Scleral perforation during retrobulbar and peribulbar anesthesia: risk factors and outcome in 50,000 consecutive injections.

PURPOSE: To measure the frequency of scleral perforation and identify related risk factors during local anesthetic injection for intraocular surgery.
SETTING: Multispecialty eye hospital.
METHODS: All patients (n = 50,000) having retrobulbar (26,857) or peribulbar (23,143) injections at the King Khaled Eye Specialist Hospital were reviewed. Cases of scleral perforation were analyzed for potential technical and ophthalmic risk factors, management of injuries, and visual and anatomic outcomes. Mean follow-up was 14.4 months (range 8 to 24 months).
RESULTS: Seven (0.014%) needlestick injuries were identified, all of which had posterior staphyloma as the only identifiable risk factor. Applying a previously measured prevalence of 10.7% for posterior staphyloma in our surgery patients gave a scleral perforation rate of 0.13% (7 of 5350) for staphylomatous eyes. All perforated globes had originally planned cataract extraction within 8 weeks of injury. Additional management consisted of observation (2 cases), cryotherapy (2 cases), and vitreoretinal procedures for retinal detachment (3 cases) and subretinal hemorrhage (1 case). At last follow-up, all retinas were attached and 3 cases (42.8%) had a visual acuity of worse than 20/160. Both cases requiring multiple retinal detachment surgeries developed proliferative vitreoretinopathy and poor visual acuity.
CONCLUSIONS: Eyes with posterior staphyloma sustained needlestick injuries at a rate of 1 in 760 compared with 0 injection perforations in more than 44,000 nonstaphylomatous eyes.