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How To Do an Ophthalmic Nerve Block

(Supraorbital Nerve Block; Supratrochlear Nerve Block)

By

Richard Pescatore

, DO, Delaware Division of Public Health

Last full review/revision Oct 2021| Content last modified Oct 2021
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An ophthalmic nerve block anesthetizes the ipsilateral forehead, frontal scalp, and sometimes the upper eyelid.

Indications

  • Laceration or other surgically treated lesion of the frontal scalp, forehead, eyebrow, or upper eyelid

A nerve block has advantages over local anesthetic infiltration when accurate approximation of wound edges is important (eg, in facial skin repair), because a nerve block does not distort the tissue as does local infiltration.

Contraindications

Absolute contraindications

  • History of allergy to the anesthetic agent or delivery vehicle (choose a different anesthetic)

  • Absence of anatomic landmarks needed to guide needle insertion (eg, due to trauma)

Relative contraindications

* Therapeutic anticoagulation (eg, for pulmonary embolism) increases the risk of bleeding with nerve blocks, but this must be balanced against the increased risk of thrombosis (eg, stroke) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.

Complications

Most complications result from inaccurate needle placement.

Equipment

  • Nonsterile gloves

  • Barrier precautions as indicated (eg, face mask, safety glasses or face shield, cap and gown)

  • Antiseptic solution (eg, chlorhexidine, povidone-iodine, alcohol)

  • Injectable local anesthetic* such as lidocaine 2% with epinephrine† 1:100,000 or, for longer-duration anesthesia, bupivacaine 0.5% with epinephrine† 1:200,000

  • Syringe (eg, 3 mL) and needle (eg, 25 or 27 gauge) for anesthetic injection

† Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg; lidocaine with epinephrine, 7 mg/kg; bupivacaine, 1.5 mg/kg. NOTE: A 1% solution (of any substance) represents 10 mg/mL (1 g/100 mL). Epinephrine causes vasoconstriction, which prolongs the anesthetic effect. Patients with cardiac disease should receive only limited amounts of epinephrine (maximum 3.5 mL of solution containing 1:100,000 epinephrine); alternatively, use local anesthetic without epinephrine.

Additional Considerations

Relevant Anatomy

  • The ophthalmic nerve is the 1st branch of the trigeminal nerve.

  • The ophthalmic nerve exits the cranium through the supraorbital foramen/notch, which is palpable on the supraorbital rim, directly above the pupil when the patient is looking straight ahead. The ophthalmic nerve may branch intraorbitally before exiting the cranium—as the supraorbital nerve and (more medially) the supratrochlear nerve.

  • Several cutaneous branches of the ophthalmic nerve then spread over the forehead.

Positioning

  • Position the patient inclined or supine.

Step-by-Step Description of Procedure

  • Check sensation in the ophthalmic nerve distribution.

  • Wear gloves and use appropriate barrier precautions.

  • Palpate the supraorbital rim and identify the supraorbital notch (the injection site).

  • Cleanse the skin site with antiseptic solution, keeping it out of the eye.

  • Place a skin wheal of anesthetic, if one is being used, at the supraorbital notch.

  • Insert the needle farther and gently probe medially and slightly cephalad to elicit paresthesias. Do not insert the needle into the supraorbital foramen.

  • When paresthesia occurs, withdraw the needle 1 to 2 mm.

  • Aspirate to exclude intravascular placement and then slowly (ie, over 30 to 60 seconds) inject about 3 mL of anesthetic. While injecting, apply pressure (using your finger or some gauze) under the supraorbital rim to prevent swelling of the upper eyelid.

  • If no paresthesia occurs during needle insertion, inject the anesthetic over the supraorbital notch (identified by palpation).

  • Massage the area for about 10 seconds to hasten the onset of anesthesia.

  • If these injections are unsuccessful, place a line of anesthetic subcutaneously along the orbital rim to block the branches of the ophthalmic nerve.

  • Allow about 5 to 10 minutes for the anesthetic to take effect.

Aftercare

  • Ensure hemostasis at the injection site.

  • Instruct patient regarding anticipated time to anesthesia resolution.

Warnings and Common Errors

  • To minimize the risk of needle breakage, do not bend the needle at its hub, insert it to its full depth (ie, to the hub), or attempt to change direction of the needle while it is inserted.

  • To help prevent nerve injury or intraneural injection, instruct patients to report paresthesias or pain during the nerve block procedure.

  • To help prevent intravascular injections, aspirate before injecting.

Tricks and Tips

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