Medial Canthus Single Injection Peribulbar Anesthesia using 13x0,45mm Needle: Technique Presentation.
Oliveira Ar*1, Oliveira Jbr1, Kronbauer Al2, Severo Ns3, Picetti E4
1Anesthesiologist, Roth & Roth Anesthesia Clinic, Porto Alegre, Brazil
2Ophthalmologist, Centro de Olhos do Rio Grande do Sul, Porto Alegre, Brazil
3Ophthalmologist, Visum Ophthalmology Clinic, Porto Alegre, Brazil
4Ophthalmologist, Assistant Professor of Ophthalmology in Residents Program and Chief of Glaucoma Division, Hospital Nossa Sen hora da Conceição, Porto Alegre, Brazil
Alexandre Roth de Oliveira, Roth & Roth Anesthesia Clinic, Rua Profª Cecilia Corseuil, 196. Porto Alegre.
RS. Brazil. ZIP: 91920-570, Tel: 55-51-32392898, Email: email@example.com
Oliveira AR et al. (2017), Medial Canthus Single Injection Peribulbar Anesthesia using 13x0,45mm Needle: Technique Presentation. Int J Anes & Rel. 1:2, 23-27. DOI: 10.25141/2575-9736-2017-2.0023
Copyright: ©2017 Oliveira AR et al. This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are
Received Date: October 25, 2017; Accepted Date: November 6, 2017; Published Date: November 30, 2017
The evolution of opthalmologic surgery brings back the popularity of regional anesthesia techniques. The search for the ideal anesthetic
approach have been based in safety and efficacy basis. Peribulbar medial canthus single was successfully attempted but not with a
less traumatic needle. A technique presentation of the peribulbar medial canthus single approach using a 13x0x45mm needle is detailed
and advocated as an alternative to perform ophthalmic surgeries.
Peribulbar Anesthesia, Ophthalmology, Medial Canthus, Caruncle
The main objectives to achieve during anesthesia are safe and efficacy.
The opthalmologic surgical setting considers sight and
life-threatening complications relating to safe, although the efficacy
represents optimal conditions to the patient and surgeon
during surgery. Ocular penetration and/or perforation, retrobulbar
or peribulbar hemorrhage and intrathecal anesthetic injection
(brainstem anesthesia, seizures) are one of the worst sight and
life-threatening complications possible 1,2. Optimal conditions
to patient could be in fact a pleasant experience, without pain or
any adverse event 3,4. The surgeon requires akinesia, without pain
and reflexes (specially oculocardiac reflex), and without any local
complication that could interfere with technical excellence (chemosis,
hyphema, subconjunctival hemorrhage, etc) 5.
The rationale for the technique presented could be explained answering
two questions (table 1):
a) Why use medial canthus? Because after extensive anatomical
review we concluded that both in sagittal and coronal axis this
approach could represent the safest site, with few main structures
(nerves, vascular, muscles) adjacent 6,7 and additionally the preferred
location of staphylomas be temporal and not nasal 8.
b) Why use needle 13x0,45mm? Minimize Risk: Because minimizing
the local trauma we have less chance to vascular complications
(subconjunctival hematoma or retrobulbar hematoma) and,
in case of perforation, less ocular trauma. This could be more relevant
in patients with use of antiplatelet medications 9,10. Efficacy:
The length of 13mm seems to be appropriate to reach the peribulbar
area, considering that a usual Ocular axial length is 24mm with
one third external (8mm) and two thirds internal (16mm) 4,7.
Table 1: Rationale of technique.
There was no premeditation prior to surgery. Tetracaine 1% ophthalmic
solution (2 drops), Tropic-amide 1.0% (2 drops), Phenylephrine
Hydrochloride Ophthalmic Solution 10% (1 drop) was instilled
before performing anesthesia. Usual monitoring was used.
It was injected Propofol intravenously to obtain light sedation
during the puncture 11. A 13x0,45 mm needle was fully inserted in
the semilunaris fold, just above the caruncle lacrimali (up-caruncle
approach) (Photo 1) at an angle of 90º both in longitudinal and in
transversal axis (photo 2).
Photo 1: “Up” Caruncle site of function.
PHOTO 2: The 90 degree’s angles of entrance in longitudinal and transversal axis.
The needle was fully advanced in an anteroposterior direction, at
a parallel situation among the Globe and the medial wall of Orbit.
The local anesthetic mixture was then slowly injected (lidocaine
2% + hyaluronidase 10 IU/ml) in an initial fixed volume of
5mL. Compression was then applied for 2 min using a Chandler’s
maneuver to lower intra ocular pressure and improve the orbital
spread of the anesthetic solution 12. Akinesia (globe and eyelids)
and analgesia was assessed before surgery and if necessary a supplemental
injection was performed by the anesthetist using the
same technique but with a volume of 3-5mL of anesthetic. The
time elapsed from block to surgery must be at least 10min, but ideally,
we respect more than 15min, to reach better efficacy as advocated
by former studies 13, 14. There is a special comment about
anesthesiologist position when performing the technique: The authors
realizes that while one hand keeps the eyelids open the other
hand proceed the block. In this scenario, to do not cross hands, a
right-handed anesthesiologist must be positioned right-caudal to
the patient for right eye block and cranial for left eye block (photo
3 and 4).
Photo 3: Right-handed anesthesiologist approach to the right eye of the patient
Photo 4: Right-handed anesthesiologist approach to the left eye of the patient.
Opthalmologic surgeries can be performed under topical, regional
and general anesthesia. General anesthesia usually is reserved for
special situations and have a decreased utility as the minimal invasive
techniques evolve 15. Topical anesthesia is increasing in preference
because eliminate the risks related to injection, but it presents
limitations about Peri and postoperative pain and frightening
experience to patient, and must be reserved for short surgeries and
cooperative patients 16. Peribulbar, retrobulbar and sub-tenon´s
block are the ideal regional anesthesia techniques and have been
extensively investigated in the literature 17,18 assume that peribulbar
anesthesia is a safe and effective regional anesthesia option to
perform Opthalmologic surgeries, with minimal advantages and
disadvantages compared with another needle based techniques.
The alleged safe superiority of sub-Tenon’s block is falling with
more evidences about serious complications with this approach
too 19,20,21. The ultrasound guided block could improve safety
and efficacy to regional anesthesia of the eye, but its application
to ophthalmic regional anesthesia remains restricted because the
risks related to the equipment 1. There are evidences supporting
single function. peribulbar anesthesia using caruncle site 13,14.
The difference of the previous techniques described remains in the
needle used to perform the eye block (25G) and the mean depth
introduced (15-20mm). The authors found only one reference to
caruncle approach with a similar needle, but it was used associated
with traditional inferior-lateral peribulbar block22. Those authors
postulated the efficacy of the caruncle technique based on the existence
of “hernial orifices” above and below the connective tissue
septa and check ligament in nasal side of medial rectums muscle.
The authors postulate that this technique could be ideal for Glaucoma
surgery because the low volume used and medial approach
cause less influence in IOP (Intra ocular pressure) 23.
The authors believe that this approach could be incorporated into
the practice of the ophthalmic anesthesiologists to increase the
data about its efficacy and safety. We are now conducting a comparative
study to improve the quality of the evidences about the
- Palte HD. Ophthalmic regional blocks: management, challenges, and solutions. Local and Regional Anesthesia 2015:8 57–70.
- Gayer, S. Key Components of Risk Associated with Ophthalmic Anesthesia. Anesthesiology 2006; 105:859.v.
- Chaudhry TA, Aqil A, Aziz K, Javed AA, Tauqir MZ, Ahmad
K. Patients’ visual experience during phacoemulsification cataract surgery and associated fear. BMC Res Notes. 2014 20;7: 663.
- Palte HD, Gayer S, Kumar C. Role of the anaesthetist
during cataract surgery under local anaesthesia. Br J Anaesth.
- Nouvellon E, Cuvillon P, Ripart, J; Regional Anesthesia and Eye Surgery. Anesthesiology 2010;113(5):1236-1242.
- Bertelli E, Regoli M, Bracco S. An update on the variations
of the orbital blood supply and hemodynamic. Surg Radiol Anat
- Remington LA (1998) Clinical Anatomy of Visual System. (1st
Edition), Butterworth-Heinemann, Newton, MA, USA, Chapters
8 to 13, pp 123-228.
- Vohra SB, Good PA. Altered globe dimensions of axial myopia as risk factors for penetrating ocular injury during peribulbar anaesthesia. Br J Anaesth. 2000;85(2):242–245.
- Kiire CA, Mukherjee R, Ruparelia N, Keeling D, Prendergast
B, Norris JH. Managing antiplatelet and anticoagulant drugs in patients
undergoing elective ophthalmic surgery. Br J Ophthalmol.
- Takaschima A, Marchioro P, Sakae TM, Porporatti AL, Mezzomo LA, De Luca Canto G (2016) Risk of Hemorrhage during Needle-Based Ophthalmic Regional Anesthesia in Patients Taking Antithrombotics: A Systematic Review. PLoS ONE11(1): e0147227.
- Habib NE, Balmer HG and Hocking G. Efficacy and safety of sedation with propofol in peribulbar anaesthesia Eye (2002) 16, 60–62.
- Melo MAP, Garcia EA: Chandler maneuver following peribulbar anesthesia for reduction of intra ocular pressure in facectomy. Acta Medica Misericordæ 2001; 4:29-31.
- Ripart J1, Lefrant JY, Lalourcey L, Benbabaali M, Charavel P et al. Medial canthus (caruncle) single injection periocular anesthesia. Anesth Analg. 1996; 83(6): 1234-8.
- Calvachea JA, López H, Castro-Delgado OE. Local experience with caruncular single injection peribulbar anesthesia. Rev Colomb Anestesiol 2014; 42:16-9.
- Lee RMH, Thompson JR, Eke T. Severe adverse events associated
with local anaesthesia in cataract surgery: 1 year national
survey of practice and complications in the UK. Br J Ophthalmol
- Cass GD. Choices of local anesthetics for ocular surgery. Ophthalmol Clin North Am. 2006 Jun;19(2):203-7.
- Guay J, Sales K. Sub-Tenon’s anaesthesia versus topical anaesthesia for cataract surgery.Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD006291.
- Alhassan MB, Kyari F, Ejere HOD. Peribulbar versus retrobulbar anaesthesia for cataract surgery. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004083.
- Frieman BJ, Friedberg MA. Globe perforation associated with subtenon’s anesthesia Am J Ophthalmol. 2001; 131(4):520-1.
- Subbiah S, McGimpsey S, Best RM Retrobulbar hemorrhage after sub-Tenon’s anesthesia. J Cataract Refract Surg. 2007 Sep;33(9):1651-2.
- Quantock CL, Goswami T. Death potentially secondary to sub-Tenon's block. Anaesthesia 2007; 62: 175 – 7.
- Ali-Melkkila T, Virkkila M, Leino K, Palve H. Regional anaesthesia for cataract surgery: comparison of three techniques. Br J Ophthalmol 1993; 77: 771-773.
- Paletta Guedes RA, Paletta Guedes VM, Assis de Castro Paletta J, Pereira da Silva AC. Anesthesia in glaucoma surgery. J Fr Ophtalmol. 2009;32(3):221-5.
- Kang H, Takahashi Y, Nakano T , Asamoto K , Ikeda H , Kakizaki H. Medial canthal support structures: the medial retinaculum: a review. Annals of Plastic Surgery 2015;74(4): 508-14.
Clinica Visão Oftalmologia – Porto Alegre/ Brazil
Centro de Olhos do Rio Grande do Sul – Porto Alegre/ Brazil
Conflict of Interest:
The authors declare no Conflict of Interest.