1. PERIBULBAR BLOCK AND GLOBE
PERFORATION
Dr. Saptarshi Dasgupta .(MD)
Consultant Anaesthesiologist
2. Recent experience of globe
perforation
• PLAN : PE + IOL UNDER LA
• ANAESTHESIA– PERIBULBAR ( SITES - IT & SN)
• COMPLICATION – GLOBE RUPTURE WITH IRIS
PROLAPSE & PARTIAL NUCLEUS PROLAPSE
4. Objectives of anaesthesia in intraocular
surgery
• Akinesia of globe and lids
• Anaesthesia of globe and lids and adnexa
• Control of intraocular pressure
• Control of systemic blood pressure
• Relaxation of patient
• Absence of untoward reactions
• Smooth emergence
• Adequate post-operative analgesia
6. Anatomy
• Orbit – shape of irregular pyramid
– Base at front
– Axis points posterio-medially towards skull
• Globe lies in anterior part of orbit
- sits high and lateral
7. Anatomy
• Four rectus muscles arise from the back of
orbit
• Insert into the globe just forward of equator
• Form a cone
- boundary between
two compartments
9. Techniques of peribulbar block
• 5 ml bupivacaine 0.5% and 5 ml lignocaine 2%.
• 1500 units of hyaluronidase (mixed to aid
diffusion within the orbital tissue) are
drawn into a 10 ml syringe. Superior & inferior
injections of 5 ml each are given with
an 1 inch, 23-G Steel needle or ½ inch,26-G
needle. Inferior injection is given at the junction
of the outer one
third & inner two third of the lower orbital rim.
10. Techniques of peribulbar block
• Superior injection is given usually nasally just
above the medial canthus . The superior
injection may be avoided till the time the
inferior injection takes effect (3-5 min), to
judge the necessity for the additional
injection.
11. Techniques of peribulbar block
• If good akinesia is attained by the inferior
injection, there is no need for the superior
injection. Gently press on the lower lid between
the orbital margin and the globe to
feel the inferior orbital notch and with the other
hand progressively inject 5 ml of
anesthetic solution starting just under the skin,
progressively to just behind the
equator of the globe.
13. Position Of Eyeball
• lower
outer corner of the orbit at a point on a line drawn vertically
down from the outer canthus to the infraorbital margin
•23 gauge needle no longer than 1 inch is directed paralleling the wall
of the orbit with the patient's gaze in the primary position.
14. Guiding Of Needle
• The needle should be slowly advanced, stopping
immediately
– if there is either a tugging movement of the globe,
which may indicate snagging of the needle on sclera
or an extraocular muscle (EOM), or
– Some ask the patient to look up and down to ensure
that the globe has not been impaled.[21] Others
believe that this could cause adjacent orbital
structures to be lacerated over the needle tip.
– if there is either severe pain or resistance to injection,
either of which can indicate injection into the globe.
15. Type Of Needle
BLUNT NEEDLE SHARP NEEDLE
• LESS CHANCES OF • MORE CHANCES OF
PERFORATION PERFORATION
• MORE DAMAGE IF • LESS DAMAGE
PERFORATION
17. Complications
• Venous orbital hemorrhage .
• Arterial orbital hemorrhage.
• Oculocardiac incidence
• Allergic reaction
• Ophthalmoplegia - direct damage to the EOM or
its nerve.
• Globe perforation
• Central spread of anesthetic - Life-threatening
complications can result from intrathecal spread.
• Optic nerve damage.
18. Globe perforation
• This complication is very rare in experienced hands.
• More common with longer eyes specifically with
staphyloma
• If the needle catches the sclera, the cornea first moves
toward the needle and then suddenly away from it as
the needle passes through the sclera.
• It is often painful, but not always noticed at the time.
• surgeon might notice the absence of the red reflex, an
excessively soft eye or an excessively hard eye with
cloudy cornea if LA has been injected inside the eye.
19. Globe perforation
• Sometimes, the procedure is uneventful and
the telltale retinal appearance may be noticed
years later on routine fundoscopy.
• Rarely, enough LA can be injected inside the
eye to cause ocular explosion. This requires
IOPs of 2800-6400 mmHg.[21]
• Even with immediate recognition, the visual
prognosis for such an eye is poor.
20. How to avoid Perforation ?
• Subtenon’s Block can be used as an
alternative to Peribulbar Block as incidence of
perforation is minimal.
21. RISK & SEQUELAE OF SCLERAL
PERFORATION DURING PBA
• A retrospective study of receiving 2ndary care
for complications of globe perforation, over
17 yrs period.
• Results- this review identified 9 such among
them 2 were minor, rest required one or more
vitrectomies for RD.
• 2 of the 9 regained reading ability, one eye
maintained no light perception & 6 eyes had
ambulatory vision only.
