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EW NEWS & OPINION 20 January 2016 by Matt Young and Gloria D. Gamat EyeWorld Contributing Writers instead of enucleation or eviscera- tion (historically used for intractable pain and poor visional and disfig- ured eyes). The researchers found retrobulbar alcohol injection a successful and efficient method of managing severely intractable painful blind eye, especially in patients whose primary focus of management is pain relief, and globe preservation is a second con- sideration. Further, a 2006 case report from the U.K. found retrobulbar alcohol injection effective in providing pain relief from severe orbital pain (e.g., ocular pain due to myositis or tu- mor) resistant to chronic pain med- ication. The case report highlighted the challenges encountered in the management of ocular pain that is orbital in nature and how retrobul- bar injection provided effective pain relief under difficult circumstances. The pain relief is attributed to analgesia brought about by de- struction of nerve cells [coagulative necrosis] after retrobulbar injection of absolute alcohol. "This procedure has been used for many decades and appears to be an option for patients with cosmeti- cally acceptable blind painful eyes," explained William B. Trattler, MD, Center for Excellence in Eye Care, Miami. "The decision is often made by doctors after weighing all the op- tions and trying to figure out what's or are unable to safely undergo the rigors of anesthesia, retrobulbar alco- hol injection has been identified as a viable option for ocular pain relief. Recent reports In a case series conducted at the Shifa Foundation Community Health Centre Islamabad, Islamabad, Pakistan, for a period of 2 years (from March 2012 to March 2014), 5 patients with absolute glaucoma were treated with retrobulbar alco- hol injection for ocular pain relief and had success. It was reported in the Journal of Pakistan Medical Association in June 2015. The severity of pain was record- ed using a verbal analog score (VAS: 0–10, 10 being the highest). The patients were monitored from the first day after the operation, then at weekly intervals for 1 month, to every month for the first 6 months, and finally at 1 year after the proce- dure. VAS was recorded at all follow- up time points, and patients were assessed for complications. Findings demonstrated that all patients were pain-free 12 months after the injec- tion, and no significant long-term adverse reaction was observed. In 2014, Korean surgeons pre- sented retrobulbar alcohol injections as a reasonable alternative to surgery for blind chronically painful eyes, other causes associated with ocular pain include trauma, neoplasia, in- fections and inflammation, a typical cause remains absolute glaucoma. The pain, which can originate from the cornea, conjunctiva, sclera, iris or ciliary body, negatively impacts not only patients' quality of life but also their productivity. Necessitating a multidisciplinary approach, the complexity of ocular pain involves management of spe- cialists from different areas: anesthe- sia, ophthalmology, neurology, and in rare occasions, psychiatry. Differ- ent surgical procedures in alleviating ocular pain have also been previ- ously described and tested; these in- clude cyclodestruction, enucleation, evisceration and nerve blocks with retrobulbar alcohol injection. "I was trained to do this but haven't done so for years. It's a prelude to surgical correction of the eye, [before enucleation, in other words]. If a patient is too sick to undergo surgery, this procedure still might be useful," said John D. Sheppard, MD, professor of oph- thalmology, microbiology and mo- lecular biology, and clinical director, Thomas R. Lee Center for Ocular Pharmacology, Eastern Virginia Medical School, Norfolk, Va. In patients who still have cosmetically acceptable eyes and in those who either refuse surgery Retrobulbar alcohol injection for ocular pain relief T he use of retrobulbar al- cohol in the management of painful blind eyes is not new, but it is an old technique that continues to offer potential usefulness in an extreme situation. Since the early 20th century, ophthalmologists have been using retrobulbar alcohol injection to provide relief from ocular pain. Recently published worked of Pakistani researchers reported that retrobulbar alcohol injection is a safe and effective method in allevi- ating severe and refractory ocular pain in patients affected by absolute glaucoma. A century later, this old ocular pain relief technique still has a place in the modern ophthalmologist's armamentarium. But a reminder from Pakistan—where alcohol is not exactly typically favored—might be helpful. Ocular pain and absolute glaucoma Ocular pain, although multifacto- rial in nature, often occurs at some point in patients with blind eyes and unsalvageable vision. Although Old trick that still works for pain relief EyeWorld Blog Focusing on Refractive • Advances in technology • Refractive advice • Surgical techniques • Ask a question • Post a comment • Recommend a topic Visit: Blog.EyeWorld.org