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Arch Ophthalmol. 1999;117:1089-1090.

A rare case of retained intraorbital needle fragment complicating retrobulbar anesthesia is reported. Prompt combined open exploration, removal of the needle fragment, and subsequent phacoemulsification and intraocular lens implantation resulted in unveventful recovery with a best-corrected visual acuity of 20/30 OD. Although serious needle-related complications are not common, they could be sight- or even life-threatening. The "needle-free" techniques of administering local anesthesia by topical drops or by sub-Tenon infusion with a plastic cannula may eliminate such complications and are therefore worth considering.

Report of a Case.
A 71-year-old Chinese woman originally scheduled for cataract surgery on the right eye was referred to us for further management of a retained intraorbital fragment from a broken retrobulbar needle following the retrobulbar injection of the anesthetic solution. The needle was a metallic reusable 25-gauge retrobulbar needle that was 3.8 cm long. The needle had broken at the hub-needle junction with its shaft left intraorbitally. The patient experienced nausea and diminished movements of the right eye, but no impairment of vision.

On ophthalmic examination, visual acuity was 20/400 OD and there was an immature cataract. The pupillary reactions were normal and there was no evidence of globe perforation. The needle entry wound was at the junction of the lateral one third and medial two thirds of the orbital floor. No trace of the needle fragment could be seen or felt. The needle fragment was clearly shown by orbital radiograph (Figure 1). An axial orbital computed tomographic scan (Figure 2) demonstrated that the needle fragment was situated just beneath the optic nerve. No retrobulbar soft tissue abnormality was evident. Prompt surgical exploration and removal of the needle fragment were followed by phacoemulsification and intraocular lens implantation. No intraoperative or postoperative complications were encountered. Four months postoperatively, the best-corrected visual acuity was 20/30 OD and the patient was doing well.

View larger version (90K): [in this window] [in a new window] Figure 1. Anteroposterior view of an orbital x-ray film showing the radiopaque needle fragment.

View larger version (50K): [in this window] [in a new window] Figure 2. Axial orbital computed tomographic scan showing a portion of the retained needle fragment located intraconally and adjacent to the optic nerve.

Comment.
A retained intraorbital needle fragment complicating retrobulbar anesthesia is rare and, to the best of our knowledge, has not been previously reported in the English-language literature. A small inert intraorbital foreign body (FB) that is not causing vision impairment can be left in place.¹ For our patient, however, we considered that prompt removal was needed because it seemed that subsequent damage to the optic nerve or other intraorbital tissue would be likely. Removal of a retained orbital needle is not always easy. Endoscopic removal of a retained orbital FB has been reported to be successful with only minimal additional trauma.^2-3 The instrument is passed along the wound tract until the FB is located and removed with forceps.³ However, the needle track created by a 25-gauge needle is so small that introducing an endoscope would be very difficult. Open surgical exploration seems preferable. Subsequent cataract surgery can be performed safely to enable early visual rehabilitation. The keys to success for intraorbital FB removal include accurate preoperative localization, careful exploration with an operating microscope, and gentle instrumentation to avoid pushing the FB further into the orbit. Last but not least, prevention is the best treatment. The use of disposable retrobulbar needles is encouraged to lower the risk of needle breakage from metal fatigue caused by repeated sterilization. "Needle-free" techniques of administering local anesthesia by topical drops or by sub-Tenon infusion with a plastic cannula⁴ have the advantage of avoiding needle-related complications.

AUTHOR INFORMATION
This work was supported in part by the Mrs Annie Wong Eye Foundation, Hong Kong.

Dennis S. C. Lam, FRCS, FRCOphth; Ricky W. K. Law, FRCS; Alfred T. S. Leung, FRCS; Wai-Man Chan, FRCS; Arthur C. K. Cheng, MBBS; Wai-Kiu Shum, FRCS
Shatin, Hong Kong

Reprints: Dennis S. C. Lam, FRCS, FRCOphth, Department of Ophthalmology & Visual Sciences, Eye Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin NT, Hong Kong (e-mail: dennislam{at}cuhk.edu.hk).

REFERENCES
1. Duke-Elder S, MacFaul PA. Retained foreign bodies. In: Duke-Elder S, ed. System of Ophthalmology. London, England: Henry Kimpton; 1972:655-670. 2. Norris JL, Cleasby GW. An endoscope for ophthalmology. Am J Ophthalmol. 1978;85:420-422. WEB OF SCIENCE | PUBMED 3. Norris JL. Endoscopic orbital surgery: report of a case. Arch Ophthalmol. 1981;99:1400-1401. FREE FULL TEXT 4. Greenbaum S. Parabulbar anesthesia. Am J Ophthalmol. 1992;114:776. WEB OF SCIENCE | PUBMED

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