Transient orbital apex syndrome with magnetic resonance imaging evidence following sub-Tenon’s ropivacaine anesthesia during combined cataract and macular surgery: a case report

Although sub-Tenon’s anesthesia (STA) is a widely accepted regional anesthesia technique in ophthalmic surgery, we report a rare case of transient orbital apex syndrome (OAS) following its administration using ropivacaine during combined cataract and macular surgery. We describe the clinical course of a 71-year-old male who developed acute postoperative vision loss, ptosis, ophthalmoplegia, and mydriasis in the operated eye following sub-Tenon’s ropivacaine injection. Orbital MRI revealed mild perineural fluid surrounding the optic nerve and localized edema of the retrobulbar fat, without evidence of compressive lesions or optic nerve thickening. The patient received supportive therapy, including oxygen, neurotrophic agents, and osmotic and microcirculation enhancers. Remarkably, all neurological signs resolved within 24 h, and visual acuity improved to 0.15. Although STA is considered a safer alternative to needle-based techniques, this case highlights the potential for rare but reversible complications such as OAS. Early recognition and timely, supportive management contributed to the patient’s favorable recovery, although outcomes may vary in other cases. In addition, thorough preoperative counseling and vigilant postoperative monitoring are essential, particularly in elderly or high-risk patients, to ensure prompt detection and management of any unexpected complications.