OSLI Retina

April 2020

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April 2020 ยท Vol. 51, No. 4 249 The Cutting Edge Edited by Yoshihiro Yonekawa, MD, and Peter H. Tang, MD, PhD The authors present a case of retinal detachment (RD) re- pair after inadvertent perfora- tion from a retrobulbar block needle. One of the key features of this video is the decision to perform a sub-Tenon's block in which a conjunctival and Tenon's capsule cutdown is created followed by advance- ment of a blunt-tipped cannula into the retrobulbar space and injection of the an- esthetic. Compared to a peribulbar or retrobulbar block, there is almost no risk of globe perforation or retrobulbar hemorrhage. At the same time, a sub-Tenon's block offers the same advantages with excellent analgesia and akinesia. The down- side is primarily cosmetic, with development of subconjunctival hemorrhage, though it typically resolves within a week. Sometimes, if the cannu- la is not through Tenon's capsule or if too much anesthetic is injected, there can be ballooning of the conjunctiva. Risk factors for perforation with retrobulbar and peribulbar blocks include a long axial length, as seen in high myopes, and associated presence of a posterior staphyloma. Although retrobulbar blocks rarely lead to complications, when they do, they can be devastating. Few cases of scleral perfo- ration after blocks have been published; however, the outcomes tend to vary, though few appear to regain reading vision. In this case, the steps for surgical repair of the detachment from the multiple needle perforations are excellent. Using triamcinolone to visualize the hyaloid and ensure posterior vitreous separation is crucial, as residual adherent vitreous may act as a scaffold for proliferative vitreoretinopathy (PVR). When separating the hyaloid in the presence of a RD, there is also a risk of incarcerating the retina in the cutter's mouth, particularly if high suction is used. A bubble of perfluorocarbon liquid once the hyaloid is off the macula can sometimes be helpful in stabilizing the retina to avoid this complication. Also, one can use just enough suction to engage the gel into the mouth of the cutter then come off the foot pedal and just mechanically elevate the hyaloid with very little or no suction. Finally, the traumatic nature of this detachment with associ- ated vitreous and subretinal hemorrhage places this patient at a high risk for PVR. Therefore, the decision to use silicone oil primarily was a good idea beyond the stated benefits of decreased need for postoperative positioning and earlier recovery of some functional vision. Jason Hsu, MD Retina Service of Wills Eye Hospital Thomas Jefferson University Hospital Mid Atlantic Retina Philadelphia, PA Repair of Rhegmatogenous Retinal Detachment Following Globe Perforation by Retrobulbar Anesthesia Nicolas A. Yannuzzi, MD; Swarup S. Swaminathan, MD; Rehan Hussain, MD; Jayanth Sridhar, MD ABSTRACT: Globe perforation following retrobulbar or peribulbar anesthetic injection is a rare but dreaded complication that often results in suboptimal visual outcomes. This video describes a 72-year-old woman who sustained a globe perforation during retrobulbar block in the setting of cataract extraction and later developed a retinal detachment. The retina was re- paired with pars plana vitrectomy and silicone oil, resulting in a favorable visual outcome. The authors discuss various modes of local anesthesia for vitreo- retinal surgery, risks for globe perforations, and how to approach retinal detachment secondary to needle perforations, which are complex cases at high risk for proliferative vitreoretinopathy. Jason Hsu, MD

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