Globe perforation during peri-bulbar block is a complication, rarely reported these days in the era of topical surgeries. Certain predisposing lesions for globe perforation are high axial length, posterior staphyloma, previous extra-ocular surgeries, deep set eyes, uncooperative patients, and anesthesia given by non-ophthalmologists. The rate of retinal detachment after ocular perforation related to local anesthesia has been reported from 42- 56% in literature, which usually have a poor prognosis despite complex vitreo-retinal procedures. We are here reporting a case of peribulbar block-related retinal detachment where pneumatic retinopexy was used for management. This case emphasizes the importance of an early diagnosis and referral to a retina specialist in globe perforation caused by peribulbar block.
A 62-year-old male presented to our out-patient department with history of cataract surgery in the left eye 4 week back, followed by no improvement in vision and onset of floaters after surgery. Now, he was complaining of temporal field defect in the involved eye. On examination, patient had retinal detachment involving nasal retina with 2 irregular tears along superonasal arcade. Best corrected vision at presentation was 20/30. Resolving vitreous hemorrhage was present in the inferior vitreous. There was no vitreous traction upon any of the breaks. Posterior vitreous detachment (PVD) was complete as demonstrated by B-scan ultrasonography. As the break was posterior and the macula was attached, 2-stage pneumatic retinopexy was planned.
After achieving hypotony with 350 ml of intravenous mannitol 20% over 45 minutes, the patient was taken up to the operating room. After cleaning the eye locally with povidone-iodine 10% solution, a sterile surgical drap was applied. Anterior chamber paracentesis was done with 26G needle. 0.3 ml of pure C3F8 was injected intravitreally through pars plana route 3.5 mm from limbus infero-temporally. Retinal artery pulsations were checked, and the eye was patched. The patient was advised prone position. After 24 hours of tamponade, retina was reattached. Laser barrage of the breaks was done using Laser Indirect Ophthalmoscope, [Fig. 1b], and prone position was advised for 3 more days. Intra-ocular pressure was monitored every 6 hourly for the first 3 days.
At 4 weeks [Fig. 1c] and 8 week [Fig. 1d] follow-up, the retina remained attached. Inferior vitreous hemorrhage resolved and vision remained stable at 20/30.
In literature, retinal detachment associated with globe perforation has been associated with a very poor visual outcome. Puri et al. in their article concluded that cases with double perforations, with posterior breaks, or those associated with retinal detachment with PVR require complex surgical procedures and thus have poor visual prognosis. Wearne MJ in their retrospective review of 20 patients with block-related perforation concluded that eyes with retinal detachment generally had a poor visual outcome despite vitrectomy with long-acting gas or with silicone oil tamponade. In a series of 7 myopic cases with globe perforation published by Modarres M et al., the best vision achieved was 20/400. Gadkari S et al. reported 19 cases of globe perforation, out of which 8 patients had retinal detachment, all of them were managed with vitrectomy with an internal tamponade. Post-operative vision was less than 20/100 in about 50% of patients. We used 2-stage pneumatic retinopexy to repair retinal detachment with a posterior break with double perforation. Scleral buckling and cryotherapy application is difficult in such a case due to location of the break nasally and posterior to the equator. To the best of our knowledge, the use of pneumatic retinopexy has never been reported in literature for the management of peribulbar block-related scleral perforation with retinal detachment. Above case demonstrates the importance of using carefully-selected method of retinal detachment repair to help in early visual rehabilitation, better visual outcome, less patient discomfort, lesser cost, and fewer post-operative visit.
A prompt referral of the patient after globe perforation to a retina specialist is a must to achieve good visual prognosis. The aim is to treat the break before retinal detachment occurs or if detachment has already occurred, then to treat it before proliferative vitreo-retinopathy develops. PVR is likely to occur as early as 2 weeks of an injury in up to 80% of the eyes, which may necessitate vitreo-retinal surgery with encircling band. These eyes with PVR usually have poor structural and functional outcome[3–6910] and are difficult to manage.
1. Vohra SB, Good PA. Altered globe dimensions of axial myopia as risk factors for penetrating ocular injury during peribulbar anaesthesia Br J Anaesth. 2000;85:242–5
2. Edge R, Navon S. Scleral perforation during retrobulbar and peribulbar anesthesia: Risk factors and outcomes in 50,000 consecutive injections J Cataract Refract Surg. 1999;25:1237–44
3. Berglin L, Stenkula S, Algvere PV. Ocular perforation during retrobulbar and peribulbar injections Ophthalmic Surg Lasers. 1995;26:429–34
4. Wearne MJ, Flaxel CJ, Gray P, Sullivan PM, Cooling RJ. Vitreoretinal surgery after inadvertent globe penetration during local ocular anesthesia Ophthalmology. 1998;105:371–6
5. Puri P, Verma D, McKibbin M. Management of ocular perforations resulting from peribulbar anaesthesia Indian J Ophthalmol. 1999;47:181–3
6. Modarres M, Parvaresh MM, Hashemi M, Peyman GA. Inadvertent globe perforation during retrobulbar injection in high myopes Int Ophthalmol. 1997;21:179–85
7. Gadkari SS. Evaluation of 19 cases of inadvertent globe perforation due to periocular injections Indian J Ophthalmol. 2007;55:103–7
8. Coles WH, Haik GM. Vitrectomy in intraocular trauma. Its rationale and its indications and limitations Arch Ophthalmol. 1972;87:621–8
9. Gillow JT, Aggarwal RK, Kirkby GR. Ocular perforation during peribulbar anesthesia Eye (Lond). 1996;10:533–6
10. Grizzard WS, Kirk NM, Pavan PR, Antworth MV, Hammer ME, Roseman RL. Perforating ocular injuries caused by anaesthesia personnel Ophthalmology. 1991;98:1011–6
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Conflict of Interest: None declared.