve injury is not well explainable, we suggest lidocaine toxic reaction. To our knowledge, This is the first reported case in the literature. We report this case with available literature review.

Comparison of Effects of Topical, Pinpoint and Retrobulbar Anesthesin in Cataract Surgery using Clear Corneal Incision

In order to evaluate the efficacy of topical anesthesia as an alternative to pinpoint or retrobulbar anesthesia in clear corneal cataract surgery, ninety patients were randomly assigned to the topical(n=30), pinpoint(n=30), or retrobulbar(n=30) anesthesia groups prospectively. All procedures including CCC, phacoemulsification, and foldable IOL implantation were performed using a temporal clear corneal approach by one surgeon(Joo). visual rehabilitation, change of astigmatism, degree of pain, comfortability, cooperation, and intraoperative and postoperative complications were compared. Intraocular pressure was higher in pinpoint anesthesia than in topical anesthesia at the beginning point of operation(p<0.05). Four hours after surgery, topical of pinpoint anesthesia group had significantly better visual acuity than retrobulbar anesthesia group(p<0.05). Pain score in topical anesthesia was marginally higher than that in retrobulbar anesthesia during the phacoemulsification. Comfortability was prominent in topical anesthesia group. There was no difference among the groups in change of astigmatism, cooperation and risk of serious complicatins. With these results it was found that topical anesthesia would be a safe, effective alternative to pinpoint or retrobulbar anesthesia in cataract surgery using clear corneal incision.

Transient Visual Loss after Retrobulbar Anesthesia in the Advanced Glaucoma Patients

Retrobulbar Anesthesia is injecting local anesthetics into the retrobulbar space within the muscle cone, which affects the third cranial nerve, ciliary ganglion and optic nerve. Proper retrobulbar anesthesia can temporarily weaken somatosensory, motor and visual sensory. It also narrows visual fields. However, it does not result in complete loss of visual acuity. According to the authors, all 4 advanced cases which showed transient and complete visual loss after retrobulbar anesthesia of Lidocaine Hcl[2% lidocaine, einephrine, 1:100,000] were advanced glaucoma patients who had normal fundus except glaucomatous change and self-recovered within 1 to 4 hours. The decrease in vision may be related to the effects of the anesthetic agent on the optic nerve, or it may be related to the relative ischemia produced by compression, or caused by entopsias induced by compression. The authors cases suggest that transient visual loss after retrobulbar anesthesia may not reduce postoperative visual acuity and visual fields in the advanced glucoma patients.

Comparision of Ocular pain Between Topical and Retrobulbar Anesthesia for Cataract Surgery

We analysed a perceiving pain at each step (8 step: traction suture, wound incision, anterior capsulotomy, phacoemulsification, irrigation and aspiration, intraocular lens (IOL) implantation, wound suture, subtenon's injection) of cataract surgery by using visual analogue scale (0-10), prospectively. One hundred cases of cataract surgery were performed from November 1995 to March 1996 at Chonnam national university hospital and topical or retrobulbar anesthesia prior to cataract surgery was applied to each 50 patients. There was no difference of age, sex, running time for surgery, and incision method between topical and retrobulbar anesthesia. Pain scores at phacoemulsi fication. irrigation and aspiration, and subtenon's injection were higher than those at other steps in both types of anesthesia. However, a major range of pain scores at each step except of subtenon's injection was mild (1-3). In topical anesthesia, pain score was higher than retrobulbar anesthesia, but there was no statistically significant difference except a step of subtenon's injection. In conclusion, topical anesthesia might be an adequate anesthetic method for cataract surgery.

Comparison on Preoperative Intraocular Pressure Elevation after Performing between Pin Point Anesthesia and Retrobulblar Anesthesia

The importance of the preoperative intraocular pressure cannot be overemphasized for cataract operation. We compared the preoperative intraocular pressure between the conventional retrobulbar anesthesia technique and the pin point anesthesia technique with different anesthetic dosage using tono-pen in 23 patients(41 eyes) divided into 4 groups. In the 1st group(10 eyes), after conventional retrobulbar injection was performed using 3ml of 2% lidocaine, digital massage was done for 10 minutes. In 2nd group(13 eyes), 2% lidocaine 1.0ml was injected into subtenon's space(true muscle cone) through the small hole in the superior temporal quadrant 8mm posterior to limbus using specially designed blunt, curved cannula without any method to decrease the intraocular pressure (pin point anesthesia). In the 3rd group(13 eyes), and 4th group(5 eyes), same procedure was performed as 2nd group using 0.75ml and 0.50ml of 2% lidocaine respectively. As a results, in 1st group, average intraocular pressure was decreased around 5.6mm Hg after digital massage. In the 2nd, 3rd, and 4th group, preoperative intraocular pressure increased by 2.2, 0.8, and 0.5mmHg. As comparison of three group of the pin point anesthesia, in the 2nd group, sometimes there were mild chemosis, in the 4th group, often discomfort, in contrast, in 3rd group there were no chemosis, pain or discomfort. As a conclusion we want to recommend a pin poit anesthesia using 0.75ml of 2% lidocaine for the routine cataract operation.

The Change of Intraocular Pressure: Retrobulbar vs Peribulbar Anesthesia

In order to compare the influence of retrobulbar and peribulbar anesthesia technique to the change of intraocular pressure(IOP), we measured the IOP sequentially in 40 eyes of 40 patients(retrobulbar group: 20 eyes, peribulbar group: 20 eyes). The intraocular pressure was checked at one hour prior to operation, just after application of Honan apparatus with 30 mmHg for 30 minutes, just after the injcetion of anesthetics with technique retrobulbar and with peribulbar technique, and after digital massage for 5 minutes. Injected volume of anesthetics was 3 ml in retrobulbar technique and 6 ml in peribulbar technique. In retrobular group, the IOP mean was 16.55 mmHg at one hour prior to operation, 10.96 mmHg just after Honan application, 17.36 mmHg just after the injection of anesthetics and 10.38 mmHg after digital massage. In peribulbar group, the IOP mean was 16.97 mmHg at one hour prior to operation, 11.08 mmHg just after Honan application, 18.11 mmHg just after the injection of anesthetics and 11.31 mmHg after digital massage. The mean increase of IOP after the injection of anesthetics was 6.40 mmHg in retrobulbar group and 7.03 mmHg in peribulbar group. There was no statistical difference in the change of IOP between the two groups.(Student t-test, p>0.10).