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Postoperative Complications of Periocular Anesthesia

Ignatius C. Cyriac, M.D. Roberto Pineda, II, M.D.

Even as current trends move away from retrobulbar blocks and topical anesthesia gains greater widespread acceptance, ocular anesthesia still is most commonly administered with a needle. Although rare, numerous complications associated with the administration of periocular anesthesia have been described, ranging from the innocuous hemorrhage to life threatening systemic situations. Early recognition is paramount, and judi cious management of these complications can result in more favorable visual outcomes and significantly less morbidity. The local anesthetic ocular complications that are reviewed include retrobulbar hemorrhage, globe perforation, optic nerve trauma, and mus cle injury. As systemic complications can be associated with direct central nervous system (eNS) spread of anesthetic, signs and symptoms of this situation also are addressed.

Techniques
The aim of retrobulbar anesthesia administration is to direct the tip of the retrobulbar needle toward the orbital apex within the muscle cone to allow diffusion of anesthetic within this space. When the ocular motor nerves (III and VI) and sensory nerves (V) are blocked, akinesia and anesthesia is achieved. Ophthalmic surgery has been performed with local anesthesia for more than 100 years. Herman Knapp was the first to describe retrobulbar anesthesia with cocaine in 1848. However this method fell into disrepute because of serious and fatal complications. The modern technique of retrobulbar anesthesia using lidocaine was described by Atkinson in 1948. This technique of retrobulbar anesthesia as described by Atkinson has undergone various modifications in general use but essentially is un-

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changed from his original method. Atkinson originally recommended the technique of positioning the globe in an up and inward gaze using a blunted needle of no longer than 35 mm. Because of the blind approach of this technique, Unsold and associates' performed studies that involved scanning orbits of cadavers after introducing a retrobulbar needle. They demonstrated the optic nerve, ophthalmic artery, superior orbital vein, and posterior pole of the globe to be in close proximity to the needle. The authors recommended placing the globe in primary position or in a down and outward gaze, suggesting that the optic nerve, vessels, and inferior oblique are placed outside the path of the anesthetic needle. Peribulbar anesthesia administration seeks to avoid the optic nerve, ophthalmic artery and vein, and posterior globe by placing the anesthesia outside the retrobulbar space just posterior to the equator. Akinesia and anesthesia is achieved through diffusion of anesthesia in this area. The actual technique is more varied in its use than is the retrobulbar method of administration. The technique described by Davis and Mandel/ serves as representative example of this block. With the eye in primary position, a 12mm 27-gauge needle injects a diluted 1 % lidocaine solution into the anterior orbit inferotemporally. In this same area, an 18 to 24-mm 23 to 26-gauge needle is used to inject a solution of lidocaine, marcaine, and wydase. Supplemental blocks of this same preparation are administered into the superonasal or inferonasal orbit as needed. Peribulbar anesthesia has been believed to be less painful and to result in fewer postoperative complications than is retrobulbar anesthesia. Fewer cases of retrobulbar hemorrhage, globe perforation, and brainstem anesthesia have been reported.f

Anatomical Considerations
To understand the mechanisms of complications from periocular nerve blocks first requires knowledge of orbital anatomy. Motor nerves (cranial nerves III, IV, and VI) insert into rectus muscles between the pos terior and middle thirds of the muscle belly. Thus, the muscular branches of the third nerve may be blocked within the muscle cone in the posterior orbit, notably in the area of the optic nerve and ophthalmic vein, whereas the inferior oblique's nervous and vascular branches insert more anteri orly on the muscle and, therefore, are more susceptible to damage by blocks provided along the orbital floor. The origin of the superior oblique in the posterior-superotemporal orbit and its relative immobility render superotemporal blocks perilous. Needle length with relation to anatomical dimensions also can increase the risk of complications for a particular block. It has been shown that the average length from the lateral one-third of the inferior orbital rim to the orbital apex is 48 mm or less. 4 Also, the intracanalicular portion

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of the optic nerve is relatively immobile and extends anteriorly from here. Risk from using long needles then becomes apparent. Using blunt needles was thought to resolve this risk, but complications have been reported with blunt needles as well. 5

Local Complications
Hemorrhage The most common complication of periocular anesthetic administra tion is retrobulbar and periocular hemorrhage. Incidence of hemor rhages with retrobulbar blocks is between 1 and 3% and, when combined with peribulbar blocks, incidences of 1 : 1,000 to 1 : 60 have been re ported." However, most of these cases are mild in nature. Acquired vascu lar disease is thought to be a risk factor for this occurrence. The vast majority of orbital and periocular hemorrhages are venous in origin. Usually, they are not vision-threatening and more often require postponement of surgery than any intervention. Alternatively, arterial he morrhages can produce proptosis, ecchymosis, and chemosis. In the pres ence of rapid orbital swelling causing a tight orbit, marked proptosis, oph thalmoplegia, and blood-staining of periorbital tissues, a retrobulbar hemorrhage of arterial origin should be suspected. Vision loss occurs as a result of the tamponade effect of the periorbital swelling wherein the in traorbital pressure rises higher than does the intraarterial pressure. Also, occlusion of the microvasculature of the optic nerve can occur, causing a late optic atrophy. If the diagnosis of retrobulbar hemorrhage is suspected, pressure measurement and ophthalmoscopy are indicated. Treatment is immedi ate lateral canthotomy-cantholysis and close follow-up of intraocular pres sure (lOP) and vision. Emergent orbital decompression surgery may be considered if the optic nerve is compromised. Permanent impairment of vision in such patients has not been shown to occur. Direct arterial trauma is the suspected cause, and no modifica tion in technique has demonstrated avoidance of this complication.

Globe Perforation Globe perforation is one of the most dreaded complications of local anesthesia. Several retrospective studies reported isolated cases of globe perforation. Incidence of globe perforation ranges from 1: 1000 to 1 : 4200 in reported cases and, in patients with axial lengths greater than 26 mm, the incidence increases to 1 : 140. 7 In addition, axial myopes also have thinner sclera, placing them at further risk. Other risk factors for globe perforation include enophthalmos or nanophthalmos, multiple injections or injection sites, and a history of a scleral buckling procedure.

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Whether advantages accrue to sharp rather than blunt needles is un known. Use of blunt needles has been thought to avoid this risk, but cases of blunt-needle perforation have occurred. Also, performing strictly peribulbar blocks does not obviate the risk of perforation, although the incidence is lower with the peribulbar technique.f Because techniques and needle types vary, determining the relative risk of globe perforation is difficult. The risk of perforation has not been proven in any controlled study. Symptoms of ocular penetration include severe pain and sudden loss of vision, and signs include hypotony, sudden increase in lOP, and sub conjunctival hemorrhage. When suspected, indirect ophthalmoscopy should be performed to confirm the diagnosis, but scleral exploration is not necessary, as the perforation sites often are small and self-sealing. If the media are not clear enough to allow visualization of the retina, the sur geon may proceed with cataract surgery. Otherwise, treatment entails immediate cryopexy or episcleral implant for anterior perforations or laser photocoagulation to posterior perforations. Systemic antibiotics should be administered to reduce the risk of endophthalmitis. Complications of perforation include subretinal, retinal, and vitreous hemorrhage; retinal holes; or detachment. The degree of postoperative visual recovery depends on the location of the perforation (although the majority are below the fovea), presence of a retinal detachment, and development of proliferative vitreoretinopathy.

Muscle Injury

Although exceedingly rare, another complication oflocal ocular anes thesia is direct muscle trauma with subsequent diplopia. The cases reported most commonly are of inferior rectus palsies or contracture after blocks .m d of superior rectus overaction. Increased use of peribulbar blocks has been implicated as a cause, given the multiple injections or injection sites used with this method; however that the use of hyalu ronidase is thought to improve the efficacy of this technique, thereby re quiring less injection of anesthetic. The mechanism of muscle injury is speculative. One theory contends that direct injection of anesthetic into the recti and subsequent myotoxic ity cause postoperative strabismus. Studies by Rainin and Carlson" sug gested that surrounding an isolated rectus muscle with high concentra tions and volume of anesthetic can cause muscle fiber destruction. Trauma to nerves and needle damage of the rectus muscles also are spec ulated to be causes of postoperative strabismus. Another accepted theory is that muscle injury occurs in one of two ways: Laceration of anterior ciliary vessels causes a hematoma or a large volume of anesthetic is injected into this same intramuscular or perimus cular space." The compressive effect of blood or anesthetic is thought to

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result in vascular compromise and subsequent muscle fibrosis and con tracture. Overall, muscle paresis after cataract surgery is noted to be temporary, but cases of permanent muscle injury have been described. These cases of permanent strabismus are thought to be the result of a myotoxic effect of the local anesthetic, but the lack of pathological studies in these cases cannot confirm the etiology.'?

Optic Nerve Injury Injury to the optic nerve with the anesthetic needle is a great concern in administering periocular anesthesia. Severe visual deficit on the first postoperative day may be the clinical presentation. Direct needle trauma to the optic nerve is not thought to be the mech anism of optic neuropathy after surgery. In fact, optic nerve injury and dysfunction occurring after local ocular anesthesia is related inherently to retrobulbar hemorrhage and to central artery occlusion. Retrobulbar hemorrhage can cause a marked rise in lOP or intraor bital pressure, thereby causing a central retinal artery occlusion. Intravas cular injection of anesthetic also can cause a central vein or artery occlu sion via vasospasm. A third mechanism for vasoocclusion is the injection of anesthetic into the nerve sheath, causing a compressive effect first on the venous circulation and later compromising arterial inflow. Direct needle trauma to the retinal artery in the posterior orbit, prior to its pen etration of the optic nerve, also is thought to occur. All these mechanisms cause optic atrophy as a result of vascular compromise. Needle penetration of the optic nerve rarely causes vision loss but, if associated with a central retinal artery occlusion, visual dysfunction can be profound and permanent.

CNS Complications
CNS complications oflocal anesthetic injection can have lethal effects. In extremely rare instances, after receiving periocular anesthesia, a pa tient may experience cardiovascular and pulmonary problems, such as hy potension and respiratory arrest. Drug toxicity can be a cause and may manifest initially as tremors, agitation, slurred speech, and (eventually) seizure activity. Moreover, overall nervous system collapse causing respira tory depression and cardiovascular collapse can occur. The fisk of nerve trauma or subsequent intrathecal administration of anesthesia (or both) are thought to be linked. A study of CNS complica tions after retrobulbar block demonstrated an incidence of 1: 375. Reported rates of CNS complications range from 0.09% to 1.50%. A life threatening complication can occur in 0.13%.11 Effects included apnea

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and respiratory depression, convulsions, and cardiopulmonary arrest. In

terestingly, no reported cases occurred in studies wherein a needle length shorter Conclusion
than 1.5 inch was used. In peribulbar anesthesia, many suggest using needles no longer than 25 mm.technique of local ocular anesthesia is free of compli No method or cation. The clinical picture of CNS anesthesia can be varied. Affected patients with We recommend that surgeons perform their preferred technique properly and may experiencein confusionposition. The use (which may be normal consider mm for ing the globe primary and agitation of blunted, shorter needles 33 administration of intravenous sedation), dizziness, tremors (ranging from retrobulbar blocks and 20 mm for peribul bar blocks) also is recommended. shivering to marked convulsions), ophthalmoplegia or amaurosis of the have an Furthermore, the peribulbar technique, although not proved, appears to fellow eye, tinnitus or the retrobulbar problems with speechthe risk of complications. onset of ing. The advantage over deafness, and technique in reducing or breath symptoms usually occurs within a have minutes, peaking at approximately 15 Many advances in technique few enabled surgeons to achieve excel lent minutes anesthesia and akinesia. With careful monitoring son, we recommend that the surgical after anesthesia administration. For this rea by qualified individuals patient be observed, without anesthesia, the 15 minutes after administering with experience in local ocular drapes, for vast majority of cases result in no anesthesia. The averageHowever,ofbecause the administra3 hours. of anesthesia is serious complication. duration these symptoms is 2 to tion essentially a "blind" anesthesia include damage consciousness, apnea, structures, Signs of CNS maneuver, risk of loss of to vital neurovascular and limb orbital tissues, and even to the globe arterial inherent. Therefore, occasional paralysis. CNS blockade can manifest as itself is hypertension and tachycardia or complications should be expected. hypotension and bradycardia with cardiac arrest and pul monary edema. These signs and symptoms can occur in any combination, whereas the earliest findings are contralateral eye signs and loss of con sciousness. With proper diagnosis and prompt treatment, full recovery is normal. Treatment is specifically directed toward seizure control, hemo dynamic support and, in some cases, administration References of cardiopulmonary resuscitation. The nature of this complication of ocular anesthesia Unsold R, Stanley .lA, Deg-root J . The CT-topography ofof the patient by aanatomic12. emphasizes the need for careful monitoring retrobulbar anesthesia: qualified anesthesia staff. of complications and suggestion of a modified technique. Graefes Arch cinical correlation Clin Exp Ophthalmol 1981 ;217:125-136 The mechanism of this complication is debated. Intravenous or in traarterial 13. Davis DB, Mandel MR. Posterior peribulbar anesthesia: an alternative to retrobulbar administration has been postulated, but blood levels in patients were not in the anesthesia.J Cataract Refract Surg 1986;12:182-184 toxic range. Also, doubt has been cast on the intraarterial theory, because no 14. Davis DB, Mandel MR. Efficacy and complication rate of 16,224 consecutive peri bulbar reports have citedCataract Refract Surg 1994;20:327-335 hemorrhages. Intravascular blocks. J blood in syringes or retrobulbar injection should produce immediate seizure activity. Grand mal seizure path length. 15. Katsev DA, Drews RC, Rose BT. An anatomic study of retrobulbar needle activity Ophthalmology 1989;96:1221-1224 usually is the predominant sign but is not necessarily always present. Respiratory 16. and cardiovascular collapse also should occur injust few seconds. depression Hay A, Flynn HW, Hoffman .II, Rivera AH. Needle penetration ofathe globe during retrobulbar and peri bulbar injections. Ophthalmology 1991 ;98: 1017-1024 This clinical picture after periocular anesthesia has not been reported. 17. Edge KR, Martin .I, Nicoli V. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. The Analg widely accepted Anesth most 1994;76:1019-1022 explanation is direct injection into the nerve sheath, and it has been shown through orbitography studiesperforation during retrobulbar 18. Duker JS, BelmontJB, Benson WE, et al. Inadvertent globe using radiocontrast dye. 12 Anesthetics can gain access to the cranial nerve roots, pons, midbrain, and and peribulbar anesthesia. Ophthalmology 1991;98:519-526 spinal19. Rainin EA, Carlson BM. Postoperative diplopia and ptosis. Arch Ophthalmol 1985; 102:1337 cord. Also, the cerebrospinal fluid analysis of patients who developed 20. respiratoryHamed LM. Strabismus presenting after cataract surgery. Ophthalmology 1991;98: 247-252 arrest demonstrated lido caine and bupivicaine.P The neurological 21. Esswein MB, Von Noorclen CK. Paresis of a vertical rectus muscle after cataract extraction. signs or vision loss from this mechanism are thought to be short-lived, and no Am J Ophthalmol 1993; 116:424-430 permanent effects have been noted. Direct injection into the subarachnoid space 22. McGoldrick KE. Anesthesia for ophthalmic and otolaryngologic surgery. Philadelphia: would cause1992 Saunders, respiratory arrest within a few minutes, and this is the common clinical scenario. DB. Experimental subdural retrobulbar injection of anesthetic. Ann Ophthal 23. Drysdale
24. 1984;16:716-718 Kober, KA. Cerebrospinal fluid recovery of lidocaine and hupivicaine following respiratory arrest subsequent to retrobulbar block. Ophthalmic Surg 19H7;lH:II-13