I read with great interest the article from Bourla and associates. I compliment the authors for clearly showing the indications for the adjuvant treatments during vitreoretinal surgery. The very well described 25-gauge selective sutureless technique really seems to enhance the success rate in vitreoretinal surgery for rhegmatogenous retinal detachment, in their hands. In fact, they show brilliant surgical results with a very high single-operation success rate.

I only have some concerns regarding the anesthetic technique the authors used in all patients who underwent the 25G vitrectomy, and I would seek their opinion on this subject.

Whereas intraconal and extraconal blocks using needles are commonly used, and the techniques are generally safe; serious sight- and life-threatening complications, although rare, have occurred following the inappropriate placement of needles. The sub-Tenon’s block technique was introduced as a safer alternative. If it is true that there is no absolutely safe ophthalmic regional block, I wonder whether the retrobulbar anesthesia is probably the less safe among the available different options. The authors do not state the prevalence of myopic patients in their series. As is well known, myopic patients are more prone to incur retinal detachment and their longer axial length represents a risk factor for complications associated with intraconal retrobulbar anesthesia.

I would challenge the authors to agree that the medial percutaneous peribulbar anesthetic technique with short needle, proposed by Rizzo and associates, and the 1-quadrant sub-Tenon’s peribulbar anesthetic technique, proposed by Stevens, represent safer alternatives to the retrobulbar anesthesia in vitreoretinal surgery. If obtaining akinesia is one of the main concerns, we can clearly understand that the Rizzo technique has been demonstrated to produce an echographically evident infiltration of the intraconal retrobulbar space and that the sub-Tenon’s block technique, especially when associated with hyaluronidase, is able to obtain a good motor blockade.

Sub-Tenon’s and retrobulbar anesthesia have already been compared in a prospective randomized comparative clinical interventional study, with the former being safe and effective and requiring less local anesthetic than retrobulbar anesthesia.