Orbital varix rupture during cataract surgery

We report a case of orbital varix rupture during cataract surgery with retrobulbar anesthesia. No remarkable changes were observed 10 minutes after retrobulbar anesthesia was administered, but a rise in intraocular and intraorbital pressure was noted about 10 minutes after phacoemulsification began. The eyelid could not be closed at the end of surgery because of severe proptosis. Follow-up by magnetic resonance imaging and color Doppler imaging revealed orbital hemorrhage and varix. Based on the time of its appearance, the hemorrhage was thought to be the result of venous congestion caused by anesthetic agent in the muscle cone. Although intermittent exophthalmos is a symptom of orbital varix, silent orbital varix should be considered when selecting the method of anesthesia for ocular surgery.     

Ipsilateral globe penetration and transient contralateral amaurosis following retrobulbar anesthesia

PURPOSE: To report a rare complication of retrobulbar anesthesia with ipsilateral globe penetration and transient contralateral amaurosis. DESIGN: Interventional case report. METHODS: A 63-year-old woman complained of vision loss in the right eye immediately following cataract surgery on the left eye. RESULTS: Right eye vision decreased to no light perception with clear media and normal fundus. The vision recovered to baseline in 12 hours. Left eye vision was checked and demonstrated only light perception. Fundus examination disclosed preretinal and vitreous hemorrhage. During vitrectomy of the left eye, a penetrating wound below the optic disk with retinal detachment was found. CONCLUSION: The ipsilateral globe penetration wound depicts the mechanism of contralateral amaurosis following retrobulbar anesthesia of the case.     

Persistent vertical binocular diplopia after cataract surgery

PURPOSE: To report the incidence of, and factors associated with, persistent vertical diplopia after cataract surgery. DESIGN: Consecutive interventional case series. METHODS: Retrospectively, all adult patients examined during a five year, five month period because of new onset persistent (>3 months) vertical binocular diplopia after cataract surgery were analyzed. All patients had their cataract surgery at the same outpatient ophthalmic surgery center, and were referred to the author, enabling calculation of incidence. Trends in anesthesia type and strabismus complications therefrom were also assessed. Comparison was made between ophthalmologist-administered retrobulbar anesthesia versus anesthesia staff-administered retrobulbar anesthesia. Incidence during a period in which hyaluronidase was not incorporated in the retrobulbar anesthetic was calculated. RESULTS: Persistent vertical diplopia occurred after cataract surgery in 32 (0.18%) of 17,531 eyes that had cataract surgery. No patient whose cataract surgery was conducted with topical anesthesia (3817 eyes) had persistent vertical diplopia, whereas 32 (0.23%) of the 13714 eyes whose cataract surgery was done after retrobulbar anesthesia were affected. No cases of persistent postoperative diplopia were found among 7410 cataract surgery eyes after retrobulbar injection given by one cataract surgeon. There was a threefold greater number of left eyes involved than right eyes (P <.005). No significant (P >.20) increase in cases of persistent vertical diplopia was noted during a period of hyaluronidase shortage. CONCLUSIONS: In this study, persistent binocular vertical diplopia after cataract surgery occurred in 0.23% of cases in which retrobulbar anesthesia was performed. No cases were found after topical anesthesia. Occurrence may be technique-related.     

表面麻醉白内障摘除术的临床研究

目的 :评估表面麻醉下行白内障手术的安全性、可靠性及有效性。方法 :收集 940例经表面麻醉行白内障手术的病例 (研究组 ) ,其中 65 8例行白内障超声乳化术 ,2 82例行小切口白内障摘除术 ;随机选取 981例同期经常规球后麻醉行白内障手术的病例作为对照组。对两种不同麻醉方法下行白内障手术的两组病例的麻醉效果及并发症进行比较 ,作回顾性分析。结果 :研究组中有 6例牵拉上直肌或电凝止血时感到轻微疼痛 ,3例术中手术器械接触虹膜时有挤眼动作 ,其余 93 1例均无疼痛感。与对照组比较差异无显著性 (P >0 2 5 )。对照组中 ,球结膜水肿、眼睑皮下瘀血、睑裂变小、球后出血的发生率明显高于研究组 (P <0 0 0 1)。结论 :表面麻醉行白内障手术是一种安全、有效、并发症少的麻醉方法。     

Retrobulbar hemorrhage

Retrobulbar hemorrhage associated with retrobulbar anesthesia has been construed as a contraindication to cataract surgery. Cancellation of the surgery results in disappointment for both the patient and surgeon. A retrospective study of 60 eyes was undertaken to evaluate the safety of proceeding with small-incision phacoemulsification surgery after retrobulbar hemorrhage when specific criteria are met. If digital massage achieved a soft globe that was easily retropulsed and the eyelids were loose and easily mobilized, the surgery was performed as scheduled. If the globe remained firm within a tense orbit and proptosis with tight lids was present, surgery was cancelled. Fifty-seven cases with retrobulbar hemorrhage met these criteria and underwent phacoemulsification with implantation of a posterior chamber intraocular lens. The lack of intraoperative and postoperative complications suggests that small-incision cataract surgery can be safely performed when preceded by a limited retrobulbar hemorrhage.     

Mastication Induced Retrobulbar Hemorrhage

Abstract

Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.     

Retrobulbar hemorrhage after sub-Tenon's anesthesia

We present a case of retrobulbar hemorrhage from uneventful, infranasal, sub-Tenon's anesthesia before cataract surgery. To our knowledge, this is the first report of such a complication.     

Vertical diplopia after cataract operation

PURPOSE: Presentation and analysis of patients with vertical diplopia appearing after cataract surgery in retrobulbar anesthesia. SUBJECTS AND METHODS: Between 1990 and 1998 9 Patients with vertical diplopia following cataract surgery in retrobulbar anesthesia were studied in our Orthoptic Department. Each patient had complete orthoptic examination with Hess-screen-test. Additionally, some patients underwent neuroradiologic imaging and forced-duction testing. RESULTS: We subdivided the patients in a group of 4 patients with hypertropia and of 5 patients with hypotropia of the operated eye. All hypotropias were left-sided. Seven patients showed an overaction of the involved muscle without regression. Seven patients underwent surgery of a vertical muscle. Only 1 patient needed prismatic therapy postoperatively. The other 2 non-operated patients were satisfied with prisms alone. CONCLUSIONS: The proposed pathogenesis of vertical diplopia in these cases is fibrosis and contracture of the injured muscle, which could be due to anesthetic myotoxicity after direct injection into the muscle or to an intramuscular hemorrhage. On the other hand hypertropia could be a result of placement of bridle sutures. We discuss prevention and therapy of such complications.     

Inferior rectus paresis and medial rectus overaction following retrobulbar anesthesia for cataract surgery

Strabismus is a well recognized complication of retrobulbar anesthesia for cataract surgery. This may manifest as either paresis or sometimes contracture (overaction) in the late stage. Management of the patient is tailored to the individual case. Herein, we report a patient with inferior rectus paresis and medial rectus overaction after retrobulbar anesthesia. The presenting symptom was diplopia increasing on downgaze, which improved with medial rectus recession and plication of the inferior rectus.     

球结膜下浸润麻醉行青光眼小梁切除术临床观察

目的 评估和比较结膜下麻醉和球后麻醉行青光眼小梁切除术的可靠性和安全性。方法 对103例（120只眼）青光眼患者采用结膜下麻醉实施小梁切除术,与98例（109只眼）青光眼患者采用球后麻醉实施小梁切除术进行比较。对照分析两组麻醉方法的并发症、患者术中的配合程度及手术的安全性。结果 结膜下麻醉组115只眼（95．83%）、球后麻醉组中107只眼（98．16％）麻醉效果佳,球后麻醉组中有4只眼球后出血,1只眼光感消失,而球结膜下麻醉组无严重并发症出现。结论 球结膜下麻醉对于青光眼小梁切除是一种安全有效、并发症少的麻醉方法,值得推广。     

Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery

OBJECTIVE: To synthesize the findings of the randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: The authors performed a systematic search of the literature to identify all articles pertaining to regional anesthesia during cataract surgery on adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting the anesthesia approaches was graded by consensus as good, fair, poor, or insufficient. MAIN OUTCOME MEASURES: Evidence supporting the effectiveness of different forms of regional anesthesia. RESULTS: There was good evidence that retrobulbar and peribulbar blocks provide equivalent akinesia and pain control during cataract surgery. Additionally, sub-Tenon's blocks were at least as effective as retrobulbar and peribulbar blocks. There was good evidence that retrobulbar block provides better pain control during surgery than topical anesthesia, and there was fair evidence that peribulbar block provides better pain control than topical anesthesia. CONCLUSIONS: This synthesis of the literature demonstrates that currently used approaches to anesthesia management provide adequate pain control for successful cataract surgery, but there is some variation in the effectiveness of the most commonly used techniques. Data are needed on patient preferences to determine the optimal strategies for anesthesia management during cataract surgery.     

Localized retinal detachment with combined central retinal artery and vein occlusion after retrobulbar anesthesia

The authors report a patient who was observed to have a localized retinal detachment with combined central retinal artery and vein occlusion after cataract surgery performed with retrobulbar anesthesia. The authors propose that this condition resulted from injection of the anesthetic mixture into the optic nerve. No acute neurologic symptoms occurred, but visual loss was severe and permanent. This case adds to the previously reported spectrum of complications from retrobulbar anesthesia.     

Inadvertent ocular perforation and intravitreal injection of an anesthetic agent during retrobulbar injection

We report the clinical management of a patient who sustained scleral perforation and intraocular injection of local anesthetic agent during retrobulbar block. We discuss the management options for this rare complication of local anesthesia in cataract surgery.     

Progression of thyroid orbit disease after retrobulbar anesthesia

CASE REPORT: We present a 71 year-old woman with good control of her eye disease who developed a severe Graves' ophthalmopathy after retrobulbar anesthesia for cataract surgery. DISCUSSION: Local pressure in the retrobulbar compartment can cause the development of a severe ophthalmopathy in a patient with Graves' ophthalmopathy.     

Immediate contralateral amaurosis after retrobulbar anesthesia

Many potential complications associated with retrobulbar anesthesia have been reported. Of these, sudden loss of vision in the contralateral eye is the least expected. We report a case of immediate loss of vision in the fellow eye after retrobulbar anesthesia for cataract extraction. Possible etiology such as emboli thrown during ventricular fibrillation, direct optic nerve anesthetic injection with reflux to the chiasm, cortical stroke, amaurosis fugax, arterial injection of anesthetic material, and hysteric reaction are discussed.     

手法小切口白内障手术球后麻醉发生球后出血的处理

目的观察手法小切口白内障摘出人工晶状体植入手术球后麻醉发生球后出血的处理方法及效果。方法对我院开展创建白内障无障碍市活动中，2007年5月至2008年5月所做的1196例（1200眼）手法小切口白内障手术球后麻醉发生球后出血的处理及效果，进行回顾性分析。结果1196例1200眼球后麻醉中，发生球后出血4例4眼，发生率0．33％。其中外伤性白内障1例1眼，老年性白内障3例3眼。球后麻醉拔针后发生出血2例2眼，手术进行中发生出血2例2眼。手术开始前发生出血者，经过压迫止血有效者5min后进行手术，无效者，暂停手术，1周后表麻下手术。手术进行中开始出血者，经压迫无效，中止手术。1周后表麻下继续完成手术。所有患者经如上处理后均取得良好的手术效果。结论球后麻醉发生球后出血者，根据发生时间、出血量的多少、眼球突出程度、眼压及眶压的高低，采取正确的处理方法，可取得良好的临床疗效。     

Bilateral cataract: extraction in classic haemophilia with retrobulbar anaesthesia and peripheral iridectomy.

A 47-year-old factor VIII deficient haemophiliac successfully underwent bilateral cataract extraction. The use of cryoprecipitates to achieve haemostasis permitted retrobulbar anaesthesia and a peripheral iridectomy without complication. We consider that the use of cryoprecipitated factor VIII concentrate allows safe elective ocular surgery in patients with classic haemophilia.     

Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar block

PURPOSE: Topical anesthesia is increasingly being used for cataract surgery. However, it is believed that topical anesthesia causes an increased risk of intraoperative complications from unrestricted eye movement and insufficient pain control and more need for sedation. It is difficult to compare pain and anxiety experienced by individual patients; therefore, the authors used the method of patient-controlled sedation to determine whether there is a difference in sedation requirements under topical or retrobulbar anesthesia. METHODS: In this prospective study, patients received either topical anesthesia (n=87) or retrobulbar block (n=104) and self-administered a mixture of midazolam (0.5 mg) and fentanyl (25 microg) in increments using a patient controlled analgesia infuser to achieve sedation. At the end of surgery, patients rated their pain on a 10-point numerical rating scale and their comfort on a 5-point scale. The number of demands and deliveries were noted from the patient controlled analgesia infuser display. RESULTS: Pain scores were between 0 and 2 in 95.4% in the topical and in 94.2% in the retrobulbar group (p>0.05). Patient comfort was equal in both groups with 2.94+/-0.92 in the topical group and 2.92+/-0.99 in the retrobulbar group (p>0.05). Mean sedation requirements were similar in both groups: 26.4% of patients in the topical group and 19.2% in the retrobulbar group did not request any sedation (not significant, p>0.05). CONCLUSIONS: Sedation requirements were similar for cataract surgery under topical and retrobulbar anesthesia.     

Brainstem anesthesia presenting as dysarthria.

After having a retrobulbar injection for anesthesia before cataract surgery, a patient developed dysarthria. This was the presenting sign for penetration of the optic nerve sheath by the retrobulbar injection, with subsequent brainstem anesthesia. Thereafter, the patient demonstrated cranial nerve dysfunctions with tongue deviation, tachycardia, hypertension, and contralateral sixth and third nerve palsies. I believe this is the first documented case in which dysarthria is the presenting sign for brainstem anesthesia resulting from a retrobulbar injection.     

Effect of retrobulbar injection of lidocaine on saccadic velocities

PURPOSE: To determine whether exposing the extraocular muscles (EOMs) to lidocaine via retrobulbar injection for cataract surgery has a demonstrable negative effect on subsequent function of the muscle. SETTING: York Finch Eye Associates, Humber River Regional Hospital, and Toronto Western Hospital Research Institute, Toronto, Ontario, Canada. METHODS: This study comprised 37 eyes that had phacoemulsification and posterior chamber intraocular lens implantation; 13 eyes had retrobulbar lidocaine with hyaluronidase and 24 eyes, topical anesthesia. The postoperative saccadic velocities were compared with the preoperative velocities using a sensitive recording device. The results were compared within and between the retrobulbar lidocaine and topical anesthesia groups. RESULTS: No detectable decrement in postoperative saccadic velocities was detected in any patient, and no difference was found between the groups. CONCLUSIONS: Exposing EOMs to lidocaine for cataract surgery had no detectable negative effect on saccadic velocities 1 week after surgery.