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An 82-year-old man was referred with acute bilateral visual loss. He had multiple vascular risk factors and was taking warfarin.
On the day of presentation, he had been admitted elsewhere for elective extraction of a right-sided cataract. Retrobulbar anaesthesia comprised a single injection of 4 ml of 1% lignocaine/2% ropivacaine using a 38 mm 25-gauge needle inserted into the infero-temporal orbit, aiming for the peribulbar space. Fifteen minutes after anaesthesia, he complained of complete loss of vision.
Formal examination demonstrated no perception of light in either eye. Anterior chambers and fundi were unremarkable. There was no pupillary response to light in the right eye, and only a very sluggish response in the left eye. Extraocular movements were globally impaired on the right in keeping with the intended …