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Choroidal Neovascularization After Globe Penetration by Peribulbar Anesthesia
Arch Ophthalmol. 2004;122:1544-1546.
Iatrogenic choroidal neovascularization is a rare complication of ocular surgery. It is usually a result of laser photocoagulation, retinal cryotherapy, or subretinal fluid drainage. It was believed to be induced by damaging the Bruch membrane and/or retinal pigment epithelium, from which the reparative processes trigger the release of angiogenic factors.1
We report a case of global penetration–induced choroidal neovascularization following peribulbar anesthesia for cataract surgery.
Report of a Case
A 75-year-old woman originally scheduled for phacoemulsification with an intraocular lens implant in the right eye had a procedure complicated by global penetration during peribulbar anesthesia. Dilated fundus examination revealed a suspected penetration site; preretinal and subretinal hemorrhages were also found in the right posterior pole. The operation subsequently proceeded because the intraocular pressure was not soft after penetration. It was then complicated by a posterior capsular tear, and an anterior vitrectomy was done to complete the surgery. Two months after surgery, the patient's best-corrected visual acuity was 20/100 OD with preretinal and subretinal hemorrhages around the macula on ophthalmoscopic examination.
Preoperatively, the patient was a hypermetrope. Subjective refraction was + 1.5 diopters (D) in the right eye and + 1.0 D in the left eye. Best-corrected visual acuity was 20/60 OU. The axial length was 23.04 mm in right eye and 23.21 mm in the left eye.
Examination of cornea, anterior chamber, pupil, and intraocular pressure readings were unremarkable except nuclear sclerosis of bilateral lens. There were no signs of macular degeneration in each eye.
The visual acuity was stable until 8 months after the surgery. The patient visited the clinic complaining of a gradual blurring of her vision in the right eye. Dilated fundus examination revealed residual preretinal hemorrhage and a choroidal retinal lesion, corresponding to the previously suspected penetrating site Figure 1, A). In the early phase of a fluorescein angiography, there was an oval lesion with hypofluorescence and a clear margin surrounded by a ring of hyperfluorescence (Figure 1, B). The adjacent area became progressively hyperfluorescent during the transit phase with leakage in the late phase (Figure 1, C and D). The patient was diagnosed with iatrogenic choroidal neovascularization resulting from global penetration while administering peribulbar anesthesia.
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A, Color fundus photograph shows preretinal hemorrhage (small arrow) and subretinal fibrous scar (large arrow) around the macula. B, The oval hypofluorescent area corresponding to the penetrating lesion is surrounded by an area of hyperfluorescence in the early phase. C and D, Increased hyperfluorescence (arrows) is noted during the transit phase, followed by leakage in the late phase, characteristic of subretinal neovascularization.
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Comment
Peribulbar anesthesia, during which local anesthetic is injected outside the muscle cone, has been cited by proponents as having the advantages of greater ease of performance and a lower rate of globe perforation.2 However, ocular penetrations (single entry) and perforations (entry wound and exit wound) have been reported occasionally, especially in patients with long axial length.
In clinical situations, the detection of preretinal, subretinal, or vitreous hemorrhage either immediately after surgery or on postoperative visits should remind the physician of the possibilities of global penetration. Most of the penetrating site becomes a chorioretinal scar rather than a choroidal neovascularization in the end.
The penetrating site, which was very close to the macula, developed into choroidal neovascularization that resulted in visual loss in this patient. This represents an unusual complication of global penetration by peribulbar anesthesia. To our knowledge, there are no prior reported cases of choroidal neovascularization developed in the penetrating site by peribulbar anesthesia. Ophthalmologists should be aware of this complication, which might lead to loss of vision.
The authors have no relevant financial interest in this article.
AUTHOR INFORMATION
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Nan-Kai Wang, MD;
Wei-Chi Wu, MD;
Lan-Hsin Chuang, MD;
Yeou-Ping Tsao, MD, PhD;
Tun-Lu Chen, MD;
Chi-Chun Lai, MD
Correspondence: Dr Lai, Department of Ophthalmology, Chang Gung Memorial Hospital, 5 Fu-Hsing St, Kwei-Shan, Tao-Yuan, Taiwan (ccl404{at}cgmh.org.tw).
REFERENCES
1. Lim JI. Iatrogenic choroidal neovascularization. Surv Ophthalmol. 1999;44:95-111.
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2. Kimble JA, Morris RE, Witherspoon CD. Globe perforation from peribulbar injection [letter]. Arch Ophthalmol. 1987;105:749.
SECTION EDITOR: W. RICHARD GREEN, MD
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