608 LETTERS TO THE EDITOR ANESTH ANALG

1994;78:601-13

the least amount of axial force of all the 18-gauge Tuohy
needles compared.
In conclusion, we report a second case of a severely dam-
aged 18-gauge epidural Tuohy needle used on an obese pa-
tient when landmarks were difficult to palpate. Thus, we rec-
ommend that 17-gauge Tuohy needles be used on obese
patients for epidural injection or catheter placement instead
of the more easily deformed l&gauge needles.
Eugene G. Lipov, MD
Robert J. McCarthy, PharmD
Anthony D. Ivankovich, MD
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4. Hustead RF, Hamilton RC. Techniques. In: Gills IP, Hustead RF. Sanders
DR, eds. Ophthalmic anesthesia.- Thorofare, NJ: Slack Incorporated,
1993:141.
In Response:
Dr. Hamilton in his letter claims that we quoted from his
article (1)a retrobulbar hemorrhage prevalence of 1% and 3%.
We believe he has misread the paper, inasmuch as other pa-
pers were also quoted. We apologize for any misunderstand-
ing, and we should have quoted the prevalence as between
0.02% and 3%. There is a paucity of literature on the preva-
lence of retrobulbar hemorrhage; we list information avail-

Rush-Presbyterian-St. Luke’s Medical Center

1653 W. Congress Parkway able from sources in the literature in Table 1.
Chicago, IL 60622
Table 1. Prevalence of Retrobulbar Hemorrhage
References First No. of No. of
1. Dunn SM, Steinberg RE, OSullivan PS, et al. A fractured epidural needle: author Reference cases rbh Percentage
case report and study. Anesth Analg 1992;75:1050-2.
Hamilton 1 5325 5 <0.02
Cionni 2 3530* 60 1.7
Morgan 3 N/A N/A 1-3
Sullivan 4 N/A N/A 1-2
Retrobulbar Hemorrhage After Edge 5 12,500 55 0.45
Retrobulbar Blocks Hustead 6 20,000 1 0.005
rbh = retrobulbar hemorrhages; N/A = not available.
*Calculated.
To the Editor:
Dr. Hamilton is to be congratulated on achieving such a
Drs. Edge and Nicoll in their recent paper (1)have cited a 1988 low prevalence of retrobulbar hemorrhage in his unit. We
article from this department (2) and quoted from that same wonder how many members of his staff are doing retrobulbar
paper a retrobulbar hemorrhage prevalence of between 1% blocks and whether the superb figures are perhaps a result of
and 3%.It seems that the paper has been misread. The actual his excellenttechnique rather than the diameter of the needle.
reported incidence of retrobulbar hemorrhage was five cases
out of two of the groups described in the publication (those Kenneth R. Edge, FFA (SA)
patients who had retrobulbar blocks as opposed to peribulbar J. Martin V. Nicoll, FFA (sA)
Department of Anesthesia
blocks), comprising 5235 anesthetics. This represents less King Khaled Eye Specialist Hospital
than a 0.02%occurrence. The other hemorrhages described in Riyadh, Saudi Arabia
the paper are listed as eyelid, conjunctival, and peribulbar
ecchymoses, which had a total incidence of about 3%and in References
the discussion are ranked as minor in nature, certainly not 1. Hamilton RC, Gimbel HV,Strunin L. Regional anesthesia for 12,000 cata-
retrobulbar either in location or significance. ract and intraocular lens implantation procedures. Can J Anaesth 1988;
My current practice is to use a sharp, 27-gauge 31-mm dis- 35:615-23.
2. Cionni RJ, Osher RH. Retrobulbar hemorrhage. Ophthalmology 1991;98:
posable needle at controlled orbit depth, i.e., a maximum or- 1153-5.
bit penetration of 31 mm as advocated by Katsev et al. (3). 3. Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated
With this technique, retrobulbar hemorrhage has not been with retrobulbar injections. Ophthalmology 1988;95660-5.
seen in an additional series of 18,000 patients, all of whom 4. Sullivan KL, Brown GC, Forman AR, et al. Retrobulbar anesthesia and
retinal vascular obstruction. Ophthalmology 1993;90:373-7.
have received retrobulbar injections. Hustead and I reported 5. Edge KR, Nicoll JMV. Retrobulbar hemorrhage after 12,500 retrobulbar
a single retrobulbar hemorrhage in 20,000 retrobulbar blocks blocks. Anesth Analg 1993;761019-22.
also performed with a sharp, 27-gauge 31-mm disposable 6. Hustead RF, Hamilton RC. Techniques. In: Gills JP, Hustead RF, Sanders
needle at controlled orbit depth (4). Therefore, the incidence DR, eds. Ophthalmic anesthesia. Thorofare, NJ: Slack Incorporated,
1993141.
of retrobulbar bleeding from needles placed within the
muscle cone can be all but abolished with the use of a fine
needle combined with controlled depth injection.
Robert c. Hamilton, MB, BCh, FRCPC Dose-Response Calculations Revisited
Department of Anaesthesia
The University of Calgary
Calgary, Alberta, Canada T2N 2T9 To the Editor:
References We read with great interest the paper of Silverman and Bmll
1. Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500 retrobulbar (1) describing the potency of mivacurium given in two di-
blocks. Anesth Analg 1993;76:1019-22, vided doses separated by 60 s. One of the goals of this paper
2. Hamilton RC, Gimbel HV, Strunin L. Regional anaesthesia for 12,000 is to exemplify the critical requirement that the method cho-
cataract extraction and intraocular lens implantation procedures. Can J
Anaesth 1988;35:615-23.
sen to examine potency be appropriate for the pharmacoki-
3. Katsev DA, Drews RC, Rose BT. An anatomic study of retrobulbar needle netics of a particular muscle relaxant when potency is as-
path length. Ophthalmology 1989;9612214. sessed from the effects of two (or more) doses. In the case of