Cluster of diplopia cases after periocular anesthesia without hyaluronidase

Abstract

Purpose: To describe a cluster of cases of iatrogenic diplopia after cataract surgery that occurred in 1998, when hyaluronidase was unavailable for use in periocular anesthetic regimens.

Setting: The clinical practices of the authors.

Methods: This study comprised a retrospective chart review.

Results: Twenty-five cases of transient or permanent diplopia were reported. Of these, 13 eyes had retrobulbar and 10 had peribulbar injections; in 2 cases the injection technique was unknown. The inferior rectus was affected in 19 eyes; of these, 1 had a temporary palsy and 18 had permanent restriction. Temporary paresis developed in the lateral rectus in 5 cases and the superior rectus in 2. Eleven cases were submitted by 4 anterior segment surgeons, who collectively had a zero incidence of iatrogenic postoperative diplopia in the preceding 4 to 11 years of practice (approximately 6900 cases).

Conclusion: Hyaluronidase may be more important than previously suspected in preventing anesthetic-related damage to the extraocular muscles. The inferior rectus muscle is particularly vulnerable, presumably because of the injection technique.