Peribulbar Anaesthesia in Ophthalmic Surgery: Evolution, Efficacy, and Emerging Advances

Abstract

Peribulbar anaesthesia has become one of the most widely practised regional anaesthetic techniques in ophthalmology, balancing safety and efficacy for diverse surgical procedures. Initially developed as a modification of the retrobulbar block to minimise risks of optic nerve injury and brainstem anaesthesia, it has since gained widespread acceptance for cataract, glaucoma, vitreoretinal, and strabismus procedures. Large clinical series and institutional experiences have established its reliability. This narrative review, based on a targeted literature search, synthesises historical developments, techniques, pharmacological adjuncts, safety considerations, and emerging innovations. Over time, multiple refinements have emerged to enhance both safety and effectiveness. Innovations include medial canthal and transcaruncular approaches, ultrasound guidance, and the use of blunt cannulas to reduce perforation risks. Pharmacological advances have further expanded options, with adjuvants such as hyaluronidase, magnesium sulphate, dexmedetomidine, and clonidine improving onset, duration, and block density. Newer local anaesthetics like levobupivacaine and ropivacaine offer alternatives with favourable safety profiles. Though generally safe, peribulbar anaesthesia is not without risks. Common minor complications include chemosis and subconjunctival haemorrhage, whereas rare but serious events such as globe perforation, vascular occlusion, hypersensitivity reactions, and neurological effects have been reported. Recent imaging-based studies, including optical coherence tomography angiography (OCTA), have begun to shed light on subtle physiological effects on ocular perfusion, opening avenues for future research. Despite the increasing adoption of topical anaesthesia in routine cataract surgery, peribulbar block continues to have an important role in complex anterior and posterior segment procedures and in uncooperative or anxious patients where reliable akinesia is desirable.