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关键词:一过性黑朦, 球后注射, 利多卡因 摘要:关于球后注射并发症的报道很多,从球后出血等一般情况,到呼吸暂停等 紧急抢救均有报道。其中球后注射后产生的一过性黒朦,鲜有报道。究其原因, 病人有时在手术中会误认为其出现是“术中必要步骤”,而其自愈性也成为了阻 碍医生进行分析总结的重要原因。本文旨在分析球后注射后产生一过性黒朦的原 因,认为黒朦发生时如不伴其他症状,可不行处理并在严密监视下继续治疗。 Does amaurosis fugax after retrobulbar injection need any treatment? ZHANG Ju, WEI Wen-bin Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology & Visual Sciences Key Laboratory, Beijing 100730, China (ZHANG J and Wei W-B) Correspondence to: Prof. WEI Wen-bin, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology & Visual Sciences Key Laboratory, Beijing 100730, China (Tel: 86-10-58269152. Fax: 86-10-58269154. Email: [email protected] Keywords: amaurosis fugax; injections, intraocular; lidocaine Many potential complications resulting from retrobulbar injection have been reported, from the more commonly encountered retrobulbar hemorrhage to the life-threatening respiratory arrest. As one of the major complications, the happening of amaurosis fugax may not be noted by the doctor during a surgery since the patient may take it as normal and not report it to the surgeon after injection. Fortunately, in most of the cases the visual loss is transient, and the patients with amaurosis fugax may recover their vision soon after an injection. We searched Pubmed and several other databases for investigations about amaurosis fugax, but found that relevant reports about the complication in the literature were very limited in number. Herein we aim to analyze the predisposing cause of amaurosis fugax, to find out whether amaurosis fugax could be self-healing without treatment, and to determine in which situation the surgery would be allowed to proceed after the complication happens. N umerous complications associated with retrobulbar anesthesia in the eye and orbit have been reported, such as retrobulbar hemorrhage (1.3% in 1083 cases1, 0.75% in 3453 cases2), central retina artery occlusion (0.015% in 19700 cases3), paralysis of the extra-ocular muscles,4 perforation of the eye globe,5 injury and atrophy of the optic nerve,6 and accidental injection of anesthetic into the subdural or subarachnoid space.4 Systemic symptoms (0.267% in 6000 cases7) include respiratory distress, elicitation of the oculocardiac reflex, bradycardia, nausea, grand mal seizures, low blood pressure, toxic reaction, loss of consciousness, brain stem anesthesia with unconsciousness and apnea. These complications above in retrobulbar surgery are rare. Amaurosis fugax, however, occurs more often due to retrobulbar injection during the surgery. Although there is no statistical presentation about the morbidity of amaurosis fugax after retrobulbar injection,8 most surgeons prefer to examine the vision of the patients at the end of the surgery. THEORETICAL BASIS Several causes might explain the happening of amaurosis fugax, including vascular sapsm, sensory blockade of the optic nerve, anesthetic toxicity, and psychological factors. 1. Vascular changes One possible explanation for the happening of amaurosis fugax is that intraorbital pressure and vascular compression increased by injection might lead to vasospasm of the central retinal artery. 6 Akar et al9 and Sergott et al10 found that under funduscopy, patients with amaurosis fugax showed vasospasm of the central retinal artery and optic disk pale. However, in some others reports, normal retinas and optic discs were shown. In some investigations, Color Doppler Imaging was introduced in detecting ischemia changes of blood flow in patients with amaurosis fugax. Sergott et al10 evaluated the blood flow velocity and vascular resistance of the retinal artery in patients with amaurosis fugax using Color Doppler Imaging, and found that all of the patients with normal blood flow of the retinas were in the pain-free interval. More interestingly, the vessel resistance was shown to increase in some cases of amaurosis fugax.11 It is worth mentioning that adrenaline, usually mixed with the anesthetic in the injection, though may increase the vessel resistance, was shown to be less likely to cause amaurosis fugax in retrobulbar injection. 12, 13 2. Sensory block Another explanation of amaurosis fugax is that retrobular anesthesia might cause a sensory blockade of the optic nerve by the connection between normal electroretinogram and former analogous visual evoked potentials, in which consistent increase in latency and decrease in amplitude of the waves were shown.14, 15 3. Machanical trauma Furthermore, retrobulbar injection may lead to an increasing risk of direct injury of the optic nerve. A sharp needle tip might cause penetration of the optic nerve, and the anesthetic may be injected into the optic nerve sheath, 6 causing mechanical compression, drug toxicity and allergic reaction. 4. Anethetic toxicity Anesthetics may play an important role in causing amaurosis fugax. It was shown by Kitagawa et al16 that Lidocaine directly disintegrated the nerve membrane and thus resulted in nerve injury, while Covino et al17 found that bupivacaine was less neurotoxic than lidocaine. As we know, lidocaine and bupivacaine are both commonly used in ocular surgery. The anesthetics are usually given through subconjunctival, periocular and block injection. However, the potential toxicity on periocular anesthetics is still unclear. Clinical profiles of neurotoxicity of the anesthetics were reported in cauda equina or spinal anesthesia.18 Therefore, the ocular neurotoxicity was not known yet. 5. Psychological factors Anxiety might be a predisposing cause of amaurosis fugax.19 Patients with anxiety may be more apt to suffer from arteriolar constriction. Such a vascular change may aggravate transient ischemia,20 especially in patients with hypertension. Therefore, psychological situation was thought to be a contributing factor in the neurological complications in patients receiving regional anesthesia during surgery.21 Although some people would report to the doctor when amaurosis fugax happens, others may take it as a normal procedure during surgery to “turn off” his or her eyes after the retrobulbar injection. It is probable that a patient in anxiety may not be able to find the right way to communicate with the doctor. In these cases, the visual loss may not be noted by the doctor until the covering drapery is removed and the vision of the patient is checked. Such a situation may make doctor feel stressful and cause even more severe panic of the patient, 22 and prolongs the self-recovery time. CLINICAL CHARACTERISTICS Several cases of amaurosis fugax after retrobulbar injection during a surgery have been reported in the literature. We reviewed the reports by Chinchurreta-Capote et al4, Lau et al5 and Mo et al23. In their investigations, the ages of the cases of amaurosis fugax ranged from 45 to 75 years, and no difference of the prevalence was shown between male and female patients. Most of the patients were reported to receive glaucoma, cataract and vitreoretinal surgery. In the literature before the 1990’s, such a complication was frequently reported in late-stage glaucoma cases.24 Some doctors would refrain from using retrobulbar lidocaine in late glaucoma patients. 23 To date, although retrobulbar anesthesia is no longer the most frequently used anesthetic method in cataract and glaucoma surgery, cases of amaurosis fugax are still reported sometimes. By reviewing the literature, we concluded that the anesthetic commonly used in injection included 2% lidocaine injection, the complex injection of lidocaine and 0.5%~0.75% bupivacaine, and the complex injection of lidocaine and adrenaline. Marcaine, mepivacaine and novocaine were rarely used.25 The injected volume of retrobular injections varied from 2ml to an extreme 8 ml. 7, 26 Amaurosis was usually described to happen 5 to 20 minutes after injection, 7 and in some cases it was discovered nearly at the end of the surgery. Based on reports, the self-recovery duration varied from 20 minutes to 12 hours. 5, 27 In most of the cases, it was reported to take 2 to 6 hours. 4, 28 Most doctors believe that amaruosis fugax could be self-healing without any treatment. This possible mechanism lies in a theory that intracellular Ca2+ concentration can be extremely increased by lidocaine or other anesthesia. Some studies showed that the group of cases injected with 1.5% lidocaine and 0.75% bupivacaine would not cause irreversible conduction block, while in the group of cases injected with 5% lidocaine permanet damage was shown. 29 However, it is still hard to define when the amaurosis happens, whether any other complications happen, or whether there would be a permanent visual loss. Therefore, some doctors tend to use atropine, oxygen or intravenous fluids to improve blood circulation of drugs. 3 Based on the reports on amaurosis fugax without other complications, all patients do not suffer from permanent sequelae due to retrobulbar injection. 3, 23, 30,31 CONCLUSION Effective anesthesia in major intraocular and extraocular surgery has been achieved by retrobulbar injection in the past. Until now, such an anesthetic method still has many advantages compared with general anesthesia. Laboratory and clinical experiments have shown that anesthetics may have potential neurotoxicity, which is not yet fully understood both cytological and morphological changes.32 To minimize the risks of amaurosis resulting from retrobulbar injections, we suggest surgeons pay attention to the following issues: 1. Control the injected volumes to 2 to 3 ml with slow injection; 4 2. Find a proper position of the eye being operated and ask the patients to take a deep breath prior to injection to relieve their anxiety; 3. Use dull needles to prevent mechanical penetration; 4. Be extremely careful in cases with late-stage glaucoma with fragile and sensitive optic nerve fibers to the anesthetic; 23 5. Enhance the confidence of the clinician to avoid anxiety. Usually the visual changes would be noted and reported by the patients when amaurosis fugax happens. In such a situation, it is imperative for the surgeon to check the periocular tissues and fundus carefully to rule out the signs of severe complications and to alleviate the anxiety of the patients. Doctors should discriminate transient amaurosis from permanent visual loss timely when the patients complain, so that immediate treatment would be applied to save vision or the surgeon would proceed with the operation. REFERENCES 1 Ruben S. The incidence of complications associated with retrobulbar injection of anaesthetic for ophthalmic surgery. Acta Ophthalmol (Copenh) 1992; 70(6): 836-838. PMID:1488897 2 Kaushik NC. Orbital haemorrhage following retrobulbar injection. Indian J Ophthalmol 1988; 36(3): 128-130. PMID:3255702 3 Henc Petrinović L, Gabrić N, Metez Soldo K, Konjarek Dorn L, Busić M, Petrinović J. Risks of retrobulbar application of anesthetics and drugs. Acta Med Croatica 1992; 46(1): 59-61. PMID:1380361 4 Chinchurreta-Capote A, Beltrán-Ureña FJ, Fernández-Ramos MA, Martínez-de-Velasco-Santos C. Contralateral amaurosis and extraocular muscle palsies after retrobulbar injection. Arch Soc Esp Oftalmol 2006; 81(1): 45-47. PMID:16450262 5 Lau LI, Lin PK, Hsu WM, Liu JH. Ipsilateral globe penetration and transient contralateral amaurosis following retrobulbar anesthesia. Am J Ophthalmol 2003; 135(2): 251-252. PMID:12566043 6 Brod RD. 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Temporary amaurosis from retrobulbar lidocaine injection in late glaucoma patients. Zhonghua Yan Ke Za Zhi (chin) 1991; 27(5): 265-267. PMID:1815916 24 Scuderi N, Recupero SM, D'Andrea F, Ribuffo D. Glaucoma as etiopathogenic hypothesis of amaurosis after blepharoplasty. Apropos of a clinical case. Ann Chir Plast Esthet 1990; 35(5): 410-413. PMID:1712568 25 SEDAN J. Two cases of temporary blindness after retrobulbar injection of novocaine-adrenalin carried out for the purpose of iridencleisis, occurring in hypertensive iridocyclitic patients. Acta Ophthalmol Scand 1999; 77(1): 19-22. PMID:14444433 26 Chang JL, Gonzalez-Abola E, Larson CE, Lobes L. Brain stem anesthesia following retrobulbar block.Anesthesiology 1984; 61(6): 789-790. PMID:6507939 27 Friedberg HL, Kline OR Jr. Contralateral amaurosis after retrobulbar injection. Am J Ophthalmol 1986; 101(6): 688-690. PMID:3717252 28 Williams JV, Williams LR, Colbert SD, Revington PJ. 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