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Retrobulbar Block

Retrobulbar Block. Introduction . Commonly used for intraocular procedures including those involving cornea, lens, and anterior chamber. Goals of the retrobulbar block Akinesia Extraocular muscle paralysis Anesthesia conjunctivae, cornea, uvea. Contraindications. Absolute CI’s

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Retrobulbar Block

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  1. Retrobulbar Block

  2. Introduction • Commonly used for intraocular procedures including those involving cornea, lens, and anterior chamber. • Goals of the retrobulbar block • Akinesia • Extraocular muscle paralysis • Anesthesia • conjunctivae, cornea, uvea

  3. Contraindications • Absolute CI’s • Patient refusal • Infection • Relative CI’s • <15 y/o • Globes with high risk of perforation (large axial length) • Relatively long procedures (90 min) • Cough, tremor, convulsive disorder, anxiety, others

  4. Innervation • Motor • Abducens (CN VI) • Trochlear (CN IV) • All others (CN III) • Sensory • Ophthalmic division of CN (V) • Lacrimal branch: conjunctiva • Nasociliary branch: cornea, sclera, iris, ciliary body. • Ciliary Ganglion (parasympathetic) • Supply ciliary body and pupillary schinter muscles • Retrobulbar blockade affects all of the above except for cranial nerve IV.

  5. Preperation • Alcohol prep pads • 4 x 4 gauze • 50/50 mix 0.75% Marcaine and 2% Lidocaine. Also, lidocaine 1% and bupivicaine 0.375%. • 5 cc syringe • Atkinson 25 guageretrobulbar needle with blunt tip.

  6. Preparation • Ask patient to look straight ahead (not upward) • Clean lower lid with prep wipe • Can ask an assistant to pull up on upper lid to watch for movement • Palpate inferior orbital margin for infraorbital notch (2/3 distance from medial aspect) • Make skin wheel just lateral to notch

  7. Procedure • Advance block needle straight down at site of wheel, perpendicular to plane of face, until you encounter distinct pop. • Angle block needle 45 medially and 45 superiorly, toward apex • Advance until 2nd pop • Aspirate for blood • Inject 2-3 mL of anesthetic solution • Note proptosis

  8. Procedure Cont’d • Withdraw and inject 1ml under skin as you withdraw (orbicularis) • Gently massage of globe to spread local evenly throughout the orbit • Monitor for bradycardia (late bradycardia also possible); atropine .4 to .6 mg IV • Test block

  9. Complications • Retrobulbar hemorrhage • Observe for increasing proptosis, subconjunctival blood • Puncture of blood vessel in retrobulbar space • Causes sudden increase in IOP, subconjunctival hemorrhage, ecchymoses over eyelids • Postpone surgery 2-4 days • Oculocardiac reflex • Central retinal artery occlusion • Punctured globe • Penetration of optic nerve • Unintended brainstem anesthesia

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