We are indebted to Mootha et al1 for reporting a most unusual complication of retrobulbar injection. They reported a retrobulbar hemorrhage and a subperiosteal orbital hemorrhage after a retrobulbar injection, which resulted in permanent visual loss from angle-closure glaucoma and occlusion of the central retinal artery.
I have advocated a combination of periorbital and retrobulbar analgesia2 that can prevent retrobulbar hemorrhage and might have prevented the subperiosteal hemorrhage described. My method involves beginning injection of the anesthetic solution as soon as the needle (25 gauge, 2.54 cm) passes through the skin; injection (7 mL) continues slowly as the needle point is moved through the periorbital space and finally into the muscle cone. The continuously injected solution pushes the tissues away from the needle tip as it is inserted, which avoids penetration of the globe and rupture of extraocular blood vessels, nerves, and muscles.
Girard LJ. Subperiosteal Orbital Hemorrhage From Retrobulbar Injection Resulting in Blindness. Arch Ophthalmol. 1997;115(8):1085-1086. doi:10.1001/archopht.1997.01100160255028