Periocular Inflammation After Retrobulbar Chlorpromazine (Thorazine) Injection

The Ruptured Globe, Sympathetic Ophthalmia, and the 14-Day Rule

PURPOSE

Prophylactic enucleation of a ruptured globe with no light perception within 14 days of injury to prevent sympathetic ophthalmia (SO) has been an established dictum in academic teaching for more than 100 years. This treatment strategy was originally based on observation, speculation, and careful thought, but there was never any scientific proof. This review summarizes and updates the current state of our knowledge about globe rupture and SO, examines the origin and validity of the 14-day rule, and emphasizes the importance of trying to save the traumatized eye whenever possible.

METHODS

A comprehensive literature review of SO and globe rupture was performed.

RESULTS

SO is a rare disorder that may potentially occur following traumatic globe rupture as well as following a variety of other intraocular surgeries. Vitreoretinal surgery may be a more common cause than trauma according to some studies. SO may still occur despite having the eye removed within 14 days of the trauma. A variety of new medications including biologic agents are now available to treat SO with improved efficacy in suppressing the associated ocular inflammation and allowing retention of some useful vision. Removing the traumatized, blind eye may have other important psychological consequences associated with it that require consideration before eye removal is carried out. Retaining the blind, phthisical, disfigured eye avoids phantom vision and phantom pain associated with enucleation as well as providing a good platform to support and move an overlying prosthetic eye. Data on the occurrence of SO following evisceration and enucleation with and without predisposing factors confirms the exceedingly low risk.

CONCLUSION

Most civilian open globe injuries can be successfully repaired with modern, advanced microsurgical techniques currently available. Because of the exceedingly low risk of SO, even with the severity of open globe trauma during military conflicts being more devastating as a result of the blast and explosive injuries, today every attempt is made to primarily close the eye rather than primarily enucleate it, providing there is enough viable tissue to repair. The 14-day rule for eye removal after severe globe ruptures is not scientifically supported and does not always protect against SO, but the safe time period for prophylactic eye removal is not definitively known. In the exceptional cases where SO does occur, several new medications are now available that may help treat SO. We advocate saving the ruptured globe whenever possible and avoiding prophylactic enucleation to prevent the rare occurrence of SO. When an eye requires removal, evisceration is an acceptable alternative to enucleation in cases that do not harbor intraocular malignancy.

Suspected systemic uptake of chlorpromazine after retrobulbar injection

Purpose

To present a case of suspected systemic uptake of chlorpromazine after a patient underwent retrobulbar injection for a blind painful eye.

Observations

The patient is a 63-year-old Hispanic female who presented to the surgery center with neovascular glaucoma and uncontrolled intraocular pressure of her right eye. Immediately following retrobulbar injection of chlorpromazine, the patient became very sedate and difficult to arouse and blood pressure recordings fell. After 4.5 hours, her symptoms improved, and the patient was discharged. There were no further systemic symptoms reported on follow up.

Conclusion: and importance

Systemic uptake of chlorpromazine following retrobulbar injection is a risk that should be considered when managing blind painful eyes. Ophthalmologists should practice caution with this technique and educate patients and staff on potential risks.

Retrobulbar chlorpromazine injection in a child with gliosarcoma invasion into the orbits

This paper has two main purposes: (1) to report a rare case of paediatric gliosarcoma that invaded the surrounding orbit and (2) to demonstrate chlorpromazine injection as a potential treatment option for blind, painful eye caused by tumour invasion. A 12-year-old man who presented with headaches was found to have glioblastoma multiforme and it was excised and treated with radiation and chemotherapy. Seven months later, the tumour recurred as gliosarcoma, a rare variant of glioblastoma multiforme containing distinct gliomatous and sarcomatous components. In spite of treatment, the tumour progressed and eventually invaded into the right orbit. He subsequently developed a proptotic, blind, painful eye and was treated with retrobulbar chlorpromazine injection, which provided immediate symptomatic relief.

Efficacy of Care for Blind Painful Eyes

PURPOSE

Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions.

METHODS

A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed.

RESULTS

Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure.

CONCLUSIONS

Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

Retrobulbar chlorpromazine in management of painful eye in blind or low vision patients

OBJECTIVE

To evaluate the results of applying retrobulbar chlorpromazine in the management of patients with painful blind eyes or with very poor vision.

METHODS

A retrospective, descriptive review was carried out on the medical records of 33 patients who were treated with a retrobulbar injection of chlorpromazine (25mg) for the management of painful blind eyes in Centro Oftalmológico Virgilio Galvis.

RESULTS

Pain control was achieved in 90% of cases (with mean follow-up of 2.1 years). The mean intraocular pressure decreased by 37%. In 7 out of 12 eyes that maintained residual vision, loss of some degree of vision was acknowledged. One patient required an additional cyclodestructive procedure, another one required an absolute alcohol injection, and in an additional case evisceration surgery was necessary to achieve pain control. No serious complications were noted with this therapy.

CONCLUSIONS

Retrobulbar injection of chlorpromazine is a valid option in painful, blind eye cases (or with very poor vision) with a poor visual prognosis.

Retrobulbar Injections for Blind Painful Eyes: A Comparative Study of Retrobulbar Alcohol Versus Chlorpromazine

PURPOSE

The purpose of the study was to evaluate 2 agents used during retrobular injections to relieve pain in blind eyes.

METHODS

This masked prospective randomized study compared retrobulbar injections for blind painful eyes that were divided into 2 groups: eyes in group 1 (G-I) received 1.5 mL of absolute alcohol (ethanol) and those in group 2 (G-II) received 1.5 mL of chlorpromazine (25 mg/mL). The pain was graded before, during, and after intervention using a verbal numeric visual analog scale. Intraocular pressure (IOP) and adverse events were also recorded. Complete success was defined as no pain after injection. Treatment failures were classified as further intervention (evisceration-enucleation) or no change in visual analog scale pain scores.

RESULTS

Both groups included 16 patients each. Complete success was achieved in 7 of 16 (43.7%) patients in G-I and in 6 of 16 (37.5%) in G-II. The failure rate was 5 of 16 (31.3%) in G-I and 6 of 16 (37.5%) in G-II. Postoperative adverse events occurred in 33.3% of patients in G-I and 56% of patients in G-II. Transient eyelid edema was more prominent in G-II. Reduction in IOP occurred after injection in both groups. In G-I, IOP decreased from a mean of 24.3 to 14 mm Hg. In G-II, IOP decreased from 27 to 15 mm Hg. Five of the 7 (71.4%) patients with initial IOP>45 mm Hg suffered from severe pain. After injection, only 1 patient with an IOP>27 mm Hg had moderate pain.

CONCLUSIONS

Retrobulbar alcohol or chlorpromazine decreased IOP and reduced pain in approximately two-thirds of blind painful eyes with few postoperative complications. However, 33% of patients required further intervention to manage pain.

Histologic Evidence of Orbital Inflammation from Retrobulbar Alcohol and Chlorpromazine Injection: A Clinicopathologic Study in Human & Rat Orbits

PURPOSE

Retrobulbar injections of alcohol and chlorpromazine are used for the treatment of blind, painful eyes. There have been reports of inflammation after retrobulbar injections of these agents, but the histologic effects are not well characterized. A clinical case with histopathologic confirmation of inflammation after retrobulbar alcohol injection led the authors to develop a rat model to examine these effects.

METHODS

Adult Lewis rats were given retrobulbar injections of either 0.1 ml of absolute alcohol or 25 mg/ml chlorpromazine in the right orbit, and 0.1 ml of saline in the left orbit as a control. Rats were euthanized, perfused, and postfixed at 1 to 2 weeks after injection. Exenterated orbital tissue was sectioned for histologic staining. Slides were reviewed by a masked ocular pathologist who evaluated the level of orbital inflammation.

RESULTS

Histopathology demonstrated foci of granulomatous inflammation in the orbit of the patient and similar inflammation in the rat orbits injected with retrobulbar alcohol. In the chlorpromazine group, only 1 rat demonstrated small foci of inflammation, while the control orbits injected with saline showed no inflammation. On blinded qualitative analysis, the orbits receiving retrobulbar alcohol had greater inflammation than the orbits receiving either saline or chlorpromazine.

CONCLUSIONS

Our findings in this preclinical pilot study suggest that retrobulbar alcohol injections incite significant orbital inflammation, whereas retrobulbar chlorpromazine induces little or no inflammation. This potential inflammatory response should be considered when selecting an agent for pain management, particularly if future orbital surgery is anticipated.

Neurotrophic corneal ulcer after retrobulbar injection of chlorpromazine

An 80-year-old woman with a painful, poorly seeing right eye underwent retrobulbar chlorpromazine injection for pain control. After the injection, the patient's symptoms improved; however, a neurotrophic ulcer developed within 2 weeks after the procedure. It is postulated that chlorpromazine may lead to sensory denervation to the cornea with the subsequent development of neurotrophic keratopathy, as observed in this case. Awareness of this potential adverse effect is important for proper patient safety, education, and postinjection management.

Chronic orbital inflammation and fibrosis after retrobulbar alcohol and chlorpromazine injections in a patient with choroidal melanoma

A 59-year-old woman developed a choroidal melanoma in her right eye and was successfully treated with plaque radiotherapy in 1995. She subsequently developed a blind, painful eye and was treated with retrobulbar alcohol and chlorpromazine injections. A transient acute severe inflammatory reaction to chlorpromazine was noted, and chronic pain persisted. MRI performed 5 months later revealed diffuse orbital enhancement suggestive of either fibrosis or tumor recurrence. Following enucleation, diffuse orbital fibrosis was confirmed. The unusual fibrosis could have been related to the orbital injections or remotely related to long-term effects of radiotherapy.