|Year : 2017 | Volume
| Issue : 2 | Page : 49-53
Management of globe perforation: From laser to silicon oil
Balbir Khan, Vartika Sobat Anand, Meenu Kashyap
Department of Ophthalmology, Adesh Medical College and Hospital, Ambala, Haryana, India
|Date of Web Publication||17-Nov-2017|
Vartika Sobat Anand
House No. 169, Sector 19A, Chandigarh
Source of Support: None, Conflict of Interest: None
Purpose: To analyze clinical manifestations, management, and visual outcome in cases with globe perforation due to variable etiologies. Material and Methods: Fifty cases (35 males and 15 females) were included in the study. Out of the fifty cases, 5 cases had perforation after giving posterior subtenon's injection, 2 cases had after injecting subconjunctival gentamycin and dexamethasone, 35 cases after peribulbar anesthesia, 4 cases while taking suture during retinal detachment (RD) surgery, and 4 while making scleral tunnel in RD surgeries. A total of 41 patients underwent vitrectomy, from which 37 patients had vitrectomy with fluid–gas exchange and endolaser and 4 patients had vitrectomy with scleral buckle and silicon oil. Five patients underwent indirect argon laser photocoagulation to seal the retinal break, and in 4 cases, scleral buckle were placed and cryotherapy was done. Results: The final visual acuity after a mean follow-up of 6 months was better than 20/30–20/40 in 28 patients, between 20/40 and 20/60 in 5 patients, and 20/120–20/200 in 17 patients. Conclusion: If diagnosed early and treated adequately, a majority of patients with globe perforation could be saved with a good visual outcome.
Keywords: Laser indirect photocoagulation, perforation, vitrectomy
|How to cite this article:|
Khan B, Anand VS, Kashyap M. Management of globe perforation: From laser to silicon oil. Egypt Retina J 2017;4:49-53
| Introduction|| |
Ocular perforation for a variety of causes can occur with even experienced surgeons while giving block. It is a recognized but uncommon complication. Globe perforation during peri-bulbar block is a complication, rarely reported these days in the era of topical surgeries. Certain predisposing factors for globe perforation are high axial length (AL) >25 mm (as sclera is thin and stretched), posterior staphyloma, retinal detachment (RD) surgeries due to high buckle effect (there is an elongation of globe anteroposteriorly and sideways), deep-set eyes, severe enophthalmos, uncooperative patients because of unsteady gaze and not fixating the eye properly, anesthesia given by nonophthalmologists, and high-volume camp surgeries. Mostly, needle track is in inferotemporal (IT) quadrant and it can occur in superonasal site also. Severe pain while giving peribulbar anesthesia and sudden hypotony are early recognizable features. Visual prognosis in these patients depends on early diagnosis and management as injected drugs can cause retinal toxicity, especially hyaluronidase. We present a series of fifty cases that were diagnosed with ocular perforation due to variable etiologies.
| Material and Methods|| |
The study was done over a period of 3 years from June 2012 to May 2015, in a tertiary eye care center. Forty-two patients were referred from outside and 8 were at our center. (4 while taking suture for scleral buckle and 4 while making scleral tunnels for placing encircling band). A total of fifty patients from which 35 patients had a history of undergoing phacoemulsification with intraocular lens (IOL) implant for cataract surgery under peribulbar anesthesia. A two-needle injection peribulbar technique was used as told by the operating surgeon. The first injection was given at lateral third of the lower orbital rim by transcutaneous approach and the second at the medial third of the upper orbital rim through the upper lid in all cases. And eight patints undergoing scleral buckling for rhegmatogenous retinal detachment had iatrogenic ocular perforation while taking sutures and making tunnels with a crescent knife. Five patients while giving posterior subtenon develop perforation and two while injecting subconjunctival gentamycin and dexamethasone.
In the entire series, either 24-gauge needles or 26-gauge disposable needles had been used for the injection. Block was made for cataract surgery, while the subconjunctival injections were made for postoperative inflammation. Evaluation of the patient involved recording of visual acuity (VA), complete ophthalmic examination including fundus photograph and B-scan.
| Results|| |
[Table 1] summarizes the relevant information of each case in the series. A total of fifty patients (35 males and 15 females) were included in the study. The AL of the operated eyes was normal (range: 22–23.48 mm) in all cases except three patients who were myopic and two patients who had scleral buckling prior.
No penetration was noticed at the time of administration of local anesthesia. The possibility of perforation was suspected during or after the surgery. Thirty-five patients had peribulbar perforation, from which thirty patients who were referred from outside came to us within 7–10 days after undergoing cataract surgery with IOL implantation successfully. In these cases on the first postoperative day, vitreous hemorrhage (VH), hypotony, diminution of vision, and hyphema were noticed by an anterior segment surgeon and they were referred to us. In all cases, 23-gauge pars plana vitrectomy (PPV) with fluid–gas exchange (FGE) and endolaser (EL) photocoagulation to the break was done.
Moreover, five cases developed unusually soft eye following peribulbar anesthesia. The diagnosis of perforation was made on the table. As media was sufficiently clear after cataract surgery under general anesthesia, in these cases, indirect argon laser photocoagulation was done as the retina was attached.
Other five patients had ocular perforation while giving posterior subtenon's triamcinolone (Aurocort from Aurolab) for intermediate uveitis and posterior uveitis. From these, three patients had RD, so these patients underwent 23-gauge PPV with FGE EL and encircling buckle, while the remaining two had PPV with endolaser to the break. In these cases, a large amount of triamcinolone was found in the vitreous cavity during vitrectomy and was removed.
Four patients had perforation while taking sutures during RD surgery with 5–0 ethibond scleral buckling. Two cases were found to have associated subretinal hemorrhage, and subretinal fluid got drained in all four cases, so we placed scleral buckle (279 tyre) posterior to the perforation site which was treated with cryopexy.
In another four cases where perforation was noted while making scleral tunnel for placing an encircling buckle in RD surgeries with proliferative vitreoretinopathy (PVR), scleral tunnel was sutured and another site was chosen for making scleral tunnel. Fresh bleeding was noted in two cases and two had small subretinal bleeding not reaching up to the macula. In these cases, scleral buckle with vitrectomy with silicon oil implantation was done.
Two cases got retinal break after giving subconjunctival gentamycin and dexamethasone. Hence, these cases underwent early vitrectomy within 24 h after presentation was done as gentamycin diffuses rapidly and can cause macular infarction.
All patients were followed up for 6 months. Final VA was better than 20/30–20/40 in 28 cases, between 20/40 and 20/60 in 4 cases, and 20/120–20/200 in 18 cases.
| Discussion|| |
The incidence of globe perforation during peribulbar injection has been reported to be 1 in 874 cases. Inadvertent globe perforation can occur during peribulbar, retrobulbar, subconjunctival, and subtenon's injections, strabismus surgery, botulinum toxin injections for strabismus,, and has been reported even during chalazion surgery. Complications related to periocular injections, ranging from innocuous subconjunctival hemorrhage, VH optic nerve injury, and RD to intracranial diffusion, have been described.
Peribulbar injections are considered safer. However, some techniques need more than one injection, statistically increasing the chance of a mishap. Single use disposable fine gauge needles were used. The risk factors for perforation described in literature  and observed in our series were myopia in three cases and previous buckling surgery in two cases. Myopia has dual risk due to thinned-out sclera and an elongated eyeball (posterior staphyloma). Buckling surgery causes adhesions between the globe and orbital tissues. Some studies show a higher incidence of this complication during a second injection, as in some cases, technician performs the injection while patient is in the sitting position which should never be done. The first step in iatrogenic perforation is the penetration of the globe. At this stage, the damage is usually restricted to a retinal break. Injection of the medication into the globe results in a sudden rise of intraocular pressure. This could lead to a central retinal artery occlusion  corneal clouding or pressure-induced damage to the intraocular structures. In such conditions, the effect of the medication on the retina is important. Lignocaine is relatively safe as shown by reversal of electroretinogram changes in animal models. Gentamycin, however, is known to cause macular ischemia. Hyaluronidase which is mixed with lignocaine is toxic to retina. Double perforation is more likely to be missed preoperatively  as the medication is injected into the retrobulbar space; however, we can see a needle track [Figure 1]. A high index of suspicion is required in all cases of iatrogenic globe perforation as almost 50% of cases are not recognized at the time of occurrence.,, Perforation signs noted by Berglin et al. in a series of 25 cases included VH in 100%, subretinal hemorrhage in 76%, and RD in 56%. Modarres et al. reported VH in all seven myopic cases, with RD in four of them. Gillow et al. reported six cases with VH in all and RD in five cases. Wearne et al. reported twenty cases where nine had RD. Localization of the retinal break in most series was posterior to the equator. The IT location was the most common, as in our series [Figure 2]. Laser photocoagulation has been advocated for the treatment of breaks when visible and not obscured by VH [Figure 3].
Early vitrectomy with FGE was done in dense VH and/or RD. Early vitrectomy helps to treat the retinal breaks and clear VH. It serves to remove any medication, which may have found its way into the globe, like depot steroids. Increased duration from injury to surgery increases the chances of PVR as in any posterior segment perforating injury needing buckle placement. Vitrectomy helps to remove the vitreous scaffolding as also the tract along which traction can occur. In this series, three patients who had a RD did reasonably well. The early intervention could be responsible for these results. The study retrospectively evaluated a series of cases referred with globe perforation, by single surgeon. The study was unable to ascertain the incidence of this complication, as we were not aware to confidential information of the total blocks given or surgeries done by referring hospitals and whether some cases were referred elsewhere. A larger multicenter study would help to increase our understanding of this complication.
It is evident that, although ocular perforation is a serious complication, early diagnosis and management seem to hold good visual outcomes. Giving peribulbar block and if aspiration is blood stained needle should be withdrawn and another site chosen for block.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Morris RJ, Rosen PH, Fells P. Incidence of inadvertent globe perforation during strabismus surgery. Br J Ophthalmol 1990;74:490-3.
Liu M, Lee HC, Hertle RW, Ho AC. Retinal detachment from inadvertent intraocular injection of Botulinum
toxin A. Am J Ophthalmol 2004;137:201-2.
Mohan M, Fleck BW. Globe perforation during Botulinum
toxin injection. Br J Ophthalmol 1999;83:503-4.
Shiramizu KM, Kreiger AE, McCannel CA. Severe visual loss caused by ocular perforation during chalazion removal. Am J Ophthalmol 2004;137:204-5.
Marqués-González A, Onrubia-Fuertes X, Bellver-Romero J, Seller Losada JM, Pertusa-Collado V, Barberá-Alacreu M, et al.
Intracranial diffusion. A complication of retrobulbar anesthesia. Rev Esp Anestesiol Reanim 1997;44:284-6.
Stevens JD, Franks WA, Orr G, Leaver PK, Cooling RJ. Four-quadrant local anaesthesia technique for vitreoretinal surgery. Eye (Lond) 1992;6(Pt 6):583-6.
Schneider ME, Milstein DE, Oyakawa RT, Ober RR, Campo R. Ocular perforation from a retrobulbar injection. Am J Ophthalmol 1998;106:35-40.
Gopal L, Badrinath SS, Parikh S, Chawla G. Retinal detachment secondary to ocular perforation during retrobulbar anaesthesia. Indian J Ophthalmol 1995;43:13-5.
] [Full text]
Ball JL, Woon WH, Smith S. Globe perforation by the second peribulbar injection. Eye (Lond) 2002;16:663-5.
Parikh S, Shanmugam MP, Biswas J. Bisected macula following retrobulbar steroid injection. Indian J Ophthalmol 1999;47:247-8.
] [Full text]
Liang C, Peyman GA, Sun G. Toxicity of intraocular lidocaine and bupivacaine. Am J Ophthalmol 1998;125:191-6.
Berg P, Kroll P, Küchle HJ. Iatrogenic eye perforation in Para-and retrobulbar injections. Klin Monbl Augenheilkd 1986;189:170-2.
Ramsay RC, Knobloch WH. Ocular perforation following retrobulbar anesthesia for retinal detachment surgery. Am J Ophthalmol 1978;86:61-4.
Hay A, Flynn HW Jr., Hoffmann JI, and Rivera AH. Needle perforation of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991;98:1017-24.
Grizzard WS, Kirk NM, Pavan PR, Antworth MV, Hammer ME, Roseman RL, et al.
Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991;98:1011-6.
Berglin L, Stenkula S, Algvere PV. Ocular perforation during retrobulbar and peribulbar injections. Ophthalmic Surg Lasers 1995;26:429-34.
Modarres M, Parvaresh MM, Hashemi M, Peyman GA. Inadvertent globe perforation during retrobulbar injection in high myopes. Int Ophthalmol 1997;21:179-85.
Gillow JT, Aggarwal RK, Kirkby GR. Ocular perforation during peribulbar anaesthesia. Eye (Lond) 1996;10(Pt 5):533-6.
Wearne MJ, Flaxel CJ, Gray P, Sullivan PM, Cooling RJ. Vitreoretinal surgery after inadvertent globe perforation during ocular local anesthesia. Ophthalmology 1998;105:371-6.
Gopal L, Bhende M, Sharma T. Vitrectomy for accidental intraocular steroid injection. Retina 1995;15:295-9.
[Figure 1], [Figure 2], [Figure 3]