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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.
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