I TINJAUAN PUSTAKA I

Blok Peribulbar: Modalitas Anestesi Rawat Jalan untuk Pembedahan Eviserasi

O%almika
Intra Peribulbar Block: A Modality in Ambulatory Anesthesia for Ophthalmic Eviscera!on
Surgery
Andi Salahuddin
latori yaitu biaya murah, aman bagi pasien dan nyaman.
ABSTRACT
The classical extraconal (peribulbar) block was introduced in 1986 as a safer alterna!ve to the retrobulbar
block, in which the needle !p remained outside the muscle
cone.
Intraconal (retrobulbar) block involves the injec!on
of a local anaesthe!c agent into the muscle cone, behind
the globe that is more easy to occur complica!on. Muscle
cone formed by 4 rec! muscles and the superior and inferior oblique muscles. Eviscera!on is the surgical removal
of the contents of the eye, leaving the white part of the
eye and the eye muscles intact. Usually, this procedure under general anaesthesia technique, but that have worried
about prolong ven!la!on a#er surgery or other complica!on related general anaesthesia, and ambulatory se*ng
changes. Knowledge of orbital anatomy and training are essen!al for the prac!ce of safe orbital regional anaesthesia
and similar the aim of ambulatory anaesthesia low cost,
pa!ent safety and sa!sfac!on.
Keywords: Peribulbar block, modality ambulatory, eviscera!on
ABSTRAK
Blok Peribulber yang telah diperkenalkan tahun
1986 merupakan pilihan cara yang lebih aman dibanding
blok retrobulber dimana ujung jarum ditempatkan diluar
muscle cone. Pada blok retrobulber ujung jarum ditempatkan di dalam muscle cone, dibelakang bola mata sehingga mudah terjadi komplikasi. Muscle cone dibentuk
oleh 4 otot rektus dan otot oblik superior dan inferior.
Eviserasi adalah operasi pengeluaran isi bola tanpa mengangkat sklera dan tanpa memotong otot-otot bola mata.
Biasanya operasi ini dilakukan dengan teknik anestesi
umum. Namun ada kekhawa!ran terjadinya prolong ven!la!on atau komplikasi lainnya sehubungan dengan tehnik
anestesi umum yang menyebabkan prosedur ambulatory
berubah. Blok Peribulber dapat merupakan suatu modalitas anestesi ambulatori karena dengan teknik ini dapat kita
hindari komplikasi akibat anestesi umum. Pengetahuan
anatomi bola mata yang baik disertai pela!han yang baik
diperlukan dalam praktek regional anestesia mata yang
aman dan hal ini sesuai dengan tujuan pada anestesi ambu-

Kata kunci: Blok peribulber, modalitas ambulatori, eviserasi.

INTRODUCTION
The terminology used for regional orbital blocks is
controversial. A name based on the likely anatomical placement of the needle is accepted widely. An intraconal (retrobulbar) block involves the injec!on of a local anaesthe!c
agent into the part of the orbital cavity (the muscle cone),
behind the globe that is formed by 4 rec! muscles and the
superior and inferior oblique muscles. The classical extraconal (peribulbar) block was introduced in 1986 as a safer
alterna!ve to the retrobulbar block, in which the needle !p
remained outside the muscle cone.
The provision of ophthalmic regional anaesthesia
for eye surgery varies worldwide. These may be chosen to
eliminate eye movement or not and both non-akine!c and
akine!c methods are widely used. Pa!ent comfort, safety
and low complica!on rates are the essen!als of regional
anaesthesia.
The anaesthe!c requirements for ophthalmic surgery are dictated by the nature of the proposed surgery, the
surgeons preference and the pa!ents wishes. Eviscera!on
surgery is the commonest ophthalmic surgical procedure
and general anaesthe!c technique is usually preferred. 4,7
Ambulatory anesthesia is tailored to meet the
needs of ambulatory surgery so you can go home soon after your opera!on. Short-ac!ng anesthe!c drugs and specialized anesthe!c techniques as well as care specically
focused on the needs of the ambulatory pa!ent are used to
make your experience safe and pleasant. In general, if you
are in reasonably good health, you are a candidate for ambulatory anesthesia and surgery. A ques!on is How about
a pa!ent with co-excis!ng disease (example : Staphyloma cornea with destroyed lung/ asthma bronchiale etc,
undergoing to eviscera!on surgery ), usually, who are undergoing eviscera!on surgery with general anaesthesia

Andi Salahuddin
Department of Anesthesiology, Intensive Care and Pain
Management of Dr. Wahidin Sudirohusodo Hospital
Faculty of Medicine Hasanuddin University Makassar

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Blok Peribulbar: Modalitas Anestesi Rawat Jalan untuk Pembedahan Eviserasi Oftalmika I Intra Peribulbar Block: A Modality in Ambulatory Anesthesia for

Ophtalmic Evisceration Surgery

technique, but some anaesthe!st worry about prolong

ven!la!on a%er surgery or asthma a+ack, and ambulatory
se<ng changes (see. Fig.1,2) .Based on your medical history, a type of anaesthe!c may have an addi!onal margin
of safety. As an outpa!ent, some techniques may allow you
to recover more quickly with fewer side eects, for example
: peribulbar regional ophthalmic anaesthesia.
There are many advantages of regional anesthesia.
First, the pa!ent is conscious during surgery. Therefore, the
pa!ent can maintain his own airway, contain his own gastric
secre!ons, and warn the surgeon of impending complica!ons, for example ver!go in stapes surgery. Next, unlike
general anesthesia, pa!ents are awake and usually have a
smooth postopera!ve course. This allows for less nursing
care a%er procedures, and shorter recovery !mes facilitating outpa!ent surgery. Another advantage is the elimina!on of painful aerent s!muli for the opera!ve site plus
the blockade of eerent sympathe!c nerves to endocrine
glands eliminates or greatly reduces the metabolic endocrine changes seen a%er surgical opera!ons. 1,2,3
Each pa!ent is unique, your anesthesiologist will
carefully evaluate you and your health status to determine
if you should undergo ambulatory anesthesia.6
With the growth in ambulatory surgery and anesthesia in the United States comes a parallel growth in liability for the anesthesiologist providing ambulatory anesthesia
services. The U.S. government es!mates that about half of
all anesthesia procedures are conducted on an ambulatory
basis. The good news for anesthesiologists prac!cing in an
outpa!ent se<ng is that fewer than half of all closed anesthesia malprac!ce claims arise from procedures conducted
on an ambulatory basis.2
Assessment and Prepara!on
Preopera!ve prepara!on and assessment vary
worldwide. In the UK, the Joint Colleges Working Party Report recommended that pa!ents are not fasted but fas!ng
policies vary considerably. Complica!on rates as a result of
starva!on or aspira!on in ophthalmic regional anaesthesia
are unknown and dangers remain if a pa!ent vomits whilst
undergoing any form of anaesthesia and surgery. According to published guidelines and reported evidence, rou!ne
inves!ga!on of pa!ents undergoing cataract surgery is not
essen!al because it improves neither the health nor the
outcome of surgery, but tests can be done to improve the
general health of the pa!ent if required. The preopera!ve
assessment should always include a specic enquiry about
bleeding disorders and related drugs. There is an increased
risk of haemorrhage and this requires that a clo<ng prole
is available (and recorded) prior to injec!on. Pa!ents receiving an!coagulants are advised to con!nue their medica!on. Clo<ng results should be within the recommended
therapeu!c range. Currently there is no recommenda!on
for pa!ents receiving an!platelet agents. Procedures under
topical, subconjunc!val, sub-Tenons or shallow peribulbar
blocks are recommended.
There are a number of risk factors that predispose
the globe to needle penetra!on. The presence of a long
eye, staphyloma or enophthalmos, faulty technique, a lack

of apprecia!on of risk factors, an uncoopera!ve pa!ent

and the use of unnecessarily long needles are some of the
contribu!ng causes. Pa!ents presen!ng with axial myopia
have greater risk of globe puncture compared with pa!ents
with normal axial length and carry a risk rate of one perfora!on for every 140 needle blocks performed in eyes with
an axial length greater than 26 mm. A precise axial length
measurement is usually available for intraocular lens dioptre power calcula!on before cataract surgery. If the block is
performed for other surgery and the axial length measurement is not known, close a+en!on to the dioptre power of
pa!ents spectacles or contact lenses may provide valuable
clues to globe dimension. In the presence of high myopia,
a classical peribulbar block or a single medial peribulbar
injec!on is advocated. Similar cau!on will apply where
there is a pre-exis!ng scleral buckle from an earlier re!nal
opera!ve procedure. Once the decision is made to operate, the anaesthe!c and surgical procedures are explained
to the pa!ents to enable informed consent. All monitoring
and anaesthe!c equipment in the opera!ng environments
should be fully func!onal. Blood pressure, oxygen satura!on and ECG leads are connected and baseline recordings
are obtained. Intravenous line must be inserted before embarking on a needle block. The presence of a secure intravenous line remains good clinical prac!ce.
Applied Anatomy
As with all regional anaesthe!c techniques, knowledge of the anatomy of the orbit and its contents is essen!al to the safe prac!ce of ophthalmic regional anaesthesia
and many excellent textbooks on anatomy are available.
The orbit is an irregular four-sided pyramid with its apex
poin!ng posteromedially and its base facing anteriorly. The
annulus of Zinn, a brous ring arising from the superior
orbital ssure, forms the apex. The base is formed by the
surface of the cornea, the conjunc!va and the lids. Globe
movements are controlled by the rectus muscles (inferior,
lateral, medial and superior) and the oblique muscles (superior and inferior).
The rectus muscles arise from the annulus of Zinn
near the apex of the orbit and insert anterior to the equator of the globe, forming an incomplete cone. The distance
from the inferior temporal orbital rim to the annulus measures 42 to 54 mm. Within the annulus and the muscle cone
lie the op!c nerve (II), the oculomotor nerves (III containing
both superior and inferior branches), the abducent nerve
(VI nerve), the nasociliary nerve (a branch of V nerve), the
ciliary ganglion and vessels. The superior branch of oculomotor nerve supplies the superior rectus and the levator palpebrae muscles. The inferior branch of oculomotor
nerve supplies the medial rectus, the inferior rectus, and
the inferior oblique muscles. The abducens nerve supplies the lateral rectus. The trochlear nerve (IV nerve) runs
outside and above the annulus, and supplies the superior
oblique muscle (retained ac!vity of this muscle is frequently observed as anaesthe!c agents o%en fail to block this
nerve).
Corneal and perilimbal conjunc!val and superonasal quadrant of the peripheral conjunc!val sensa!ons are

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ANDI SALAHUDDIN

mediated through the nasociliary nerve. The remainder of

the peripheral conjunc!val sensa!on is supplied through
the lacrimal, frontal and infraorbital nerves coursing outside the muscle cone; hence, intraopera!ve pain may be
experienced if these nerves are not blocked. The fascial
sheath (Tenons capsule) is a thin membrane that envelops
the globe and separates it from the orbital fat. It thus forms
a socket for the globe. The inner surface is smooth and
shiny and is separated from the outer surface of the sclera
by a poten!al space called the episcleral space. Crossing
the space and a+aching the fascial sheath to the sclera are
numerous delicate bands of connec!ve !ssue (Fig. 1).
Anteriorly, the fascial sheath is rmly a+ached to
the sclera, about 3 to 5 mm posterior to the corneoscleral
junc!on. However, the descrip!on of Tenons capsule does
vary and one major textbook of anatomy suggests that the
space under the Tenon capsule is actually a lymph space
and this follows the op!c nerve and con!nues with subarachnoid space.
Posteriorly, the sheath fuses with the meninges
around the op!c nerve and with the sclera around the exit
of the op!c nerve. The tendons of all 6 extrinsic muscles of
the eye pierce the sheath as they pass to their inser!ons on
the globe. At the site of perfora!on the sheath is reected
along the tendons of these muscles to form, on each, a tubular sleeve. The superior oblique muscle sleeve extends as
far as the trochlea and the inferior oblique muscle sleeve
extends to the origin of the muscle.
The tubular sleeves for the 4 rec! muscles also have
expansions. Those for medial and lateral rec! are strong
and are a+ached to the lacrimal and zygoma!c bones and
are called the medial and lateral check ligaments respec!vely. Thinner and less dis!nct expansions extend from the
superior rectus tendon to that of the levator palpebrae superioris and from the inferior rectus to the inferior tarsal
plate. The inferior part of the fascial sheath is thickened and
is con!nuous medially and laterally with the medial and lateral check ligaments. A matrix of connec!ve !ssue, which
supports and allows dynamic func!on of the orbital contents, also controls the injectate spread.
Globe and conjung!val anesthesia (conduc!on
block of intraorbital sensory devisions of the ophthalmic
branch of the trigeminal nerve) are achieved more easily
than globe akinesia (conduc!on block of intraorbital por!ons of the oculomotor cranial nerves III, IV and VI). The
oculomotor nerve enter the muscle bellies of the four rectus muscles from the conal surface 1,0 1,5 from the apex
of the orbit. Local anaesthe!cs, in blocking concentra!ons,
have to reach an expose 5 10 mm segment of these motor
nerve in the posterior intracone space for conduc!on block
of those nerves and akinesia of their supplied muscles to
occur. Retained ac!vity of the superior oblique muscle frequently seen a%er intraconal local anaesthe!cs injec!on,
because its motor nerve, the trochlear, runs an extraconal
course.
There is insucient space between the lateral rectus muscle and adjacent lateral orbit wall, and between the
inferior rectus muscle and adjacent orbit oor, to consider
place injectate in either loca!on without risking injury to

the respec!ve muscles.

Corneal and perilimbal conjung!val sensa!on is
mediated via nasociliary nerve which lies within the cone
of muscles; intracone blocks therefore produce anaesthesia
of the cornea and conjunc!va immediately surrounding it.
However the sensa!on of the peripheral conjunc!va is supplied through the lacrimal, frontal and infraorbital nerve
coursing outside the muscle cone; intraopera!ve pain maybe experienced in this area a%er a solely intracone block.

Fig. 1. Anatomy of the orbit and contents

Globe posi!on
The tradi!onal teaching of having pa!ent
look up and in during retrobulbar block needle placement has been superseded by instruc!on to direct their
eyes in primary gaze. With the globe in primary gaze
the op!c nerve assumes a much safer loca!on, totally on the medial side of the mid- sagital plane. (g.2,3)

Fig. 2. View from front

Fig. 3. View from above

Site and deep injec!on
Rela!vely avascular areas suitable for injec!on are
the anterior half of the orbit in the inferotemporal quad-

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Ophtalmic Evisceration Surgery

rant, and the compartement of the nasal side of the medial

rectus muscle; needle must never be inserted deeply to the
orbital apex. (Fig 2,3).
Anaesthesia mixture
Any of the full potency local anaesthe!cs may be
used, the eventual choice depending on the availlability, pa!ent age and desired dura!on of eect. Concentra!ons up
to but not exceeding 2% lignocaine (or Bupivacaine 5%) are
appropriate. Adrenaline is use commonly for prolonga!on
of block dura!on and to increase extend of block, but may
be contraindicated if orbital vascular pathology is present;
a concentra!on 1: 200.000, given the volume of injectate
used in ophthalmic regional anaesthesia, is devoid of systemic eect.
Adjuvants3,4,5
Vasoconstrictors: Vasoconstrictors (epinephrine
and felypressin) are commonly mixed with local anaesthe!c
solu!on to increase the intensity and dura!on of block, and
minimise bleeding from small vessels. Absorp!on of local
anaesthe!c is reduced, thus avoiding high concentra!ons
of local anaesthe!c in the plasma. Epinephrine is commonly mixed with the local anaesthe!c agent to prolong
the dura!on and intensity of the block. A concentra!on of
1:200,000 has no systemic eect. However, epinephrine
may cause vasoconstric!on of the ophthalmic artery, compromising the re!nal circula!on. The use of epinephrinecontaining solu!ons should also be avoided in elderly pa!ents suering from cerebrovascular and cardiovascular
diseases. Phacoemulsica!on cataract extrac!on is usually
of short dura!on; hence the dura!on of block achieved by
lidocaine without epinephrine usually suces.
Dexmetomidine: Dexmedetomidine, a more selec!ve -2 adrenoceptor agonist, is also known to enhance
central neural blockades. 8
Hyaluronidase: Hyaluronidase is an enzyme, which
reversibly liquees the inters!!al barrier between cells by
depolymerisa!on of hyaluronic acid to a tetrasaccharide,
thereby enhancing the diusion of molecules through !ssue planes. It is available as a powder readily soluble in local anaesthe!c solu!on. Hyaluronidase has been shown to
improve the eec!veness and the quality of needle as well
as sub-Tenons block but its use remains controversial. The
amount of hyaluronidase used in published studies varies
from 5 to150 IU/mL. The UK data sheet limits the concentra!on to 15 IU/mL. Orbital swelling due to rare allergic
reac!ons or excessive doses of hyaluronidase and orbital
pseudo-tumour has been reported. Excellent blocks can
be achieved without hyaluronidase but there are reports of
muscle dysfunc!on when it is not used during needle block.
pH Altera!on: Commercial prepara!on of lidocaine
and bupivacaine are acidic solu!ons in which the basic local
anaesthe!c exists predominantly in the charged ionic form.
It is only the nonionised form of the agent that traverses
the lipid membrane of the nerve to produce the conduc!on
block. At higher pH values, a greater propor!on of local anaesthe!c molecules exist in the nonionised form, allowing
more rapid inux into the neuronal cells. Alkalinisa!on has

been shown to decrease the onset !me and prolong the

dura!on of eect a%er needle block but no such benet is
seen during sub-Tenons block.
Others: The addi!on of muscle relaxants, clonidine
and other chemicals are known to increase the onset and
potency of orbital block but their use is neither rou!ne nor
recommended.
Seda!on and Ophthalmic Regional Blocks3,4,5
Seda!on is commonly used during topical anaesthesia. Selected pa!ents, in whom explana!on and reassurance have proved inadequate, may benet from seda!on.
Shortac!ng benzodiazepines, opioids and small doses of
intravenous anaesthe!c induc!on agents are favoured but
the dosage must be minimal. The rou!ne use of seda!on is
discouraged because of an increased incidence of adverse
intraopera!ve events. It is essen!al that when seda!on is
administered, a means of providing supplementa!on oxygen is available. Equipment and skills to manage any life
threatening events must be immediately accessible.
Intraocular Pressure (IOP) and Ophthalmic Regional
Blocks3,4,5
Changes in intraocular pressure a%er retrobulbar
and peribulbar injec!ons are controversial but IOP is generally reported to increase immediately a%er injec!on. Prior
reduc!on of IOP is associated with fewer opera!ve complica!ons, notably shallowing of the anterior chamber and
vitreous loss during large-incision extracapsular cataract
extrac!ons. These complica!ons are less likely to happen
during modern small-incision phacoemulsica!on procedure as the tendency for the anterior chamber to collapse
is reduced. Any rise in IOP may have other serious consequences in pa!ents with glaucoma and pa!ents with advanced visual eld loss.
Retained Visual Sensa!ons During Ophthalmic Regional
Blocks
Many pa!ents experience intraopera!ve visual
sensa!ons that include light, colours, movements and instruments during surgery under all forms of local ophthalmic anaesthesia. Although the majority of pa!ents feel
comfortable with the visual sensa!ons they experience, a
small propor!on nd the experience unpleasant or frightening. Therefore, pa!ents receiving orbital blocks should
receive preopera!ve advice as this may alleviate an unpleasant experience.1,3
Intraopera!ve Care and Monitoring
The pa!ent should be comfortable and so% pads
are placed under the pressure areas. All pa!ents undergoing major eye surgery under local anaesthesia should be
monitored with pulse oximetry, ECG, non-invasive blood
pressure measurement and the maintenance of verbal contact. Pa!ents should receive an oxygen-enriched breathing
atmosphere to prevent hypoxia and at a ow rate enough
to prevent re-breathing and the ensuing hypercarbia once
draped. ECG and pulse oximetry should be con!nued. Once

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ANDI SALAHUDDIN

the pa!ent is under the drapes, verbal and tac!le contacts

are maintained.1,3
Dirences between younger and older Adult pa!ent
Younger adult pa!ent present more of a challenge
an achieving total akinesia than the elderly because of more
dense connec!ve !ssues hindering access of anaesthe!cs
to the oculomotor nerve.3

Intracone (Retrobulbar) Block

Although there is communality between the fat
compartement within and outside the geometric connes
of the cone of the rectus muscles, injectate placed in midorbit intraconnaly (see Fig.7) compared with periconnaly
(see Fig.6) is more eec!ve in producing globe akinesia.
Precision placement is the key to avoidance of complica!on.

Needle Type and syringe size

Tradi!onal teaching favoured blunt !pped, intermediated gauge needles with the supposed advantages
that blood vessels were pushed a side rather than trauma!zed and that !ssue planes could be more accurately dene. (Fig.4). Although a commonly held belief among ophthalmologists, it is not true is more dicult to penetrate the
globe, the op!c nerve sheath or blood vessels with a blunt
needle. Larger blunt needles compared with ne dispossible
ones cause more serious damage if the globe is penetrated.
Because dispossible cu<ng needles produce minimal !ssue
distor!on, li+le or no pain results. Tac!le discrimina!on is
progressively reduced with increasing needle size. Special
a+en!on should be paid to the lenght of needle entering
beyond orbital rim; 31 mm as measured from the orbit rim
should never be exceded in order to exclude op!c nerve
impalement. All needles used for intracone or pericone.

Fig. 5. Preblock inspec!on of the globe and eyelid

Tabel.1. Summary nerve supply to the orbit

Fig. 4. Needle for main inferotemporal injec!on (27 gauge,

2 cm long).
Placement should be oriented tangen!ally to the
globe with the bevel opening faced towards the globe. Because less force has to be excerted, a change in resistance
to injectate ow is detected more easily by the injec!ng
hand when using a needle mounted on a smaller syringe
compared with a larger size. This ability to detect more easily changes in resistance to injec!on is more important in
the avoidance of complica!ons.
Preblock Inspec!on of The Globe and Eyelids (See Fig. 5.)
Most, but not all, inferotemporal injec!ons may be
made with tranconjunc!val entry. If on digital retrac!on of
the pa!ents lower eyelid in a downward and outward direc!on the eyelid margin is found to be !ghtly held agains
the globe, if the globe is deeply, recessed within the globe
if there is the wide lateral canthal fold, or if the pa!ent is
blinking uncontrollably, a transcutaneous approach is o%en
the safest choice. In all cases the axial length measurement
of the globe is carefully note; in the presence of high myopia, pericone as opposede to intracone, placement or even
general anaesthesia may be more prudent.

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Ophtalmic Evisceration Surgery

eliminates intraopera!ve discomfort, some!mes encountered in low volume solely intracone techniques. The
rou!ne combina!on of inferotemporal pericone injec!on
with superonasal pericone injec!on (medial compartement
block recommended) (Fig.9.) produces block anaesthesia/
akinesia, intraopera!ve pa!ent comfort and eyelid akinesia
be+er than other techniques.

Fig.6.Periconal/ Extraconal (Peribulbar) block.

Inferotemporal injec!on
The lower lid is retracted manually and the needle
is placed halfway between the lateral canthus and the lateral limbus (edge of the iris). The injec!on is not painful as
it is passing through an already anaesthe!sed conjunc!va.
If there is not enough room for the needle to be posi!oned
correctly then the injec!on may be made directly through
the skin (see.Fig.9) .

Fig. 9. Superonasal pericone injec!on.

Fig.7. Intracone (Retrobulbar) block

Fig.8.. Inferotemporal pericone injec!on

Pericone (Peribulbar, Periocular) Block
Although injectate deposited within the orbit but
not entering the geometric connes of the cone of the rectus muscles was introduced as being safer than intraconal
blocking for avoidance of serious complica!ons, nevertheless problems have been reported. Knowledge of orbital
anatomy is as important as with intracone techniques.
A failure rate to achieve akinesia with periconal
blocking of up to 50% has been reported, there are many
varia!ons of the pericone technique, a common one as being placement in two loca!ons, one in the inferotemporal
kwadrant, and one in the superonasal quadrant. A preferable alterna!ve to the la+er site of injec!on is the fat compartement of the nasal side of the medial rectus muscle.
Access of local anaesthe!cs to the motor nerve supply of
the superior oblique muscle and, by spread through the
orbital septum, of the orbicularis muscle, are promoted.
Addi!onally enhance peripheral conjunc!val anaesthesia,

Classically the point of needle inser!on was made

in line with the edge of the limbus, however more recently
a point midway between here and the lateral canthus has
been adopted. The needle is advanced in the sagi+al plane,
parallel to the orbital oor passing under the globe. There
is no need to apply pressure to the syringe as it will easily
advance without resistance. When the needle !p is judged
to be past the equator of the globe the direc!on is changed
to point slightly medial (20) and cephalad (10 upwards) to
avoid the bony orbital margin. Advance the needle un!l the
hub (which is at 2.5 cm) is at the same depth as the iris. It
is important to orientate the bevel of the needle facing the
globe and any movement of the eye during needle inser!on
should alert the anaesthe!st to possible globe penetra!on.
Avoid any tendancy to wiggle the needle to conrm the
globe is disengaged as this only increases the risk of perfora!on. Following nega!ve aspira!on, 5-8 ml of the solu!on
is slowly injected. There should not be any resistance while
injec!ng. If resistance is encountered, the !p of the needle
may be in one of the extraocular muscles and should be
reposi!oned.
During the injec!on the lower lid may ll with the
anaesthe!c mixture and there may be some conjunc!val
oedema (chemosis). Should the upper lid close quickly or
the globe become tense or proptosed a%er only small volumes of local anaesthe!c mixture the needle point is likely
to be retrobulbar, and cau!on should be taken not to inject
further. Within 5-10minutes of this injec!on, most pa!ents
will develop adequate anaesthesia and akinesia. Some pa!ents however may not and a top up injec!on can be given
either at the same site or via a nasal approach.1,3,5
The same needle is inserted through the skin/ conjunc!va on the nasal side, medial to the caruncule and di-

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rected straight back parallel to the medial orbital wall pointing slightly cephalad (20) un!l the hub of the needle is at
the same level as the iris.
The needle traverses the tough medial canthal
ligament and may require rm gentle pressure. This may
cause the the eye to be pulled medially briey. A%er nega!ve aspira!on up to 5ml of the anaesthe!c mixture is injected. The eye is then closed with adhesive tape. A piece
of gauze is placed over the lids and pressure applied with a
Macintyre oculopressor or Honan balloon for 10 minutes
at a pressure of 30 mmHg. If no oculopressor is available
gently press on the eye with the ngers of one hand. This
is to lower intraocular pressure (IOP) by reducing aqueous
humour produc!on and increasing its reabsorb!on. Assessment of the block is usually judged a%er an interval of 10
minutes.1,3,5
The signs of a succesful block are:5
Ptosis (drooping of the upper lid with inability to open
the eyes)
Either no eye movement or minimal movement in any
direc!on (akinesia)
Inability to fully close the eye once opened.

Fig.10. Assesment of the block ( eye movement lateral, medial, inferior, superior)
A simple akinesia score known as the Brahma score
can be used for assessment of the block. Eye movement is
assessed in four direc!ons inferior, superior, medial and
lateral. Normal movement is scored at 3, par!al movement
at 2 and and ickering movement at 1 and no movement
is scored at zero. A score of less than 2 is acceptable. Since
the local anaesthe!c is placed outside the muscle cone the
concentra!on around the op!c nerve may not be sucient
to abolish vision completely. Some light percep!on will
therefore remain, however the pa!ent is not able to see
the opera!on. If, a%er 10 minutes the block is inadequate
a supplementary injec!on of 2-5 ml of the anaesthe!c mixture may be required. If the residual eye movements are
downward and lateral, the supplementary injec!on is given
at the inferotemporal site and if upward and medial, at the
nasal site. Pressure is then reapplied for a further 10 minutes.5
Complica!ons of Needle Block 3,5
There are many complica!ons of needle blocks,
ranging from simple to serious, that have been reported
in many reviews. The complica!ons may be limited to the
orbit or may be systemic. Orbital complica!ons include failure of the block, corneal abrasion, chemosis, conjunc!val
haemorrhage, vessel damage leading to retrobulbar haemorrhage, globe perfora!on, globe penetra!on, op!c nerve
damage and extraocular muscle damage. Systemic complica!ons, such as local anaesthe!c agent toxicity, brainstem

anaesthesia and cardio-respiratory arrest, may be due to

intravenous or intrathecal injec!ons or the spread or misplacement of drug in the orbit during or immediately a%er
injec!on.3
Intravascular injec!on and anaphylaxis can occur,
hence resuscita!on facili!es must always be readily available.
Haemorrhage - retrobulbar haemorrhage is characterised by rapid orbital swelling and proptosis along with
a sudden rise of IOP and usually requires surgery to be postponed. The surgeon should be informed immediately and
the pulsa!on of the central re!nal artery assessed. A lateral
canthotomy can be performed to alleviate the rise in IOP.
It is very rare with shallow retrobulbar or peribulbar injec!ons (0.07%). Subconjunc!val haemorrhage is less signicant as it will eventually be absorbed.
Subconjunc!val oedema (chemosis): This is un-desirable as it may interfere with suturing. It can be minimised
by slowing the rate of injec!on. It rapidly disappears when
gentle pressure is applied to the closed eye.
Penetra!on or perfora!on of the globe (<0.1%) this is more likely to occur in myopic eyes which are longer but also thinner than normal and may have developed
staphylomata. A diagnosis of perfora!on may be made if
there is pain at the !me the block is performed, sudden loss
of vision, hypotonia, a poor red reex or vitreous haemorrhage. Perfora!on may be avoided by carefully inser!ng the
needle tangen!ally and by not going up and in un!l the
needle !p is clearly past the equator of the globe.
Central spread of local anaesthe!c - this is due to
either direct injec!on into the dural cu which accompanies the op!c nerve to the sclera or to retrograde arterial
spread. A variety of symptoms may follow including drowsiness, vomi!ng, contra-lateral blindness caused by reux
of the drug to the op!c chiasma, convulsions, respiratory
depression or arrest, neurological decit and even cardiac
arrest. These symptoms usually appear within about 5min.
Oculomedullary reexes discussed below.
Op!c nerve atrophy. Op!c nerve damage and
re!nal vascular occlusion may be caused by direct damage
to the op!c nerve or central re!nal artery, injec!on into
the op!c nerve sheath or haemorrhage within the nerve
sheath. These complica!ons may lead to par!al or complete visual loss.
Oculomedullary reexes5
Oculocardiac reex causes bradycardia, nodal
rhythms, ectopic beats or sinus arrest due to pressure, torsion or trac!on on the extraocuar muscles. It is a trigeminovagal reex the aerent arc is via long and short ciliary
nerves to the ciliary ganglion and the ophthalmic division of
the trigeminal nerve with the eerent impulses conveyed
by the vagus. This reex most commonly occurs in paediatric squint pa!ents. Local anaesthe!c blocks may a+enuate
the aerent arc and muscarinic antagonists block the eerent limb at the level of the heart. Hypercarbia sensi!ses the
reex and should be avoided.3,4,5
Oculorespiratory reex may cause shallow
breathing, reduced respiratory rate and even full respira-

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Blok Peribulbar: Modalitas Anestesi Rawat Jalan untuk Pembedahan Eviserasi Oftalmika I Intra Peribulbar Block: A Modality in Ambulatory Anesthesia for

Ophtalmic Evisceration Surgery

tory arrest. The aerent pathways are similar to the above

reex and it is thought that a connec!on exists between the
trigeminal sensory nucleus and the pneumotac!c centre in
the pons and medullary respiratory centre. Again this reex
is commonly seen in strabismus surgery and atropine has
no eect. If controlled ven!la!on is not rou!nely employed
then extra a+en!on is needed.5
Oculoeme!c reex is likely responsible for the
high incidence of vomi!ng a%er squint surgery (60- 90%).
Again this is a trigemino-vagal reex with trac!on on the
extraocular muscles s!mula!ng the aerent arc. Whilst an!eme!cs may reduce the incidence, a regional block technique provides the best prophylaxis.5
Jerome Morrel. et.al demonstrate in randomized,
double-blind, controlled study that 1% ropivacaine peribulbar (PB) block in conjunc!on with general anesthesia (GA)
were similar with respect to the incidence of postopera!ve
nausea and vomi!ng. Overall, PB block combined with GA
improves opera!ve condi!ons and postopera!ve analgesia
compared with GA combined with subcutaneous normal
saline injec!on into the inferior eyelid. 6

vomi!ng may be related to anesthesia, the type of surgical procedure or postopera!ve pain medica!ons. Although
less of a problem today because of improved anesthe!c
agents and techniques, these side eects con!nue to occur
for some pa!ents. Medica!ons to minimize postopera!ve
pain, nausea and vomi!ng are o%en given by your anesthesiologist during the surgical procedure and in recovery.

Regional versus general anaesthesia.1,3,4,5

Advantages
May be performed as day cases.
Produce good akinesia and anaesthesia.
Minimal aect on IOP.
Requires minimum equipment.
Disadvantages
Not suitable for some pa!ents (children, mentally
handicapped, deaf, language barrier).
Complica!ons as above.
Depends on the skill of anaesthe!st.
Unsuitable for certain types of surgery (e.g. dacrocystorhinostomy-DCR).

In general, for 24 hours a"er your anesthesia:

Do not drink alcoholic beverages or use nonprescrip!on medica!ons.
Do not drive a car or operate dangerous machinery.
Do not make important decisions.
You will be given telephone numbers to call if you have any
concerns or if you need emergency help a%er you go home.

RECOVERY IN THE SURGICAL FACILITY

What can I expect a"er the opera!on un!l I go
home?
A%er surgery, you will be taken to the postanesthesia care unit, o%en called the recovery room. Your anesthesiologist will direct the monitoring and medica!ons needed
for your safe recovery. For about the rst 30 minutes, you
will be watched closely by specially trained nurses. During this period, you may be given extra oxygen, and your
breathing and heart func!ons will be observed closely. In
some facili!es, you may then be moved to another area
where you will con!nue to recover, and family or friends
may be allowed to be with you. Here you may be oered
something to drink, and you will be assisted in ge<ng up.
Will I have any side eects?
The amount of discomfort you experience will depend on a number of factors, especially the type of surgery.
Your doctors and nurses can relieve pain a%er your surgery
with medicines given by mouth, injec!on or by numbing
the area around the incision. Your discomfort should be tolerable, but do not expect to be totally pain-free. Nausea or

When will I be able to go home?

This will depend on the policy of the surgery center, the type of surgery and the anesthesia used. Most pa!ents are ready to go home between one and four hours
a%er surgery. Your anesthesiologist will be able to give you
a more specic !me es!mate. Occasionally, it is necessary
to stay overnight. All ambulatory surgical facili!es have arrangements with a hospital if this is medically necessary.
What instruc!ons will I receive?
Both wri+en and verbal instruc!ons will be given.
Most facili!es have both general instruc!ons and instruc!ons that apply specically to your surgery.

RECOVERY AT HOME
What can I expect?
Be prepared to go home and nish your recovery
there. Pa!ents o%en experience drowsiness and minor a%er
eects following ambulatory anesthesia, including muscle
aches, sore throat and occasional dizziness or headaches.
Nausea also may be present, but vomi!ng is less common.
These side eects usually decline rapidly in the hours following surgery, but it may take several days before they are
gone completely. The majority of pa!ents do not feel up to
their typical ac!vi!es the next day, usually due to general
!redness or surgical discomfort. Plan to take it easy for a
few days un!l you feel back to normal. Know that a period
of recovery at home is common and to be expected.
CONCLUSION
Eye blocks provide excellent anaesthesia for ophthalmic surgery and success rates are high. Sa!sfactory anaesthesia and akinesia can be obtained with both needle
and cannula. Although rare, orbital injec!ons may cause severe local and systemic complica!ons. Knowledge of orbital
anatomy and training are essen!al for the prac!ce of safe
orbital regional anaesthesia and the aim of ambulatory anaesthesia low cost, pa!ent safety and sa!sfac!on come
true.
REFERENCE

Anestesia & Critical Care Vol 28 No.2 Mei 2010 78

ANDI SALAHUDDIN

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6.

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Hamilton, R.C. Techniques of Orbital Regional Anesthesia. Bri!sh Journal Of Anesthesia 1995;75:
88 92.
Posner, KL: Liability Prole of Ambulatory Anesthesia. ASA Newsle&er. 2000; 64(6):10-12.
Chandra M Kumar. Review Ar!cle: Ophthalmic Regional Block. Ann Acad Med Singapore
2006;35:158-67
American Society of Ophthalmic Plas!c and Reconstruc!ve Surgery. COPYRIGHT 2005, ASOPRS.
ALL RIGHTS RESERVED
Dr. Kim Chish!. Anaesthesia for Ophthalmic Surgery Part 1, 25/5/2009. ANAESTHESIA TUTORIAL
OF THE WEEK 135, 25TH MAY 2009. email worldanaesthesia@mac.com.
Jerome Morel, MD. et.al. Preopera!ve Peribulbar
Block in Pa!ents Undergoing Re!nal Detachment
Surgery Under General Anesthesia: A Randomized
Double-Blind Study. Anesth Analg 2006;102:1082
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Bakht Samar Khan, Mohammad Naeem Khan, Akbar Shah, Zia ul Islam. Eviscera!on, Enuclea!on,
and Exentra!on: painful but life saving surgical procedures. Pakistan J. Med. Res. 2005. Vol. 44, No.2.
Takuya Miyawaki, DDS, PhD, et.al. Dexmedetomidine Enhances the Local Anesthe!c Ac!on of Lidocaine via an -2A Adrenoceptor. Anesth Analg
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