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      Ipsilateral transient amaurosis, mydriasis and light reflex absence after subconjunctival local anesthesia with mepivacaine in three patients with refractory glaucoma – a case report

      case-report

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          Abstract

          Background

          The subconjunctival anesthesia with local anesthetics is considered as a low-risk procedure allowing ocular surgery without serious complications typical for retro- or parabulbar anesthesia, especially in patients with preexisting Optic Nerve damage. We report development of ipsilateral transient amaurosis accompanied with mydriasis and both, direct and consensual light response absence.

          Case presentation

          Three patients with advanced refractory glaucoma undergoing laser cyclophotocoagulation (CPC) for intraocular pressure lowering experienced these adverse effects just few minutes after subconjunctival injection of mepivacaine 2% solution (Scandicaine® 2%, without vasoconstrictor supplementation).

          The vision was completely recovered to usual values in up to 20 h after mepivacaine application. Extensive ophthalmological examination, including cranial magnetic resonance imaging (MRI), revealed no further ocular abnormalities, especially no vascular constriction or thrombotic signs as well as no retinal detachment. The oculomotor function remained intact. The blockade of ipsilateral ciliary ganglion parasympathetic fibers by mepivacaine may be the responsible mechanism. Systemic pathways as drug-drug interactions seem to be unlikely involved. Importantly, all three patients tolerated the same procedure previously or at a later date without any complication. Overall, our thoroughly elaborated risk management could not determine the causative factor explaining the observed ocular complications just in the current occasion and not at other time points.

          Conclusions

          Doctors should be aware and patients should be informed about such rare complications after subconjunctival local anesthetics administration. Adequate risk management should insure patients’ safety.

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          Most cited references13

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          • Article: not found

          Ophthalmologic complications after intraoral local anesthesia with articaine.

          A series of 14 cases of ophthalmologic complications after intraoral anesthesia of the posterior superior alveolar nerve is presented. The most commonly encountered symptoms were diplopia, mydriasis, palpebral ptosis, and abduction difficulties of the affected eye. In all cases, these effects occurred a few minutes after injection of the anesthetic, followed by complete resolution without sequelae on cessation of the anesthetic effect. The pathogenic mechanism underlying such ophthalmologic disorders is discussed in terms of a possible diffusion of the anesthetic solution toward the orbital region.
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            Postoperative diplopia and ptosis. A clinical hypothesis based on the myotoxicity of local anesthetics.

            Postoperative diplopia and ptosis can be temporary or permanent complications in patients who have undergone ophthalmic surgery while under local anesthesia. We encountered six patients with such complications and hypothesize that some cases of postoperative diplopia and ptosis could be attributed to myotoxic effects of local anesthetics. These effects may cause the degeneration and subsequent regeneration of muscle fibers of the levator or extraocular muscles and result in temporary or permanent muscle weakness.
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              • Record: found
              • Abstract: not found
              • Article: not found

              Ocular complications of dental local anaesthesia.

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                Author and article information

                Contributors
                0049 - 511 / 532 - 3061 , hoehmann.katharina@mh-hannover.de
                Kristine.Chobanyan-Juergens@med.uni-heidelberg.de
                stichtenoth.dirk@mh-hannover.de
                volkmann.ingo@mh-hannover.de
                hufendiek.katerina@mh-hannover.de
                framme.carsten@mh-hannover.de
                Journal
                BMC Ophthalmol
                BMC Ophthalmol
                BMC Ophthalmology
                BioMed Central (London )
                1471-2415
                28 August 2019
                28 August 2019
                2019
                : 19
                : 195
                Affiliations
                [1 ]ISNI 0000 0000 9529 9877, GRID grid.10423.34, Department of Ophthalmology, , University Eye Hospital, Hannover Medical School, ; Carl-Neuberg-Str.1, 30625 Hannover, Germany
                [2 ]ISNI 0000 0000 9529 9877, GRID grid.10423.34, Institute of Clinical Pharmacology, , Hannover Medical School, ; Carl-Neuberg-Str.1, 30625 Hannover, Germany
                Author information
                http://orcid.org/0000-0002-6447-2336
                Article
                1202
                10.1186/s12886-019-1202-2
                6712733
                aa29b97f-c951-4ff2-a39a-420fb54b9d20
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 21 June 2019
                : 15 August 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001663, Volkswagen Foundation;
                Award ID: Niedersachsen Vorab
                Award Recipient :
                Categories
                Case Report
                Custom metadata
                © The Author(s) 2019

                Ophthalmology & Optometry
                glaucoma,mepivacaine,cyclophotocoagulation,amaurosis,mydriasis
                Ophthalmology & Optometry
                glaucoma, mepivacaine, cyclophotocoagulation, amaurosis, mydriasis

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