Risk Management

Reducing Your Risk of Hypodermic Perforations

By Jerome W. Bettman Sr., MD, and Byron H. Demorest, MD

Argus, December, 1991

Cases of hypodermic perforation of the eye during lid or orbital injections have been recorded in the literature more frequently than one might imagine, indicating how easily such incidents can occur. The sharp disposable needles currently used for injections around the eye may penetrate the sclera unless special care is taken. When such complications do occur, it is imperative to provide appropriate follow-up treatment promptly.

A review of two case histories illustrates this complication. A 68-year-old insulin dependent diabetic man with eight diopters of myopia was being prepared for a cataract extraction. After an uneventful akinesia, retrobulbar injection of Xylocaine was given using a 27-gauge disposable 1-1/4 inch needle. The patient complained of pain and decreased vision. The eye was extremely soft and the surgeon could not see a red reflex. Ultrasound disclosed a hemorrhagic choroidal detachment and later, a retinal detachment. After the blood cleared, a scar in the posterior fundus was seen, apparently the result of perforation by the retrobulbar needle.

In the second case, a prophylactic subconjunctival injection of 40 mg. of gentamicin was given following an uncomplicated cataract extraction with an implant. The patient complained of severe pain and inability to see. The cornea was hazy and the pressure elevated. Several days later, marked retinal ischemia and a cherry red spot were seen in the macula. Vision was light perception. Weeks later, the optic nerve was pale. Vision was NLP.

Penetration of the eye with a retrobulbar needle can happen even to a very skilled and competent surgeon. One can only evaluate where the needle tip is by the angle that the syringe is held, the amount of needle in the orbit and a sense of resistance. Orbital relationships, the length of the globe, and the resistance of the tissue all vary. A myopic eye is longer than a hyperopic eye. An inflamed eye is soft. The globe may be enophthalmic or exophthalmic.

A globe perforation is a complication that may be successfully defended if care is taken to follow up on the side effects, including intraocular hemorrhage, optic nerve atrophy, and arterial or venous occlusions. Unfortunately, death from presumed injection into the optic nerve sheath has also been reported. These problems may occur with the use of either sharp disposable or so-called “dull” retrobulbar needles. Excellent surgeons often use one or the other and neither is considered substandard.

Medicolegal hazards are also associated with penetration during subconjunctival or subtenons injections. Fortunately, this is easier to avoid. During the past several decades, articles have publicized the fact that a subtenon or subconjunctival needle should be moved extensively before any fluid is injected. Such movement provides the assurance that the needle is not engaged in the sclera.

If penetration of the globe should occur, the eye must be treated as it is following any traumatic injury. The patient should be examined with ultrasound when indicated, intraocular infection should be avoided by proper use of antibiotics, and vitreous hemorrhage must be managed even with vitrectomy if needed to prevent retinal detachment or loss of the globe. Timely referral to the appropriate specialist is advised and the patient must be informed of the nature and severity of the complication.

In conclusion, penetration of the globe with a hypodermic needle is relatively common. Liability from perforation following retrobulbar injections can usually be successfully defended if reasonable care, proper documentation and informed consent have been followed. Fortunately, perforation from subconjunctival or subtenons injections is easier to avoid if proper precautions are taken.