The local anaesthesia given in ophthalmic surgery, if performed correctly has been proved to be highly successful with low incidence of complications. This review article outlines the possibility of the complication of local anaesthesia in ophthalmic surgery.Pravilno davanje lokalne anestezije u očnoj kirurgiji veoma je uspješno s malom učestalošću komplikacije. Ovaj članak opisuje moguće komplikacije lokalne anestezije u očnoj kirurgiji

Lovro Bojić

Milan Ivanišević

Zdravko Mandić

English

Bojić, Lovro

Mandić, Zdravko

Ivanišević, Milan

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Acta clin Croat, Vol. 41, Suppl. 4, 2002 51Bojiæ L. et al. Local ophthalmic anaestesiaActa clin Croat 2002; 41 (Suppl 4): 51-54 Profes onal PaperCOMPLICATIONS OF LOCAL OPHTHALMIC ANAESTESIALovro Bojiæ,1 Zdravko Mandiæ,2 Milan Ivanieviæ1Eye Clinic, Clinical Hospital, Split11University Department of Ophthalmology, Sestre Milosrdnice University Hospital, Zagreb,2 CroatiaSUMMARY- The local anaesthesia given in ophthalmic surgery, if performed correctly has been proved tobe highly successful with low incidence of complications. This review article outlines the possibility of thecomplication of local anaesthesia in ophthalmic surgery.Key words: ophthalmic anaesthesia, complicationsThe ideal anaesthetic for ophthalmic surgery wouldprovide globe and conjunctival anaesthesia, globe, lid andperiorbital akinesia and intraocular hypotonia. However,the need for full akinesia has been brought into questionby the increased popularity of topical, sub-Tenons infu-sions of anaesthetics and subconjunctival anaesthesia.Complications of local anaesthesia for ophthalmic surgerycan be elicited from the agents used or from the block tech-nique itself Complication of agent used for topical anaes-thesia are very rarely associated with damage of the cor-nea except with cocaine.1Systemic complications may be caused by overdose orallergic reactions. The symptoms include convulsions, un-consciousness and cardiorespiratory arrest can be a conse-quence of systemic complications following injection oflocal anaesthetic within a cuff of dura of the optic nerve orintraarterial injection.2 Brainstem anaesthesia is potentiallya life- threating complication of retrobulbar anaesthesia.The symptoms include confusion, difiiculty in breathing,cyanosis, dysphagia, impaired hearing, hypertension andtachycardia . Management is mainly supportive and sur-gery can usually proceed. Direct injection of local anaes-thetics into the cerebrospinal fluid can occur by acciden-tal puncture of dural cuff of the optic nerve as it runs to-wards the sclera. Injection of anaesthetic into subarachnoidspace may result in sensory blockade of contralateral vision,Correspondence to: Lovro Bojiæ MD, PhD, Eye Clinic, Clinical HospitalSplit, 21000 Split, Croatia, Fax: +385 21 365 738CNS depression, paralysis, seizures, hypotension and car-diac arrest. The upwards and inwards gaze is responsiblefor this complication by rotating the optic nerve in an in-ferotemporal direction. Retrobulbar blocks carries thehighest risk of central nervous system involvement.Complications of ocular blocksRetrobulbar and peribulbar block are the most fre-quently used techniques for ophthalmic surgery.3 Retrob-ulbar block was first described in 1884 by Knapp.4 Theintroduction of better local anaesthetic agents made thisprocedure an effective and popular choice for most oph-thalmic surgeries Peribulbar block is an alternative ap-proach, which is believed to reduce the risk of globe per-foration or traumatising the neurovascular structures.5Orbital haemorrhageOrbital haemorrhage is the most common complicationof retrobulbar injection, reported in 0. 1% to 1.7% of pro-cedures.6,7,8 Haemorrhage may be venous or arterial. Venoushaemorrhage is not serious and probably does not causelong-term visual complications. An arterial haemorrhageproduces a rapid orbital swelling, subconjunctval and pe-riorbital haemorrhage, proptosis with immobility of the eyeand blood-stained eyelids. The increase of intraorbitalpressure may couse retinal artery compression . Measure-ment of intraocular pressure is helpful in assessing the risk52 Acta clin Croat, Vol. 41, Suppl. 4, 2002Bojiæ L. et al. Local ophthalmic anaestesiaof ishemic damage of the retina and the optic nerve. In thecase of retinal artery compression, manitol, acetozolamide,urgent decompressive surgery, lateral canthotomy or para-centesis may be required.Globe perforationInadvertent globe perforation can occurr during retrob-ulbar or peribulbar blocks.9 The incidence of globe perfo-ration is less than 0.1%.10 Most commonly this involves atangential penetration in the inferolateral quadrant andmay include penetration of the inferior oblique muscle, too.Predisposing factors include previous eye surgery, globeswith an axial length of >26 mm (high myopia) and poorpatient co-operation.11,12 Needle perforation of the globehas been reported in association with retrobulbar andperibulbar blocks.12 Careful observation ofthe globe dur-ing needle entry may alert the surgeon to impending globepenetration by rotation of the eye toward the direction ofneedle entry. The so-called wiggle test is useful in de-termining if the needle tip has impaled an orbital struc-ture fixed to the eye.13 In this test, when the retrobulbarneedle is in the orbit, the needle is moved from side to side;any rotation of the eye suggests that the sclera, optic nerve,or an extraocular muscle may have been penetrated. Sud-den loss of vision vitreous haemorrhage, hypotonia and painon injection may indicate to globe perforation.14 Needleslonger than 3 cm should never be used and the needleshould not be inserted more than 2.5 cm. If the cataractallows visualisation of the penetration site with indirectophthalmoscopy, cataract surgery should be cancelled andarrangements made for retinopexy to the perforation site.If the cataract prevents adequate visualisation of the ret-ina, some surgeons recommend that it should be removedto allow retinal surgeon to perform photocoagulation orretinal surgery. The effects of local anaesthetics injectedinto the globe are temporary and produce no detectablehistologic damage to the retina.Amaurosis and optic nerve atrophyRetrobulbar injections of local anaesthetics can veryrarely can cause amaurosis as a consequence of optic nerveblocked.15 Optic nerve atrophy can be a consequence ofdamage of the optic nerve or central retinal artery withinjection into optic nerve sheath or haemorrhage.16 Thesecomplications may be related to or incidental to the tech-nique of retrobulbar block. Sharp needles may cause pierc-ing injury of the optic nerve and even rounded needles mayresult in tearing of neural tissues. There is often nothingunusual during the insertion of the needle or injection ofanaesthetic. The loss of vision may have been attributedto the effect of local anaesthetic blockade and the visualimpairments are noticed only when the blockade is pro-longed. Fundus examination reveals optic disc oedema,retinal oedema and vitreous haemorrhage and in the laterstage signs of optic nerve atrophy. CT scan and ultrasono-graphic examination may reveal dilatation of the opticnerve either due to haemorrhage or injection of anaesthet-ic. The injection should be made with the globe in theprimary gaze position when the optic nerve remains in itsnormal position behind the globe.17Oculocardiac reftexAlthough the retrobulbar or peribulbar block can pre-vent the oculocardiac reftex, traction on the extraocularmucles (especially the medial rectus) or conjunctiva, orpressure on the globe can trigger cardiac arrythmias suchas bradycardia and hypotension via reflex pathway of thevagus nerve. The blocks take a minute or two to block thereflex arc and the pressure on the globe immediately afterblocking can stimulate the reflex. Cardiac rhythm chang-es resulting from oculocardiac reflex are much less com-mon during local than during general anaesthesia; howev-er, cardiac rhythm monitoring is essential during local an-aesthesia.Extraocular muscle palsyDirect injection of local anaesthetic into any of theextraocular muscles may result in myotoxicity and musclepalsy. Diplopia can occur following inadvertent retrobul-bar injection of local anaesthesia into muscles involved withocular alignment. Extraocular muscle palsies, especially theinferior rectus muscle have been described.18 They usual-ly recover completely. Many mechanisms of injury to theextraocular muscle associated with eye surgery have beenproposed. A popular one is the ocular myotoxic effect ofthe local anaesthetics. The highest concentrations of lo-cal anaesthetics and direct injection into the muscle shouldbe avoided.Raising of the intraocular pressureThe intraocular pressure is increased after injectionsof local anaesthetic and thus it may cause the vitreous lossduring intraocular surgery. Many techniques have beenused to soften the eye prior to ocular surgery includingActa clin Croat, Vol. 41, Suppl. 4, 2002 53Bojiæ L. et al. Local ophthalmic anaestesiaintermittent digital pressure, Storz Autopressor, mercurybag, or Honan ballon.A mild degree of pain is inevitable whilst performinglocal anaesthesia. Severe pain, particularly on injection isa good indicator of incorrect needle placement.The sub-Tenons infusion is an excellent way to getparalysis of the movement of the eye. After making a smallincision in the conjunctiva, 1.5 to 2.0 cc of the anaestheticis infused through the cannula into the retrobulbar space.Good anaesthesia using long-acting anaesthetics via thesub-Tenons route can be used instead of retrobulbar ap-proach. Sub-Tenons anaesthesia produces the lowest over-all level of discomfort, both during the administration ofthe block and intraoperatively.19  7. EDGE KR, NICOLL JMV. Retrobulbar hemorrhage after 12,500retrobulbar blocks. Anesth Analg 1993; 76: 1019-22.  8. DAVIS DB II, MANDEL MR. Efficacy and complications rate of16,224 consecutive peribulbar blocks. A prospective multicenterstudy. J Cataract Refract Surg 1994;20:327-37.  9. DUKER JS, BELMONT JB, BENSON WE, LOGAN BROOKKHJR, BROWN GC,FEDERMAN JL, FISHER DH, TASMAN WS.Inadvertent globe perforation during retrobulbar and peribulbaranesthesia.Patient characteristic, surgical management and visualoutcome. Ophthalmology 1991;98:519-26.10. HAMILTON RC, GIMBEL HV, STRUNIN L. Regional anesthe-sia for 12000 cataract extraction and intraocular lens implantationprocedures. Can J Anaesth 1988;35:61523.11. FEIBEL RM. Current concepts in retrobulbar anaesthesia. SurvOphthalmol 1985;30: 102-10.12. HAY A, FLYNN HW JR, HOFIMAN JI, RIVERA AH. Needle per-foration of the globe during retrobulbar and peribulbar injections.Ophthalmology 1991;98:1017-24.13. DUTTON JJ. I. EDITORIAL: Anatomic considerations in oph-thalmic anestesia. Surv Ophthalmol 2001;46: 172-8.14. SCHNEIDER ME, MILSTEIN DE, OYAKAWA RT, OBER RR,CAMPO R. Ocular perforation from retrobulbar injection.Am JOphthalmol 1988;106:35-40.15. ARORA R, VERMA L, KUMAR A, KUNTE R. Regional anaesthe-sia and optic nerve conduction. J Cat Ref Surg 1991;17:506-8.16. MORGAN CM, SCHARTZ H, VINE AK, CANTRILL HL, DAVI-DORF FH, GITTER KA, RUDICH R. Ocular complications asso-ciated with retrobulbar injections.Ophthalmology 1988;95:660-5.17. KATSEV DA, DREWS RC, ROSE BT. An anatomic study of retrob-ulbar needle path length.Ophthalmology 1989;96:1221-4.18. RAO VA, KAWATRA VK. Ocular myotoxic etiects of local aneste-htics. Can J Ophthalmol 1988;23: 171-3.19. BRIGGS MC, BECK SA, ESAKOWITZ L. Sub-Tenon versusperibulbar anesthesia for cataract surgery. Eye 1997;11:639-43.SaetakKOMPLIKACIJE LOKALNE ANESTEZIJE U OFTALMOLOGIJIL. Bojiæ, Z. Mandiæ, M. IvanieviæPravilno davanje lokalne anestezije u oènoj kirurgiji veoma je uspjeno s malom uèestaloæu komplikacije. Ovaj èlanak opisujemoguæe komplikacije lokalne anestezije u oènoj kirorgiji.Kljuène rijeèi: oèna anestezija, komplikacijeReferences1. ROSENWASER GOD. Complications of topical ocular anaesthet-ics. Int Ophthalmol Clin 1989;29:153-8.2. FEITL ME, KRUPIN T. Rettobulbar anesthesia. OphthalmologyClinics of North America. Regional anesthesia for intraocular sur-gery. In:Zahl K, Meltzer MA, eds. Philadelphia: WB Saunders,1990:3(1):83-91.3. GARDNER S, RYALL D. Local anaesthesia within the orbit. CurrAnaesth Crit Care 2000;11:299-305.4. KNAPP H. On cocaine and its use in ophthalmic and general sur-gery. Arch Ophthalmol 1884;13:402-48.5. DAVIS DB II, Mandel MR. Peribulbar anesthesia: a review of tech-nique and complications. Ophthalmology Clinics of North Ameri-ca 1990;3: 101-10.6. CIONI RJ, OSCHER RH. Retrobulbar haemorrhage. Ophthalmo-logy 1991;98:1153-5.

Komplikacije lokalne anestezije u oftalmologiji

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