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Paper text:
a 77-year - old male patient was referred by his primary ophthalmologist , who suspected an inadvertent globe perforation .
the patient was a myope and had been previously diagnosed to have nuclear sclerosis grade iii in both eyes .
the patient was scheduled for a left eye cataract surgery for which peribulbar anesthesia was administered , following which the intraocular pressure was found to be hard and on indirect ophthalmoscopy , vitreous hemorrhage was noted . the surgery was canceled and an ultrasound b - scan of the eye confirmed vitreous hemorrhage and a rhegmatogenous retinal detachment ; however , the ultrasound showed intact ocular coats and no obvious vitreous incarceration . with a working diagnosis of an occult - globe perforation causing a retinal detachment and vitreous hemorrhage ,
a small incision cataract surgery was performed to extract the cataractous lens ; following which an encircling silicone band was placed ; vitrectomy , fluid air exchange , endolaser and silicone oil injection were completed uneventfully .
the globe was thoroughly examined , and no obvious scleral dehiscence was found . at the end of the surgery , the intraocular pressure was maintained with no obvious signs of leakage or hypotony .
however , on taking off the surgical drapes , both the periorbital regions were swollen ; with the right side significantly more affected than the left side [ fig .
crepitus could be palpated all over the swollen area , which , on closer examination was found to be extending up to the patient 's chest [ fig .
there was no pain , and the patient 's vitals were found to be stable .
the patient was closely monitored and at the end of 1-week , the subcutaneous emphysema had resolved completely .
the operated eye recovered well , and subsequently underwent silicone oil removal and had an uneventful recovery .
external photograph taken immediately after the surgery demonstrating the bilateral subcutaneous emphysema ( a ) , extending up to the level of the chest on both sides ( b and c ; black arrowheads )
cervicofacial surgical emphysema develops where air enters into the fascial planes of the head and neck .
these planes consist of loose connective tissue , which harbor potential spaces between layers of muscles and other structures .
once air enters the deep soft tissue under pressure , such as passage through syringes or high - pressure tubings , it follows the path of least resistance through the connective tissue , along the fascial planes , reaching distant spaces . in our case
however , as the primary ophthalmologist had suspected , the 24 g needle used to administer the peribulbar anesthesia had caused an occult globe perforation ; perhaps a double perforation [ fig . 2 ] . given the beveled tip of the needle and the oblique angle of entry , we postulate that the scleral entry wound could have possibly been a flap - like shelved entry , which acted as a one - way valve during the fluid gas exchange .
fluid air exchange is usually performed while maintaining an intraocular pressure of 30 mm hg , which would have allowed the air to escape through the sclera and into the subconjunctival space and into the orbit . the needle tract which passed through the skin , the subcutaneous tissue , orbital septum and through the orbital fat
would have provided the path of least resistance for the air to escape and enter the subcutaneous plane .
the laxity of the subcutaneous tissue , especially in a 77-year - old patient could have further contributed it . on retrospective questioning ,
the patient denied any episode of sneezing , trauma , coughing or nose blowing in the interim period between the initial injection and the subsequent surgery .
( a ) line drawing showing the needle tract , which served as the path of least resistance for the escaping air . points a and b indicate the possible points of scleral perforation and point c indicates the site of the retinal break .
( b ) line drawing showing the possible route taken by the air to escape , through the scleral opening and conjunctiva ( d ) , into the orbital tissue . and
through the orbital septum ( e ) and muscular plane and into the subcutaneous plane ( f ) . the passage of the air being facilitated by the previously created needle tract ( a ) ophthalmic procedures that have reported to have caused emphysema include balloon dacryoplasty and orbital decompression surgery .
damasceno et al . have reported a case of subcutaneous emphysema involving the orbit , mediastinum , and face after pars plana vitrectomy with the fluid gas exchange . however , the patient had an old orbital fracture and the authors hypothesize that in the presence of an old orbital fracture , the high gas pressure during fluid gas exchange allowed air to travel from the eye into the soft tissue , orbit , and chest .
venous - air embolism has also been reported to be one of the rare complications of intra - ocular surgery involving a fluid gas exchange .
the incidence of globe perforation has been reported in as many as 0.75% of retrobulbar and peribulbar injections .
surgical emphysema could be a rare , but possible complication while performing vitreoretinal surgery in cases of inadvertent globe perforation while administering peribulbar anesthesia .
serious complications of cervicofacial emphysema include the involvement of retropharyngeal , mediastinal and peritoneal spaces , which may in turn lead to cardiopulmonary distress .
surgical emphysema is defined as gas or air trapped in the subcutaneous tissue plane . here , we report a rare case of bilateral periorbital and cervicofacial subcutaneous emphysema following a vitreoretinal surgery for inadvertent globe perforation during the administration of peribulbar anesthesia . 
 this condition , although self - resolving when restricted to the subcutaneous plane has the potential to spread into deeper tissue planes such as the retropharyngeal space . 
 the presence of crepitus helps to distinguish it from angioneurotic edema . 
 ophthalmologists must be sensitive to the fact that surgical emphysema can be a very rare , but possible complication of an intraocular surgery following globe perforation .