Ocular Complication After Local Anaesthesia

Ocular Complication After
Local Anaesthesia
Introduction
• Local anesthesia is defined as a loss of sensation in a circumscribed area of the
body caused by a depression of excitations of nerve endings or an inhibition of
the conduction process in the peripheral nerves. Local anesthetic drugs are
routinely administered for oral and maxillofacial surgical procedures. Despite
careful patient evaluation, proper tissue preparation, and a meticulous
administration technique, local and systemic complications associated with local
anesthesia occasionally develop. Neurologically related complications appear to
be rarely reported in the literature. Oculomotor disturbances have been known
to occur as rare complications to injections of local anesthetic agents. Nerve-
related ophthalmic complications other than direct trauma can arise after
anesthetic injection-like paralysis of the extraocular muscles, diplopia, amaurosis
(temporary blindness), Horner's syndrome, blurring of vision, and so on.
•
The most frequently reported symptoms included:
• Diplopia (double vision) (72%)

• Partial or full ophthalmoplegia (26%)
• Ptosis (drooping of upper eyelid) (22%)
• Mydriasis (dilatation of pupil) (18%)
• Amaurosis (partial or total blindness without visible
change in the eye) (13%)
• Orbital pain (12%)
Diplopia(72)%
Ophthalmolpegia (26%)
Ptosis (22%)
Mydriasis(18%)
This type of complication is understood by
pathophysiological hypotheses that include:
(AJ’s Classification)
• Intravascular (intra-arterial and intra-venous).
• Autonomic dysregulation (activation of sympathetic
system in surrounding blood vessels).
• Direct spread of local anesthetic agent toward orbital
region (deep injection and diffusion).
Intravascular (intra-arterial and intravenous):
1-Intra-arterial injection of LA agent:
• Deposition of the anesthetic solution within the inferior alveolar
artery causes a back flow (via retrograde flow) into the
connecting maxillary artery and subsequently into the middle
menengial artery.
• There exists a constant anastomosis between the orbital branch
of the middle menengial and the recurrent menengial division of
the lacrimal branch of the ophthalmic artery.
• This lacrimal artery supplies the lateral rectus muscle, the
lacrimal gland, and the outer half of the eyelids, which due to
these anatomical considerations may explain these symptoms.
Intra-arterial spread of LA to
orbit
Intravascular (intra-arterial and intravenous):
2-Intra-venous injection of LA agent:

The local anesthetic solution reaches the inferior
ophthalmic vein via the pterygoid plexus or its
communicating branches.
Autonomic dysregulation (activation of sympathetic system
in surrounding blood vessels):
• Arteries with surrounded sympathetic plexus maintain the

tone of these vessels; any direct damage to the vessel wall
leads to activation of this sympathetic system. Autonomic
dysregulation leads to damage to optic nerve and retina.
• Autonomic dysregulation caused by vascular wall trauma
is manifested clinically as blanching of facial skin due to
vasoconstriction of the infraorbital artery usually arising in
conjunction with the posterior superior alveolar artery.
Autonomic dysregulation
Direct spread of local anesthetic agent toward orbital
region (deep injection and diffusion)
• Magliocca et al. stated that the absence of anatomical barriers and supine
position of the head during administration of intraoral anesthesia favors diffusion of
LA toward the orbit.
• Boynes et al. and Heasman, in their respective studies, stated that high
diffusion of LA in orbital region during deposition in the posterior vestibular area of
the maxilla is due to proximity of the region to the anesthetic site. The close
proximity of orbit with pterygomaxillary region and the extensive tissue diffusion
properties of the modern anesthetic solution (articaine) and intraorbital diffusion of
the injected solution are possible mechanisms for development of ocular
complications following local maxillary anesthesia.
• Thomas Von AXR stated that an ‘oily’ embolization of the central retinal artery by
the LA, or a toxic effect of the LA upon the cells of the retina can be a cause of
amaurosis in patients subjected to local anesthesia.
Direct spread of local anesthetic agent toward orbital
region
Management
• Reassure the patient regarding the usually transient
nature of the complications.
• Cover the affected eye with a gauze dressing to protect
the cornea for the duration of anesthesia.
• The patient should be escorted home by a responsible
adult.
• If ocular complications last longer than six hours, refer
the patient to an ophthalmologist for evaluation.
Prevention
• Aspiration techniques should be practiced mandatorily at
least in two planes every time prior to injection of the LA
solution.
• For the proper administration of the PSA nerve block, the
patient is positioned such that the maxillary occlusal
plane is at a 45-degree angle to the floor.
• After palpating all the anatomical landmarks, a 1⅝ inch,
25 gauze needle is inserted to the depth of 14 – 16 mm
and the LA is injected.
References
• Dr. Anil Managutti, Departments of OMFS, Modern Dental College and Research Center,
Gandhinagar, Indore - 453 112, India. CASE REPORT Diplopia with local anesthesia.
National Journal of Maxillofacial Surgery 2(1):p 82-85, Jan–Jun 2011.
• Ajit Joshi, Anuj Jain and Monica Mahajan Chimote. Etiology and Pathophysiological
Pathways of Ocular Complications Associated with Local Dental Anesthesia and
Odontogenic Infections: A Systematic Review. J Maxillofac Oral Surg. 2022 Jun; 21(2):
648–667.Published online 2022 Apr 16.
Thank You
Omnia Tarek Hosni
Maxillo-Facial Surgery

Ocular Complication After Local Anaesthesia

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Ocular Complication After

• Diplopia (double vision) (72%)

2-Intra-venous injection of LA agent:

• Arteries with surrounded sympathetic plexus maintain the

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