Retinal Vascular Occlusion Without Retrobulbar or Optic Nerve Sheath Hemorrhage After Retrobulbar Injection of Lidocaine

Abstract

We report a case of retinal vascular occlusion in a patient with severe diabetic retinopathy after retrobulbar injection of lidocaine. Several features of the occlusion are of interest: 1) rapid onset and relatively rapid reversal temporally associated with intervention; 2) numerous areas of focal vascular constriction; 3) absence of retrobulbar hemorrhage or dilated optic nerve sheath on CT scan; and 4) recurrence of nonperfusion after a second injection into the inferior peribulbar space. This suggests that patients with severe vascular disease may suffer retinal vascular occlusion after retrobulbar injections in the absence of identifiable retrobulbar or intraoptic nerve sheath hemorrhage. Though the mechanism is uncertain, this unusual complication deserves consideration, since its early recognition could possibly be of benefit in the management of some patients.

Retinal artery occlusion after ophthalmic surgery under regional anaesthesia: A narrative review

“…RAO appeared to be unrelated to the type of regional block: the reported cases occurred in relation to retrobulbar blocks (40/97, 41%) 5,7,13,14,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] (Supplementary Table 1), peribulbar blocks (36/97, 37%) 27,32,34-42 (Supplementary Table 2), sub-Tenon's blocks (19/97, 20%) 16,32,39,[43][44][45][46][47][48][49] (Supplementary Table 3), one topical local anaesthetic (1/97, 1%) 50 and one unknown local anaesthetic technique (1/97, 1%), 51 which contained no anaesthetic details.…”

“…The mean (standard deviation) central retinal artery systolic pressure is 54 (14) mmHg while normal intraocular pressure (IOP) ranges from 10 to 21 mmHg. 9,10 The pressure gradient enables adequate ocular perfusion.…”

“…After a second retrobulbar block, recurrent RAO has been reported in two patients without a proved cause determined. 13,14 We believe that it is, therefore, prudent that ophthalmic block, either the same or another type, is not used again for the fellow eye. The patient's cardiac status should be optimised.…”

“…We identified 97 cases of RAO after ophthalmic surgery under regional anaesthesia, including two cases of recurrent RAO after a second ophthalmic block, 13,14 which fulfilled our search criteria. Our search only included those without immediate signs of block-related complications, and under-reporting is common in the literature, thus the actual number of cases may be higher.…”