Ultrasound-guided periconal block in severe ocular trauma: Avoiding general anesthesia

Dear Editor, Severe ocular trauma presents significant anesthetic challenges. Penetrating globe trauma can result in collapse or distortion of the anterior segment, loss of anterior chamber integrity, and exposure of intraocular tissues, all of which markedly increase the risk of irreversible visual loss, infection, and secondary complications such as endophthalmitis or glaucoma.[1] Although regional techniques such as the peribulbar block may be appropriate for selected patients with stable, closed-globe injuries, their use in ocular trauma is frequently limited.[1,2] While general anesthesia is commonly used in ocular trauma, it may not always be the optimal approach in patients with significant comorbidities, and predictors of difficult airway. Regional techniques under Ultrasound guidance have emerged as a valuable adjunct in regional ophthalmic anesthesia, enabling real-time visualization of orbital structures, and the spread of local anesthetic.[1,3] This letter describes the use of an ultrasound-guided peribulbar block for urgent ocular surgery in a patient with traumatic orbital hematoma, distorted anatomy, predictors of difficult airway, and significant comorbidities, in whom avoiding general anesthesia was considered a safer anesthetic strategy. A 74-year-old woman was admitted after a fall from standing height, presenting with traumatic brain injury and a right orbital fracture associated with penetrating globe trauma. Her medical history included many comorbities. On physical examination, marked ecchymosis and edema were observed in the right periorbital region, extending to the perioral area. Airway assessment revealed several predictors of difficult airway. The patient was scheduled for urgent anterior chamber reconstruction. An ultrasound-guided peribulbar block was performed using a linear transducer (Butterfly IQ + probe, ophthalmologic preset) positioned obliquely over the closed right eyelid between the 1 and 2 o’clock positions. Initial ultrasound evaluation revealed marked distortion of ocular anatomy, including mobile punctate vitreous echoes, extensive retinal detachment, and temporal ciliochoroidal detachment [Figure 1].Figure 1: USG of the right eye with anatomic distortionThe block was performed in two stages. First, the needle was introduced following the conventional peribulbar approach. Subsequently, real-time ultrasound guidance was used to optimize needle positioning in the extraconal space. The needle was visualized as a hyperechoic linear structure and advanced in-plane toward a point approximately 3 mm beyond the posterior margin of the globe and 5 mm lateral to the optic nerve. An anesthetic solution consisting of 8 mL of 1% ropivacaine, 2 mL of 2% lidocaine, and hyaluronidase (10 IU) was injected with ultrasound confirmation of appropriate spread [Figure 2].Figure 2: Visualization of needling with the needle present as a linear hyperechoic imageBlock adequacy was confirmed by ocular akinesia and absence of pain upon corneal stimulation. The postoperative course was uneventful. Ultrasound guidance may be particularly valuable in patients with orbital trauma, where hematoma, edema, and structural disruption can distort normal anatomical landmarks. Real-time visualization allows identification of orbital structures, confirmation of needle trajectory, and monitoring of local anesthetic spread, potentially reducing the risks of globe perforation, intravascular injection, or retrobulbar hemorrhage.[4-6] Randomized trials and observational series suggest that ultrasound guidance may improve block success rates—often exceeding 90%—and reduce complication rates when compared with landmark-based techniques.[3,5,7] Despite its advantages, ultrasound-guided ophthalmic regional anesthesia has limitations. The technique requires availability of appropriate ultrasound equipment and operator expertise. Furthermore, standardized approaches and training protocols are still evolving.[8,9] In conclusion, ultrasound-guided peribulbar block may represent a feasible anesthetic strategy for urgent ocular surgery in selected high-risk patients with ocular trauma. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.