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Diplopia and ptosis following injection of local anesthesia without hyaluronidase
Diplopia and ptosis following injection of local anesthesia without hyaluronidase Faisal S. Jehan, MD, John C. Hagan III, MD, Thomas J. Whittaker, MD, Manju Subramanian, MD ABSTRACT In a university ophthalmology department, a cluster of postoperative diplopia and ptosis cases occurred in the initial 3 months after hyaluronidase (Wydase姞) became unavailable for use with injection anesthesia. These cases suggest that hyaluronidase, when used with injection anesthesia, may protect extraocular muscles and nerves from the toxic effects of local anesthetic agents. The spreading action of hyaluronidase facilitates uniform diffusion of anesthetic agents. This prevents elevated extracellular tissue pressure, a cause of ischemic damage to extraocular muscles or nerves. Hyaluronidase may also prevent focal accumulations and concentrations of local anesthetic agents, which at high enough levels may cause myotoxic or neurotoxic damage, fibrosis, and contracture of extraocular muscles or nerves. J Cataract Refract Surg 2001; 27:1876 –1879 © 2001 ASCRS and ESCRS
D
iplopia and ptosis are infrequent but established complications of cataract surgery with injection anesthesia. Several authors1,2 note an increase in permanent diplopia following injection anesthesia (peribulbar or retrobulbar injection) during a national shortage of hyaluronidase (mid-1998 to early 1999). Wyeth-Ayerst was the sole manufacturer of hyaluronidase (Wydase威) approved by the U.S. Food and Drug Administration (FDA). The company has permanently stopped the manufacture of Wydase, and it is no longer available. The Department of Ophthalmology at the University of Kansas routinely mixed Wydase with local anesAccepted for publication July 16, 2001.
thetic agents for injection anesthesia before cataract surgery. In September 2000, Wydase supplies were depleted at our teaching hospitals. Injection anesthesia was then done without hyaluronidase. In the following 3 months, 5 cases (4.2%) of postoperative diplopia or ptosis (or combined diplopia and ptosis) occurred in the 120 cases of cataract surgery done at these hospitals. In the previous 3 months, no ptosis or diplopia had occurred in a similar number of cases. A private attending physician reported another case of ptosis soon after Wydase was removed from the market. We report these cases, which support the hypothesis that hyaluronidase protects extraocular muscles from the myotoxic effects of local anesthetic agents.
From the Department of Ophthalmology, University of Kansas Medical Center, Kansas City, Kansas, USA. None of the authors has a proprietary or financial interest in the products mentioned. Correspondence to John C. Hagan III, MD, Discover Vision Centers, 9401 North Oak Trafficway, Suite 200, Kansas City, Missouri 64155, USA. E-mail: [email protected]. © 2001 ASCRS and ESCRS Published by Elsevier Science Inc.
Case Reports Case 1 A 38-year-old white woman had uneventful phacoemulsification cataract extraction and insertion of a posterior chamber intraocular lens (PC IOL) via a temporal clear corneal incision on September 19, 2000. Anesthesia was obtained 0886-3350/01/$–see front matter PII S0886-3350(01)01099-9
CASE REPORTS: JEHAN
using a retrobulbar injection of 4.5 cc of a 1:1 mixture of lidocaine 1% (Xylocaine威) and bupivacaine 0.75% without Wydase. Placement and volume of the injection were carefully monitored. Constant tactile ballotement of the globe and orbit was used to leave the orbit soft and the globe easy to retropulse. No bridle sutures were placed. On postoperative day 1, the patient complained of double vision in the left eye. There was marked underaction of the left lateral rectus. An oral prednisone pulse-taper was started. The diplopia resolved by postoperative day 8.
Case 6 A 66-year-old white man had uneventful phacoemulsification and PC IOL implantation via a temporal clear corneal incision in the left eye on January 25, 2001. Anesthesia was obtained using a retrobulbar injection of 5.0 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were placed. On postoperative day 1, the patient complained of vertical diplopia and was found to have weakness of the left inferior rectus muscle. The diplopia and inferior rectus weakness resolved by postoperative day 8.
Case 2 A 75-year-old white woman had phacoemulsification and PC IOL implantation via a temporal clear corneal incision in the left eye on September 13, 2000. Anesthesia was obtained uneventfully with an inferior orbital peribulbar injection of 9.0 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were used. On postoperative day 1, the patient had complete ptosis. The ptosis improved slowly over the next 6 weeks, and further treatment was unnecessary.
Case 3 A 72-year-old white man had phacoemulsification and PC IOL implantation in the right eye on October 20, 2000. Anesthesia was obtained uneventfully with a retrobulbar injection of approximately 6.0 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were placed. On postoperative day 1, the patient complained of diplopia and was found to have right lateral rectus weakness. He was observed and by postoperative day 4, the diplopia and rectus weakness had resolved.
Case 4 A 75-year-old black man had phacoemulsification and PC IOL implantation in the right eye via a temporal clear corneal incision on November 9, 2000. Anesthesia was obtained by a retrobulbar injection of 8 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were placed. On postoperative day 1, the patient had complete ptosis of the right upper eyelid. The ptosis gradually improved and had resolved by postoperative day 7.
Case 5 A 74-year-old white man had phacoemulsification and PC IOL implntation in the right eye via a temporal clear corneal incision on October 2, 2000. Anesthesia was obtained uneventfully by retrobulbar injection of approximately 7 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were used. On postoperative day 1, the patient complained of vertical diplopia and was found to have weakness of the right inferior rectus muscle. Twelve weeks postoperatively, there was no significant improvement.
Discussion Diplopia is an established complication of retrobulbar and peribulbar anesthesia, with an incidence of 0.85% to 2.00%.3,4 The elimination of bridle sutures, prolonged patching, and less traumatic injection and intraoperative techniques have reduced the incidence of postoperative ptosis and diplopia. Postoperative diplopia may result from various etiologies, including weakness, contracture, or overaction of an extraocular muscle. Rainin and Carlson5 report 6 cases of postoperative diplopia and were the first to suggest that direct injection of an anesthetic agent into the muscle belly causes a myotoxic injury, leading to muscle weakness and diplopia. Anesthetic toxicity to the nerve supplying the muscle may account for paresis.6 Muscle contracture, with positive forced-duction testing, has also been implicated as a cause of postoperative diplopia.7,8 Contracture has been attributed to direct injury of the muscle with resulting inflammation and fibrosis, either from direct anesthetic myotoxicity or needle penetration or laceration of the muscle. Ischemic injury from high tissue pressure and vascular compromise with subsequent inflammation and fibrosis is another mechanism. This might occur from an intramuscle or extramuscle hematoma or a large volume of anesthetic agent within the orbit or the muscle.9 –11 Muscle overaction may also cause postoperative diplopia.12,13 These cases have ocular deviations that are greater in the field of action of the injured muscle. It is postulated that overactive muscles are a result of segmental fibrosis from local anesthetic myotoxicity. Restrictive patterns may follow initial periods of muscle overaction as contracture occurs. Other possible mechanisms of postoperative diplopia include changing from monocular central vision to binocular central vision. The improved visual acuity in
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the operated eye may cause a previously undiagnosed or asymptomatic strabismus or anisometropia to become manifest.14 Hyaluronidase is an enzyme frequently added to local anesthetic agents for ophthalmic local anesthesia. It is prepared from bovine testes and improves the rapidity of onset, dispersion, depth, and duration of local anesthesia.15–18 Its action is accomplished by a depolymerization of extracellular hyaluronic acid, the intercellular cement substance of connective tissues. This allows anesthetic agents to spread faster throughout the orbit across fine connective tissue septal barriers. Hyaluronidase also reduces the incidence of ptosis and extraocular muscle paresis.19 When hyaluronidase is not used with the local anesthetic agent, increased concentrations of the anesthetic agent may loculate around the extraocular muscles, causing myotoxicity.1 Focally increased orbital extracellular pressure may also cause ischemic damage by decreasing blood flow through the muscular branches of the ophthalmic artery. The inferior rectus muscle is especially vulnerable because of its location in the area where most retrobulbar and peribulbar injections occur. From September 2000 to November 2000, when Wydase became unavailable, approximately 120 phacoemulsification cataract surgeries were performed at our teaching institutions. During this period, 5 cases of ptosis or postoperative diplopia occurred. One was permanent. This 4.2% incidence of diplopia/ptosis is higher than previously reported rates of 0.85% to 2.00%.3,4 During the previous 3 months, there were no cases of diplopia or ptosis in a similar number of cases. In cases such as these, the 6 surgeons who performed the surgeries would normally have added Wydase to the injected local anesthetic agent. Each of these 6 instances of diplopia and ptosis occurred shortly after Wydase became unavailable. The sudden appearance of postanesthetic ptosis and diplopia in the clinical practices of multiple surgeons coincident with the shortage of hyaluronidase suggests a causal relationship. There were no other variables or changes in the type of anesthesia or surgical technique other than Wydase not being added to the local anesthetic agent. This suggests that when added to the injected local anesthetic agent, hyaluronidase reduces diplopia and ptosis after cataract and IOL surgery. Fortunately, only 1 of our cases was permanent. Claims of large series of cataract surgery that have not 1878
had any diplopia or ptosis postoperatively, with or without hyaluronidase, are uncontrolled, retrospective, and anecdotal.20 Our university program is performing more surgeries under topical and intracameral anesthesia. Smaller volumes of injectant are being used for retrobulbar or peribulbar local anesthesia without hyaluronidase. A prospective controlled study of Wydase will not be possible because of its permanent unavailability. Whether hyaluronidase adds to the safety of injection anesthesia is an important issue. Injection anesthesia remains the preferred technique for many United States surgeons21 and in many residency training programs. Surgeons who use topical or intracameral anesthesia often use an injection for their most difficult cases or patients. Injection anesthesia is used for other ophthalmic surgery, especially retinal and oculoplastic. Some U.S. surgeons are using hyaluronidase prepared by compounding pharmacies. These hyaluronidase preparations are not FDA approved and are subject to various rules and regulations regarding purchase and use. One such source (O’Brien’s Compounding Pharmacy, Kansas City, Missouri) has been reported to be satisfactory.22
References 1. Brown SM, Brooks SE, Mazow ML, et al. Cluster of diplopia cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999; 25:1245–1249 2. Hagan JC III, Whittaker TJ, Byars SR. Diplopia cases after periocular anesthesia without hyaluronidase (letter). J Cataract Refract Surg 1999; 25:1560 –1561 3. Golnik KC, West CE, Kaye E, et al. Incidence of ocular misalignment and diplopia after uneventful cataract surgery. J Cataract Refract Surg 2000; 26:1205–1209 4. Cadera W. Diplopia after peribulbar anesthesia for cataract surgery. J Pediatr Ophthalmol Strabismus 1998; 35: 240 –241 5. Rainin EA, Carlson BM. Postoperative diplopia and ptosis; a clinical hypothesis based on the myotoxicity of local anesthetics. Arch Ophthalmol 1985; 103:1337–1339 6. Hunter DG, Lam GC, Guyton DL. Inferior oblique muscle injury from local anesthesia for cataract surgery. Ophthalmology 1995; 102:501–509 7. Tejedor J, Rodriguez Sanchez JM. Vertical strabismus after local anesthesia (letter). Ophthalmology 1996; 103: 545–546 8. Corboy JM, Jiang X. Postanesthetic hypotropia: a unique syndrome in left eyes. J Cataract Refract Surg 1997; 23: 1394 –1398
J CATARACT REFRACT SURG—VOL 27, NOVEMBER 2001
CASE REPORTS: JEHAN
9. Egan R, Rizzo JF III. Neuroophthalmological complications of ocular surgery. Int Ophthalmol Clin 2000; 40(1):93–105 10. Hamed LM. Strabismus presenting after cataract surgery. Ophthalmology 1991; 98:247–252 11. Hamilton SM, Elsas FJ, Dawson TL. A cluster of patients with inferior rectus restriction following local anesthesia for cataract surgery. J Pediatr Ophthalmol Strabismus 1993; 30:288 –291 12. Capo´ H, Roth E, Johnson T, et al. Vertical strabismus after cataract surgery. Ophthalmology 1996; 103:918 – 921; discussion by DL Guyton, 921 13. Capo´ H, Guyton DL. Ipsilateral hypertropia after cataract surgery. Ophthalmology 1996; 103:721–730 14. Koide R, Honda M, Kora Y, Ozawa T. Diplopia after cataract surgery. J Cataract Refract Surg 2000; 26:1198 – 1204 15. Kallio H, Paloheimo M, Maunuksela EL. Hyaluronidase as an adjuvant in bupivacaine-lidocaine mixture for retrobulbar/peribulbar block. Anesth Analg 2000; 91:934 –937
16. Rowley SA, Hale JE, Finlay RD. Sub-Tenon’s local anaesthesia: the effect of hyaluronidase. Br J Ophthalmol 2000; 84:435– 436 17. Menzel EJ, Farr C. Hyaluronidase and its substrate hyaluronan: biochemistry, biological activities and therapeutic uses. Cancer Lett 1998; 131:3–11 18. Lewis-Smith PA. Adjunctive use of hyaluronidase in local anaesthesia. Br J Plast Surg 1986; 39:554 –558 19. Mather C, Hayden Smith J, Bloom PA. The efficacy of 0.75% bupivacaine with pH adjustment and hyaluronidase for peribulbar blockade: the incidence of prolonged ptosis. Eur J Ophthalmol 1994; 4:13–18 20. Hagan JC III. Permanent diplopia following cataract surgery. J Cataract Refract Surg 2000; 27:341–342 21. Leaming DV. Practice styles and preferences of ASCRS members—1999 survey. J Cataract Refract Surg 2000; 26:913–921 22. Hagan JC III, Hill WE. Use of a compounding pharmacy hyaluronidase for ophthalmic injection anesthesia. J Cataract Refract Surg 2001; 27:1712–1714
J CATARACT REFRACT SURG—VOL 27, NOVEMBER 2001
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D
iplopia and ptosis are infrequent but established complications of cataract surgery with injection anesthesia. Several authors1,2 note an increase in permanent diplopia following injection anesthesia (peribulbar or retrobulbar injection) during a national shortage of hyaluronidase (mid-1998 to early 1999). Wyeth-Ayerst was the sole manufacturer of hyaluronidase (Wydase威) approved by the U.S. Food and Drug Administration (FDA). The company has permanently stopped the manufacture of Wydase, and it is no longer available. The Department of Ophthalmology at the University of Kansas routinely mixed Wydase with local anesAccepted for publication July 16, 2001.
thetic agents for injection anesthesia before cataract surgery. In September 2000, Wydase supplies were depleted at our teaching hospitals. Injection anesthesia was then done without hyaluronidase. In the following 3 months, 5 cases (4.2%) of postoperative diplopia or ptosis (or combined diplopia and ptosis) occurred in the 120 cases of cataract surgery done at these hospitals. In the previous 3 months, no ptosis or diplopia had occurred in a similar number of cases. A private attending physician reported another case of ptosis soon after Wydase was removed from the market. We report these cases, which support the hypothesis that hyaluronidase protects extraocular muscles from the myotoxic effects of local anesthetic agents.
From the Department of Ophthalmology, University of Kansas Medical Center, Kansas City, Kansas, USA. None of the authors has a proprietary or financial interest in the products mentioned. Correspondence to John C. Hagan III, MD, Discover Vision Centers, 9401 North Oak Trafficway, Suite 200, Kansas City, Missouri 64155, USA. E-mail: [email protected]. © 2001 ASCRS and ESCRS Published by Elsevier Science Inc.
Case Reports Case 1 A 38-year-old white woman had uneventful phacoemulsification cataract extraction and insertion of a posterior chamber intraocular lens (PC IOL) via a temporal clear corneal incision on September 19, 2000. Anesthesia was obtained 0886-3350/01/$–see front matter PII S0886-3350(01)01099-9
CASE REPORTS: JEHAN
using a retrobulbar injection of 4.5 cc of a 1:1 mixture of lidocaine 1% (Xylocaine威) and bupivacaine 0.75% without Wydase. Placement and volume of the injection were carefully monitored. Constant tactile ballotement of the globe and orbit was used to leave the orbit soft and the globe easy to retropulse. No bridle sutures were placed. On postoperative day 1, the patient complained of double vision in the left eye. There was marked underaction of the left lateral rectus. An oral prednisone pulse-taper was started. The diplopia resolved by postoperative day 8.
Case 6 A 66-year-old white man had uneventful phacoemulsification and PC IOL implantation via a temporal clear corneal incision in the left eye on January 25, 2001. Anesthesia was obtained using a retrobulbar injection of 5.0 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were placed. On postoperative day 1, the patient complained of vertical diplopia and was found to have weakness of the left inferior rectus muscle. The diplopia and inferior rectus weakness resolved by postoperative day 8.
Case 2 A 75-year-old white woman had phacoemulsification and PC IOL implantation via a temporal clear corneal incision in the left eye on September 13, 2000. Anesthesia was obtained uneventfully with an inferior orbital peribulbar injection of 9.0 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were used. On postoperative day 1, the patient had complete ptosis. The ptosis improved slowly over the next 6 weeks, and further treatment was unnecessary.
Case 3 A 72-year-old white man had phacoemulsification and PC IOL implantation in the right eye on October 20, 2000. Anesthesia was obtained uneventfully with a retrobulbar injection of approximately 6.0 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were placed. On postoperative day 1, the patient complained of diplopia and was found to have right lateral rectus weakness. He was observed and by postoperative day 4, the diplopia and rectus weakness had resolved.
Case 4 A 75-year-old black man had phacoemulsification and PC IOL implantation in the right eye via a temporal clear corneal incision on November 9, 2000. Anesthesia was obtained by a retrobulbar injection of 8 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were placed. On postoperative day 1, the patient had complete ptosis of the right upper eyelid. The ptosis gradually improved and had resolved by postoperative day 7.
Case 5 A 74-year-old white man had phacoemulsification and PC IOL implntation in the right eye via a temporal clear corneal incision on October 2, 2000. Anesthesia was obtained uneventfully by retrobulbar injection of approximately 7 cc of a 1:1 mixture of Xylocaine and bupivacaine 0.75% without Wydase. No bridle sutures were used. On postoperative day 1, the patient complained of vertical diplopia and was found to have weakness of the right inferior rectus muscle. Twelve weeks postoperatively, there was no significant improvement.
Discussion Diplopia is an established complication of retrobulbar and peribulbar anesthesia, with an incidence of 0.85% to 2.00%.3,4 The elimination of bridle sutures, prolonged patching, and less traumatic injection and intraoperative techniques have reduced the incidence of postoperative ptosis and diplopia. Postoperative diplopia may result from various etiologies, including weakness, contracture, or overaction of an extraocular muscle. Rainin and Carlson5 report 6 cases of postoperative diplopia and were the first to suggest that direct injection of an anesthetic agent into the muscle belly causes a myotoxic injury, leading to muscle weakness and diplopia. Anesthetic toxicity to the nerve supplying the muscle may account for paresis.6 Muscle contracture, with positive forced-duction testing, has also been implicated as a cause of postoperative diplopia.7,8 Contracture has been attributed to direct injury of the muscle with resulting inflammation and fibrosis, either from direct anesthetic myotoxicity or needle penetration or laceration of the muscle. Ischemic injury from high tissue pressure and vascular compromise with subsequent inflammation and fibrosis is another mechanism. This might occur from an intramuscle or extramuscle hematoma or a large volume of anesthetic agent within the orbit or the muscle.9 –11 Muscle overaction may also cause postoperative diplopia.12,13 These cases have ocular deviations that are greater in the field of action of the injured muscle. It is postulated that overactive muscles are a result of segmental fibrosis from local anesthetic myotoxicity. Restrictive patterns may follow initial periods of muscle overaction as contracture occurs. Other possible mechanisms of postoperative diplopia include changing from monocular central vision to binocular central vision. The improved visual acuity in
J CATARACT REFRACT SURG—VOL 27, NOVEMBER 2001
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CASE REPORTS: JEHAN
the operated eye may cause a previously undiagnosed or asymptomatic strabismus or anisometropia to become manifest.14 Hyaluronidase is an enzyme frequently added to local anesthetic agents for ophthalmic local anesthesia. It is prepared from bovine testes and improves the rapidity of onset, dispersion, depth, and duration of local anesthesia.15–18 Its action is accomplished by a depolymerization of extracellular hyaluronic acid, the intercellular cement substance of connective tissues. This allows anesthetic agents to spread faster throughout the orbit across fine connective tissue septal barriers. Hyaluronidase also reduces the incidence of ptosis and extraocular muscle paresis.19 When hyaluronidase is not used with the local anesthetic agent, increased concentrations of the anesthetic agent may loculate around the extraocular muscles, causing myotoxicity.1 Focally increased orbital extracellular pressure may also cause ischemic damage by decreasing blood flow through the muscular branches of the ophthalmic artery. The inferior rectus muscle is especially vulnerable because of its location in the area where most retrobulbar and peribulbar injections occur. From September 2000 to November 2000, when Wydase became unavailable, approximately 120 phacoemulsification cataract surgeries were performed at our teaching institutions. During this period, 5 cases of ptosis or postoperative diplopia occurred. One was permanent. This 4.2% incidence of diplopia/ptosis is higher than previously reported rates of 0.85% to 2.00%.3,4 During the previous 3 months, there were no cases of diplopia or ptosis in a similar number of cases. In cases such as these, the 6 surgeons who performed the surgeries would normally have added Wydase to the injected local anesthetic agent. Each of these 6 instances of diplopia and ptosis occurred shortly after Wydase became unavailable. The sudden appearance of postanesthetic ptosis and diplopia in the clinical practices of multiple surgeons coincident with the shortage of hyaluronidase suggests a causal relationship. There were no other variables or changes in the type of anesthesia or surgical technique other than Wydase not being added to the local anesthetic agent. This suggests that when added to the injected local anesthetic agent, hyaluronidase reduces diplopia and ptosis after cataract and IOL surgery. Fortunately, only 1 of our cases was permanent. Claims of large series of cataract surgery that have not 1878
had any diplopia or ptosis postoperatively, with or without hyaluronidase, are uncontrolled, retrospective, and anecdotal.20 Our university program is performing more surgeries under topical and intracameral anesthesia. Smaller volumes of injectant are being used for retrobulbar or peribulbar local anesthesia without hyaluronidase. A prospective controlled study of Wydase will not be possible because of its permanent unavailability. Whether hyaluronidase adds to the safety of injection anesthesia is an important issue. Injection anesthesia remains the preferred technique for many United States surgeons21 and in many residency training programs. Surgeons who use topical or intracameral anesthesia often use an injection for their most difficult cases or patients. Injection anesthesia is used for other ophthalmic surgery, especially retinal and oculoplastic. Some U.S. surgeons are using hyaluronidase prepared by compounding pharmacies. These hyaluronidase preparations are not FDA approved and are subject to various rules and regulations regarding purchase and use. One such source (O’Brien’s Compounding Pharmacy, Kansas City, Missouri) has been reported to be satisfactory.22
References 1. Brown SM, Brooks SE, Mazow ML, et al. Cluster of diplopia cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 1999; 25:1245–1249 2. Hagan JC III, Whittaker TJ, Byars SR. Diplopia cases after periocular anesthesia without hyaluronidase (letter). J Cataract Refract Surg 1999; 25:1560 –1561 3. Golnik KC, West CE, Kaye E, et al. Incidence of ocular misalignment and diplopia after uneventful cataract surgery. J Cataract Refract Surg 2000; 26:1205–1209 4. Cadera W. Diplopia after peribulbar anesthesia for cataract surgery. J Pediatr Ophthalmol Strabismus 1998; 35: 240 –241 5. Rainin EA, Carlson BM. Postoperative diplopia and ptosis; a clinical hypothesis based on the myotoxicity of local anesthetics. Arch Ophthalmol 1985; 103:1337–1339 6. Hunter DG, Lam GC, Guyton DL. Inferior oblique muscle injury from local anesthesia for cataract surgery. Ophthalmology 1995; 102:501–509 7. Tejedor J, Rodriguez Sanchez JM. Vertical strabismus after local anesthesia (letter). Ophthalmology 1996; 103: 545–546 8. Corboy JM, Jiang X. Postanesthetic hypotropia: a unique syndrome in left eyes. J Cataract Refract Surg 1997; 23: 1394 –1398
J CATARACT REFRACT SURG—VOL 27, NOVEMBER 2001
CASE REPORTS: JEHAN
9. Egan R, Rizzo JF III. Neuroophthalmological complications of ocular surgery. Int Ophthalmol Clin 2000; 40(1):93–105 10. Hamed LM. Strabismus presenting after cataract surgery. Ophthalmology 1991; 98:247–252 11. Hamilton SM, Elsas FJ, Dawson TL. A cluster of patients with inferior rectus restriction following local anesthesia for cataract surgery. J Pediatr Ophthalmol Strabismus 1993; 30:288 –291 12. Capo´ H, Roth E, Johnson T, et al. Vertical strabismus after cataract surgery. Ophthalmology 1996; 103:918 – 921; discussion by DL Guyton, 921 13. Capo´ H, Guyton DL. Ipsilateral hypertropia after cataract surgery. Ophthalmology 1996; 103:721–730 14. Koide R, Honda M, Kora Y, Ozawa T. Diplopia after cataract surgery. J Cataract Refract Surg 2000; 26:1198 – 1204 15. Kallio H, Paloheimo M, Maunuksela EL. Hyaluronidase as an adjuvant in bupivacaine-lidocaine mixture for retrobulbar/peribulbar block. Anesth Analg 2000; 91:934 –937
16. Rowley SA, Hale JE, Finlay RD. Sub-Tenon’s local anaesthesia: the effect of hyaluronidase. Br J Ophthalmol 2000; 84:435– 436 17. Menzel EJ, Farr C. Hyaluronidase and its substrate hyaluronan: biochemistry, biological activities and therapeutic uses. Cancer Lett 1998; 131:3–11 18. Lewis-Smith PA. Adjunctive use of hyaluronidase in local anaesthesia. Br J Plast Surg 1986; 39:554 –558 19. Mather C, Hayden Smith J, Bloom PA. The efficacy of 0.75% bupivacaine with pH adjustment and hyaluronidase for peribulbar blockade: the incidence of prolonged ptosis. Eur J Ophthalmol 1994; 4:13–18 20. Hagan JC III. Permanent diplopia following cataract surgery. J Cataract Refract Surg 2000; 27:341–342 21. Leaming DV. Practice styles and preferences of ASCRS members—1999 survey. J Cataract Refract Surg 2000; 26:913–921 22. Hagan JC III, Hill WE. Use of a compounding pharmacy hyaluronidase for ophthalmic injection anesthesia. J Cataract Refract Surg 2001; 27:1712–1714
J CATARACT REFRACT SURG—VOL 27, NOVEMBER 2001
1879