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Med Oral Patol Oral Cir Bucal. 2011 Aug 1;16 (5):e688-93.

Journal section: Oral Surgery Publication Types: Review

Occular alterations in anesthesia

doi:10.4317/medoral.17078

http://dx.doi.org/doi:10.4317/medoral.17078

Occular complications following dental local anesthesia

Jose-Maria Aguado-Gil 1 , Cristina Barona-Dorado 2 , Juan-Carlos Lillo-Rodríguez 3 , David-Sebastian De la Fuente-González 4 , Jose-Maria Martínez-González 5

1 ��entist.entist. MasterMaster��ss degreedegree inin ��entalental ��ciences.ciences. ��tudenttudent inin thethe MasterMaster��ss ��rograrogra�� inin OralOral ��urgerurger�� andand ������lantologlantolog�� atat thethe ��nini��erer-- sit� Hos�ital of Madrid

2 Associate Professor of Oral �urger�. �chool of �entistr�. Co��lutense �ni�ersit� of Madrid

3 �entist. Assistant �irector of the Master�s �rogra� in Oral �urger� and ���lantolog�. �ni�ersit� Hos�ital of Madrid

4 �entist. Collaborating Professor. �chool of �entistr�. Co��lutense �ni�ersit� of Madrid

5 Professor of Maxillofacial �urger�. �chool of �entistr�. Co��lutense �ni�ersit� of Madrid. Head of the �e�art�ent of Oral �urger� and ���lantolog�. �ni�ersit� Hos�ital of Madrid

Correspondence:

School of Dentistry Pza Ramón y Cajal s/n Madrid, Spain hospimar@hotmail.com

Recei�ed: 27/04/2010

Acce�ted: 21/05/2010

Aguado-Gil JM, Barona-�orado C, Lillo-Rodríguez JC, �e la Fuente- González ��, Martínez-González JM. Occular co��lications following dental local anesthesia. Med Oral Patol Oral Cir Bucal. 2011 Aug 1;16

(5):e688-93.

htt�://www.�edicinaoral.co�/�edoralfree01/�16i5/�edoral�16i5�688.�df

Article Number: 17078 eMail: medicina@medicinaoral.com Indexed in:
Article Number: 17078
eMail: medicina@medicinaoral.com
Indexed in:

�cience Citation �ndex Ex�anded Journal Citation Re�orts �ndex Medicus, ME�L�NE, PubMed �co�us, E�base and E�care �ndice Médico Es�añol

http://www.medicinaoral.com/

© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946

Abstract

Objecti�e: To deter � ine the frequenc� of a��earance and the factors �ost co��onl� associated with ocular co�- �lications following dental local anesthesia, also establishing the location and t��e of anesthesia used. �tud� �esign: An indexed search in the Pub�ed and Co��ludoc databases was carried out with the ke�words “oral anesthesia”, “ocular”, “o�hthal�ologic”, “da�age”, “co��lications”, “injection”. We established a li�itation that the literature had to ha�e been �ublished after the �ear 1970. A total of 19 articles were obtained, for�ing a total sa��le of 37 �atients. The �atient�s sex, age, ner�e anesthetized, t��e of anesthetic used, o�hthal�ological co��lication �resent, reco�er� ti�e, treat�ent and side effects were anal�zed. Results: There is a higher in�ol�e�ent of fe�ales (77%). The a�erage age was 34.2 �ears. There was no �reference for an anesthetic technique. �i�lo�ia was the �ost co��on co��lication (65%), which coincides with the data fro� other authors. Al�ost all of the co��lications were of a te��orar� nature, with an a�erage reco�er� ti�e of 68 �inutes. Conclusions: This is one of the few studies of its kind in dental literature, it thus being difficult to make precise conclusions. O�hthal�ological co��lications are seldo� a �roble�, di�lo�ia being the �ost co��on a�ong the�. The authors a��ear to indicate an intra�ascular injection of the anesthetic as the cause of the �roble�, and therefore, it should be a�oided in order to �re�ent accidents at the ocular le�el.

Key words: Accidents, ophthalmology, dental anesthesia.

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Med Oral Patol Oral Cir Bucal. 2011 Aug 1;16 (5):e688-93.

Introduction

For �an� �ears, dental literature describes signs and s���to�s at the o�hthal�ic le�el following injection of anesthesia into the oral ca�it�, both in regional tech- niques at a su�erior le�el, due to the �roxi�it� with the orbital region, as well as in the �andibular blocking of the inferior dental ner�e. The �ain co��lications that �a� occur in regards to intraoral anesthesia �a� include: te��orar� di�lo�ia, transitor� unilateral a�aurosis, strabis�us due to �a- ral�sis of the extrinsic �uscles of the e�e, and �al�ebral �tosis. To date, the �echanis� that �roduces such co�- �lications is unclear, although the authors suggest an intra�ascular injection of the anesthetic, which would follow a retrograde �ath towards the infraorbital arter� or the �iddle �eningeal arter�. �es�ite being described as a local t��e of co��lication of anesthesia, the ocular alterations are quite unco�- �on, re�resenting a��roxi�atel� 0.1% of the co��lica- tions. The �ur�ose of this stud� was to deter�ine the ocular co��lications the a��ear �ost frequentl� following ad- �inistration of dental local anesthesia, seeking to deter- �ine the relationshi� with a certain co��on factor or �ariable, as well as the �resence of such co��lications according to the anesthetic technique and t��e of anes- thetic used, and finally, to determine the duration of the ocular co��lications.

Study Design

An indexed search in the Pub�ed and Co��ludoc data- bases was carried out with the ke�words “oral anesthe- sia”, “ocular”, “o�hthal�ologic”, “da�age”, “co��lica- tions”, “injection”. As inclusion criteria, we took into consideration that there had to be at least one case de- scribed of an ocular alteration following so�e t��e of anesthetic �rocedure carried out in the �outh; and that each and e�er� one of the following �ariables was taken into account in the descri�tion of the case: age and sex of the �atient, t��e and location of the anesthesia, �ain co��lication �resent and acco��an�ing s���to�s, du-

ration of the e�ent, treat�ent a��lied and whether or not the �atient ex�erienced an� side effects. The search was li�ited to articles �ublished after 1970. With these criteria, we obtained a total of 22 articles (Table 1), considering in each and e�er� one of the� the �ariables that are described as follows, for�ing a total sa��le of 35 �atients (1-19). The �ethod used consisted of a descri�ti�e statistical anal�sis of the following �ariables:

1. �ex: �ale (M) or fe�ale (F), in �ercentage and ratio.

2. Age: the exact age of each �atient described in each

article was used, after which the different statistical

�ariables within this section were calculated.

3. OO��hthalhthal��ologicalological coco����lication:lication: thethe ocularocular coco����licalica--

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Occular alterations in anesthesia

tion �resent in each case was recorded. The acco��an�- ing signs �resent were also noted.

4. Technique:Technique: thethe ��atientsatients werewere distinguisheddistinguished accord-accord-

ing to whether the anesthesia was ad�inistered on the

inferior dental ner�e (��N) or on the �osterior su�erior al�eolar ner�e (P�AN).

5. Anesthetic:Anesthetic: bothboth thethe tt����ee ofof anestheticanesthetic andand itsits concon--

centration (in %) has been described, as well as the �a- soconstrictor used and in what �ro�ortion.

6. Reco�er� ti�e: ex�ressed in �inutes or hours.

7. Treat �ent carried out b� the �rofessional at the ti�e

that the ocular alteration occurs.

8. �ide effects: if an� co��lications re�ain after the

ti�e for reco�ering sensiti�it� after anesthesia.

Results

�ex: Of the 35 cases selected, 7 affected �ales (20%) and 28 affected fe�ales (80%), which results in a F/M ratio of 4:1. Age: The a�erage age of the �atients included in the �e- ta-anal�sis was 29.5 �ears old. The �ean of the distribu- tion of the data, 32 �ears, and the �ode, which re�eats on 3 occasions, is 25 �ears old. The range of age is fro� 4 to 73 �ears old (Fig. 1). The age inter�al with the high- est nu�ber of �atients was fro� 20-29 �ears old. Anesthetic technique: a technique was �racticed on the �osterior su�erior al�eolar ner�e in 19 �atients and a di- rect �andibular block was ad�inistered in 15 �atients, as well as a case in which both techniques were �rac- ticed. Ocular co��lication: The �ost co��on ocular co��li- cation was di�lo�ia, �resent in 23 cases (66%), followed b� �al�ebral �tosis in 12 cases (34%), �idriasis in 5 cases (14%), unilateral transitor� a�aurosis and blurr� �ision in 4 �atients (11%) and Horner s�ndro�e and strabis�us, affecting 9% and 6% of the �atients, res�ec- ti�el� (Fig.2). Other ocular co��lications, which are not included in the table due to being �er� unco��on, were o�hthal�o�legia, ��osis and sudden blackout, all �resent in a single case (3%), along with �er�anent a�aurosis. �n ter�s of other signs and associated s���to�s, the following is worth noting: ische�ia or �aleness of the area, which was �resent in 7 of the �atients; nu�bing of the �eriorbital area and burning of the e�e, both �resent in three �atients. Reco�er� ti�e: The range of reco�er� ti�e �aried fro� 10 �inutes to 24 hours. The a�erage ti�e was 63 �in- utes. For the calculation, the onl� case in which reco�- er� fro� the side effects did not occur was not taken into account, nor was the case of 24 hours, due to be- ing �er� far fro� the rest of the results, which would significantly modify the data. Thus, only 33 of the 35 �atients were taken into account when calculating the reco�er� ti�e (Fig. 3).

Med Oral Patol Oral Cir Bucal. 2011 Aug 1;16 (5):e688-93.

Table 1. Articles and selected cases. Variables anal�zed.

Occular alterations in anesthesia

AUTHOR

NO.

SEX

AGE

OCCULAR COMPLICATION

TECHNIQUE

TIME

CASES

(min.)

Rood JP (1)

1

F

24

Ptosis, di�lo�ia

��N

45

(1972)

Campbell RL

1

F

34

Ptosis, ��osis

��N

120

(2) (1979)

Petrelli EA (3)

1

F

42

�i�lo�ia

P�AN

90

(1980)

Norris L (4)

1

F

17

�i�lo�ia

��N

20

(1982)

Goldenberg AS (5) (1983)

1

F

58

�i�lo�ia, strabis�us and unilateral transitor� a�aurosis

��N

20

Kronman JH

           

(6) (1984)

1

F

37

�i�lo�ia

P�AN

50

Clarke JR (7)

1

F

10

�nilateral transitor� a�aurosis and di�lo�ia

P�AN

30

(1987)

Goldenberg A

1

F

31

�i�lo�ia, blurred �ision

P�AN

180

(8) (1990)

Dryden JA (9)

1

F

33

�i�lo�ia and �tosis

��N

90

(1993)

Marinho R

           

(10) (1995)

1

M

25

�i�lo�ia

P�AN

180

Van der Bijl P (11) (1996)

1

F

14

�i�lo�ia

��N

1440

Spierer A (12)

2

F

5

�i�lo�ia, strabis�us

��N

15

(1999)

M

4

Ptosis

��N

20

   

F

65

Pal�ebral �tosis, Eno�hthal�os, M�osis

P�AN

50

F

29

Pal�ebral �tosis, Eno�hthal�us, M�osis

P�AN

20

M

53

Pal�ebral �tosis, Eno�hthal�us, M�osis

P�AN

40

F

49

�i�lo�ia, �tosis, ��driasis

P�AN

45

F

60

�i�lo�ia, �tosis, ��driasis

P�AN

30

Peñarrocha M

F

25

�i�lo�ia, �tosis, ��driasis

P�AN

60

14

         

(13) (2000)

F

24

�i�lo�ia

P�AN

30

 

F

32

�i�lo�ia

P�AN

45

 

F

22

�i�lo�ia

P�AN

60

M

35

�i�lo�ia

P�AN

90

F

40

�i�lo�ia

P�AN

120

F

73

�i�lo�ia

P�AN

120

F

65

�i�lo�ia

P�AN

50

F

40

�i�lo�ia

P�AN

30

Wilkie GJ (14)

1

M

45

�nilateral transitor� a�aurosis, ��driasis, �tosis, di�lo�ia

��N

30

(2000)

Webber B (15)

1

F

33

Blurred �ision

��N

45

(2001)

Rishiraj B (16)

1

M

73

Per�anent a�aurosis, �idriasis

��N, P�AN

Per�

(2005)

Ngeow WC

2

F

20

Blurred �ision

��N

15

(17) (2006)

F

21

Blurred �ision

��N

15

Uckan S (18)

2

M

25

Burning sensation in the e�e

��N

20

(2006)

F

30

�nilateral transitor� a�aurosis

��N

45

Scott JK (19)

1

F

28

�i�lo�ia

��N

120

(2007)

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Age 10 8 6 4 2 0 0 9 10 19 20 29 30 39
Age
10
8
6
4
2
0
0 9 10 19 20 29 30 39 40 49 50 59 60 69 70 79
years years years years years years years years

Fig. 1. �istribution of the �atients according to their age grou�.

Primary occular complication 70% 60% 50% 40% 30% 20% 10% 0% DP PT MD AUT
Primary occular complication
70%
60%
50%
40%
30%
20%
10%
0%
DP
PT
MD
AUT
VB
SH
EST

Fig. 2. Percentage of �atients according to the ocular co��lication �resented. �i�lo�ia (�P), Ptosis (PT), M�driasis (M�), �nilateral Transitor� A�aurosis (A�T), Blurred Vision (VB), Horner ��n- dro�e (�H), �trabis�us (E�T).

Recovery time 25 20 15 10 5 0 10 60 minutes 90 120 minutes 3
Recovery time
25
20
15
10
5
0
10 60 minutes 90 120 minutes
3 5 hours
24 hours

Fig. 3. �istribution of the �atients according to their reco�er� ti�e after the ocular co��lication.

Discussion

As afore�entioned, ocular co��lications are an unco�- �on �roble�. Although there were authors that suggest- ed a frequenc� of 0.1%, if a calculation is �ade based on the studies b� Me�er (1999), who esti�ated ten �ears ago that there were 30 �illion cases in which anesthesia

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Occular alterations in anesthesia

was ad�inistered in Ger�an� each �ear, we would be talking about one case of an ocular accident for e�er� 500 �illion or 1 billion cases in which �atients are ad- �inistered anesthesia, which clearl� indicates that these alterations are �er� unco��on. Howe�er, that does not �ean that the� do not occur, which requires researching the causes that �a� lead to these e�ents, as well as their �echanis� of �roduction. Although the latter is not �et clear, all of the authors a��ear to suggest an intra�ascu- lar injection of the anesthetic in the cases of troncular anesthesia of the inferior dental ner�e, which would fol- low a retrograde �echanis� until reaching the �ediu� �eningeal arter�, through which it would connect with the lacri�al arter�. �n the case of anesthesia of the su- �erior �osterior al�eolar ner�e, this refers to diffusion to the orbit fro� the infrate��oral and �ter�go�alatine fossa (13). This �a� be based, abo�e all, on the troncu- lar blocks of the �axillar� ner�e through the �osterior �alatine duct, as in the stud� b� ��ed et al. (20), carried out on 101 �atients on who� this anesthetic technique was a��lied, u� to 39% of the cases �resented so�e t��e of ocular alteration, although the� onl� s�eak of 8% of the cases in which an as�iration of blood in the anes- thetic car�ule was noted. �n ter�s of the sex of the �atients, in our stud�, 77% of the cases affected fe�ales, which re�resents a large dif- ference with res�ect to �ales. This data coincides with the data obtained b� Peñarrocha et al. (13), in the stud� which we also took into account for our �eta-anal�sis. �ue to not ha�ing �ore articles which consider �ore than 2 or 3 cases, there is no stud� that contradicts these results, but in general, we can affirm that there is a high- er inclination towards fe�ales. With res�ect to age, the a�erage age obtained was 34.2 �ears old, as well as a �ore co��on �resentation in the 3rd and 4th decades of life. According to the stud- ies conducted b� Peñarrocha et al. (13), the� obtained a higher a�erage age (44 �ears old); although the� concur that this �heno�enon occurs �ost frequentl� during the 3rd decade of life. The a�erage age of the �atients of our study is influenced by the 2 cases that occurred at the dental �ediatric le�el, although we also take into ac- count the cases of �atients o�er the age of 65, thus �ak- ing our data rather objecti�e. �n regards to the ocular co��lication �ost frequentl� described, the results are si�ilar, with these authors indicating di�lo�ia due to the �aral�sis of the extrin- sic �uscles of the e�e as the �ost co��on co��lica- tion that occurs at the o�hthal�ological le�el. Our data is also corroborated b� ��ed et al. (20), who s�oke in their afore�entioned stud� of di�lo�ia as the �ost co�- �on co��lication, following b� strabis�us and �tosis. Pal�ebral �tosis, �resent in 3 cases studied b� Peñar- rocha et al. (13) as a s�ndro�e si�ilar to Horner, which concurs with our obser�ation that it is the second �ost

Med Oral Patol Oral Cir Bucal. 2011 Aug 1;16 (5):e688-93.

co��on co��lication. The afore�entioned �echanis� of the �ossible retrograde �assing or diffusion of the anesthetic will �ost co��onl� affect the ���, �V and V� �ar than the o�tical ner�e, due to its �ath closest to the �lace of injection, which generates the �aral�sis that causes double �ision. With res�ect to the ner�e anesthetized, our data re�eals a �er� slight difference in ter�s of the anesthetic tech- nique on the inferior dental ner�e and on the �osterior al- �eolar ner�e, with a slight inclination towards the latter. These data are contrasted b� that shown b� Peñarrocha et al. (13), who exclusi�el� na�e the su�erior �eria�i- cal anesthesia on the �osterior al�eolar ner�e. Whereas there are authors that reco��end the retrograde �ath of anesthetic b� intra�ascular injection on the inferior dental arter�, u� to the �ediu� �eningeal arter� and the connecting of this arter� with the lacri�al arter�, an anasto�osis alwa�s a��ears between both, which enables the relationshi� between the arterial �lexus of the �ediu� �eningeal and the o�hthal�ic arter� (4, 11-12); others (3,7) suggest a connection at the �ter�go- �axillar� fossa, where the anesthetic would �enetrate into the �ter�goid �enus �lexus, being distributed to the ophthalmic vein at its connection in the orbital fissure. With the data that we ha�e obtained in this stud�, we are unable to establish so�e clear conclusions on whether the mechanism of production is the first or the second, or whether both �a� be in�ol�ed in the de�elo��ent of ocular co��lications. Howe�er, this does not concur with that described b� authors such as �r�den et al. (9), in whose case they refer an infiltration with negative as- �iration after using a Gow-Gates technique. This onl� ser�es to show the lack of unani�it� in these �echa- nis�s of �roducing the co��lications. The anesthetic �ost often used was articain 2% with e�ine�hrine 1:100,000, used on 35% of the �atients. �es�ite this, this data does not a��ear entirel� conclu- si�e, as anesthesia has been �racticed with �an� t��es of anesthetics (lidocain, �e�i�acain, �rocain, etc.) with ocular alterations �resent in the use of all of the�. �n addition, we �ust kee� in �ind that articain is currentl� one of the �ost co��onl� used anesthetics. Our stud� also coincided that the total of the ocular co��lications corres�onds with that of the stud� conducted b� Peñar- rocha et al. (13), knowing the dedication of this grou� to the field of oral surgery, where the use of this anesthetic is e�en �ore frequent due to its higher �las�a half-life and duration of the anesthetic effect. The usual reco�er� ti�e of these accidents was 70 �in- utes, although �ore than 60% of the �atients reco�ered within the first hour. This concordance in our results is also e�ident in the stud� b� Peñarrocha et al. (13). As has alread� been ex�lained in the results, the onl� case of a �er�anent co��lication was not taken into ac- count. With res�ect to the this case, Rhisiraj et al. (16)

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state that it had to do with a �atient who suffered a seri- ous s�ste�ic alteration (andocarditis of the �itral �al�e due to �. sali�arius, awaiting substitution), which �a� ha�e �la�ed a role in �roducing this e�isode, as the onl� case of �er�anent a�aurosis or that of an� other t��e of �er�anent alteration after injection of local anesthesia was found in dental science �ublications. �n the �ajorit� of the cases of di�lo�ia, the affected e�e was co�ered for the duration of the s���to� in order to �re�ent the �atient fro� suffering the strain of double �ision. �es�ite all of this, in the �ajorit� of the cases, dental treat�ent was continued with the �ere obser�a- tion and care of the �atient. �n certain cases, the �atient was ad�ised to �isit the o�hthal�ologist if the s���- to�s were not relie�ed within a few hours, although the s���to�s were alwa�s relie�ed within this ti�e, exce�t in the case of �er�anent blindness, in which ocular �assage was e�en atte��ted. The �ain li�itation of our stud� was not ha�ing �ore articles in which �arious cases of ocular co��lications are conte��lated so that we could establish a broader and �ore in-de�th co��arison of the results, which would have enabled us to make specific and clear conclusions. We belie�e that it would be interesting for the authors to �ublish this t��e of ex�erience encountered in the dental clinic, in order to conduct an exhausti�e stud� on the �echanis�s of �roduction of the ocular co��lica- tions, enabling the researchers to establish so�e �roto- cols for �re�enting the�, which, in turn, would result in better qualit� and co�fort in treating our �atients, gi�en that oral anesthesia is �robabl� the �ost co��on �rocedure �racticed b� sto�atologists and dentists in their dail� work, and these co��lications �a� lead to unco�fortable and un�leasant situations when treating the �atients. The best wa� of a�oiding the a��earance of co��lica- tions, both ocular as well as clinical, is to exa�ine the �atient and use a careful and correct technique, es�e- ciall� being careful to a�oid intra�ascular injection of the anesthetic. �n the e�ent that such a co��lication does occur, the �ost i��ortant ste� is to cal� the �atient. �n cases of di�lo�ia, it is reco��ended to co�er the �a- tient�s affected e�e in order to �re�ent the un�leasant sensation of double �ision (21).

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