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Cataract Surgery in the Face of Retrobulbar Hemorrhage
Ophthalmology
Volume 99, Number 2, February 1992
Ideally, practitioners of whatever medical discipline, who are performing eye blocks, should have special knowledge acquired from attending formal courses in orbit anatomy (including cadaver dissection), pertinent physiology, and the recognition and management of potential complications. ROBERT C. HAMILTON, MB, BCH Calgary, Alberta, Canada References
1. Hamilton RC, Gimbel HV, Strunin L. Regional anesthesia
2. 3. 4. 5. 6.
7.
for 12,000 cataract extraction and intraocular lens implantation procedures. Can Anaesth 1988; 35:615-23. Javitt JC, Addiego R, Friedberg HL, et al. Brain stem anesthesia after retrobulbar block. Ophthalmology 1987; 94:71824. Morgan GE. Retrobulbar apnea syndrome: a case for the routine presence of an anesthesiologist [letter]. Reg Anesth 1990; 15:107. Grizzard WS, Kirk NM, Payan PR, et al. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991; 98:1011-6. Hay A, Flynn HW Jr, Hoffman JI, Rivera AH. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991; 98:1017-24. Duker JS, Belmont JB, Benson WE, et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia. Patient characteristics, surgical management, and visual outcome. Ophthalmology 1991; 98:519-26. UnsOld R, Stanley JA, DeGroot J. The CT-topography of retrobulbar anesthesia. Anatomic-clinical correlation of complications and suggestion of a modified technique. Albrecht von Graefes Arch Klin Exp Ophthalmol 1981; 217: 125-36.
Cataract Surgery in the Face of Retrobulbar Hemorrhage Dear Editor: An operative procedure need not be cancelled if a retrobulbar hemorrhage occurs if the following technique is
170
followed. A Stevens scissors should be inserted in the inferior nasal quadrant and passed through the conjunctiva and Tenon's capsule by blunt dissection and spreading of the blades of the scissors. When the retrobulbar space is encountered, further spreading will allow exit of the hemorrhage, which usually stops within a few minutes and allows continuance of the procedure. I have not had a retrobulbar hemorrhage in many years but when they did occur in the past, this maneuver served me very well. Recently, I had occasion to assist a plastic surgeon who experienced a retrobulbar hemorrhage during a blepharoplasty. I was in an adjoining operating room and was able to perform this maneuver, which allowed the plastic surgeon to continue the procedure. LoUIS J. GIRARD, MD Houston, Texas
Dear Editor: It appears the order of priorities has changed and the best interests of the patient may no longer come first. Your editorial entitled, "The Relative Value of Quality Care" (Ophthalmology 1991; 98:1151-2) and the article entitled, "Retrobulbar Hemorrhage" (Ophthalmology 1991; 98: 1153-5) illustrate two examples. I agree that ophthalmologists should be the ones to administer retrobulbar (or peribulbar) anesthesia. The article on performing cataract surgery in the presence of a retrobulbar hemorrhage conveys a message that it is all right to do what one can get away with. However, less potential harm to the patient usually results from following the safer procedure. If the cataract surgeon is so busy that he has someone else perform retrobulbar blocks or if he is reluctant to reschedule a patient in whom a retrobulbar hemorrhage develops, perhaps his priorities need to be restructured. JOHN F. NOWELL, MD Arlington, Virginia
Volume 99, Number 2, February 1992
Ideally, practitioners of whatever medical discipline, who are performing eye blocks, should have special knowledge acquired from attending formal courses in orbit anatomy (including cadaver dissection), pertinent physiology, and the recognition and management of potential complications. ROBERT C. HAMILTON, MB, BCH Calgary, Alberta, Canada References
1. Hamilton RC, Gimbel HV, Strunin L. Regional anesthesia
2. 3. 4. 5. 6.
7.
for 12,000 cataract extraction and intraocular lens implantation procedures. Can Anaesth 1988; 35:615-23. Javitt JC, Addiego R, Friedberg HL, et al. Brain stem anesthesia after retrobulbar block. Ophthalmology 1987; 94:71824. Morgan GE. Retrobulbar apnea syndrome: a case for the routine presence of an anesthesiologist [letter]. Reg Anesth 1990; 15:107. Grizzard WS, Kirk NM, Payan PR, et al. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991; 98:1011-6. Hay A, Flynn HW Jr, Hoffman JI, Rivera AH. Needle penetration of the globe during retrobulbar and peribulbar injections. Ophthalmology 1991; 98:1017-24. Duker JS, Belmont JB, Benson WE, et al. Inadvertent globe perforation during retrobulbar and peribulbar anesthesia. Patient characteristics, surgical management, and visual outcome. Ophthalmology 1991; 98:519-26. UnsOld R, Stanley JA, DeGroot J. The CT-topography of retrobulbar anesthesia. Anatomic-clinical correlation of complications and suggestion of a modified technique. Albrecht von Graefes Arch Klin Exp Ophthalmol 1981; 217: 125-36.
Cataract Surgery in the Face of Retrobulbar Hemorrhage Dear Editor: An operative procedure need not be cancelled if a retrobulbar hemorrhage occurs if the following technique is
170
followed. A Stevens scissors should be inserted in the inferior nasal quadrant and passed through the conjunctiva and Tenon's capsule by blunt dissection and spreading of the blades of the scissors. When the retrobulbar space is encountered, further spreading will allow exit of the hemorrhage, which usually stops within a few minutes and allows continuance of the procedure. I have not had a retrobulbar hemorrhage in many years but when they did occur in the past, this maneuver served me very well. Recently, I had occasion to assist a plastic surgeon who experienced a retrobulbar hemorrhage during a blepharoplasty. I was in an adjoining operating room and was able to perform this maneuver, which allowed the plastic surgeon to continue the procedure. LoUIS J. GIRARD, MD Houston, Texas
Dear Editor: It appears the order of priorities has changed and the best interests of the patient may no longer come first. Your editorial entitled, "The Relative Value of Quality Care" (Ophthalmology 1991; 98:1151-2) and the article entitled, "Retrobulbar Hemorrhage" (Ophthalmology 1991; 98: 1153-5) illustrate two examples. I agree that ophthalmologists should be the ones to administer retrobulbar (or peribulbar) anesthesia. The article on performing cataract surgery in the presence of a retrobulbar hemorrhage conveys a message that it is all right to do what one can get away with. However, less potential harm to the patient usually results from following the safer procedure. If the cataract surgeon is so busy that he has someone else perform retrobulbar blocks or if he is reluctant to reschedule a patient in whom a retrobulbar hemorrhage develops, perhaps his priorities need to be restructured. JOHN F. NOWELL, MD Arlington, Virginia