179
International Ophthalmology 21: 179–185, 1998.
c 1998 Kluwer Academic Publishers. Printed in the Netherlands.
Inadvertent globe perforation during retrobulbar injection in high myopes
Mehdi Modarres1 , Mohammad M. Parvaresh1 , Masih Hashemi1 & Gholam A. Peyman2
1
Department of Ophthalmology, Rasool Akram Medical Center, Iran University of Medical Sciences, Tehran,
Iran; 2 the LSU Eye Center, Louisiana State University Medical Center School of Medicine, New Orleans, LA, USA
Accepted 29 August 1997
Key words: myopia, perforating injuries, retrobulbar injection
Abstract
Purpose: To report ocular perforation that occurred during retrobulbar injection in 7 highly myopic eyes. Methods:
Seven patients with a diagnosis of globe injury during retrobulbar injection for ocular anesthesia before cataract
surgery were managed by vitreoretinal surgery. All injections were performed by ophthalmologists. The surgeon
recognized the perforation in 4 cases at the time of injection. The preoperative vision was hand motion perception
in 4 eyes and light perception in 3 eyes. All patients underwent vitreoretinal surgery because of the presence of
vitreous hemorrhage and/or retinal detachment diagnosed by funduscopy or ultrasonography. At the time of surgery,
all eyes had vitreous hemorrhage and 4 eyes had rhegmatogenous retinal detachment. The number of vitreoretinal
procedures performed was: 1 procedure in 4 patients, 2 procedures in 2 patients, and 3 procedures in 1 patient. The
period of follow-up ranged from 4 months to 4 years, averaging 20 months. Results: At the end of the follow-up
period, the retina was attached in 6 patients. The postoperative vision was 20/400 in 3 eyes, finger counting in 3
eyes, and light perception in 1 eye. Conclusion: Special care should be taken in retrobulbar injection of highly
myopic globes, which have an increased risk of perforation. The functional outcome of surgical repair of these eyes
was poor.
Introduction
The use of local anesthesia for eye surgery was
first introduced by Knapp [1] in 1884; Atkinson [2–
4] first described the injection of local anesthetic
into the muscle cone; his technique of retrobulbar
anesthesia has been standard for many years, and
although modified [5, 6], remains one of the mostly commonly used techniques for ocular anesthesia.
Since the early 1980s, numerous reports of complications of retrobulbar anesthesia have appeared in
the literature. These complications include cardiopulmonary arrest [7, 8], grand mal seizures [9], retrobulbar hemorrhage resulting in central retinal artery
occlusion [10–12], optic neuritis [13], optic atrophy
[14, 15], blindness from retrobulbar injection into
the optic nerve [16], contralateral amaurosis [17, 18],
contralateral nerve palsies [19, 20], choroidal vascular occlusion, subretinal air [20], Purtscher’s type of
retinopathy from intraneural injection [21, 22], and
direct injury of the globe with the injection needle
causing ocular penetration or perforation [23-28]. The
largest series of globe perforations ever reported is that
by Duker et al. [29] in 1991, consisting of 20 myopic
and nonmyopic eyes. We hereby report our experience with ocular perforation, using the classification
by Kuhn et al. [30], during retrobulbar injection in 7
highly myopic eyes, all with posterior staphyloma.
Patients and methods
Between June 1990 and September 1995, 7 patients
were managed by us with the diagnosis of globe injury
during retrobulbar injection for cataract surgery (Figure 1). One patient sustained globe injury during such
an injection in our center and the others were referred
by other physicians. Peribulbar anesthesia was not used
for any of these patients. All injections were administered by ophthalmologists. The injection needle was
180
Figure 1. Schematic diagram of location of ocular perforations in 7 patients who underwent retrobulbar injection. The numbers refer to the
patient’s number in the series.
Table 1. Preoperative findings
Patient
number
Gender
Age
VA
Positive findings
in anterior segment
IOP (mm Hg)
Funduscopic
findings
Time from perforation
to referral
1
2
3
4
5
6
7
F
F
M
M
F
M
F
50
60
62
55
54
68
72
LP
LP
LP
HM
HM
HM
HM
Corneal edema & aphakia
Corneal edema & pseudophakia
Corneal edema & aphakia
Corneal edema & cataract
Corneal edema & cataract
Cataract
Pseudophakia
2
4
10
8
0
3
14
NV (VH)
NV (VH)
NV (VH)
NV
NV
NV
Hazy media
RD, VH, PVR
1 day
14 days
7 days
1 day
1 day
Immediate vitrectomy
20 days
NV = not visible; VH = vitreous hemorrhage; RD = retinal detachment; LP = light perception; HM = hand motion; AS = anterior segment;
PVR = proliferative vitreoretinopathy.
sharp in 4 cases. The kind of needle could not be verified in 3 cases.
Four of the patients were female and three were
male. Their ages ranged from 50 to 72 years (average
60 years). The extent of myopia was 12.0 to 24
diopters, as determined by measuring prior glasses and
biometric measurement of the involved eye and the
fellow eye in patients with bilateral myopia. None of
the eyes had previous scleral buckling or any other
surgery.
In 4 patients, the surgeon diagnosed ocular perforation at the time of the injection. The surgery was cancelled in 2 of these cases and the patients were referred
to us for vitreoretinal management. In 1 patient, the
globe was reformed with the injection of balanced
salt solution (BSS Plus), and the cataract surgery was
performed uneventfully. The fourth patient had ocular
perforation during retrobulbar anesthesia in our center
and the lens removal was combined with immediate
vitreoretinal surgery. In the other 3 patients, the ocular perforation was not diagnosed during injection and
patients were referred postoperatively for management
of vitreous hemorrhage.
The initial examination included measurement of
visual acuity, afferent pupillary defect, ocular motility examination, slit-lamp examination, measurement
of intraocular pressure (IOP), detailed dilated indirect funduscopy, and A-scan and B-scan ultrasonography. Preoperative findings in all patients are shown
in Table 1 and ultrasonographic findings in Table 2.
181
Table 2. Preoperative ultrasonographic findings
Patient number
Ultrasonographic findings
1
2
3
4
5
6
7
Posterior staphyloma, total PVD, VH, localized hemorrhagic RD
Posterior staphyloma, total PVD, VH
Posterior staphyloma, total PVD, VH
Posterior staphyloma, total PVD, VH, RD
Posterior staphyloma, total PVD, VH
Ultrasonography not performed; immediate vitrectomy
Total PVD, VH, RD
PVD = posterior vitreous detachment; RD = retinal detachment; VH = vitreous hemorrhage.
Table 3. Intraoperative findings
Patient number
Intraoperative findings
1
2
3
4
5
6
7
Total PVD, dense VH, localized hemorrhagic RD, perforation, posterior staphyloma
Total PVD, VH, hemorrhagic RD, subtotal RRD, perforation, posterior staphyloma
Total PVD, localized hemorrhagic RD around perforation site, VH, posterior staphyloma
Total PVD, VH, perforation, RRD, posterior staphyloma
Total PVD, VH, perforation, posterior staphyloma
PVD, VH, hemorrhagic RD at perforation sites and macula, perforation, posterior staphyloma, RRD
Total PVD, VH, RRD, perforation, posterior staphyloma
PVD = posterior vitreous detachment; RRD = rhegmatogenous retinal detachment; VH = vitreous hemorrhage; RD = retinal
detachment.
The preoperative visual acuity was light perception with projection in 3 eyes and perception of hand
movements in 4 eyes.
A three-port bimanual pars plana vitrectomy was
performed in all patients. After total removal of the
vitreous, as much of the posterior hyaloid face was
removed as possible. Any epiretinal membranes were
removed. Liquid perfluorocarbon was used to reattach
the retina in cases of retinal detachment. Endolaser
photocoagulation was performed around the needle
entrance and exit sites and posterior to the vitreous
base for 360deg in 3 or 4 rows. A total perfluorocarbon liquid-air exchange was performed. An encircling
band (No. 240, Mira) was placed around all globes
midway between the ora and the equator. At the end of
the procedure, SF6 (2 eyes) or C3 F8 (5 eyes) gas was
injected in nonexpanding concentrations.
Results
All eyes were found to have posterior staphyloma at
vitrectomy. All had perforations and both entrance and
exit sites of the needle were recognized in all cases.
The fundus findings at vitrectomy are summarized in
Table 3 and were generally consistent with ultrasonographic findings.
Two patients required one additional procedure and
1 patient underwent 2 additional procedures. Patient
No. 3 developed macular pucker 2 months after the initial surgery; this was repaired and the retina remained
attached. Patient No. 5 developed mild proliferative
changes from the posterior perforation, puckering the
macula, which was removed 4 months after initial
surgery. Patient No. 7 developed a total retinal detachment with proliferative vitreoretinopathy (PVR) C-3
one month after initial surgery and underwent repeat
vitreoretinal surgery with retinal reattachment. Four
months later, he developed macular pucker, which was
removed, and the retina remained attached. Patient No.
6 developed a total retinal detachment with PVR D-1
two months after initial vitrectomy, but refused further
surgery. Eventually, this case was the only failure in
this series. In the other 6 cases, the retina was attached
at the end of the follow-up period, which ranged from
4 months to 4 years, averaging 20 months. The postoperative vision was 20/400 in 3 eyes, finger counting
from 1-2 meters in 3 eyes, and light perception in 1
eye.
182
Discussion
Ocular perforation is a rare but serious complication
of local anesthesia for ocular surgery. The incidence
of globe perforation during the administration of ocular anesthesia can be estimated to be 0.1%. Cibis [31]
in 1965 reported 1 case of ocular perforation in 1000
retrobulbar injections delivered for retinal detachment
surgery. Ramsay and Knobloch [23] reported 3 cases of
globe perforation in 4000 retrobulbar injections administration for retinal detachment surgery. To reduce the
risk of globe perforation, the use of peribulbar anesthesia has been suggested [4, 32–34]. Davis and Mandel
[32] reported no incidence of ocular perforation in 2000
consecutive cases of peribulbar anesthesia. It should
be considered, however, that the incidences reported
by Cibis (0.1%) and Ramsay and Knobloch (0.075%)
were derived entirely from patients undergoing scleral buckling and therefore may have had a relatively
higher rate of high axial myopia.
Although the rate of globe perforation associated
with peribulbar injections may be less than that with
retrobulbar injections, its occurrence is well established [29, 34, 35]. Kimble and associates [36] reported
1 case of globe perforation in 200 consecutive cases of
peribulbar anesthesia by a single anesthesiologist who
had previously administered more than 4000 retrobulbar injections without any perforation. Of 12 ocular
perforations reported by Grizzard et al. [37] in 1991, at
least 4 were caused by peribulbar injection needles. To
date, there has been no report comparing the rates of
globe perforation between retrobulbar and peribulbar
injection techniques in similar patient series.
In our patients, all perforations occurred during
retrobulbar injections. Several risk factors for ocular perforation during local anesthesia for eye surgery
have been mentioned in the literature [23, 27, 31, 36,
38]. These factors include increased axial length in
eyes with high myopia, posterior staphyloma, presence
of scleral buckle, enophthalmos, use of sharp needles
for injection, multiple injections, and the administration of anesthetic injection by nonophthalmologists.
High myopic eyes frequently have long anteroposterior diameters and may be associated with posterior staphylomas and thus are especially prone to perforation by anesthetic needles. Birch and associates
[39] took ultrasound photographs of the globe during
retrobulbar injections for routine ocular surgery in 25
patients. They demonstrated that, when the needles
were in ‘proper position’, the distance between needle
tip and the posterior wall of the globe ranged between
0.2 to 3.3 mm. In 14 cases in their series, the needle shaft was actually seen to indent the globe. It is
obvious, then, that if retrobulbar injections are given
in a ‘routine’ manner in high myopic eyes, which have
larger anteroposterior diameters than average eyes and
may have posterior staphylomas, there is an increased
chance of ocular perforation during the passage of the
needle into the retrobulbar space. Duker and associates
[29], in their report of 20 ocular perforations from
retrobulbar and peribulbar injections, determined an
approximate incidence of 1 perforation in 140 injections in eyes with axial length equal or greater than
26 mm. This incidence rate (0.71%) is approximately
10 times the incidence of ocular perforation reported
by Ramsay and Knobloch in their mixed population
of patients with retinal detachment [23]. In addition to
large axial length, thinness of sclera in these patients
may be a factor which facilitates the perforation of the
globe. The perforation may go unnoticed because of the
decreased resistance of the sclera. The signs of ocular
perforation at the time of anesthetic injection include
hypotony, loss of red reflex, or the appearance of a dark
red reflex [40]. These signs are frequently overlooked
by the surgeons. From 12 cases of ocular perforation
reported by Rinkoff [40], ocular injury by needle was
noticed in only 5 cases at the time of injection. In the
series reported by Duker [29], ocular perforation was
noticed by the surgeon in only 10 of 20 cases. In our
patients, ocular perforation was recognized in 4 of 7
cases at the time of injection.
As this is a rare complication, the surgeon may
not have its possibility in mind, and the signs of perforation, especially when subtle, may escape his/her
attention. The eye may not be hypotonus and the presence of mature cataract prevents the visualization of
the dark red reflex. Also, the injection of anesthetic by
nonophthalmologists may be responsible for the lack
of recognition of the signs of perforation [37, 40].
The use of blunt needles to decrease the chance of
perforation is controversial. While some investigators
have strongly advocated the use of blunt needles to
decrease the chance of ocular perforation [20, 41, 42],
others have seriously questioned the safety of blunt
needles [37]. Ocular perforation from blunt needles has
also been reported [27, 37, 43] and it is conceivable that
the thin sclera of high myopes can be readily perforated
by both sharp and blunt needles. In our patients, the
majority of the injections were known to have been
performed using sharp needles.
The optimal management of the patients with ocular perforation during injection is of utmost concern.
183
Immediately after injection, when the surgeon recognizes or becomes suspicious of ocular perforation, indirect ophthalmoscopy should be performed. If there is
dense vitreous hemorrhage with or without visible retinal detachment, anterior segment surgery should be
cancelled and the patient should be referred to a vitreoretinal surgeon. Duker et al. [29] suggest that the
cataract surgery may be performed in cases where anesthesia is adequate, the eye is not hypotonus, and dense
cataract prevents visualization of the fundus. Even the
implantation of an intraocular lens may be considered,
as the subsequent vitreoretinal surgery may be performed with pseudophakos in place [44]. In our series,
of 4 patients in whom perforation was recognized during injection, the cataract surgery was cancelled in 3
and they were referred for vitreoretinal management. In
one patient, the globe was formed with injection of BSS
Plus and the cataract was removed. This patient, who
had dense vitreous hemorrhage at the time of referral,
underwent vitreoretinal surgery. The retina was found
to be attached, except for subretinal hemorrhage at the
site of posterior perforation, and remained attached
during the follow-up period.
However, if there is adequate visualization of the
fundus and the retina is not detached, it has been suggested that the cataract procedure be cancelled and
arrangements made for treatment of the perforation
site with laser retinopexy or cryopexy [29, 45]. We
did not have any such cases in our patients, as all of
them had vitreous hemorrhage with or without retinal detachment. This finding may be ascribed to high
myopic characteristics of the globes in our patients, as
well as the fact that more severe cases are more likely
to be referred to a tertiary care center.
The outcome in the eyes with perforation during
anesthetic injection depends on the initial injury. In
cases in which the retina has not been detached, observation or retinopexy with laser or cryotherapy yielded
good results, with the retina remaining attached and a
good visual outcome [37, 40]. However, in eyes with
retinal detachment, there has been an alarming rate
of PVR development after the initial vitrectomy. In
the series reported by Duker et al. [29], of 11 eyes
which had retinal detachment at referral, 7 eyes later developed PVR. In our patients, this took the form
of PVR C-3 and D. In one patient, macular pucker
developed and in another patient, macular pucker with
tractional detachment of the posterior perforation site
occurred. Rinkoff et al. [40] had 4 patients with retinal
detachment in their series. Two of their patients were
successfully treated with vitrectomy and scleral buck-
ling. In the other 2 patients, pneumatic retinopexy was
performed. Both of these eyes developed PVR and
underwent multiple surgical procedures with eventual failure. Pneumatic retinopexy does not seem to be
appropriate treatment for these eyes, as the traction
effects from the air bubble may aggravate the pathology in an eye with disturbed, incarcerated vitreous, thus
increasing the chance of PVR.
The anatomic results after surgery in our patients
were encouraging as 6 of 7 patients eventually retained
attached retinas. Our visual results, however, were not
satisfactory, as only 3 patients achieved visual acuity
of 20/400. These results seem to be related, in part, to
the highly myopic nature of these eyes with associated
chorioretinal degeneration.
The accumulation of experience regarding ocular
perforation during ocular anesthesia allows for some
recommendations to be made. Special attention should
be paid to highly myopic globes as the danger of perforation in these globes is at least 10 times that of
normal-sized globes. Considering the high incidence
of perforation in highly myopic eyes, general anesthesia seems to be justified for these patients. In highly
myopic patients with cataracts that prevent a view of
the fundus, we suggest that B-scan ultrasonography
be performed prior to surgery so that any posterior or
posterotemporal staphyloma can be detected.
After any retrobulbar or parabulbar injection, the
surgeon should look for signs of perforation. These
include hypotony, loss of red reflex, or the appearance of dark red reflex. If any part of the anesthetic is
injected inside the eye, the patient experiences sudden
severe pain. Vitreous hemorrhage noted postoperatively should also alert the physician as to the possibility
of inadvertent globe perforation.
In cases of definite or suspected perforation, if the
cataract is dense and the eye is not hypotonus, the surgeon may proceed with cataract surgery. Alternatively,
the operation may be cancelled and the patient referred
for vitreoretinal management. If a fundus view is possible and the retina is attached, immediate arrangements should be made for laser retinopexy or cryopexy.
If there is dense vitreous hemorrhage and/or retinal
detachment, vitreoretinal surgery is indicated.
Acknowledgements
Supported in part by U.S. Public Health Service grant
EY02377 from the National Eye Institute, National
Institutes of Health, Bethesda, MD and by an unre-
184
stricted departmental grant from Research to Prevent
Blindness, New York, NY.
21.
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Address for correspondence: G.A. Peyman, LSU Eye Center, 2020
Gravier St., Suite B, New Orleans, LA 70112-2234, USA
Fax: (504) 568-6193; E-mail: pchias@lsumc.edu.us