Profound vascular stasis of retina and optic nerve following retrobulbar anesthesia

Figures & data

Table 1 Demographics, background patient and surgeon characteristics, past medical history, and outcomes of patients included in the series

	Case 1 (February 7, 2013)	Case 2 (February 28, 2013)	Case 3 (March 26, 2013)
Operating room	Satellite hospital	Satellite hospital	University hospital
Surgical indication	ERM	Macula-on recurrent RD s/p recent SB	FTMH
PMHx	History of GCA (no ophthalmic involvement), s/p carotid EA, s/p CABG	Healthy	Healthy
Block	RBB (5 mL: 2% lido [+MP], 0.75% bupi)	RBB (5 mL: 2% lido [+MP], 0.75% bupi)	RBB (7 mL: 4% lido [–MP], 0.75% bupi, hyal)
Surgeon	Attending surgeon only	Attending surgeon only	Fellow/attending
Vascular stasis	Severe	Mild (immediately improved with VTX)	Mild (immediately improved with VTX)
Visual outcome	CF	20/32	20/50 (POM#3, then LTF)

Abbreviations: ERM, epiretinal membrane; RD, retinal detachment; SB, scleral buckle; FTMH, full-thickness macular hole; GCA, giant cell arteritis; carotid EA, carotid endarterectomy; CABG, coronary artery bypass grafting; RBB, retrobulbar block; lido, lidocaine; bupi, bupivacaine; hyal, hyaluronidase; MP, methylparaben; VTX, vitrectomy; CF, count fingers; POM#3, postoperative month 3; LTF, lost to follow-up; PMHx, past medical history.

Figure 1 Intraoperative view of optic nerve and macular ischemia in Case 1 patient.

Notes: At the beginning of the case, prior to initiation of vitrectomy, marked optic nerve pallor, retinal vessel attenuation, and box-carring were noted (A). There was instantaneous but partial improvement in optic nerve and macular perfusion as soon as the vitreous cutter was engaged (B). The perfusion continued to improve throughout the procedure, as shown after ILM staining (C) and after membrane peeling (D). Macular OCT shows preoperative ERM (E). At 6-week follow-up, there is improved macular thickening and resolution of intraretinal cysts but significantly worsened visual acuity (F).
Abbreviations: ERM, epiretinal membrane; ILM, internal limiting membrane; OCT, optical coherence tomography.