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Complications of retrobulbar marcaine injection
236
Surv Ophthalmol
29( 3) November-December
1984
CURRENTOPHTHALMOLOGY
rod ERG abnormalities of both amplitude and implicit time were found for pericentral RP, in keeping with the classical descriptions of peripheral RP; the other macular dystrophies showed much less rod involvement. Further segregation is possible by considering the extent ofcone ERG impairment: cone dystrophy exhibited a very significant amplitude reduction. Pericentral RP also showed a severe cone involvement, consistent with the funduscopic macular changes. Less severe amplitude depressions were noted both for Stargardt’s and for fundus flavimaculatus, in keeping with the suggestion by many authors that these last two dystrophies are a continuum of the same disease. As a point of comparison, malattia leventinese, a European synonym for autosomal dominant drusen, showed only modest impairment of the ERG. This malady, named after a Swiss-Italian village, Leventina, with a large number of affected families, extensively involves the posterior fundus. In spite of the extent and size of retinal pigment epithelial drusen, ERG responses were only modestly depressed, indicating that damage is localized to regions of funduscopic involvement and probably does not affect retinal function diffusely. This is in distinction to the severe and diffuse ERG changes noted in the “macular” dystrophies of cone- and pericentral RP. Neimeyer and DeMant provide a reminder worthy of repetition: the ERG pictures of these maculopathies are unique only as group profiles. The application to any individual patient’s results must be done with care and in the specific clinical context. PAUL
SIEVING
SAN FRANCISCO, CALIFORNIA
Compiications
Garcia,
of Retrobulbar
and C? Blankenship.
Marcaine Injection, by H.P. Beltranena, J Clin Neuroophthalmol 2: 159-l 6 1, 1982
M.J. Vega, J.J.
An increasing number of case reports documenting complications following retrobulbar marcaine injections have been reported. This can be attributed to increasing awareness or wider use of marcaine for retrobulbar blocks. Respiratory arrest following retrobulbar marcaine injection is documented in three patients. To decrease the frequency and severity of complications associated with retrobulbar blocks utilizing marcaine as the anesthetic agent, the authors suggest that the injection be slowly delivered, utilizing a small gauge needle with attention directed at aspirating before injection, to be certain the needle is not in an intravascular space.
Comment This paper adds three cases to the literature of prolonged apnea following retrobulbar injection of 0.75% marcaine. In each case 6 ml was given, proptosis was noted to be minimal, and within a few minutes the patients exhibited anxiety followed by an apneic period of approximately 30 minutes. There was a shortterm rise in blood pressure and pulse rate but no other instability or other neurologic signs were noted, and in each case the recovery was without further event. The authors speculate about interarterial injections, but a blood sample was not taken until at least 10 minutes into the reaction in one case. No consideration is given to a possible injection into the subarachnoid or subdural space surrounding the orbital portion of the optic nerve. Such an injection would produce respiratory depression and other brainstem signs, especially when large volumes (over 4 cc) are injected rapidly. The lack of proptosis, with a 6 cc to 8 cc retrobulbar injection supports either a vascular or a subarachnoid injection but the former is not as likely, given the dose, to produce a toxic systemic effect, The authors wisely suggest to slow the speed of the injection, use a smaller gauge needle (they used a 26 gauge), reduce the volume injected, and have cardiopulmonary resuscitative support immediately available. JOHN A. STANLEY SAN FRANCISCO, CALIFORNIA
Longterm Results of Trabeculectomy in the Japanese: An Analysis by Life Table Method, by Z. Inaba. Jpn J Ophthalmol ,X:361-363, 1982 Among various microsurgical standard procedure throughout
procedures for the treatment of glaucoma, trabeculectomy has become a the world. In addition to the original technique of Cairns and modification of
Surv Ophthalmol
29( 3) November-December
1984
CURRENTOPHTHALMOLOGY
rod ERG abnormalities of both amplitude and implicit time were found for pericentral RP, in keeping with the classical descriptions of peripheral RP; the other macular dystrophies showed much less rod involvement. Further segregation is possible by considering the extent ofcone ERG impairment: cone dystrophy exhibited a very significant amplitude reduction. Pericentral RP also showed a severe cone involvement, consistent with the funduscopic macular changes. Less severe amplitude depressions were noted both for Stargardt’s and for fundus flavimaculatus, in keeping with the suggestion by many authors that these last two dystrophies are a continuum of the same disease. As a point of comparison, malattia leventinese, a European synonym for autosomal dominant drusen, showed only modest impairment of the ERG. This malady, named after a Swiss-Italian village, Leventina, with a large number of affected families, extensively involves the posterior fundus. In spite of the extent and size of retinal pigment epithelial drusen, ERG responses were only modestly depressed, indicating that damage is localized to regions of funduscopic involvement and probably does not affect retinal function diffusely. This is in distinction to the severe and diffuse ERG changes noted in the “macular” dystrophies of cone- and pericentral RP. Neimeyer and DeMant provide a reminder worthy of repetition: the ERG pictures of these maculopathies are unique only as group profiles. The application to any individual patient’s results must be done with care and in the specific clinical context. PAUL
SIEVING
SAN FRANCISCO, CALIFORNIA
Compiications
Garcia,
of Retrobulbar
and C? Blankenship.
Marcaine Injection, by H.P. Beltranena, J Clin Neuroophthalmol 2: 159-l 6 1, 1982
M.J. Vega, J.J.
An increasing number of case reports documenting complications following retrobulbar marcaine injections have been reported. This can be attributed to increasing awareness or wider use of marcaine for retrobulbar blocks. Respiratory arrest following retrobulbar marcaine injection is documented in three patients. To decrease the frequency and severity of complications associated with retrobulbar blocks utilizing marcaine as the anesthetic agent, the authors suggest that the injection be slowly delivered, utilizing a small gauge needle with attention directed at aspirating before injection, to be certain the needle is not in an intravascular space.
Comment This paper adds three cases to the literature of prolonged apnea following retrobulbar injection of 0.75% marcaine. In each case 6 ml was given, proptosis was noted to be minimal, and within a few minutes the patients exhibited anxiety followed by an apneic period of approximately 30 minutes. There was a shortterm rise in blood pressure and pulse rate but no other instability or other neurologic signs were noted, and in each case the recovery was without further event. The authors speculate about interarterial injections, but a blood sample was not taken until at least 10 minutes into the reaction in one case. No consideration is given to a possible injection into the subarachnoid or subdural space surrounding the orbital portion of the optic nerve. Such an injection would produce respiratory depression and other brainstem signs, especially when large volumes (over 4 cc) are injected rapidly. The lack of proptosis, with a 6 cc to 8 cc retrobulbar injection supports either a vascular or a subarachnoid injection but the former is not as likely, given the dose, to produce a toxic systemic effect, The authors wisely suggest to slow the speed of the injection, use a smaller gauge needle (they used a 26 gauge), reduce the volume injected, and have cardiopulmonary resuscitative support immediately available. JOHN A. STANLEY SAN FRANCISCO, CALIFORNIA
Longterm Results of Trabeculectomy in the Japanese: An Analysis by Life Table Method, by Z. Inaba. Jpn J Ophthalmol ,X:361-363, 1982 Among various microsurgical standard procedure throughout
procedures for the treatment of glaucoma, trabeculectomy has become a the world. In addition to the original technique of Cairns and modification of