Ultrasound guidance allow anesthesiologist increase security and efficacy of ophtalmic blocks. We can visualize staphyloma, local anesthetic diffusion, guide the needle .. let's have a look and come to practice with me in Bordeaux, France. Book a training on medtandem.com

1. Ultrasound guided
Peribulbar block
Lucie Beylacq
BORDEAUX
FRANCE

2. ORBIT
orientée à 23°
NASAL
POST
TEMPORAL
Superior View
23°
Lucie BEYLACQ M.D. BORDEAUX FRANCE

3. 3
ORBITE

4. LE GLOBE
Episclère
Sclère
Rétine
Sclère
Conjonctive
Ou capsule de Tenon
Episclère
ChoroïdeCornée
Corps Ciliaires
Iris
Lucie BEYLACQ M.D. BORDEAUX FRANCE
Enveloppe externe
Uvée
Corps Vitré
Sclère + Cornée
Choroïde
+ Corps ciliaires + Iris
Gaine externe
Episclere + conjonctive
Cristallin

5. CÔNE
FASCIO-MUSCULAIRE
Antérieur
Temporal
Antérieur
Temporal
Vues supérieures
Lucie BEYLACQ M.D. BORDEAUX FRANCE

6. Coupe coronale de l’orbite au tiers postérieur
Médial
Supérieur
Ant
M Droit
Latéral
M Droit Sup
M Droit Inf
M Droit Medial
V Opht Inf
V Opht Sup
M Grand oblique
Artère ophtalmique
N nasociliaire
N VI
N Frontal
N III
N Lacrymal
N Optique
CONTENU DU CÔNE
Lucie BEYLACQ M.D. BORDEAUX FRANCE

7. ARTERE
OPHTALMIQUE
NERF OPTIQUE
Muscle Droit Inférieur
Muscle Droit Supérieur
Muscle Droit Médial
ANTERIEUR
MEDIAL
SUPERIEUR
VUE MEDIALE
NERF OPTIQUE /
ARTERE OPHTALMIQUE
Lucie BEYLACQ M.D. BORDEAUX FRANCE

8. COUPE CORONALE du NERF OPTIQUE
ARACHNOÏDE
NERF OPTIQUE
ARTERE
CENTRALE
RETINE
Gaine du nerf optique
NERF OPTIQUE /
ARACHNOIDE
Lucie BEYLACQ M.D. BORDEAUX FRANCE

9. INNERVATION SENSITIVE
du GLOBE
N Frontal
N Lacrymal
N Naso- Ciliaire
V2 N Maxillaire
Foramen Rond
V3 N Mandibulaire
Foramen Ovale
Ganglion de Gasser N Trijumeau
N Optique
Canal optique
Vue supérieure de l’orbite
Temporal
Antérieur
V1 N Ophtalmique
Fente Sphénoïdale
Lucie BEYLACQ M.D. BORDEAUX FRANCE

10. N naso-ciliaire
INNERVATION du GLOBE
III
II
IV
V2 N Infra obitaire
V1 N frontal
V1
N Ciliaires longs
N Ciliaires courts
Gglion ciliaire
Coupe schématique sagittale de l’orbite
Supérieur
Antérieur
VI
Motrice
Sensitive
Lucie BEYLACQ M.D. BORDEAUX FRANCE

11. NERFS CILIAIRES
Lucie BEYLACQ M.D. BORDEAUX FRANCE

12. US &
Regional
Anesthesia

13. Peripheral
blocks & US
Decrease FAILURE
Decrease
COMPLICATIONS
Increase
PREDICTIBILITY
Decrease Local
anesthetic VOLUME

14. BUT....
UltraSound & EYE ....

15. BUT....
Regional anesthesia & EYE ....

16. Stevens JD. A new local anesthesia technique for cataract extraction by one quadrant sub-
Tenon's infiltration. The British journal of ophthalmology. 1992;76(11):670-4.
Sub Tenonien
Block

17. Atkinson WS. Local Anesthesia in Ophthalmology. Transactions of the American
Ophthalmological Society. 1934;32:399-451.
Atkinson WS. Local Anesthesia in Ophthalmology. Transactions of the American
Ophthalmological Society. 1934;32:399-451.
Retrobulbar
Block

18. Peribulbar
Block

19. WHY ?

20. HOW ?

21. WHEN?

22. WHY
?FAILURE
COMPLICATIONS
My Failure : 30%
My Fear : globe perforation

23. Cochrane 2008
Péri / RétroBr:
10 à 30% Suppléments
35%
10%
15%
28%
13%
12%
20%
11%
10 à 35% Failure
FAILURE?

24. Nnaso-ciliaire
III
II
IV
V2NInfraobitaire
V1Nfrontal
N Ophtalmique V1
NCiliaireslongs
NCiliairescourts
Gglionciliaire
Coupe schématique sagittale de l orbite
Supérieur
Antérieur
Where is the target?
OPTIC NERVE
CILIAR NERVES
Anterior
Superior

25. APB/ARB
RB
2
1
PB
CONDUCTION
PROXIMALBLOCK
DISTALBLOCK
DIFFUSION
ST
Sub Tenonien/ PeriBulbar /RetroBulbar
PB
RB
PROXIMAL BLOCK
DISTAL BLOCK
2
1
Cranial
Anterior
Where is the target?
Sub Tenonien/ PeriBulbar /RetroBulbar

26. US & Target
?

27. SOUS-TENONIENNE
PERI-BULBAIRE
RETRO-BULBAIRE
Sub tenonien
Peribulbar Retrobulbar
US & the target?
Sub Tenonien/ PeriBulbar /RetroBulbar
US & LA Target :
YES

28. Orbital hemorrhage 0.74%
Globe Perforation 0.006%
Expulsive hemorrhage 0.013%
Grand mal seizure 0.006%
DIPLOPIA
Gomez-Arnaud Br J Anaesth 2003
COMPLICATIONS

29. STAPHYLOMA ?Major Risk factor Axial Lengh >29mm
GLOBE
PERFORATION ?

30. US &
STAPHYLOMA
?

31. NORMAL GLOBE
US & STAPHYLOMA ?
POSTERIOR STAPHYLOMA
US & Staphyloma :
YES

32. SEIZURE ?
Cerebrospinal fluid ?
Orbital Fissure?
Atkinson WS. Local Anesthesia in Ophthalmology. Transactions of the American
Ophthalmological Society. 1934;32:399-451.
Where is the injection ?
COUPE CORONALE du NERF OPTIQUE
ARACHNOÏDE
NERF OPTIQUE
ARTERE
CENTRALE
RETINE
Gaine du nerf optique
OPTIC NERVE
Retina central
artery
Optic nerve
sheath
ARACHNOÏD
OPTIC NERVE CORONALVIEW

33. US & NEEDLE
?
& Optic Nerve
& Orbital Fissure

34. Orbite
OPTIC NERVE
US & OPTIC NERVE ?
US & Optic nerve :
YES

35. US & ORBITAL FISSURE??
Globe
Optic Nerve
Orbital wall
Orbital Fissure
US & Orbital Fissure:
YES

36. Where was the needle ?
Glo
Optic
Orbital
Orbital
US & NEEDLE:
YES

37. Where was the needle
?
NEEDLE
US & NEEDLE:
YES

38. INTRA- MUSCULAR INJECTION
TDM A: coupe Sagittale B: coupe Frontale;
C reconstruction 3D
A
B
C
INJECTA
Superior M
Optic N
Superior M +
INJECTA
DIPLOPIA
Sagital orbital view 3OD
Crânial
Postérieu

39. US & MUSCLE
?

40. INFERIOR MUSCLE
Orbite
US and MUSCLE ?
US & Muscle :
YES

41. ORBITAL
HEMORRHAGE
Ophtalmic artery
punction
ARTERE
OPHTALMIQUE
NERF OPTIQUE
Muscle Droit Inférieur
Muscle Droit Supérieur
Muscle Droit Médial
ANTERIEUR
MEDIAL
SUPERIEUR
VUE MEDIALE
OPHTALMIC
ARTERY
OPTIC NERVE
MEDIAL MUSCLE
SUPERIOR MUSCLE
INFERIOR MUSCLE
MedialView

42. US & Ophtalmic
Artery
?

43. MI 0.23TIs 0.1 8C-RS
ARTERE OPHTALMIQUE
Coupe para axiale inférieure Vue supérieure
Doppler couleur + pulsé
Artère ophtalmique
US & OPHTALMIC ARTERY??
OPHTALMIC ARTERY
Para-axial inferior view
Color and pulse Doppler
fev 2010 CHU Bordeaux
US & Ophtalmic artery :
YES

44. WHEN
?

45. YESTERDAY !!!
US & Ophtalmic Blocks
The Ultrasonic Localisation of Retrobulbar Needles during
Retrobulbar Block
Alexander A. Birch, MD, ark Evans, BS, Ellen Redembo, COA
Ophthalmology volume 102, Issue 5, May 1995, Pages 824-826 1995
1999

46. TODAY again..
Abstract 161 ASRA 2010
Ultrasound-Guided Retrobulbar Block is Feasible and Safe in
Patients Undergoing Vitrectomy Surgery
Sean DaSilva, M.D. Sugantha Ganapathy, FRCPC - University Western Ontario - London, Ontario
Maxim Rachinsky, M.D. - University Western Ontario - London, Ontario
ASRA 2010
BJA 2008
ASA 2011

47. ASA 2011
and again...
RAPM 2012
E-Poster Discussion 10
Friday- september 07, 2012
16:10-16:15
Ultrasound -guided peribulbar block: a 17 patients case serie
L. Beylacq,A. Lasserre, M. Chouraqui, M. Penna, P. Maurette, K. Nouette-Gaulain
University hospital, Bordeaux, France
ESRA 2012

48. WHEN ?
• Yesterday : ultrasound and ophtalmic indications
• TODAY, every day, for all the patients : Imaging
time before regional anesthesia
• TOMORROW :
• Ultrasound Guided Peribulbar block
• Ultrasound Guided Retrobulbar block

49. HOW
?

50. HOW ?
• Ultrasound machine, Special eye settings
• Probe
• ANESTHESIOLOGIST.... Crazy like a
regional anethesiologist, Ultrasound addict
and Coool

51. PROBE
Low Frequency
Microconvex
INDEX MECANIQUE MI ≤0,23
INDEX THERMIQUE TI ≤1,0OUI maisYES but
MECANICAL INDEX
THERMAL INDEX
USUAL
Ultrasound machine
SECURITESECURITY SETTINGS

52. ANESTHESIOLOGIST

54. ULTRASOUND
and
Every day EYE Block : level 1
1. Is it SECURE to perform Eye Block with my usual
technic? SECURITY
= are there contra indications?
= Staphyloma?
2. Will my eye block be efficient? PREDICTIBILITY
= where is the Local Anesthesic spread target?

55. 1. Can I perform EFFICIENT Eye Block ?
SUCCESS
= where can I put the Needle? the Probe?
Can I reduce the volume?VOLUME
2. Can I extend the indications?
= What about Staphyloma? can I even block?
Guidance = PRECISION, SECURITY and
ULTRASOUND
and
Expert EYE Block : level 2

56. IMAGING- TIME
• Why ?
• Identify staphyloma
• Visualise local anesthetic position

57. 1/ Horizontal
&Vertical positions
1ANT
INF
Picture 1: horizontal position of the
probe angled at 23° nasal
ANT
INF
Picture 2 : incidence N°1 Horizontal
centered on the
globe inclined at 23° nasal
Picture 1: Reference views
1: horizontal probe position
2: vertical probe position
Nose
2
1
Picture 3: Incidence N°2 Vertical
centered on the globe at 23° en
nasal
SUP
INT
Picture 4: vertical position of
the probe inclined at 23° en
nasal
SUP
INT

58. INCIDENCE HORIZONTALE
COUPE HORIZONTALE
23°
HORIZONTALVIEW
HorizontalView
COUPE HORIZONTALE
Nasal
Ant
Nasal
MUSCLES
DROITS
Interne et
externe
MI 0.23 TIs 0.0 8C-RS
Lateral &
Medial
muscle

59. MI 0.23 TIs 0.0 8C
NERF OPTIQUE
GRAISSE
PERI-
ORBITAIRE
GLOBE
PAROI ORBITAIRE
OPHTOPHT
PAROI ORBITAIREPAROI ORBITAIRE
MUSCLE DROIT INF
NERF OPTIQUENERF OPTIQUE
GRAISSE
PERI-
ORBITAIRE
GRAISSE
PERI-
ORBITAIRE
GLOBEGLOBE
TIsMI 0.23 TIs 0.0 8C-RS
Ant
Cranial
INFERIOR MUSCLE
ORBITAL WALL
OPTIC NERVE
ORBITAL
FAT
PAROI ORBITAIRE
GRAISSE PERI-
ORBITAIRE
DECOLLEMENT DE RETINERETINA
PERI-ORBITAL
FAT
ORBITAL WALL
COUPE VERTICALE
Nasal
23°
INCIDENCE VERTICALE
VERTICALVIEW
VERTICAL VIEW

60. 2/ Is there
STAPHYLOMA ?
26mm
NORMAL GLOBE
22mm
32mm
POSTERIOR STAPHYLOMA

61. =
?
Lucie BEYLACQ BORDEAUX

62. IM=0,23 IT=0
LA=26mm
Macula
LA=32mm
Macula
STAPHYLOMA
Lucie BEYLACQ BORDEAUX

63. 63
STAPHYLOMA

64. 64
STAPHYLOMA
Beylacq et al CHU Bordeaux Clinique Ophtalmologique Thiers 2013-2016
Lucie BEYLACQ BORDEAUX

65. 65
STAPHYLOMA
CylenderBarrel
Lucie BEYLACQ BORDEAUX

66. 4/ Carefull about the
artery ?

67. Globe
AL
Artère OphtalmiqueNerfOptique
Lucie BEYLACQ BORDEAUX

68. Lucie BEYLACQ BORDEAUX

69. 69
ARTERE OPHTALMIQUE
Needle LA Diffusion
Lucie BEYLACQ BORDEAUX

70. 4/ Where is the local
anesthetic ?
AVANT APRES
PAROI ORBITAIRE
AL
BEFORE AFTER

71. AL
AVANT APRES
4/ Where is the local
anesthetic ?
BEFORE AFTER

72. US & Target
?

73. The
TARGET ?

74. Probe
position
Vertical view

75. The
TARGET ?
INTRACONIC spread
=> SUCCESS EXTRACONIC
spread => FAILURE

76. ULTRASOUND Spread visualisation
is more predictible than Anesthesiologist judgement
The
TARGET ?

77. US &
GUIDANCE
?

78. 1/ Cadaver

79. BJA 2008
RETROBULBAR BLOCK
ULTRASOUND
GUIDANCE ?

80. ULTRASOUND
GUIDANCE ?
PERIBULBAR BLOCK

81. RETRO-BULBAIREULTRASOUND GUIDED BLOCK
GOOD NOT GOOD
NEEDLE
NEEDLE
EXTRACONIC spread
INTRACONIC spread

82. 1/ Patient

83. Ultrasound Guidance
Inferior peribulbar block

84. Abstract 161 ASRA 2010
Ultrasound-Guided Retrobulbar Block is Feasible and Safe in
Patients Undergoing Vitrectomy Surgery
Sean DaSilva, M.D. Sugantha Ganapathy, FRCPC - University Western Ontario - London, Ontario
Maxim Rachinsky, M.D. - University Western Ontario - London, Ontario
ULTRASOUND
GUIDANCE ?
Stop study

85. ULTRASOUND
GUIDANCE ?
E-Poster Discussion 10
Friday- september 07, 2012
16:10-16:15
Ultrasound -guided peribulbar block:
a 17 patients case serie
L. Beylacq,A. Lasserre, M. Chouraqui, M.
Penna, P. Maurette, K. Nouette-Gaulain

86. AL

89. ULTRASOUND
GUIDANCE NEEDLE??
SONOEYE !

90. Every day practice
in Bordeaux

91. Imaging
Time

92. Needling
Time

93. Imaging
Time
After Block

94. Testing

95. Ultrasound Guidance
Caruncular block

97. Many Many Thanks
Simone Pajunk
Gamida team
Pr X. Capdevila, Dr O. Choquet, Dr P.Macaire
Bordeaux resident team and colleague
Mahira Penna, Mikhael Chouraqui, Thomas laterrade, Frederique Boutin, Amelie Lasserre
and Pr Karine Nouette-Gaulain
& WELCOME IN BORDEAUX

99. BORDEAUX