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Patient Safety Advisory
Produced by ECRI Institute & ISMP under contract to the Patient Safety Authority
Complications of Retrobulbar Blocks
O
ver two dozen reports of retrobulbar hemorrhages and at least three cases of respiratory
arrest have been submitted to PA-PSRS since the
program’s inception in June 2004. These reports
represent complications of the retrobulbar block, an
anesthetic technique used for intraocular surgery
that many practitioners are abandoning in place of
topical anesthetics.
Declining Use of Retrobulbar Blocks
A recent survey indicates a move away from retrobulbar blocks, while topical anesthesia is gaining
greater acceptance.1 A 2003 survey of physician
members of the American Society of Cataract and
Refractive Surgery in the United States revealed this
trend, presented in Table 1.2 Whereas in 1985, 76%
of survey respondents used retrobulbar blocks with
facial block, in 2003 only 17% of respondents used
this modality. The use of topical anesthesia has increased from 8% in 1995 to 61% in 2003. Interestingly, the use of topical anesthesia appears to be
associated with the volume of cataract procedures
performed. Those respondent surgeons performing
one to five procedures per month used topical anesthesia in 38% of their cases while those doing more
than 75 procedures monthly used it 73% of the time.
Each anesthesia modality, however, has unique
benefits and risks. Table 23 displays this information
for various anesthesia techniques used in ocular
surgery.
Anesthesia
1985
1995
2000
2001
Retrobulbar block without facial block
Retrobulbar block with
facial block
2003
11%
76%
32%
Peribulbar block
38%
Topical Anesthesia
8%
14%
9%
Indications
If a retrobulbar block is considered, several factors
will reduce the risk of complications.
Cooperation
The patient must be able to follow instructions and
cooperate with the surgical team.3,4 In order to follow
directions, patients should not be hearing impaired
or deaf, nor should there be a language barrier between the patient and surgical team.3,5,6 Hearing
aids, sign language interpreters, and/or foreign language interpreters may enhance cooperation.
Positioning
The patient must be able to lie flat on his/her back.3,5
As a result, diagnoses that prevent such a position
would be contraindications, such as severe back
pain,4 postural problems,4 or chronic cardiac or respiratory problems.6
The ability to lie still is critical.3 Therefore, conditions such as the following might make a patient an
inappropriate candidate for the block: involuntary
movements/tremors,3,6,7 uncontrolled convulsive
disorder,5 unpredictable and uncontrolled cough,6
excessive anxiety and claustrophobia.5
Patients should be older than 15 years, because
young patients are not as likely to remain still
throughout the block and surgical procedure.5,6 Likewise, oriented patients, without significant mental
impairment produced by psychiatric disorders or
dementia, are more likely to stay still and follow instructions.3,5 Moreover, oriented patients are more
likely to be able to understand and tolerate the effects of a retrobulbar block on eye movement and
vision during and for some time after surgery.3
17%
51%
− with intracameral
lidocaine
61%
81%
73%
− 1-5 cataract procedures/month
38%
− more than 75 procedures/month
73%
Table 1. Cataract Surgery Anesthesia Trends. Excerpted
from Leaming DV. Practice styles and preferences of ASCRS
members—2003 survey. J Cataract Refract Surg 2004;30:
892-900, with permission from Elsevier.
©2007 Pennsylvania Patient Safety Authority
This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 4,
No. 1—March 2007. The Advisory is a publication of the Pennsylvania
Patient Safety Authority, produced by ECRI Institute & ISMP under contract
to the Authority as part of the Pennsylvania Patient Safety Reporting System
(PA-PSRS).
Copyright 2007 by the Patient Safety Authority. This publication may be
reprinted and distributed without restriction, provided it is printed or distributed
in its entirety and without alteration. Individual articles may be reprinted in
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To see other articles or issues of the Advisory, visit our Web site at
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Page 1
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
Complications of Retrobulbar Blocks (Continued)
Coagulation
This block is appropriate for patients with no significant bleeding or coagulation disorders.5 There is a
difference of opinion concerning whether anticoagulants, NSAIDS, aspirin, or clopidogrel bisulfate
should be stopped prior to this block. One perspective is that patients receiving such medications are
at greater risk of developing a retrobulbar hemorrhage.8 Another perspective is that it is acceptable
to perform a retrobulbar block if the patient’s INR
does not exceed twice the normal values.9
Globe
Anatomical abnormalities (e.g., a myopic axial
length greater than 26 to 32mm) should not be
Anesthesia
present.6,8 There must be enough room between
the globe and the bony orbit to safely perform the
block.7 Normal intraocular pressure and absence of
glaucoma are appropriate indications.6 The block
should not be completed if the globe is perforated.5,6
The patient must have no known allergy/cross sensitivity to the local anesthetic to be used in the block.6
Co-morbidities
Because of the potential for significant complications, patients who receive retrobulbar blocks should
not be blind in the non-operated eye.6 Patients are
less likely to sustain a retrobulbar hemorrhage if
they do not have diseases that make the vasculature more fragile, such as acquired arteriosclerotic
Benefits
Risks
General
• Excellent anesthesia, analgesia, akinesia
• Duration of anesthesia can be varied to accommodate length of surgery
Malignant hyperthermia
Hemodynamic fluctuation
Postoperative nausea and vomiting
Allergic reactions
Increased risk of cardiac complications
Ocular complications:
− pressure fluctuation
− Valsava retinopathy
− corneal abrasions
− chemical injury
• Requires more medication, equipment, personnel, therefore
most costly form of anesthesia
• Inefficiency: time required for induction, intubation, extubation
Regional:
retrobulbar, peribulbar,
sub-Tenon’s
• Excellent anesthesia, analgesia, akinesia
• Duration of effect lasts for most cataract surgeries
• Cost of medications and equipment less than
general anesthesia
• Injections take little time therefore more time- and
cost-efficient than general anesthesia
• Patient may move, therefore not as controlled as general
anesthesia
• Localized swelling, bruising, subconjuntival hemorrhage
• Allergic reactions
• Brainstem anesthesia
• Ocularcardiac reflex
• Blind injection into orbit:
− retrobulbar hemorrhage
− globe perforation
− optic nerve damage
• Eye movement and vision affected for some time after
surgery
− Peribulbar block
• Decreased likelihood of optic nerve and global
perforation
• Excellent akinesia and anesthesia
• Longer duration of onset
− Sub-Tenon’s injection with
blunt cannulas
Topical
•
•
•
•
•
•
• Lower risk of local complications
• Most cost-and time-efficient
• Does not affect vision or motility therefore patients
may have improved and useful vision almost immediately after surgery
• Minimal cosmetic changes
• Avoids systemic risks of general anesthesia and
risk of local trauma
• Shortest duration of action
•
•
•
•
Rare local allergic reactions
Patients able to move eyes and other parts of the body
Patient may perceive pain or pressure
Patient may perceive visual phenomena
Table 2. Benefits and Risks of Ocular Surgery Anesthesia Types. Excerpted from Navaleza JS, Pendse SJ, Blecher MH.
Choosing anesthesia for cataract surgery. Ophthalmol Clin N Am 2006 Jun;19(2):233-7, with permission from Elsevier.
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©2007 Pennsylvania Patient Safety Authority
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
Complications of Retrobulbar Blocks (Continued)
vascular disease, hypertension, coronary artery disease, peripheral or cerebral vascular disease, or
diabetes mellitus.10
Length of Surgical Procedure
Retrobulbar blocks may be appropriate if the surgical procedure is expected to last less than 90
minutes.5
Anatomy
To understand the technique of retrobulbar block
and its complications, one must understand the
eye’s basic anatomy and its relationship to surrounding/supporting structures.
The orbit is a pyramid-shaped cavity in the skull1,7
with a posterior apex and an anterior base. The orbit
is filled predominantly with adipose tissue, and the
globe (eyeball) is in the anterior portion of the cavity.
Four rectus muscles are attached around the equator of the globe. These muscles come together at the
apex of the orbit, affixed by the tendon of Zinn.7 At
this point, the optic nerve enters the orbit. The retrobulbar cone is defined by these four rectus muscles.
The following nerves innervate the globe.1,7
• The ophthalmic nerve (V) (i.e., the first
branch of the trigeminal nerve ), which controls sensory innervation of the globe.
• The abducens nerve (VI), which regulates
motor control to lateral rectus muscle.
• The oculomotor nerve (III), which regulates motor control to all other extraocular
muscles.
• The trochlear nerve (IV), which regulates
motor control to superior oblique muscles.
All of these nerves except the trochlear pass
through the retrobulbar muscle cone. As a result,
injecting a local anesthetic inside this cone provides
anesthesia and akinesia of the globe, as well as the
extraocular muscles.1,7
In addition to motor, sensory, and autonomic innervation of the globe, there are many other structures
within the retrobulbar muscle cone that can be at
risk during retrobulbar injection including the optic
nerve and many arteries and veins of the orbit,
including the optic artery.1,7
Technique
The goal of retrobulbar anesthesia is to direct the tip
of the needle toward the orbital apex and into the
retrobulbar muscle cone to diffuse the anesthetic
within this space. This blocks the ocular motor
nerves (III and VI) and sensory nerves (V), producing akinesia and anesthesia.1
Retrobulbar Block: Insert needle
inferior to the maximum diameter of
the globe and perpendicular to the
plane of the face. Once past the axis
of the globe, angle the needle
medially and superiorly. Final needle
position is within the muscle cone.
Figure 1. How the Retrobulbar Block is Performed
©2007 Pennsylvania Patient Safety Authority
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Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
Complications of Retrobulbar Blocks (Continued)
To perform a retrobulbar block , a small amount of
local anesthetic is injected inside the retrobulbar
muscle cone (see Figure 1). The conventional
technique7 involves the following steps:
• Asking the patient to gaze in its primary
position or a “downward and outward”
position.1
• Introducing the needle through the skin
below the inferior lid at a point between the
lateral one-third and medial two-thirds of the
inferior orbital edge.
•
Directing the needle to the apex of the orbit
in a medial and cephalad direction
•
Advancing the needle to a depth of
25 to 30mm
•
Injecting 2 to 5cc of local anesthetic
Performing a facial block to prevent blinking. The technique most commonly used is the van Lindt block,7
involving infiltration of local anesthesia in the areas of
the terminal branches of the facial nerve (VII).10
Previously, Atkinson’s “up and in” gaze was used for
this block, but it is no longer advised because Liu et
al. and Unsold et al. determined that this globe position increased the risk of optic nerve injury. Because
the optic nerve passes near the path of the needle,
it can be stretched or injured by the needle, rather
than pushed aside as intended. This gaze position
also places the needle near other structures such as
the ophthalmic artery, superior orbital vein, and the
posterior pole of the globe.1,7 Unsold et al. recommends that the patient gaze with the globe in its primary position or in a down and outward position.1
These positions place the optic nerve, blood vessels, and the inferior oblique muscle outside the
needle’s path.
Retrobulbar anesthesia is a blind technique. As a
result, damage can result to the globe, orbital tissues, and neurovascular structures.1 Near the apex,
many structures are packed in a small area and
fixed by the tendon of Zinn; therefore, the structures
cannot move away from or be pushed aside by the
needle.7
Complications
The literature describes several complications of
retrobulbar blocks, including chemosis, bruising,
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retrobulbar hemorrhage, globe penetration and
perforation, optic nerve damage and atrophy, extraocular muscle malfunction and injury, brain stem
anesthesia, globe ischemia, and complications of
nerve VII.1,7,8 Table 38 displays these complications
with information concerning mechanism of injury,
risk factors, incidence, prevention, and treatment.
Two types of complications are evident in the
PA-PSRS data: (1) central nervous system spread
of anesthesia and (2) retrobulbar hemorrhages.
Central Nervous System Spread of Anesthesia
Unintentional intra-arterial injection of the anesthetic
agent during retrobulbar block may result in reverse
flow of the agent from the ophthalmic artery to the
cerebral or internal carotid artery. Seizures can result from injection of as little as 4cc.7 Rapid recovery
occurs with symptomatic treatment.
The anesthetic can also be inadvertently injected
under the dura mater sheath of the optic nerve or
directly through the optic foramen, resulting in subarachnoid spread of the local anesthetic. The local
anesthesia spreads directly to the brain from the
orbit causing partial or complete brain stem anesthesia.9 Symptoms include cranial nerve palsy or bilateral block, sympathetic activation, restlessness, confusion, total spinal anesthesia with tetraparesis, arterial hypotension, bradycardia, and respiratory arrest.
Symptoms begin within about two minutes after injection and peak within 20 minutes. Recovery occurs
in two to three hours.9 Symptomatic treatment may
include oxygen, vasopressors, tracheal intubation,
and ventilation.7
There are at least three cases of respiratory arrest
following retrobulbar blocks that have been reported
to PA-PSRS.
Retrobulbar Hemorrhage
Over two dozen reports of retrobulbar hemorrhage
have been reported to PA-PSRS. The overall incidence of this complication varies from between
0.1% to 3%.1,3,8 Hemorrhage is caused by needle
penetration of either the venous or arterial vessels in
the orbit.7,8
Venous
Most retrobulbar hemorrhages are venous, and
bleeding is slow.1 Venous hemorrhages do not ordinarily threaten vision, the consequences are less
severe than arterial hemorrages,7 and they require
no intervention other than postponing the surgery for
which the block was administered.1,7
©2007 Pennsylvania Patient Safety Authority
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
Complications of Retrobulbar Blocks (Continued)
Arterial
Arterial hemorrhages, however, can be more serious. An arterial hemorrhage is evident within a few
minutes; symptoms include proptosis and tight eyelids, ecchymosis, chemosis (i.e., conjunctival blood
vessel engorgement), blood staining of periorbital
tissues, lid swelling, and a dramatic increase in intraocular pressure.1,8 Late optic atrophy may also
result if the microvasculature of the optic nerve becomes occluded. A compressive retrobulbar hematoma may threaten retinal perfusion2 by causing
central retinal artery occlusion.1
The cause of retrobulbar hemorrhage is misplacement of the needle during this “blind” procedure.
The risk of retrobulbar hemorrhage depends on the
experience of the person performing the block; for
example, the complication is more likely if the person performing the retrobulbar block has limited
experience.7,9
Patient-related risk factors include elderly patients
receiving anticoagulants, NSAIDS, aspirin or steroids.8 However, it is considered acceptable to perform this block if the INR does not exceed twice the
normal value.9 Patients with acquired vascular disease are at risk,1 as are those with diseases promoting arterial fragility such as diabetes or
atheroma.7 Hypertensive patients may also be at
risk for this complication. Those at higher risk include patients with a history of previous eye surgery
and those with pathological abnormalities of the
globe, such as extreme myopia, myopic staphyloma, coloboma, or scleral buckle.1,8
Risk Reduction Strategies
Addressing the following issues can help achieve
safe and successful retrobulbar blocks (and any akinetic block of the eye):1,8
•
Education and competencies
− Ensuring knowledge of anatomy and the
relationship between the globe, orbit,
and other ocular-related structures.
− Having training and checking competencies in performing the technique.12
•
Patient condition
− Evaluating the globe for pathological
abnormalities (e.g., abnormal axial
length of the globe).
− In severely hypertensive patients, consider postponing surgery until blood
pressure is under greater control.9
•
Technique
− Using techniques based upon anatomical knowledge and existing ophthalmic
pathology, including the following:
°
°
°
Timely, effective treatment for retrobulbar hemorrhage can prevent permanent impairment of vision.1
Most retrobulbar hemorrhages can be successfully
treated conservatively.8 Immediate oculocompression helps limit the extent and severity of the hemorrhage.8 The goal of treatment is to reduce compartment pressure, thereby reducing intraocular
pressure, which in turn reduces negative outcomes
on retinal circulation.8 The ophthalmologist will
evaluate the extent of the hemorrhage and determine whether further interventions are necessary.1,8
Interventions may include measuring intraocular
pressure and checking retinal circulation.8 Intraocular pressure can be lowered with acetazolamide.8
Immediate lateral canthotomy/cantholysis may be
required to relieve orbital pressure caused by the
retrobulbar hemorrhage.1 Emergency orbital decompression surgery may be necessary if the optic
nerve is compromised.1,7
©2007 Pennsylvania Patient Safety Authority
°
°
°
•
Using a small gauge needle (25
gauge) no longer than 31 mm in
length.9 (This reduces the risk of
both retrobulbar hemorrhage and
brain stem anesthesia.)
Inserting the needle when the eye is
in primary gaze.
Placing the needle tangential to
the globe.
Avoiding placement of the needle
into the vascular quadrant or muscle belly by smoothly and gently
inserting the needle into a relatively
avascular area.
Aspirating before injecting the local
anesthetic agent, to check for blood.
Consider repositioning the needle if
resistance occurs during injection.
Anesthesia/sedation
⎯ Considering other anesthesia modalities
that may have fewer complications.1
Finger Index
The Finger Index (FI) is a grading system (0 to 3;
see below) used in the Helsinki University Eye
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Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
Complications of Retrobulbar Blocks (Continued)
Hospital in Finland6 that can determine the accessibility of the retrobulbar/peribulbar space in advance
of needle injection. The tighter the globe is situated
near the wall of the orbit, the more difficult the needle insertion. One finger palpates the space between the orbit and globe.
FI=2: Finger easily fits between the orbit and globe.
(Patients are suitable for retrobulbar/
peribulbar anesthesia; the block may be administered by an appropriately educated and
supervised physician in training.)
FI=0: Globe lies tightly on the rim of the orbit and
cannot be lifted at all by the fingertip.
(Retrobulbar/peribulbar blocks are contraindicated in such patients.)
FI=3: Finger reaches the level beyond the equator
of the globe. (Patients are suitable for retrobulbar/peribulbar anesthesia; the block may be
administered by an appropriately educated
and supervised physician in training.)
FI=1: Only the tip of the finger fits between the globe
and orbit. (Patients require an expert medical
staff member to perform the block.)
Further study is needed to determine whether this
grading system can be scientifically validated. However, it may provide a supplemental screening
Complications
Chemosis
Bruising
Retrobulbar hemorrhage
Globe penetration
and perforation
Optic nerve damage
Optic nerve atrophy
Damage to the
motor nerve of the
inferior rectus and
inferior oblique
muscles
Mechanism
Risk Factors
Anterior spread of
local anesthetic agent
Damage to superficial
blood vessels during
injection
Damage to arterial or
venous blood vessels
behind the globe
Penetration of globe
(wound of entry) and
perforation (wounds of
entry and exit)
Direct damage to
nerve or compression
of the nerve secondary
to hemorrhage or
vascular occlusion
Injection with smaller
needles
Elderly receiving steroids,
NSAID, aspirin
Not known
Avoid anterior injection
1-2.75%
Avoid injection through
visible blood vessels
Elderly receiving steroids,
NSAID, aspirin
0.1-3%
Myopic eye, uncooperative
patient, inexperienced
user, poor technique,
previous surgery
0-1%
Limit insertion of needle
to less than 31mm in the
relatively avascular area
Use of technique based
on sound anatomical
principles
Direct damage to
nerve, central retinal
artery or secondary to
hemorrhage
Direct trauma to the
nerve
Incidence
Prevention
Rare
Rare
Careful needle placement
Insertion of needle at the
junction of medial 2/3 and
lateral 1/3 of inferior orbital
margin
Not known
Careful needle placement
avoiding the nerve
Subject to debate but
spread through optic
nerve sheath or
through the orbital
foramina
Placement of long needle
into the apex
0.3-0.8%
Avoid using long needle
Globe ischemia
Interruption of blood
flow
Prolonged exposure of
fine muscle fibers,
injection of local anesthetic agent into the
muscle
Prolonged oculocompression
May be associated with
non-use of hyaluronidase
Rare
Use pressure limiting
oculocompression device
Proper placement of
needle
Complications of 7th
nerve block
Direct damage to the
nerve or neurogenic in
origin
Not known
Usually resolves on oculocompression
Usually resolves and spread
can be limited by oculocompression
Immediate oculocompression,
ophthalmologic opinion and
decompression surgery
Immediate senior ophthalmologic opinion
Surgical decompression may
be required
Inadvertent subarachnoid anesthesia (brain stem
anesthesia
Prolonged extraocular muscle malfunction
Treatment
Delayed complication
Extensive cardiorespiratory
support
Rare
Table 3. Complications of Akinetic Needle Block, Mechanism, Risk Factors, Incidence, and Their Prevention and
Treatment. Source: Kumar CM, Dowd TC. Complications of ophthalmic regional blocks: their treatment and prevention. Ophthalmologica 2006;220:73-82. Reprinted with permission of S. Karger AG, Basel, Publisher.
Page 6
©2007 Pennsylvania Patient Safety Authority
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
Complications of Retrobulbar Blocks (Continued)
method in addition to other risk reduction strategies
to determine: (1) patients’ appropriateness of such
procedures and (2) the level of expertise required
for the performance of the procedure.
Conclusion
The key to selecting the most appropriate anesthesia technique is for the surgeon, anesthesiologist,
and the patient to work together during the anesthesia selection process, prior to surgery, and during
anesthesia instillation.5 Describing to the patient
what he/she will experience before, during, and after
surgery will reduce fear and anxiety and promote
patient cooperation. While ophthalmologists routinely perform retrobulbar blocks, anesthesia staff
can perform such blocks, as well as provide support
to the patient by adjusting IV sedation to reduce
discomfort.3
Resources
Resources concerning anesthesia alternatives for
cataract surgery include:
• Schein OD, Friedman DS, Fleisher LA, et al.
Anesthesia management during cataract
surgery [evident report/technology assessment]. No. 16 (Prepared by the Johns Hopkins University Evidence-based Practice
Center under Contract No. 290-097-0006.)
AHRQ Publication No. 01-E017. Rockville,
MD: Agency for Healthcare Research and
Quality. December 2001
• Navaleza JS, Pendse SJ, Belcher MH.
A review of complications of ophthalmic regional
blocks includes:
• Kumar CM, Dowd TC. Complications of
ophthalmic regional blocks: their treatment
and prevention. Ophthalmologica 2006;220
(2):73-82.
Notes
1. Cyriac IC, Pineda R. Postoperative complications of periocular
anesthesia. Int Ophthalmol Clin 2000 Winter;40(1):85-91.
2. Leaming DV. Practice styles and preferences of ASCRS members—2003 survey. J Cataract Refract Surg 2004 Apr;30(4):
892-900.
3. Navaleza JS, Pendse SJ, Blecher MH. Choosing anesthesia
for cataract surgery. Ophthalmol Clin N Am 2006 Jun;19
(2):233-7.
4. American College of Eye Surgeons. Alternate guidelines for
cataract surgery [guideline]. 1996 Feb.
5. Retrobulbar blocks. Anesthesiology Info [online]. 1999 Jan 18
[cited 2006 Aug 25]. Available from Internet: http://
anesthesiologyinfo.com/articles/12092002.php.
6. Kallio H, Rosenberg PH. Advances in ophthalmic regional
anesthesia. Best Pract Res Clin Anaesthesiol 2005 Jun;19(2):
215-227.
7. Ripart J, Nouvellon E, Chaumeron A. Regional anesthesia for
eye surgery. Reg Anesth Pain Med 2005 Jan-Feb;30(1):72-82.
8. Kumar CM, Dowd TC. Complications of ophthalmic regional
blocks: their treatment and prevention. Ophthalmologica
2006;220(2):73-82.
9. Faccenda KA, Finucane BT. Complications of regional anaesthesia: incidence and prevention. Drug Saf 2001;24(6):413-42.
10. Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500
retrobulbar blocks. Anesth Analg 1993 May;76(5):1019-22.
11. Coleman R. Retrobulbar block for cataract surgery. AANA J
1980 Oct;48(5):429-36.
12. Coalition for Cataract Surgery: American College of Eye Surgeons, Ophthalmic Anesthesia Society, Outpatient Ophthalmic
Surgery Society, Society for Geriatric Ophthalmology. Alternate
guidelines for cataract surgery [guidelines]. 1993.
Choosing anesthesia for cataract surgery.
Ophthalmol Clin N Am 2006 Jun;19(2):233-7.
• Friedman DS, Bass EB, Lubomski LH, et al.
Synthesis of literature on the effectiveness
of regional anesthesia for cataract surgery.
Ophthalmology 2001 Mar;108(3):519-529.
©2007 Pennsylvania Patient Safety Authority
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Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007)
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