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Larger Retrobulbar Injections
328
CORRESPONDENCE
CORRESPONDENCE LARGER RETROBULBAR INJECTIONS
Editor, American Journal of Ophthalmology: It is gratifying to see the favorable report of Drs. Van Bergen and Swets in the No vember, 1963, A JO on the use of larger retrobulbar injections. Although the injection of 4.0 cc. or more has been advocated for a number of years, many ophthalmic surgeons still limit the size of the retrobulbar injection to 1.5 cc. If hyaluronidase and epinephrine are added to the anesthetic solution and the injection is followed by digital pressure until there is akinesia of the rectus muscles, the tension will be lower than with the injection of 1.5 cc. There will also be more profound akinesia and anesthesia. As much as 8.0 cc. has been injected in the orbit without com plications. The authors mention making injections into the muscle tissue which may account for the high incidence of orbital hemor rhages reported. Since the motor nerve sup ply to the rectus muscles enters the muscles on the inner surface 15 mm. anterior to the apex of the orbit, an injection near the mus cle in that vicinity has in my experience blocked the nerves. To produce akinesia of the orbicularis muscle, the authors stated that they aug mented the van Lint method of injection with the O'Brien. If the directions of van Lint are followed, this would be unneces sary. However, if the O'Brien method is used first, then another injection would oc casionally be required since the course of the facial nerve varies and, as shown by Kline, may pass considerably below the condyloid process over the ramus of the lower mandible and so might not be reached by the injection. The purpose of the subconjunctival in jection at the 6- and 12-o'clock positions is not explained and seems unnecessary unless the eye is inflamed. Probably these injec
tions and the use of cocaine are measures carried over from earlier years before the routine use of retrobulbar injections and be fore better topical anesthetic agents were produced. I hope the authors will continue to empha size the value of larger retrobulbar injec tions. (Signed) Walter S. Atkinson, Watertown, New York.
ROUND PUPIL AFTER VITREOUS LOSS
Editor, American Journal of Ophthalmology: In recent years, ophthalmic surgeons have recognized the importance of so planning and executing indicated surgical procedures that further complications may be operated upon and corrected with greater facility. Glaucoma surgeons advise placing the filter ing bleb in the upper nasal quadrant and the peripheral iridectomy in the upper temporal quadrant, anticipating the expected lens changes and the ease of cataract extraction from the temporal side. Retinal detachment surgeons are doing more and more pro cedures which utilize intrascleral diathermy, anticipating a revised procedure and the avoidance of the necrotic sclera and adhe sions. It is generally conceded that vitreous loss in cataract extraction predisposes to retinal detachment. The incidence varies in differ ent series. Schepens,1 in reviewing 387 cases of retinal detachment, 88 of which were aphakic, concluded that loss of vitreous was not a frequent cause of detachment in his series ; however, Hughes and Owens 2 in 1943, in reviewing 2,086 cataract extrac tions at the Wilmer Institute, concluded that vitreous loss very definitely causes retinal detachment and the detachment incidence in creased with the amount of vitreous lost. Shapland3 concludes from his studies that retinal detachment occurs in 10 percent of aphakic subjects; and therefore aphakia must predispose to retinal detachment.
CORRESPONDENCE
CORRESPONDENCE LARGER RETROBULBAR INJECTIONS
Editor, American Journal of Ophthalmology: It is gratifying to see the favorable report of Drs. Van Bergen and Swets in the No vember, 1963, A JO on the use of larger retrobulbar injections. Although the injection of 4.0 cc. or more has been advocated for a number of years, many ophthalmic surgeons still limit the size of the retrobulbar injection to 1.5 cc. If hyaluronidase and epinephrine are added to the anesthetic solution and the injection is followed by digital pressure until there is akinesia of the rectus muscles, the tension will be lower than with the injection of 1.5 cc. There will also be more profound akinesia and anesthesia. As much as 8.0 cc. has been injected in the orbit without com plications. The authors mention making injections into the muscle tissue which may account for the high incidence of orbital hemor rhages reported. Since the motor nerve sup ply to the rectus muscles enters the muscles on the inner surface 15 mm. anterior to the apex of the orbit, an injection near the mus cle in that vicinity has in my experience blocked the nerves. To produce akinesia of the orbicularis muscle, the authors stated that they aug mented the van Lint method of injection with the O'Brien. If the directions of van Lint are followed, this would be unneces sary. However, if the O'Brien method is used first, then another injection would oc casionally be required since the course of the facial nerve varies and, as shown by Kline, may pass considerably below the condyloid process over the ramus of the lower mandible and so might not be reached by the injection. The purpose of the subconjunctival in jection at the 6- and 12-o'clock positions is not explained and seems unnecessary unless the eye is inflamed. Probably these injec
tions and the use of cocaine are measures carried over from earlier years before the routine use of retrobulbar injections and be fore better topical anesthetic agents were produced. I hope the authors will continue to empha size the value of larger retrobulbar injec tions. (Signed) Walter S. Atkinson, Watertown, New York.
ROUND PUPIL AFTER VITREOUS LOSS
Editor, American Journal of Ophthalmology: In recent years, ophthalmic surgeons have recognized the importance of so planning and executing indicated surgical procedures that further complications may be operated upon and corrected with greater facility. Glaucoma surgeons advise placing the filter ing bleb in the upper nasal quadrant and the peripheral iridectomy in the upper temporal quadrant, anticipating the expected lens changes and the ease of cataract extraction from the temporal side. Retinal detachment surgeons are doing more and more pro cedures which utilize intrascleral diathermy, anticipating a revised procedure and the avoidance of the necrotic sclera and adhe sions. It is generally conceded that vitreous loss in cataract extraction predisposes to retinal detachment. The incidence varies in differ ent series. Schepens,1 in reviewing 387 cases of retinal detachment, 88 of which were aphakic, concluded that loss of vitreous was not a frequent cause of detachment in his series ; however, Hughes and Owens 2 in 1943, in reviewing 2,086 cataract extrac tions at the Wilmer Institute, concluded that vitreous loss very definitely causes retinal detachment and the detachment incidence in creased with the amount of vitreous lost. Shapland3 concludes from his studies that retinal detachment occurs in 10 percent of aphakic subjects; and therefore aphakia must predispose to retinal detachment.