Rev. Bras. Anestesiol. vol.66 número1

RevBrasAnestesiol.2016;66(1):75---77

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Treatment

of

patients

with

painful

blind

eye

using

stellate

ganglion

block

Tatiana

Vaz

Horta

Xavier,

Thiago

Robis

de

Oliveira

_,

Tereza

Cristina

Bandeira

Silva

Mendes

Dr.JosefinoFagundesdaSilvaPainTreatmentClinic,UniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil

Received18February2012;accepted11December2012 Availableonline6April2014

KEYWORDS

Eye

pain;

Pain

management;

Nerve

block

Abstract

Backgroundandobjectives: managementofpaininpainfulblindeyesisstillachallenge.

Cor-ticosteroidsandhypotensiveagents,aswellaseviscerationandenucleation,aresomeofthe strategiesemployedsofarthatarenotalwayseffectiveand,dependingonthestrategy,cause adeepemotionalshocktothepatient.Giventheseissues,theaimofthiscasereportisto demonstrateanewandviableoptionforthemanagementofsuchpainbytreatingthepainful blindeyewiththestellateganglionblocktechnique,aprocedurethathasneverbeendescribed intheliteratureforthispurpose.

Casereport: sixpatientswithpainfulblindeye,allcausedbyglaucoma,weretreated;inthese

patients,VAS(visualanaloguescaleforpainassessment,inwhich0istheabsenceofpainand 10 isthe worst pain everexperienced)ranged from7to 10.We optedfor weeklysessions ofstellateganglionblockwith4mLofbupivacaine(0.5%)withoutvasoconstrictorand cloni-dine1mcg/kg.FourpatientshadexcellentresultsatVAS,rangingbetween0and3,andtwo remainedasymptomatic(VAS=0),withouttheneedforadditionalmedication.Theothertwo usedgabapentin300mgevery12h.

Conclusion: currently,thereareseveraltherapeuticoptionsforthetreatmentofpainfulblind

eye,amongwhichstandouttheretrobulbarblockswithchlorpromazine,alcoholandphenol. However,aneffectivestrategywithlowrateofseriouscomplications,whichisnon-mutilating andimprovesthequalityoflifeofthepatient,isessential.Then,stellateganglionblockarises asademonstrablyviableandpromisingoptiontomeetthisdemand.

© 2014SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

∗_{Correspondingauthor.}

E-mail:[email protected](T.R.deOliveira).

0104-0014/$–seefrontmatter©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

76

T.V.H.

Xavier

et

al.

PALAVRAS-CHAVE

Dor

ocular;

Manejo

da

dor;

Bloqueio

nervoso

Tratamento

de

pacientes

portadores

de

olho

cego

doloroso

por

meio

de

bloqueio

de

gânglio

estrelado

Resumo

Justificativaeobjetivos: Omanejodadoremolhoscegosdolorososaindaéumdesafio.

Corti-costeroidesehipotensores,bemcomoeviscerac¸ãoeenucleac¸ão,sãoalgumasdasestratégias atéentãoempregadas,nemsempreeficazeseque,adependerdaestratégia,causamum pro-fundoabaloemocionalnopaciente.Dadasessasquestões,oobjetivodesterelatodecasoé demonstrarumanovaeviávelopc¸ãoparaomanejodessetipodedorpormeiodotratamento doolho cego doloroso combloqueios degângliocervicotorácico, técnicanuncadescritana literaturaparaessefim.

Relatodecaso:Foram tratados seispacientes portadores de olho cego doloroso, todospor

glaucoma,nosquaisaEVA(escalavisualanalógicaparaavaliac¸ãodadoremque0éausência dedore10éamaiordorjáexperimentada)variavade7a10.Optou-seporsessõessemanais debloqueiodegângliocervicotorácicocom4mLdebupivacaína(0,5%)semvasoconstritore clonidina1mcg/Kg. Quatropacientesapresentaram excelenteresultado EVA,comvariac¸ão entre0e3, edoispermaneceram assintomáticos(EVA=0),semnecessidadedemedicac¸ão suplementar.Osoutrosdoisusaramgabapentina300mgde12em12horas.

Conclusão:Atualmente, várias sãoas opc¸ões terapêuticas para o tratamento doolho cego

doloroso,entre asquais sedestacam osbloqueios retrobulbares comclorpromazina,álcool efenol.Noentanto,umaestratégiaeficaz,compequenoíndicedecomplicac¸õesgraves,não mutilante e quemelhore aqualidadede vidado paciente éimprescindível. Obloqueio do gângliocervicotorácicosurge, pois,como umaopc¸ãocomprovadamente viávelepromissora paraatenderaessademanda.

©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Managementofpaininpainfulblindeyesisstilla challengeand represents one of the most frustratingproblems in ophthalmol-ogy.Foryears,numeroustherapeuticstrategiesweretempted,with theaimtorelieveocularpainsymptoms.Corticosteroids, hypoten-sivedrugsand therapeutic contactlenseshave proveduseful in somecases.Eviscerationandenucleation1_{tendtobeproposedin}

moretreatment-resistantcases.However,theselatteroptionsare responsiblefor adeep emotionalshocktothepatient,and with respecttotheevisceration,itdoesnotalwayspromote fullpain relief.Retrobulbarinjectionswithneurolyticagentsand chlorprom-azineconstitutethemostwidespreadtherapeuticstrategies,2_but

oftencausesignificantcomplications,suchaspermanentparalysis ofocularmuscles, retrobulbarhaemorrhage,opticnerveatrophy and perforation of the globe.The case reportin question con-cernsthechoiceofanewtherapeuticstrategyforthetreatmentof painfulblindeye,wherethestellateganglionblockadewasused ---atechniquenotdescribedintheliteratureforthispurpose.

Case

report

Thesubjects weresixpatientswithpainful blindeye causedby glaucoma,inwhomthetreatmentwithtopicalagentsandspecial contactlensesintroducedbyophthalmologydidnotsucceed. Ini-tialevaluation of thesepatients showedthat the self-described painintensityrangedfrom7to10inVAS(visualanaloguescale), whichsignificantlycompromisedtheirdailyactivities.Acourseof sixweeklysessionsofcervicothoracic(stellate)ganglionblockwith 4mL of 0.5% bupivacaine without vasoconstrictor and clonidine 1mcgKg−1_{was proposed. Thesesessions wereperformed inthe}

surgicalsuite,withblockingbyparatrachealroute.

Results

Ayearhaspassedsincethebeginningoftreatmentuntilambulatory discharge.Fourpatientsshowedexcellentresponsetotreatment; two of them remained completely asymptomatic, with no need for additional medication, and two remained with residual pain self-characterized as VAS 3. These latter patients continued treatmentwithgabapentin300mgevery12h.Withrespecttothe othertwo patients,one of themabandonedtheclinicafterthe blocksand theotherpresentedmajordepressionconcomitantto hereye pain, and wasfounddrunk intwo ofthe consultations, factors that greatly compromised her treatment. At that time, thepatientwasmedicatedwithcarbamazepine200mgevery8h, morphinesulphate10mgevery 4h, sertraline150mgonce daily andnortriptyline75mgonceaday.

Discussion

According to Bonica,3 _{ophthalmic pain is characterized by its}

intensityand abilityto generateanxiety.Second onlyto fearof death,thefearofblindnessinvolvesagreatemotionalchargeto thepatientandtohis/herdoctor.Thus,adequateattentionshould be givento eyepain, notonlyfor patientcomfort, butalsofor prevention and treatment of those patients with narrow-angle glaucoma,inwhichtheextentofstructuralandfunctionaldamage iscloselyrelatedtothedurationofthepaincrisis.Glaucomacan becharacterizedasaopticneuropathyassociatedwithatypical opticnervedamage.4_{Then,thepossibilityarisesthatpartofthe}

blindglaucomatouseyepainmightbeexplainedbythisoptic neu-ropathyandbythestructuraldamageresponsibleforneuropathic pain.5,6_{Thishypothesis---thatthepaininblindandglaucomatous}

eyes could be of neuropathic origin --- was first approached by Kavaliteratos7 _{in a case report in which a patient with that}

Treatment

of

patients

with

painful

blind

eye

using

stellate

ganglion

block

77

Neuropathic

pain

and

sympathetic

nervous

system

Studiesshowthatallodyniaandhyperalgesiaappeartoinvolveboth thecentralandtheperipheralnervoussystem.Neuropathicpainof peripheraltissuesisgeneratedormaintainedexclusivelybysensory nerves,orbyaberrantactionsofthesympatheticnervoussystem insensorynerves.8

Itisalreadyknownthatperipheralnerveinjuriesprovide plas-tic changes, both of primary afferent neurons and sympathetic postganglionicneurons, depending on thetype(partial or total) ofinjury.Thisneuronalplasticityischaracterizedbydegenerative and regenerative changesand byrearrangementsculminating in biochemicallinksamongprimaryafferentandpostganglionic sym-patheticneurons,aswell asincollaterallinksinthedorsalroot ganglion by intact neurons. These links are responsible for the activationofprimaryafferentneuronsbythesympatheticnervous system,inwhichthelikelymediatorisnorepinephrine.9

Thus,onecaninferthatpartoftheeyepainhasasits main-tainerthesympatheticnervoussystem,thoughthisisnotitsprimary cause. The pain maintained by thesympathetic nervous system is characterizedbyaburning sensation, allodynia,and coldand touchhyperalgesia,10 _{symptomspresentedbypatientstreatedin}

thepresentcasereport.Numbnessandhyperesthesiaarecommon andtheremaybeswellingandothersignsofautonomicdysfunction.

Strategies

for

eye

pain

treatment

Throughtheyearsvariousstrategieshavebeendevelopedforthe treatmentofocularpain.Gruterin1918describedhisexperience withretrobulbarinjectionsofalcohol.11,12 _{Afterthisinvestigator,}

severalothersdescribedtheirexperiences,somealsowiththeuse ofphenolreplacingalcohol.Bothareneurolyticagentsstillused, butwhichhavebeenabandonedinsomecentresastheyhave lim-itedanalgesiceffect(aroundthreemonths)andtheirusemaycause significantcomplications,suchasretrobulbarhaemorrhage, perma-nentparalysisofeyemusclesandpermanentptosis.

Currentlythemostwidespreadtechniquehasbeentheuseof retrobulbarinjectionsofchlorpromazine,13_{firstsuggestedin1980}

byFioreandin1989byBastrikof,withreportedpainreliefin84%of patientsinthestudies.14_{However,thisisatechniquewithlimited}

duration,aroundsixmonths.Inaddition,therearereportsofblock techniquefailure,aswellassignificantsideeffectssuchasoedema, ptosis,sterileorbitalcellulitis,transientlimitationofextraocular movements,retrobulbarhaemorrhageandcornealepithelialinjury, amongothers.

Enucleation and evisceration are also options for the cases inwhich painisdebilitatingand doesnotrespond toanyofthe mentionedtreatments.Especiallyincasesofeyedisfiguration, evis-cerationandenucleationendupbeingthetreatmentsofchoice.15

Itshouldbeborneinmindthedeepemotionalharmthatoccursin patientswhoundergothistechnique,especiallyincaseswherethe eye,althoughpainful,waslookinggood.Inaddition, thereisthe factthatenucleationisnotalwayseffective,becausethecilliary nervesmayremainintactandthusconveyaresidualpain.

Stellate

ganglion

block

Usually,thestellateganglionisformedbythefusionofthe infe-riorcervicalandfirstthoracicganglia,beingresponsibleformost ofthesympatheticinnervationofthehead,neckandarm.Itsblock hasbeendescribedastherapeuticforvariousdisorders.Thereare reportsoftreatmentforglaucomaandfacialpainwiththeuseof thistypeofblock.6,16,17_{Thetreatmentoforofacialpainwith}

stel-lateganglionblockhasbeenwellreportedintheliterature,with

respecttothewell-knowninvolvementofthesympatheticnervous systeminthistypeofpain.18_{In1953,Millershowedthatthe}

block-ingofthisganglionalterstheintraocularpressureinglaucomatous eyes.19_{However,thetreatmentofpainfulpost-glaucomablindeye}

withstellateganglionblockhasneverbeendescribedinthe litera-ture.

Conclusion

The treatmentof painful blind eyes is controversial and poorly addressedintheliterature.Amongthevarioustherapeuticoptions, stellateganglionblockcanbeaviableandpromisingproposal.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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