ArticlePDF Available

Pain management with retrobulbar alcohol injection in absolute glaucoma

Authors:
Nadia Akhtar at Aker Solutions
Nadia Akhtar
Ali Tayyab at Islamabad Medical & Dental College
Ali Tayyab
  • Islamabad Medical & Dental College
Ayisha Kausar at Shifa College of Medicine, Islamabad, Pakistan. Shifa Internationl Hospital Islamabad.
Ayisha Kausar
  • Shifa College of Medicine, Islamabad, Pakistan. Shifa Internationl Hospital Islamabad.
Sulman Jaffar
Sulman Jaffar
Sulman Jaffar
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Download full-text PDF
Read full-text
Download citation

Abstract

Ocular pain can be multi-factorial and often refractory to treatment, in spite of the myriad options available to the ophthalmologist for its management. Initial therapy entails the use of topical and systemic pressure lowering agents as well as anti-inflammatory/analgesics for the provision of relief. Those refractory to medical therapy may require surgical intervention in the form of cyclodestructive procedures, retrobulbar injection of absolute alcohol and evisceration or enucleation. A case series of 5 patients of absolute glaucoma who were successfully treated with retrobulbar alcohol injection is reported. Pain was recorded on a verbal analogue score (VAS).All the patients were pain free twelve months after the injection. No significant long term complications were observed. This case series emphasizes the fact that retrobulbar alcohol injection can play an important role in the alleviation of pain in patients with absolute glaucoma.
Content uploaded by Ali Tayyab
Author content
All content in this area was uploaded by Ali Tayyab on Jul 13, 2016
Content may be subject to copyright.
Abstract
Ocular pain can be multi-factorial and often refractory to
treatment, in spite of the myriad options available to the
ophthalmologist for its management. Initial therapy
entails the use of topical and systemic pressure lowering
agents as well as anti-inflammatory/analgesics for the
provision of relief. Those refractory to medical therapy
may require surgical intervention in the form of
cyclodestructive procedures, retrobulbar injection of
absolute alcohol and evisceration or enucleation. A case
series of 5 patients of absolute glaucoma who were
successfully treated with retrobulbar alcohol injection is
reported. Pain was recorded on a verbal analogue score
(VAS).All the patients were pain free twelve months after
the injection. No significant long term complications were
observed. This case series emphasizes the fact that
retrobulbar alcohol injection can play an important role in
the alleviation of pain in patients with absolute glaucoma.
Keywords: Pain, Retrobulbar alcohol, Refractory
glaucoma, Neovascular glaucoma.
Introduction
Retrobulbar alcohol has been used to provide relief to
patients with painful blind eyes since the early twentieth
century.1It provides near instantaneous and continual
relief.2
Patients with blind eyes and unsalvageable vision
ultimately may experience mild to severe pain which has
a negative impact on the patients' quality of life as well as
his ability to function in a productive manner.3
The etiology of ocular pain can be multifactorial but the
most common reason leading to a painful blind eye is
absolute glaucoma.4Other causes include trauma,
neoplasia, infections and inflammations.5The pain may
originate from the cornea; conjunctiva, sclera, iris or ciliary
body. The management of ocular pain is complex and
requires a multidisciplinary approach involving specialties
such as anaesthesia, ophthalmology, neurology and at
times psychiatry.6Various surgical procedures have been
described for the alleviation of pain; these include
cyclodestruction, enucleation, evisceration and nerve
blocks with retrobulbar alcohol injection. Retrobulbar
alcohol injection is a viable option for pain relief in
patients who have cosmetically acceptable eyes as well as
those who are either unwilling or unfit for surgery.7
The aim of this case series was to determine the role of
retrobulbar absolute alcohol injection in the
management of severe and refractory ocular pain in
patients of absolute glaucoma.
Methods
The case series was conducted at the Shifa Foundation
Community Health Centre Islamabad over a period of 2
years (March 2012-March 2014). After obtaining approval
from the Institutional Review Board. Patients older than
18 years with a painful blind eye due to absolute
glaucoma and a normal fellow eye were recruited in the
study. Patients with an active orbital disease or a
neurological deficit were excluded from the study.
Patients' demographics and treatment profiles are shown
in Table-1.
A total of five patients were included. Full disclosure of the
study was made to all the cases and an informed consent
was taken. The surgical procedure was explained and all
their queries answered to their satisfaction.
The retrobulbar alcohol injections were given in the
operating room under proper asepsis. After instilling
anaesthetic (proparacaine hydrochloride 0.5%) drops in
the inferior fornix, 2% lignocaine was injected
subcutaneously in the inferotemporal quadrant to
provide injection site analgesia. A 25-gauge retrobulbar
needle was then passed into the retrobulbar space and
2ml of 2% lignocaine was injected. After an interval of 5
minutes the injection site was examined for adequate
anaesthetic effect and 2ml of absolute (96%) alcohol
followed by another 2ml of 2% lignocaine were injected
through the same needle. The intraocular pressure was
checked 15minutes after the procedure and the patients
were discharged on the topical antiglaucoma medication
that they were already using as well as on oral non-
steroidal anti-inflammatory agent.
The severity of pain was recorded using a verbal
analogue score ( VAS) that ranged from 0-10 with 10
Vol. 65, No. 6, June 2015
678
CASE SERIES
Pain management with retrobulbar alcohol injection in absolute glaucoma
Nadia Akhtar, Ali Tayyab, Ayisha Kausar, Sulman Jaffar
Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad.
Correspondence: Nadia Akhtar. Email: drnadiaakhter@yahoo.com
being the highest. The patients' VAS for pain was noted
before and after the injection. They were followed on
the 1st postoperative day, at weekly intervals for 1
month, every month for the first 6 months and at 1 year
after the procedure. At each follow up the VAS was
noted and the patients assessed for the development of
complications.
Results
Patient's demographics and medications are shown in
Table-1 while the VAS before and after the injection and
on each follow up visit are shown in Table-2.
The mean age was 59.00±16.12 years. Three (60%)
patients were females and 2 (40%) were males.
The right eye was involved in 2 (40%) and the left in 3
(60%) cases.
Four (80%) patients were on topical treatment for 1 week
after the injection and one (20%) required treatment for a
month.
All the patients' developed mild lid oedema and
conjunctival chemosis which resolved within a week. One
patient developed lower lid ectropion which required
surgical correction.
Discussion
A blind, painful eye presents several challenges for
ophthalmologists with regards to its evaluation and
management.2Retrobulbar injections of neurolytic
agents are a simple and effective method to control pain.
Alcohol and other neurolytic agents exert their effect by
destroying the nerve fibers by coagulative necrosis.1,6 The
technique of retrobulbar injection must be accurate; the
alcohol has to be injected in close proximity to the nerve
fibres barring which only a dampening of nerve fibre
conduction is achieved and the pain recurs with time.
A short acting local anaesthetic such as lignocaine is
administered before injecting absolute alcohol, which not
only ensures correct placement of the needle in the
retrobulbar space, but also provides an anaesthetic effect
that reduces intraoperative pain.8
The pain relief provided by retrobulbar alcohol was rapid
and long lasting with 4 patients being pain free within 1
week and all 5 at 1 year after injection. This is comparable
to the results of other studies.
The success rate of retrobulbar alcohol injection for pain
relief is variable and ranges between 20-87% in medline
indexed literature. Cok et al conducted a similar study in
which they observed the effect of retrobulbar alcohol
injection on 4 patients of absolute glaucoma.9They
reported a period of pain relief lasting up to1year; which
closely matches the results of our study.
Maumenee studied effect of retrobulbar alcohol in 35
blind and 15 seeing painful eyes. He reported pain free
period of 1-3 months with no permanent long term
complications.10 These findings are comparable to those
observed in our study.
Kumar reported a case of adenoid cystic carcinoma of the
maxillary sinus. The patient was suffering from severe
intractable pain in orbital region due to exposure and
compression effect of the tumour.6The pain was not
controlled by maximum dose of analgesics. Like our study
the pain was eradicated using a single injection of
retrobulbar alcohol injection. The patient was pain free for
J Pak Med Assoc
679 N. Akhtar, A. Tayyab,A. Kausar, et al
Table-1: Patient's demographics and medications.
Sr. No Age(years) Gender Eye involved Medications
Case 1 69 Male right Beta blocker, alpha agonist, Carbonic anhydrase inhibitors, Prostaglandin analouge
Case 2 36 Female Left Beta blocker, Carbonic anhydrase inhibitors, alpha agonist, Prostaglandin analouge
Case 3 70 Female Left Beta blocker, Carbonic anhydrase inhibitors, Prostaglandin analogue,, alpha agonist
Case 4 72 Male Right Beta blocker, , alpha agonist, Carbonic anhydrase inhibitors, Prostaglandin analouge
Case 5 48 Female Left Beta blocker, alpha agonist, Carbonic anhydrase inhibitors, Prostaglandin analouge
Table-2: Verbal Analogue Score of the patients.
VAS Case 1 Case 2 Case 3 Case 4 Case 5
Before injection 10 8 10 79
After injection 51 8 13
1 day after injection 20 3 00
After 1 week 10 1 50
After 2 week 10 1 50
After 3 week 10 1 10
After 4 week 10 1 00
After 2 month 10 0 00
After 3 month 10 0 00
After 4 month 00 0 00
After 5 month 00 1 00
After 6 month 00 1 00
After 1 year 00 1 00
a period of 6months prior to his death.
Al-faran reported a variable period of pain relief ranging
from 2 weeks to 2 years. A total of 39 eyes were included
in the study; of which 31 had protracted ocular pain
caused by end stage glaucoma.4It was concluded that
retrobulbar alcohol may be a useful alternative to
evisceration or enucleation in the management of painful
blind eyes.
Another study was done by Brick to observe the effect of
retrobulbar phenol injection in painful eyes. Eight out of
10 patients who were included in the study were suffering
from absolute glaucoma.11They observed a mean pain
free period of 15 months after the injection.
The postoperative complications encountered, were
anaesthesia of the skin overlying the cheek, lid and
brow, conjunctival chemosis and lid oedema. These
were comparable to those seen in published
literature.12 All these complications were temporary and
resolved without any intervention. The complications
associated with post-injection retro-bulbar
haemorrhage documented in medline indexed
literature including transient ptosis, proptosis and
external ophthalmoplegia in our patients were not
observed in this study.
Conclusion
The effect of retrobulbar alcohol injection was studied in
the presented cases, which was found to be safe and
effective.
References
1. Skorin L. Treatment of blind and seeing painful eye. [online] Jan
16, 2004 [cited 2014 March 5] Available from:
URL:www.optometry.co.uk
2. Merbs SL. Management of blind painful eye. Ophthalmol Clin
North Am 2006; 19: 287-92.
3. Tarantini A, Lanzetta P, Cuqini C. Peribulbartramadol, clonidine
and ropivacaine in blind and seeing painful eyes. Eur J Ophtalmol
2007; 17: 976-8.
4. al-Faran MF, al-Omar OM. Retrobulbar alcohol injection in blind
painful eyes. Ann Ophthalmol 1990; 22: 460-2.
5. Chen TC, Ahn Yuen SJ, Sangalang MA, Fernando RE, Leuenberger
EU. Retrobulbar chlorpromazine injections for the management
of blind and seeing painful eyes. J Glaucoma 2002; 11: 209-13.
6. Kumar CM, Dowd TC, Hawthorne M. Retrobulbar alcohol injection
for orbital pain relief under difficult circumstances: a case report.
Ann Acad Med Singapore 2006; 35: 260-5.
7. Shah-Desai SD, Tyers AG, Manners RM. Painful blind eye: efficacy
of enucleation and evisceration in resolving ocular pain. Br J
Ophthalmol 2000; 84: 437-8.
8. Webber SK, McGhee CN, McMenamin PG. Precautionary note on
retrobulbar alcohol injections. Br J Ophthalmol 1995; 79: 192-4.
9. Çok OY, Eker HE, Cantürk S, Yaycio?lu R, Aribo?an A, Arslan G. Pain
management in blind, painful eyes: clinical experience with
retrobulbar alcohol injection in 4 cases. Agri 2011; 23: 43-6.
10. Maumenee AE. Retrobulbar alcohol injections; relief of ocular
pain in eyes with and without vision. Am J Ophthalmol 1949; 32:
1502-8.
11. Birch M, Strong N, Brittain P, Sandford-Smith J. Retrobulbar phenol
injection in blind painful eyes. Ann Ophthalmol 1993; 25: 267-70
12. Olurin O, Osuntokun O. Complications of retrobulbar alcohol
injections. Ann Ophthalmol 1978; 10: 474-6.
Vol. 65, No. 6, June 2015
Pain management with retrobulbaralcohol injection in absolute glaucoma 680
... One of the techniques utilized for nearly a century was the application of absolute alcohol in various concentrations (from 33% to 95%). [2][3][4][5][6][7][8][9][10][11][12][13] Subsequently, in the early 50s, an alternative technique appeared, consisting in a retrobulbar injection of chlorpromazine, a neuroleptic with antiemetic action the action mechanism of which is not fully understood but it has been related with membrane stabilization in the ciliary ganglion, produced significant analgesia with good tolerance and apparently less collateral effects. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] The utilization of retrobulbar chlorpromazin as a therapeutic alternative in these cases is not very well known. ...
... Retrobulbar injection of ethyl alcohol has been a therapeutic practice for nearly a century in painful blind eye cases, with variable results in diminishing pain intensity and duration. [2][3][4][5][6][7][8][9][10][11][12] In addition, side effects have been documented such as optical atrophy, palpebral ptosis, severe palpebral edema and chemosis, external ophthalmoplegia, cellulite, inflammatory orbital disease and neurotrophic keratopathy. [2][3][4][5][6][7][8][9][10][11][12] On the other hand, since 1953 researchers in Italy and Russia 14-16 started using retrobulbar chlorpromazine for managing painful blind eye. ...
... [2][3][4][5][6][7][8][9][10][11][12] In addition, side effects have been documented such as optical atrophy, palpebral ptosis, severe palpebral edema and chemosis, external ophthalmoplegia, cellulite, inflammatory orbital disease and neurotrophic keratopathy. [2][3][4][5][6][7][8][9][10][11][12] On the other hand, since 1953 researchers in Italy and Russia 14-16 started using retrobulbar chlorpromazine for managing painful blind eye. As from 1970, it was utilized in France 17 and since the 80s in the United States. ...
Retrobulbar chlorpromazine in management of painful eye in blind or low vision patients
Article
  • Mar 2017
To evaluate the results of applying retrobulbar chlorpromazine in the management of patients with painful blind eyes or with very poor vision.
View
... Retrobulbar alcohol has long been used to relieve ocular pain, but the popularity of this therapy has declined among ophthalmologists in recent times. Recent case reports highlight its continued effectiveness at long term ocular pain management [11,12]. Retrobulbar alcohol works via the analgesic destruction of nerve cells. ...
View
... Akhtar conducted a study of 5 cases. The patients were with blind, painful eyes due to absolute glaucoma (17). Each patient received a single retrobulbar alcohol injection and VAS was recorded in similar manner to our study. ...
View
... Dentro de estas opciones terapéuticas menos invasivas disponemos de la aplicación de diferentes sustancias a nivel retrobulbar con el fin de interrumpir la conducción nerviosa en las fibras sensitivas del ganglio ciliar . Una de las técnicas utilizadas durante casi un siglo ha sido la aplicación de alcohol absoluto en diferentes concentraciones (de 33 a 95%) [2][3][4][5][6][7][8][9][10][11][12][13] . Posteriormente, a inicios de la década de 1950, empezó a tomar fuerza una técnica alternativa que empleaba la inyección retrobulbar de clorpromazina, un neuroléptico con acción antiemética, cuyo mecanismo de acción no está totalmente comprendido, pero que se ha relacionado con la estabilización de la membrana en el ganglio ciliar, y que produce una analgesia importante, con buena tolerancia y, al parecer, con menos efectos colaterales [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] . ...
Clorpromazina retrobulbar en el manejo del ojo doloroso ciego o con baja visión
Article
  • Mar 2017
Objective: To evaluate the results of applying retrobulbar chlorpromazine in the management of patients with painful blind eyes or with very poor vision. Methods: A retrospective, descriptive review was carried out on the medical records of 33 patients who were treated with a retrobulbar injection of chlorpromazine (25mg) for the management of painful blind eyes in Centro Oftalmológico Virgilio Galvis. Results: Pain control was achieved in 90% of cases (with mean follow-up of 2.1 years). The mean intraocular pressure decreased by 37%. In 7 out of 12 eyes that maintained residual vision, loss of some degree of vision was acknowledged. One patient required an additional cyclodestructive procedure, another one required an absolute alcohol injection, and in an additional case evisceration surgery was necessary to achieve pain control. No serious complications were noted with this therapy. Conclusions: Retrobulbar injection of chlorpromazine is a valid option in painful, blind eye cases (or with very poor vision) with a poor visual prognosis.
View
Pain management in blind, painful eyes: Clinical experience with retrobulbar alcohol injection in 4 cases
Article
Full-text available
  • Jan 2011
  • Agri Agri
Ocular pain is often difficult to treat and may be caused by many eye diseases. The first step in pain management is medical therapy combined with analgesics; however, severe and resistant cases may require neurolytic eye blocks or definitive surgery. Retrobulbar block with neurolytic agents such as alcohol may be preferred, if the eye is cosmetically normal or the patient is medically or psychologically unsuitable for enucleation or evisceration. Here, we present our successful and efficient pain management using retrobulbar alcohol injection in 4 patients with painful blind eyes. Patients with neovascular glaucoma presenting with painful blind eyes were accepted to our clinic for pain management. The patients had continuous pain with an increasing severity in the recent months. We planned to perform retrobulbar alcohol injection as the pain of the patients was resistant to medical therapy. We noted measurement of verbal analogue scale for pain (VAS) before the block (7, 9, 9 and 10, respectively), after retrobulbar lidocaine and alcohol injection, at the postoperative 1st day, 1st, 2nd 3rd and 4th weeks, and 3rd, 4th, 5th, 6th and 12th months. Early and late complications were also recorded. On the first day after injection, no patient required additive analgesic therapy and their VAS scores were 0, 0, 0, and 3, respectively. Except for one patient who underwent enucleation because of a bacterial infection, the other three patients' VAS scores were 1, 0 and 1 at the 12th month assessment. We suggest that neurolytic retrobulbar block is an efficient pain management strategy in blind painful eyes.
View
View
Painful blind eye: efficacy of enucleation and evisceration in resolving ocular pain
Article
Full-text available
  • May 2000
To assess the effectiveness of enucleation or evisceration in relieving pain from painful blind eyes. 24 patients with intractable ocular pain underwent enucleation or evisceration with or without an orbital implant. Complete pain relief was achieved in all patients at an average time of 3 months (range 1-15 months). Seven patients required further medical or surgical treatment in addition to removal of the globe. Enucleation and evisceration were effective in relieving ocular pain in all patients with a painful blind eye in our study. However, complications of surgery and orbital implants can cause recurrent pain.
View
Peribulbar tramadol, clonidine, and ropivacaine in blind and seeing painful eyes
Article
  • Nov 2007
Purpose: To report on the treatment of painful eyes by peribulbar injection of tramadol, clonidine, and ropivacaine. Methods: The authors treated a 72-year-old woman with chronic prephthisical pain in the left eye secondary to graft rejection after penetrating keratoplasty and an 81-year-old woman with severe ocular pain in her left eye for neovascular glaucoma secondary to an ischemic central vein occlusion. They were treated with a medial canthus injection of tramadol (100 mg/2 mL ampules), clonidine (0.15 mg/1 mL ampules), and 1% ropivacaine. Results: Both injections were very well tolerated and neither transient nor lasting complications were reported. Complete pain relief was obtained in both patients within 1 day and was maintained throughout the follow-up (11 months and 7 months). Conclusions: Peribulbar tramadol, clonidine, and ropivacaine injection may represent a safe and effective treatment modality in the management of chronic ocular pain.
View
View
Retrobulbar alcohol injection in blind painful eyes
Article
  • Jan 1991
  • Ann Ophthalmol
We studied 39 blind painful eyes in 39 patients who were treated with retrobulbar injection of absolute (96%) alcohol for their severe ocular pain at the King Khaled Eye Specialist Hospital from January 1984 to January 1987. There were 21 (54%) male and 18 (46%) female patients; all were followed for at least three months. The protracted ocular pain was mainly due to: end-stage (absolute) glaucoma in 31 (80%) eyes, uveitis or endophthalmitis in four (10%) eyes, or corneal ulcer in two (5%) eyes. One eye had painful phthisis bulbi, and one eye had infraorbital neuralgia. The complications encountered were transient and included blepharoptosis in eight (21%) eyes, external ophthalmoplegia, and corneal epithelial defect. The effective time of the injection to relieve pain ranged from two weeks to two years (mean, 29 weeks). The authors believe that there is still a place for retrobulbar alcohol injection for blind painful eyes when enucleation or evisceration is not possible.
View
Retrobulbar phenol injection in blind painful eyes
Article
  • Aug 1993
  • Ann Ophthalmol
Retrobulbar phenol injection was used as a neurolytic to manage blind chronically painful eyes in ten patients. The cause of the blind painful eye was absolute glaucoma in eight of the ten eyes. We used 1.5mL of 1:15 (6.7%) aqueous phenol solution in each case. None of the patients experienced any pain from the injection. Seven patients obtained complete pain relief after the procedure, and one patient had some improvement. We found a range of duration of pain relief of 4.5 to 48 months (mean, 15 months), which compares favorably with retrobulbar alcohol injection. We believe retrobulbar phenol injection is preferable to alcohol. It has the advantage of being less painful during injection because of its local anesthetic properties.
View
Retrobulbar Chlorpromazine Injections for the Management of Blind and Seeing Painful Eyes
Article
  • Jul 2002
  • J GLAUCOMA
To report the efficacy of primary retrobulbar chlorpromazine injections for the management of blind and seeing painful eyes. Retrospective case series from three university hospitals was done. Twenty eyes of 20 patients with at least 3 months of follow-up are reported. Ten of these 20 eyes did not receive any other ophthalmic medications either 2 weeks before chlorpromazine injection or at any time point after injection. Treatment was considered successful if pain control lasted for at least 3 months, without the need for reinjection or enucleation. Sixteen of 20 (80.0%) eyes achieved successful pain control. There were no permanent complications in any patient. Retrobulbar chlorpromazine appears to be safe and effective for the management of pain in blind eyes.
View
View
Management of a Blind Painful Eye
Article
  • Jul 2006
  • Ophthalmol Clin
Debilitating ocular pain poses a significant challenge to the ophthalmologist. When the pain is intractable and the eye has very poor vision and is disfigured, surgical removal of the eye has traditionally been the definitive treatment of choice. Because many people are uncomfortable psychologically with removal of their eye, however painful, and other patients are not good surgical candidates, an alternative to enucleation is sometimes warranted, and injection of a neurolytic substance can often induce long-lasting anesthesia for a blind painful eye. This article reviews a range of options for management of blind painful eye from anesthesia to enucleation.
View