Assessment of complications of peribulbar block in patients undergoing cataract surgery in tertiary care center – A record-based observational study

Santhi Periasamy; S Srinivasan; G Damodharan

doi:10.4103/tjosr.tjosr_84_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 59 | Issue : 4 | Page : 354-358

Assessment of complications of peribulbar block in patients undergoing cataract surgery in tertiary care center – A record-based observational study

Santhi Periasamy, S Srinivasan, G Damodharan
Department of Ophthalmology, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India

Date of Submission	14-Jun-2021
Date of Decision	07-Aug-2021
Date of Acceptance	11-Aug-2021
Date of Web Publication	21-Dec-2021

Correspondence Address:
Dr. Santhi Periasamy
S2, Kubera Block, New Number: 813 Viswak Oakland, Kolaperumal School Street, Arumbakkam, Chennai - 600 106, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_84_21

Abstract

Aim: This study aims to assess the various ocular and systemic complications of peribulbar block in supine posture among patients undergoing cataract surgery in a tertiary care center in Chennai. Materials and Methods: A retrospective analysis of complications that occurred in 880 patients who had been given peribulbar block in supine posture, during 36 months between January 2016 and January 2019 among patients who underwent cataract surgery at a tertiary care hospital. Patients with uncontrolled diabetes mellitus, hypertension, bronchial asthma, and cardiac illness were excluded from the study. The other exclusion criteria were pediatric age group and trauma. The data thus collected from the records were entered and analyzed using descriptive analysis. Results: Out of 880 patients operated in a 36-month period at Government Medical College Hospital who received peribulbar block in the supine posture, 42 (4.77%) patients had block-related systemic complications; bradycardia and vasovagal attack-40 (4.54%) patients; brainstem anesthesia and syncope-2 (0.22%). The incidence of orbital complications was 82 (9.31%). Out of the orbital complications, the most common complication was periorbital hematoma occurred in 50 (5.68%), followed by retrobulbar hemorrhage occurred in 32 (3.63%). Conclusion: The observation-based conclusion is various ocular and systemic complications can occur in peribulbar block. Hence, the operation theatre should be equipped with appropriate instruments and trained personnel to deal with all kinds of emergencies.

Keywords: Cataract surgery, complications, peribulbar block

How to cite this article:
Periasamy S, Srinivasan S, Damodharan G. Assessment of complications of peribulbar block in patients undergoing cataract surgery in tertiary care center – A record-based observational study. TNOA J Ophthalmic Sci Res 2021;59:354-8

How to cite this URL:
Periasamy S, Srinivasan S, Damodharan G. Assessment of complications of peribulbar block in patients undergoing cataract surgery in tertiary care center – A record-based observational study. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2023 Jan 28];59:354-8. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/354/333181

Introduction

Cataract is the most commonly performed surgical procedure by ophthalmologists across the globe. Majority of the affected population are elderly people, often suffering from various comorbidities. Hence, cataract surgery under general anesthesia methods in this population group has been almost totally replaced by regional anesthesia. Apart from reduced systemic complications, enhanced ability to handle large volumes of surgeries reduced cost, and overall enhancement in operating room efficiency are the other important advantages of regional anesthetic methods.^[1] Ophthalmic surgeries are performed under a wide range of anesthesia technique. It started with Carl Koller using cocaine as topical anesthesia for ocular surgery in 1884. In the same year, Knapp introduced retrobulbar anesthesia. As late as 1980s, per bulbar anesthesia was discovered by Davis and Mandel,^[2] and since then, peribulbar anesthesia has been the most commonly used anesthesia for a variety of ocular surgeries. Most eye operations can be performed under local anesthesia, which can be either topical or orbital regional anesthesia.^[2],[3] In recent years, the topical anesthesia has become a common modality of anesthesia for cataract surgery. However, orbital regional anesthesia is preferred by many ophthalmologists for cataract, as well as other forms of ophthalmic surgery. According to recent studies, many patients prefer orbital regional anesthesia.^[4],[5] Local anesthetic techniques are preferred because they can provide orbital analgesia and or akinesia with a lower incidence of systemic side effects, than general anesthesia.^[6] These factors are especially important for frail and elderly patients, who undergo eye surgery. However, in recent times, retrobulbar block has been progressively phased out and replaced by easier and safer methods of regional block. These methods include peribulbar block, sub-Tenon's block, and topical anesthesia. Due to diminished requirements for total akinesia due to advances in surgical methods such as phacoemulsification, these nonakinesia methods have quickly become popular across the globe. However, in resource-poor and highly populated settings, still a major portion of the ocular surgeries are performed by traditional methods, for their higher cost-effectiveness. Considering the high volumes of surgeries performed, there is huge pressure on the institutions to further enhance the operation room efficiency. There is an increased risk of various local and systemic complications [Table 1] in these routine blocks. Hence, the assessment of the various ocular and systemic complications of peribulbar block in supine posture among patients undergoing cataract surgery becomes essential and much needed.

Table 1: Complications of peribulbar block

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Materials and Methods

An observational retrospective study was conducted on analyzing the case records of the patients who had been given Peribulbar block in supine posture during 36 months' period between January 2016 and January 2019 among patients who underwent cataract surgery at a tertiary care hospital.

The case records of patients who underwent cataract surgery were analyzed, and the postoperative complications were assessed. All the patients who underwent cataract surgery during the study were included in the study.

Patients who had uncontrolled diabetes mellitus, hypertension, bronchial asthma, cardiac illness were excluded from the study. The other exclusion criteria were the pediatric age group and patients with eye trauma.

The data were sourced from patient case records maintained by the medical records department. The investigators being medical practitioners in the same institution had complete access to the required patient records. Data were entered into MS Excel, and descriptive analysis was done, where the absolute and relative frequency of block related complications were reported as frequency and percentages along with 95% confidence intervals using Statistical Package for the Social Sciences. The absolute and relative frequency of block-related complications was reported along with 95% confidence intervals.

It was observed that all the patients who had undergone cataract surgery had been thoroughly evaluated; case records had been drafted in a uniform format. Informed written consent had been taken wherever necessary, a thorough history, clinical examination was observed. Blood pressure and pulse oximetry had been measured before giving anesthesia. The drugs used method of the administration of Peribulbar anesthesia in the supine posture in infratemporal quadrant was done by trained surgeons. A 24G, 2.5 cm, sharp, disposable needle was used.

The anesthetic agent used was a mixture of equal volume of 2% lignocaine and 0.5% bupivacaine with 50 IU/ml hyaluronidase. The periocular skin was cleaned with 10% W/V povidone-iodine. The patient was asked to maintain the primary gaze position. The needle was introduced through the skin of the lower lid sulcus at the infratemporal part. The needle was inserted in a vertically downward direction along the orbital wall to a full depth of 2.5 cm. Aspiration was done to rule out intravascular injection. A total of 8 ml of the anesthetic mixture was injected and needle withdrawn [Figure 1]. This was followed by digital massage. In addition, 3–4 cc of Xylocaine was supplemented medially/super medially into the orbit if needed. Complications had been recorded. Appropriate managements had been done.

Figure 1: Peribulbar block technique

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Results

Out of 880 patients operated in a 36-month period at Government medical college hospital who received peribulbar block in supine posture, 513 patients were female and 367 were male. The age distribution was, 66 patients were in the age group of 30–40 years, 245 patients were in the age group of 41–50 years, 396 patients were in the age group of 51–60 years, 166 patients were in the age group of 61–70 years, 57 patients were in the age group of 71–80 years. Forty-two (4.77%) patients had block-related systemic complications; bradycardia and vasovagal attack-40 (4.54%) patients; brainstem anesthesia and syncope-2 (0.22%). All the above complications were treated accordingly. The patients with complications were within the age group of 60–80 years. The waiting time for the surgery after giving anesthesia was about 10–15 min, and the block duration was 10 min [Figure 2]. The proportion of patients developing systemic complications was 4.77 (%) in the study [Table 2].

Figure 2: Categorization of peribulbar block related complications in the study population (n = 880)

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Table 2: Frequency of peribulbar block related complications in patients undergoing cataract surgery (n=880)

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The incidence of orbital complications was 82 (9.31%). Out of the orbital complications, the most common complication was periorbital hematoma occurred in 50 (5.68%), followed by retrobulbar hemorrhage occurred in 32 (3.63%), globe perforation, optic nerve damage and wrong eye block had not occurred, hypersensitivity to Xylocaine in 10 (1.14%). Myotoxicity was recorded in 4 (0.45%) patients.

Discussion

Since the first reported injection of local anesthetics into eye for enucleation of the globe in 1884^[7] it took almost more than 5 decades for orbital blocks to be routinely used in eye surgery. In 1936, Atkinson's^[8] described a new method, which was firmly established as traditional retro bulbar block. There were further modifications in the methods suggested by subsequent authors like Unsöld et al.^[9] to reduce the risk of optical nerve injury.^[10] Achieving operation room efficiency without putting the patients to undue risk of complications may be extremely useful to deal with a high volume of ocular surgeries.^[11] The administration of the peribulbar block for various ocular surgeries has been reported, but this study aims at assessing the incidences of complications during and immediately following the procedure. The overall incidence of complications reported in this study was 0.45%. In a study by Riad and Akbar^[12] the total incidence of complications was 0.12%, which is considerably lower than the current study. Budd et al.^[13] have reported conjunctival chemosis as the most common complication in almost 10% of the subjects undergoing peribulbar block, with no systemic complications. Conjunctival edema (chemosis) and subconjunctival hemorrhage (ecchymosis)^[14] may occur after needle block, due to anterior spread of the local anesthetic agent and the damage of minor blood vessels with a needle tip. Conjunctival chemosis was documented in four trials (Athanikar 1991; Ali-Melkkila 1992; Ali-Melkkila 1993; Wong 1993). These minor complications usually do not interfere with surgery and resolve spontaneously within few hours. Lid hemorrhage is another minor complication of needle block and has been estimated to occur in 3% of patients.^[15] One trial (Ali-Melkkila 1993) reported lid hematoma as a local complication. Persistent ptosis occurred in 1.1% of the participants in the peribulbar group. No major systemic complications were reported in any of these trials.

We found periorbital hematoma (5.68%) and retrobulbar hemorrhage (3.63%) [Figure 2] to be the most common retrobulbar hemorrhage is a serious complication of both the intraconal and extraconal blocks, which occurs following bleeding behind the globe. The hemorrhage may be either venous or arterial in origin and may be concealed, or revealed. The spread of blood into the periorbital tissues increases the tissue volume and pressure. In a study involving 19,000 patients who had retrobulbar and peribulbar blocks, the incidence of retrobulbar hemorrhage was only 0.03%.^[16] An incidence ranging between 0.4% and 1.7% has also been reported.^[7],[17] Blindness from a retrobulbar hemorrhage has been reported,^[18] but most patients have a good visual outcome.

Damage to the globe is a rare, but serious complication, which is reported following both intraconal and extraconal block.^{[7],[19],[20]} The incidence of this complication is similar with both techniques (0%)^[21],[22] to 0.1%.^[23] Damage to extraocular muscles from orbital blocks can result in strabismus (causing diplopia), ptosis (drooping upper eyelid), and entropion (infolding of the eyelid).^[24] Transient strabismus on the first postoperative day is common after eye surgery. The most common permanently injured muscle from an eye block is the inferior rectus, but other muscles can be involved. Johnson^[25] identified postoperative strabismus in 0.18% of patients receiving retrobulbar blocks with a 38 mm needle. In contrast, Hamilton^[26] found no cases in 8,500 patients when he used a 31 mm needle in the extreme infratemporal quadrant. Ptosis is common on the 1^st postoperative day after eye surgery.

Central spread of local anesthetic agent, and the incidence of the central nervous system (CNS) complication with a 38 mm retrobulbar needle is between 0.2%, and 0.3%.^[27],[28] In one series, there was only one case of CNS spread in 6800 (0.015%) extraconal (true peribulbar) blocks. Oculocardiac reflex (OCR) this is manifested as bradycardia and hypotension in response to mechanical stimulation of the globe. Less commonly, other arrhythmias or asystole can occur.

Meyers states that OCR is a common complication of intraconal block.^[29] Hamilton et al. disputes this and noted that OCR never occurred in a series of 12,000 retrobulbar and peribulbar blocks.^[30] However, 0.6% of patients in this study were noted to have had a vasovagal episode. In the current study, the proportion of patients developing systemic complications was 4.77% with vasovagal attacks, bradycardia seen in 4.54%; and syncope seen in 0.22%. Out of 0.17% of orbital complications, Riad and Akbar^[12] have reported the incidence of systemic complications as 0.059%, which included OCR, central spread, and stress-induced epilepsy; and needle-related complications as 0.075%, including globe perforation, retrobulbar hemorrhage, lid hematoma, subconjunctival hemorrhage, and optic nerve damage. No case of optic nerve damage was reported. Davis and Mandel^[2] have reported the incidence of one globe perforation (0.006%), two expulsive hemorrhages (0.013%), one grand mal seizure (0.006%), and no cases of cardiac or respiratory depression or deaths. This study finding is comparable to the current study. No major systemic complications were reported in any of these trials.

Allergic reactions, due to anesthetics commonly used for eye anesthesia, such as lidocaine and bupivacaine are rare.

Conclusion

The observation-based conclusion is that various ocular and systemic complications can occur in peribulbar block. Hence, the operation theatre should be equipped with appropriate instruments and trained personnel to deal with emergencies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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