Peribulbar Anesthesia In Depth

Updated: Nov 19, 2019

In this post, Yael Shilo-Benjamini DVM, DACVAA discusses the technique of providing peribulbar anesthesia, an alternative to retrobulbar anesthesia that may be safer and more effective.

Dr. Shilo-Benjamini completed an anesthesia and pain management residency at the University of California Davis, and is a clinical lecturer of anesthesia and analgesia at Koret School of Veterinary Medicine, The Hebrew University of Jerusalem. She has a particular interest in perioperative analgesia, especially with the use of regional anesthetic techniques.

Yael Shilo-Benjamini, DVM, Dip. ACVAA

Peribulbar anesthesia (PBA) is a simple, inexpensive, and relatively safe and effective regional anesthesia technique. In human ophthalmic surgery, it has replaced the use of retrobulbar anesthesia because of the advantage of limited risk of injury to intraconal structures, such as the optic nerve and major blood vessels. The primary indication to use PBA is enucleation, but in people it is also used for cataract and other intraocular surgeries.

PBA is performed by introducing a needle outside of the extraocular muscle cone (extraconal injection; Figure 1). I tend to use 25-gauge, 5/8-inch (1.6 cm) in cats and small-breed dogs, and 23-gauge, 1-inch (2.5 cm) in medium to large-breed dogs. In giant-breed dogs a longer needle, such as 22-23-gauge, 1.5-inch (3.8 cm), might be required.

Figure 1 Peribulbar anesthesia (PBA): the needle is introduced in close proximity to the orbital wall outside the extraocular muscle cone (extraconal injection).

In cats, 3.5-4 mL should be used per adult cat, but in kittens, I use approximately 1 mL per kg (up to 4 mL).

In dogs, a volume of 0.2-0.8 mL/kg was reported. It is important to note that the lower dosage should be used in larger-breed dogs, and the higher dosage in tiny breeds, due to changes in body surface area to volume ratio.

Prior to enucleation surgeries, it is advisable to use longer-acting local anesthetics, such as bupivacaine or ropivacaine. Many times (especially in cats and small-breed dogs) these drugs should be diluted with saline 0.9% to avoid toxicity. Calculate the maximum recommended dose (2 mg/kg for bupivacaine and 3 mg/kg for ropivacaine) then to dilute the local anesthetic to the required volume.

The insertion point of the needle in cats is at the dorso-medial orbit (Figure 2), while in dogs several insertions were reported: ventro-lateral orbit, dorso-medial + ventro-lateral orbit (Figure 3), or medial cantus (Figure 4). In all cases, the needle is inserted in close proximity to the orbital wall (I tend to scratch the wall), in order to avoid damaging any vessels and nerves, or penetrating into the globe.

Figure 2 Dorso-medial needle insertion in a cat prior to enucleation.

Figure 3 Dorso-medial and ventro-lateral needle insertion in a dog prior to enucleation.

Figure 4 Medial canthus needle insertion in a dog prior to enucleation.