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Mohamed A Awwad,1 Mohamed Masoud,1 Mona Ahmed Elhadad2 1Department of Ophthalmology, Benha University Hospital, Benha, Qualubia, Egypt; 2Department of Anesthesia and Surgical Intensive Care, Benha University Hospital, Benha, Qualubia, EgyptCorrespondence: Mohamed A Awwad, Department of Ophthalmology, Benha University Hospital, Benha, Qualubia, Egypt, Tel +20 1017014208, Email mohamed.awad@fmed.bu.edu.eg; mohdzahir82.ma@gmail.comObjective: To assess the effect of peribulbar anesthesia on retinal microvasculature in primary open-angle glaucoma (POAG) patients undergoing cataract surgery using OCT Angiography.Participants: Forty-nine patients undergoing cataract surgery were divided into two groups. Group I included patients with no history of glaucoma, while group II included patients previously diagnosed as POAG with controlled IOP. Each participant received 6 mL of peribulbar anesthetic injection of 4 mL lidocaine 2% containing 150 IU hyaluronidase and 2 mL bupivacaine 0.5%. They were scanned with the OCT-A 10 minutes before and 10 minutes after injection for foveal deep (DCP), superficial (SCP) capillary plexuses density and total vessel density, foveal avascular zone (FAZ) diameter, optic disc total vessel density, and radial peripapillary capillary (RPC) network density. In addition, IOP was checked before and 10 minutes after injection.Results: Median percent change in DCP post-injection was significantly greater in group II (− 43%) than in group I (− 2.5%) (P < 0.001). Also, DCP total density median percent change post-injection was significantly higher in group II (− 21%) than in group I (− 0.9%) (P < 0.001). Foveal SCP vessel density and total vessel density median percent change post-injection were − 62.6% and − 16.2%, respectively, in group II and were − 2.6% and − 1.1%, respectively, in group I, which are statistically significant (P < 0.001). The FAZ diameter median percentage change post-injection was higher in group II (40.6%) than in group I (2.5%) (P < 0.001). Optic disc total vessel density and radial peripapillary capillary (RPC) network density post-injection median percent change were significantly higher in group II (− 13.6%) and (− 13.1%) respectively than in group I (− 1.1%) and (− 1.25%) respectively (P < 0.001).Conclusion: Peribulbar anesthesia harbors a deleterious ischemic effect on the retinal vascular tree of glaucoma patients, which could harmfully affect the vision and the visual field in those vulnerable patients.Keywords: peribulbar, anesthesia, glaucoma, IOP, OCT-A, retinal blood flow