Sir,

We read with interest the solutions proposed by Rossiter et al1 for eccentric eye positions that develop during general anaesthesia. Ideally, the physician should recognize the abnormal eye position before starting surgery. Allowing a few minutes to elapse between placement of a superior rectus bridle suture and the first incision should permit the intraocular pressure to normalize so that surgery can be performed safely.

As the authors indicate, a peribulbar or subtenons infiltrate of anaesthesia limited to the region around the superior rectus muscle may resolve the problem. Perilimbal traction sutures can also be helpful in providing the surgeon with more complete control of ocular movements. These are useful not only when general anaesthesia leads to eccentric eye positions but also when local anaesthesia does so.

Although the authors recommend the use of nondepolarizing muscle relaxants (NDMRs) to manage this intraoperative hurdle, we note that their use carries significant risks, as these drugs are implicated as the most common causative agents of anaphylactic reactions in anaesthetic patient populations.2 Therefore, we believe that NDMRs should be considered only as a last resort after failure of local anaesthetics, traction sutures, and the tincture of time to stabilize the globe.