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Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 95-97  

Management of iatrogenic globe perforation during peribulbar anesthesia with submacular hemorrhage

1 Vitreoretinal Divison, King Khaled Eye Specialist Hospital, Riyadh; Department of Ophthalmology, Taif University, Makkah, Taif, Saudi Arabia
2 Vitreoretinal Divison, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
3 Department of Ophthalmology, Taif University, Makkah, Taif, Saudi Arabia

Date of Submission29-Dec-2019
Date of Decision18-Feb-2020
Date of Acceptance30-Mar-2020
Date of Web Publication28-May-2020

Correspondence Address:
Abdulaziz Al-Shehri
Vitreo Retina Unit, P O B: 7191, King Khaled Eye Specialist Hospital, Riyadh 11462
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.OJO_208_2019

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A patient with an amblyopia and poor vision in the fellow eye experienced iatrogenic globe perforation during peribulbar anesthesia for cataract surgery. The injection and surgery were immediately aborted. Visual acuity was hand motion, and retinal examination revealed retinal detachment, hemorrhagic choroidal detachment, and submacular hemorrhage. These were initially managed medically until the hemorrhagic choroidal detachment resolved and afterward by combined phacoemulsification with pars plana vitrectomy, subretinal recombinant tissue plasminogen activator, and gas tamponade. Two weeks post operative, the patient achieved the best-corrected visual acuity of around 20/200, which after 1 year of follow-up improved to 20/70.

Keywords: Globe perforation, peribulbar anesthesia, submacular hemorrhage

How to cite this article:
Al-Shehri A, Al-Ghamdi A, Al-Shehri A, Alakeely A. Management of iatrogenic globe perforation during peribulbar anesthesia with submacular hemorrhage. Oman J Ophthalmol 2020;13:95-7

How to cite this URL:
Al-Shehri A, Al-Ghamdi A, Al-Shehri A, Alakeely A. Management of iatrogenic globe perforation during peribulbar anesthesia with submacular hemorrhage. Oman J Ophthalmol [serial online] 2020 [cited 2023 Mar 26];13:95-7. Available from: https://www.ojoonline.org/text.asp?2020/13/2/95/285295

   Introduction Top

Globe perforation during local anesthesia is a complication uncommonly seen in the era of topical anesthesia, especially since the peribulbar block has become a widely used technique instead of the retrobulbar block for local anesthesia in routine cataract surgery.[1] Previous studies showed different approaches in surgical interventions and the outcomes of these interventions, depending on factors such as early recognition, intraocular injection of anesthetic solution, perforation site, and lack of retinal detachment.[2],[3] We report this rare presentation of inadvertent globe perforation with submacular hemorrhage and its management with anatomical and functional outcomes.

   Case Report Top

A 68-year-old woman with a baseline best-corrected visual acuity (BCVA) of 20/50 was booked for a routine cataract surgery on her only seeing eye. She noticed sharp, excruciating pain and sudden visual loss during the peribulbar block. The block was aborted before the administration of the anesthetic solution, and the surgery was canceled.

The patient was then referred to our institution, where her BCVA was found to be hand motion in the affected eye and in the other eye, which had poor vision since early childhood as a result of amblyopia and macular scar. A slit-lamp examination of the right eye showed a mild subconjunctival hemorrhage, clear cornea, and cataractous lens. The anterior chamber was quiet and deep, and intraocular pressure was found to be 10 mmHg. A retinal examination revealed a vitreous hemorrhage extending from the premacular area inferiorly, which minimized the view of the macula with hemorrhagic choroidal detachment and retinal detachment with no visible retinal breaks [Figure 1].
Figure 1: Color fundus photo of the right and left eyes at the presentation

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Examination of the left eye's anterior segment showed a quite pseudophakic eye with a clear cornea, whereas the posterior segment showed clear vitreous, myopic fundus, tilted disc with peripapillary, and macular chorioretinal atrophy [Figure 1].

An ultrasound B-scan of the right eye demonstrated a vitreous hemorrhage, posterior vitreous detachment, and retinal and choroidal detachment located in the inferior temporal quadrant [Figure 2]. The axial length of the eye was measured and found to be 25.6 mm.
Figure 2: Serial ultrasound of the right eye preoperatively showed gradual resolution of the choroidal detachment with persistence inferior temporal retinal detachment of the right eye

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The patient was maintained in a semi-sitting position to encourage the resolution of the premacular hemorrhage. Seven days later, the fundus examination showed resolved choroidal detachment, clearing vitreous hemorrhage with an underling submacular hemorrhage, and persistent inferior retinal detachment. A repeated ultrasound B-scan confirmed the finding.

The patient was agreed to undergo combined phacoemulsification plus intraocular lens (IOL) implantation coupled with pars plana vitrectomy (PPV), subretinal recombinant tissue plasminogen activator (rt-PA) injection, and gas tamponade.

While the patient was under general anesthesia, a 23G PPV was initiated. After clearing the vitreous hemorrhage, subretinal blood was evacuated from the Foveal area with the help of 0.1 mL of rt-PA (Actilyse) at 100 mg/mL, which was injected under the retina through the posterior break using a 41G cannula to create a subretinal bleb [Figure 3].
Figure 3: Intraoperative image showing the right eye submacular hemorrhage

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After that an uneventful phacoemulsification procedure was carried out through a 2 mm incision posterior to the limbus scleral tunnel, and we subsequently implanted a 13.0 diopter AcrySof IOL (Alcon, Fort Worth, Texas, USA) in the capsular bag. Air-fluid exchange was performed and subretinal fluid was completely drained. Finally, the retina was attached, an endolaser was done around the break and in 360° manner, and 20% SF6 was injected. Then, 7.0 polyglactin (Vicryl) was used to close the sclerotomy sites, whereas a 10.0 nylon suture was used to close the scleral tunnel wound. After the operation, the patient's BCVA progressively improved to counting fingers at 2 m within 2 weeks, 20/200 at 3 months, and to 20/70 at 1 year. The subretinal hemorrhages found around the macula gradually decreased with a complete resolution at 1 month [Figure 4].
Figure 4: Right eye 1-month postoperative fundus photo and spectral-domain optical coherence tomography of the macula showing a flat retina with complete resolution of submacular hemorrhage

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   Discussion Top

Inadvertent globe perforation can occur during subconjunctival, retrobulbar, and peribulbar injections,[1] as well as during strabismus botulinum toxin injections and strabismus surgery.[4],[5] It has also been reported during chalazion excision.[6] Different adverse effects can include retinal break, severe proliferative vitreoretinopathy, vitreous hemorrhage, retinal detachment, and subretinal hemorrhage.[1],[2],[7] However, perforation remains undetected in up to a third of cases.[8] Research shows that inadvertent globe perforation as a complication of a regional eye block occurs at an incidence of 1 in every 16,000 cases of peribulbar anesthesia and 0.9 in every 10,000 cases of retrobulbar anesthesia.[1] Certain predisposing factors leading to globe perforation include posterior staphyloma, an uncooperative patient, deep-set eyes, high axial length, previous extraocular surgery, and anesthesia administered by a nonophthalmologist.[1],[7],[9]

Submacular hemorrhages are an uncommon presentation of globe perforation but can damage the photoreceptors due to fibrin meshwork contraction, iron toxicity, and reduced nutrient flux, which is usually followed by macular scarring.[10] Both experimental and clinical studies conducted by different researchers have suggested that prompt treatment should be provided to the patient to avoid tissue damage, which can take place in <24 h. If a patient does not receive fast treatment, natural history becomes poor with the mean final visual acuity being 20/1600.[10],[11] Some treatments reported include macular translocation, intravitreal anti-vascular endothelial growth factor drugs, subretinal or intravitreal tissue PA, pneumatic displacement, and retinal pigment epithelial patch.[10]

In the case study provided, the patient was found to be myopic, which is one of the major factors leading to globe perforation. However, the doctor observed the perforation in time to react, which minimized further damage from the toxic effect of the anesthetic solution. Therefore, it is recommended that the complication can be identified in the early stage and that prompt management steps to be taken. In addition, the presence of vitreous hemorrhage, hemorrhagic choroidal detachment, retinal detachment, and subretinal hemorrhage provide additional management challenges. In this case study, the medical and surgical managements performed led to a satisfactory outcome, with a final BCVA of 20/70.

In conclusion, a few cases of submacular hemorrhage after peribulbar anesthesia have been reported. As such, this case is crucial as it seeks to create awareness of the adverse sequences of events that may take place after inadvertent intraocular perforation during a local anesthetic. Therefore, it is essential to take an appropriate and timely management approach to salvage useful vision after globe perforation ensues. Nevertheless, it is crucial to carry out awareness training of the best methods that are recommended for periocular anesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Agrawal N, Nakhwa C, Jhawar S, Khare G. Management of globe perforation during cataract surgery. JCRS Online Case Rep 2017;5:24-6.  Back to cited text no. 1
Schrader WF, Schargus M, Schneider E, Josifova T. Risks and sequelae of scleral perforation during peribulbar or retrobulbar anesthesia. J Cataract Refract Surg 2010;36:885-9.  Back to cited text no. 2
Lake D, Mearza A, Ionides A. Consequence of perforation during peribulbar anesthesia in an only eye. J Cataract Refract Surg 2003;29:2234-5.  Back to cited text no. 3
Morris RJ, Rosen PH, Fells P. Incidence of inadvertent globe perforation during strabismus surgery. Br J Ophthalmol 1990;74:490-3.  Back to cited text no. 4
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.  Back to cited text no. 5
Shiramizu KM, Kreiger AE, McCannel CA. Severe visual loss caused by ocular perforation during chalazion removal. Am J Ophthalmol 2004;137:204-5.  Back to cited text no. 6
Vohra SB, Good PA. Altered globe dimensions of axial myopia as risk factors for penetrating ocular injury during peribulbar anaesthesia. Br J Anaesth 2000;85:242-5.  Back to cited text no. 7
Bullock JD, Warwar RE, Green WR. Ocular explosion during cataract surgery: A clinical, histopathological, experimental, and biophysical study. Trans Am Ophthalmol Soc 1998;96:243-76.  Back to cited text no. 8
Wadood AC, Dhillon B, Singh J. Inadvertent ocular perforation and intravitreal injection of an anesthetic agent during retrobulbar injection. J Cataract Refract Surg 2002;28:562-5.  Back to cited text no. 9
Stanescu-Segall D, Balta F, Jackson TL. Submacular hemorrhage in neovascular age-related macular degeneration: A synthesis of the literature. Surv Ophthalmol 2016;61:18-32.  Back to cited text no. 10
Schaal S, Apenbrinck E, Barr CC. Management of thick submacular hemorrhage with subretinal tissue plasminogen activator and pneumatic displacement for age-related macular degeneration. Am J Ophthalmol 2015;159:404.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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