Correspondence

Abstract

We would like to comment on the article about globe rupture during digital massage after peribulbar anesthesia that was published 2 years ago.1 We recently reported a series of cases in which a globe was ruptured or exploded in association with a periocular injection for cataract surgery.2 We included the case reported by Rathi and coauthors1 as an addition to our series. We agree with others that the globe rupture in their case was not solely secondary to ocular massage.3,4 Previously, we experimentally measured the standard and maximum force imparted to the globe and surrounding structures during digital massage with 1 finger.2 These forces corresponded to applied pressures of 258 mm Hg and 1309 mm Hg, respectively, far less than the mean pressure of 4348 mm Hg (range 2812 to 6403 mm Hg) that we found necessary to rupture human eye-bank eyes5 and the mean pressure of 2809 mm Hg (range 817 to 4685 mm Hg) that we found necessary to rupture human cadaver eyes in situ.2 The applied pressure will also be transmitted to the orbit and surrounding structures, thus lowering the net pressure applied to the globe. Ernest et al.6 found that a typical digital massage induced intraocular pressures (IOPs) ranging from 15 to 400 mm Hg in a phantom eye. Rathi and coauthors1 and Gupta7 have stated that a distinct give was felt during digital massage, presumedly corresponding to the rupture in their reported case. However, we feel that it is much more plausible that an inadvertant intraocular injection was given, which markedly increased the IOP but did not explode the eye. Since the IOP was already very high, the force of standard digital massage had an exponential effect on the induced pressure and the globe was ruptured. Gupta7 stated that, since there was no retinal toxicity or evidence of a needle puncture wound, an intraocular injection was unlikely. However, it has been previously reported that the anesthetic solution itself is relatively innocuous,8,9 and in 5 of the other 6 ocular explosion cases that we reported no needle entry site could be identified.2 One of the cases we reported2 bears close similarity to the case reported by Rathi and coauthors. In patient 3 of our series, resistance during the second (superior) injection of a peribulbar block was noted, and thereafter the cornea was observed to be hazy.2 A Honan IOP reducer was applied to the eye, and when it was removed, the eye was soft and the cornea clear. Ultimately, a 4.0 mm superior scleral laceration was found. We speculate that an intraocular injection occurred, the IOP was significantly elevated, and the application of the Honan cuff exponentially increased the IOP to the point of globe rupture. We understand that it may have been difficult for Rathi and coauthors to ascertain precisely the etiology of their unusual surgical complication, particularly since ocular explosions associated with periocular injections were unreported at the time of their incident. While we realize that in retrospect it is impossible to determine exactly what occurred in the case, we respectfully submit our account as a valid hypothesis. Ronald E. Warwar MD John D. Bullock MD Dayton, Ohio, USA