Swept source optical coherence tomography in globe perforation.

A 55-year-old lady was referred to the retina clinic, with history of globe hypotony post peribulbar anesthesia injection in the left eye (OS). Best corrected visual acuity (BCVA) in the right eye was 6/60 and in the left eye was light perception. Intraocular pressure OS was 6 mm of Hg. On examination, pupillary reactions were normal. Anterior segment examination revealed immature senile cataract in the right eye and pseudophakia in the left eye. Left eye fundus view was obscured owing to vitreous hemorrhage, whereas the right eye was normal. B-scan was done to rule out retinal detachment, and the patient was advised propped up positioning.

On 1 week follow-up, BCVA in OS had increased to 6/9, fundus examination revealed an area of intra and subretinal hemorrhage in the perifoveal region, and an inferotemporal area of whitening depicting the needle entry wound in the globe, with inferiorly settled vitreous hemorrhage [Fig. 1a and b]. The perifoveal wound site was diagonally opposite to the inferotemporal peribulbar block entry and therefore represented the area of needle penetration after globe entry.

Figure 1

Fundus picture showing the area of perifoveal retinal hemorrhage (a) depicting area of needle penetration after globe entry. Inferotemporal area of whitening representing the area of globe perforation along with inferiorly settled vitreous hemorrhage (b)

The site of perforation was studied in detail using the SS-OCT (TOPCON – Japan Inc.), which revealed a homogenous tract from the retina piercing the entire choroid and attempting for focal vitreous detachment [Fig. 2]. The advantage of the SS-OCT is in the demonstration of the entire thickness of the needle tract. Barrage laser was done around the inferotemporal break. The patient was kept under close follow-up to monitor the perifoveal wound.

Figure 2

SS-Oct of the left eye showing a full thickness perifoveal retinochoroidal breach with rupture of Bruchæs membrane. Area of hyper-reflectivity depicting intraretinal hemorrhage along with a pocket of temporal subretinal hemorrhage

Davis and Mendel introduced the technique of peribulbar anesthesia.[1] They proposed using a single injection in the inferotemporal quadrant, with a blunt tip needle sized 1.9 to 2.2 cm.[1] Frequency of globe perforation during peribulbar anesthesia has been variably reported in the literature to be 1 in 874 to 1 in 16,224.[23] Risk factors predisposing for perforation are myopic eyes, deep-set eyes, long-needle size, and injection in superonasal quadrant.[4] Clinical presentation includes retinal break formation, vitreous hemorrhage, retinal detachment, retinal hemorrhage and hypotony. Early vitrectomy with silicon oil/gas tamponade is advised in cases with retinal detachment and those with dense vitreous hemorrhage with inappreciable breaks.[5]

Our patient presented with most of the above-mentioned signs. The most dreaded complication being the full thickness retinal break. Imaging the break is impractical owing to the peripheral location and the limitations of the previous generation OCT. We utilized the latest OCT with incorporated swept source technology to reach greater choroidal depths.

To our knowledge, a SS-OCT through the area of globe perforation has not been described before. This essay highlights manifestations of peribulbar anesthesia injection-related globe perforation and showcases an example of severe intraocular injury without resultant visual compromise.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.