Iatrogenic choroidal neovascularization is a rare complication of ocularsurgery. It is usually a result of laser photocoagulation, retinal cryotherapy,or subretinal fluid drainage. It was believed to be induced by damaging theBruch membrane and/or retinal pigment epithelium, from which the reparativeprocesses trigger the release of angiogenic factors.1
We report a case of global penetration–induced choroidal neovascularizationfollowing peribulbar anesthesia for cataract surgery.
A 75-year-old woman originally scheduled for phacoemulsification withan intraocular lens implant in the right eye had a procedure complicated byglobal penetration during peribulbar anesthesia. Dilated fundus examinationrevealed a suspected penetration site; preretinal and subretinal hemorrhageswere also found in the right posterior pole. The operation subsequently proceededbecause the intraocular pressure was not soft after penetration. It was thencomplicated by a posterior capsular tear, and an anterior vitrectomy was doneto complete the surgery. Two months after surgery, the patient's best-correctedvisual acuity was 20/100 OD with preretinal and subretinal hemorrhages aroundthe macula on ophthalmoscopic examination.
Preoperatively, the patient was a hypermetrope. Subjective refractionwas + 1.5 diopters (D) in the right eye and + 1.0 D in the left eye. Best-correctedvisual acuity was 20/60 OU. The axial length was 23.04 mm in right eye and23.21 mm in the left eye.
Examination of cornea, anterior chamber, pupil, and intraocular pressurereadings were unremarkable except nuclear sclerosis of bilateral lens. Therewere no signs of macular degeneration in each eye.
The visual acuity was stable until 8 months after the surgery. The patientvisited the clinic complaining of a gradual blurring of her vision in theright eye. Dilated fundus examination revealed residual preretinal hemorrhageand a choroidal retinal lesion, corresponding to the previously suspectedpenetrating site Figure 1, A). Inthe early phase of a fluorescein angiography, there was an oval lesion withhypofluorescence and a clear margin surrounded by a ring of hyperfluorescence(Figure 1, B). The adjacent areabecame progressively hyperfluorescent during the transit phase with leakagein the late phase (Figure 1, C andD). The patient was diagnosed with iatrogenic choroidal neovascularizationresulting from global penetration while administering peribulbar anesthesia.
Peribulbar anesthesia, during which local anesthetic is injected outsidethe muscle cone, has been cited by proponents as having the advantages ofgreater ease of performance and a lower rate of globe perforation.2 However, ocular penetrations (single entry) andperforations (entry wound and exit wound) have been reported occasionally,especially in patients with long axial length.
In clinical situations, the detection of preretinal, subretinal, orvitreous hemorrhage either immediately after surgery or on postoperative visitsshould remind the physician of the possibilities of global penetration. Mostof the penetrating site becomes a chorioretinal scar rather than a choroidalneovascularization in the end.
The penetrating site, which was very close to the macula, developedinto choroidal neovascularization that resulted in visual loss in this patient.This represents an unusual complication of global penetration by peribulbaranesthesia. To our knowledge, there are no prior reported cases of choroidalneovascularization developed in the penetrating site by peribulbar anesthesia.Ophthalmologists should be aware of this complication, which might lead toloss of vision.
The authors have no relevant financial interest in this article.
Correspondence: Dr Lai, Department of Ophthalmology, Chang Gung MemorialHospital, 5 Fu-Hsing St, Kwei-Shan, Tao-Yuan, Taiwan (ccl404@cgmh.org.tw).