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• Contralateral eye spread. This usually occurs with peribulbar blocks. The anes- thetic spreads and migrates to the contralateral eye. • Optic nerve injection. Accidentally injecting anesthesia into the nerve sheath can lead to hemorrhage and vision loss. • Oculocardiac response. Dysrhythmias such as bradycardia and junctional rhythm, and even asystole, can occur when the oculocardiac reflex is stimulated. Moreover, it can occur hours later. • Central retinal artery occlusion. This is usually caused by retrobulbar hemor- rhage and can lead to total vision loss if not treated. • Brain stem amnesia. If you perforate the meningeal sheaths that surround the optic nerve and inject directly into the cerebrospinal fluid, it can cause convulsions, disorientation, aphasia, hemiplegia and cardiac arrest, all within a few minutes. • Transient blindness. This usually goes away within hours, once the medication is completely out of the system. In some situations, and for some patients, blocks shouldn't be used. In those cases, either topical or general anesthesia is a better choice. • Children. They usually shouldn't be done on patients under 15 years of age. • Long procedures. Procedures that last longer than 90 minutes. • Long bleeding times/high INR. This increases risk if a vessel is punctured. International Normalized Ratio (INR) is a measure of how much longer it takes the blood to clot when oral anticoagulation is used. • Mentally impaired patients. They usually find it difficult to hold still and cooper- ate, especially with head movement. • Other considerations. Some patients aren't candidates either because they have other comorbidities, or because they won't agree to the procedure. Peribulbar blocks are safer overall than retrobulbar blocks. They're less likely to cause retrobulbar hemorrhage or perforate the globe, and their potential for dural injection is lower, because the anesthetic is injected outside the muscle cone. But they also have disadvantages. There may be less akinesia, more volume required and a higher instance of chemosis, which can distort the operative site. Anesthesia Alert AA 3 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M A Y 2 0 1 6