Scleral perforation involving the papillomacular bundle seco
The globe perforation ordinarily occurs in the presence of posterior staphyloma. Scleral perforation needs to be considered in any patient who has had a peribulbar block and presents with vitreous haemorrhage of unknown cause at the first postoperative visit. Vitreoretinal intervention is typically required to prevent or treat subsequent retinal detachment or subretinal haemorrhage, and the potential for long-term visual recovery is limited.

A 76-year-old patient developed visual loss from vitreous haemorrhage immediately following left glaucoma gel microstent revision surgery under peribulbar anaesthesia. Once the vitreous haemorrhage cleared, central vision did not recover and fundal examination revealed multiple linear chorioretinal lesions and a juxtapapillary macular hole. Optical coherence tomography confirmed the full thickness macular hole with posterior dragging of the retinal pigment epithelium-Bruch's complex, and additional multifocal discontinuities of the superior retina. Microperimetry demonstrated complete loss of sensitivity at the fovea, extending nasally, indicative of damage to the papillomacular bundle .

These findings are suggestive of a perforating scleral injury, secondary to peribulbar injection and subsequent injury to the superior inner retina caused by the tip of the 25-gauge needle. An experienced, senior anaesthetist had delivered the injection of lidocaine 2% and bupivacaine 0.75%, via the inferolateral aspect of the orbital rim. The patient was observed for 1 year without further intervention, at which point the visual acuity was counting fingers, from a pre-operative baseline of 6/9.

This is the first example in the literature of a scleral perforation, secondary to peribulbar injection, involving the papillomacular bundle, causing loss of central vision in an eye of normal axial length.