Risk Management

Medicolegal Hazards of Local Anesthesia

By Jerome W. Bettman Sr., MD

Argus, April, 1996

Ophthalmologists usually associate retrobulbar injections with adverse claims arising from administration of local anesthesia. While more claims arise after retrobulbar injections than after other types of local anesthesia, these cases can be successfully defended.

Retrobulbar Injections

The hazards associated with retrobulbar injections are well known to ophthalmologists: penetration of the globe, optic atrophy, orbital hemorrhage, external ocular muscle palsies and, rarely, problems associated with injecting the fluid into the optic nerve sheath, which may result in respiratory arrest or a cavernous sinus syndrome.

Retrobulbar cases often are successfully defended in court because the defense experts can demonstrate for the jurors that the surgeon cannot see the needle tip, but can only attempt to judge its position based on the angle the luer is held and the depth of the injection. Jurors can be instructed that the orbits, the position of the globe, and the length of the eyeball vary from person to person, and that it is difficult to know the location of the needle tip at all times.

It also can be demonstrated that ophthalmologists cannot depend completely on their sense of touch because the sclera may be softer than usual and the tissues around the eye may deviate from what a surgeon normally expects. Given these factors, jurors can understand that complications arising from retrobulbar injections, although not common, can occur in anyone’s practice, no matter how skillful the surgeon. There are fewer complications with peribulbar injections, but the hazard of puncturing the globe does exist. Defending these cases is similar to retrobulbar cases.

Subconjunctival and Subtenons Injections

The liability and defense issues are more problematic when penetration of the globe occurs after subconjunctival and subtenons injections. The seriousness of this complication and whether a claim arises depends upon the dose and what material is mistakenly injected into the eye — some anesthesias are retinotoxic and some are tolerated by the eye. Defending these cases is more difficult than retrobulbar cases. The plaintiff will allege that the surgeon should have moved the needle point to be sure it was not engaged in the sclera unless the needle point could be seen at all times, because if it were visible, the penetration could not have happened. Jurors will have much less difficulty finding negligence for something the ophthalmologist should have been able to see.

Topical Drops

Instilling topical anesthetic drops can precipitate a malpractice claim in two types of situations. First, if an untoward reaction occurs after instillation, the plaintiff may assert that the wrong drops were used or the medication was not properly manufactured. A claim that the wrong drops were used is more likely to be based on an incident in the operating room. This mistake can usually be avoided by having only one bottle of drops on the tray at any one time. If there is an untoward incident, secure the drops and other related devices in a safe place so they can be analyzed and tested if necessary.

Second, when topical anesthetics are prescribed for home use, the patient may inadvertently traumatize the anesthetized eye, or if a corneal ulcer is present, topical anesthesia may impede its healing. When prescribing drops for home use, document that the patient understands how to instill the drops, knows the signs and symptoms of complications, and knows to contact the office immediately if problems occur.

Given the potential for complications, the ophthalmologist should warn the patient that vision loss is a possibility in all ocular operations.