Ocular trauma is the most common cause of monocular blindness and may account for more than a half million bilaterally blind people worldwide.1 In industrialized countries, trauma is the second leading ocular cause for hospital admission. In the United States, 2.4 million ocular injuries occur each year, representing 1.0% of the total population.2 The number of patients who require hospitalization for ocular trauma in industrialized countries is approximately 13 per 100 000.3–5 The causes and patterns of ocular injury change depending on the population type and the country (eg, urban, rural, industrial, developing), as shown by several epidemiological studies.2–7 Assault is the leading cause of eye injury in the United States, whereas work-related trauma and injuries at home are leading causes in other countries.6 In a recent survey conducted in Singapore for 3 months, work-related injuries accounted for 71.4% of all trauma cases; grinding, cutting metal, and drilling were involved in more than 90.0% of the cases.7
Treatment of ocular trauma depends on the patient's general condition and the location, extent, and severity of the injury.8 In patients with severe damage to the eye (eg, a perforating eye injury or rupture of the globe with extrusion of intraocular tissue), repair under general anesthesia is recommended. Retrobulbar or peribulbar local anesthesia is not recommended and is reserved for patients considered to be high-risk candidates for general anesthesia.9 The rationale for this includes avoidance of factors that increase pressure on the open globe (eg, anesthetic agent or blood in the orbit), thus increasing the possibility of prolapsed intraocular tissue. Also, local anesthesia techniques can induce severe chemosis, making it more difficult to estimate the location and extent of the trauma.
There are situations in which the patient's general condition does not permit general anesthesia. Patients with systemic, life-threatening diseases (eg, terminal heart failure, cancer, advanced chronic pulmonary diseases) are at high risk for major complications, including death, when procedures must be performed under general anesthesia. Pham and coauthors10 compared topical anesthesia with a 10.0 mm × 2.5 mm cellulose sponge soaked in oxybuprocaine 0.4% (Novesine®) placed under the upper and lower lid for 20 minutes with a conventional retrobulbar injection of prilocaine–etidocaine for cataract surgery with sclerocorneal incision.10,11 The sponge technique offered good anesthesia with minimal pain and discomfort, although the retrobulbar injection provided better analgesia than the sponge postoperatively.
We report a case of perforating ocular trauma after cataract surgery repaired under topical anesthesia with a sponge soaked in Novesine. This type of anesthesia was used because the patient's overall condition did not allow the use of general anesthesia.
A 76-year-old woman had uneventful cataract surgery in the right eye with a self-sealing sclerocorneal tunnel incision and implantation of a single-piece, rigid, posterior chamber poly(methyl methacrylate) intraocular lens (IOL). Two months after surgery, the patient fell at home, causing trauma to the operated eye.
The right eye had a visual acuity of light perception. A dehiscence of the cataract incision was observed, and some uveal tissue was exposed. Marked edema of the eyelids and a 360-degree subconjunctival hemorrhage prevented accurate assessment of the complete extension of the wound. The IOL had been pushed out of the eye and was found lying on the superior subconjunctival space. Intraocular pressure (IOP) was not accurately assessed because the eye had no tonus. Marked swelling of the eyelid, complete hyphema, chemosis, and pain made further evaluation of the eye impossible. The fellow eye was not injured and had a visual acuity of 20/40. A computed tomography (CT) scan was obtained to exclude an intraocular foreign body and showed a collapsed right globe with blood filling the vitreous and anterior chamber; a small, foreign, glass body from the patient's spectacles was seen under the conjunctiva (Figure 1, top left and bottom left). No intraocular foreign body was observed. The left eye was within normal limits.
The patient received systemic antibiotics and steroids and was scheduled for surgical repair that evening. She had a history of lung cancer with extensive lung emphysema and pleural edema, as well as an unstable cardiac condition with coronary disease (Figure 1, right). Therefore, general anesthesia was not possible. Retrobulbar and peribulbar local anesthesia were not considered because the eye had no tonus and because these techniques increase the risk for further extrusion of intraocular contents. Topical anesthesia was applied using a 10.0 mm × 2.5 mm cellulose sponge soaked with Novesine® placed under the upper and lower lid for 20 minutes. This provided sufficient anesthesia for preparation of a sclerocorneal incision and also for scleral wound closure.
The wound was repaired without complications. The eye showed an extension of the initial cataract incision to 14.0 mm (Figure 2, A). The IOL, parts of the iris and ciliary body, and some blood and vitreous were prolapsed through the wound. All exposed tissue was carefully removed, and the wound was closed with a running nylon 10-0 suture (Figure 2, B and C). Blood was irrigated from the anterior chamber, and the tonus of the eye was adjusted with balanced salt solution (BSS®). The wound was then watertight (Figure 2, D). The patient did not complain of pain during the procedure.
The follow-up was uneventful. The eye showed no inflammation, but vitreous hemorrhage prevented visual acuity from improving beyond light perception. Two months after surgery, the patient fell again and fractured her left arm. Surgical repair was performed under general anesthesia, which the patient did not tolerate, and she died.
Surgical treatment of systemically ill patients with severe ocular trauma can be challenging. Because of the danger of a second or third surgical intervention in patients with systemic conditions, minimal invasiveness should be balanced with the need for optimal success.
Although ocular trauma is generally managed best under general anesthesia, surgery in this patient was performed under topical sponge anesthesia because her unstable condition did not allow general anesthesia. Retrobulbar or peribulbar local anesthesia was not an option because of the slitlamp findings (ie, lack of tonus and exposed iris and ciliary body), the length of the wound (14.0 mm), and the CT scan that showed a collapsed eye with blood in the anterior chamber, some vitreous hemorrhage, and dehiscence of the initial cataract surgery incision. Even small amounts of an anesthetic agent injected into the retrobulbar or peribulbar space can increase orbital pressure, which can cause complete collapse of the globe with extrusion of more intraocular contents.12,13 Some local-anesthesia-related complications, such as retrobulbar hemorrhage, also can induce a rise in intraorbital pressure and subsequently in IOP, with forward displacement of the globe, increasing the risk for further prolapse of intraocular contents.13,14
Topical sponge anesthesia was the least invasive option for surgical repair of the wound in this case. It allowed scleral exploration and repair, postponing further intervention (eg, vitrectomy and secondary IOL implantation) until the eye and the patient were more stable. Two months after surgery, the patient fell again, and general anesthesia was chosen for surgical repair of an arm fracture. The patient did not tolerate the procedure and died.
Although there are reports of perforating trauma being adequately repaired under local anesthesia combined with sedation,12,15 the risk for increasing the extent of the wound and prolapse of intraocular tissue led us to use sponge anesthesia. The patient did not experience pain during the procedure. Pham and coauthors10 compared topical anesthesia with Novesine applied with a sponge alone or combined with the systemic analgesic agent ultram (Tramadol®) and conventional retrobulbar anesthesia. They found that topically applied Novesine provided adequate anesthesia during cataract surgery with a scleral incision. In combination with Tramadol, pain and discomfort were minor. The retrobulbar injection provided better analgesia only in the postoperative period.
There are some concerns regarding the toxicity of Novesine to the intraocular structures. The sponge technique attempts to prevent direct contact between the anesthetic agent and the exposed structures, although it is almost impossible to avoid this contact. In a severely injured eye, any trauma induced by the anesthetic agent is worth the risk, particularly in cases such as ours in which the only option for repair of the trauma and thus survival of the eye was the use of topical anesthesia.
In summary, we report a case of ocular trauma with rupture of the eye at the incision site in a patient who had cataract surgery 2 months earlier. Surgical repair of the wound was achieved with topical sponge anesthesia without complications or pain during the procedure. Topical anesthesia should be considered among the options in medically unstable patients and severely ill patients when general anesthesia is contraindicated.
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