Unusual Case

[shiro1]

I'd like to throw out an unusual case I saw a while back to see if more minds can help shed light on it for me.

Late 30's white male was admitted to the hospital for abdominal pain and, concerned that he may have gallstones he underwent an ERCP, which I believe lasted 2-3hrs. While undergoing this he was lying prone, slightly on his left side to help the GI doc. As soon as he woke up he complained of not being able to see anything at all out of his left eye. For whatever reason, I got the consult the following day, approximately 24 hours later. 20/30 OD, LP os. Big time APD. Moderate orbital signs of proptosis (2 mm by Hertels) mild limitation of adduction and 1+ conjunctival injection. Fundus examination completely normal, no retinal swelling, optic nerve looks very healthy. So I get a STAT CT, nothing, but a little proptosis. MRI, same thing. I call my friendly neuro-opth, who is concerned that he may have bleed into his optic nerve and offers optic nerve sheath decompression! Anyway, while I'm waiting I do a bolus Solumedrol, with little change in his vision. I also get a fluorescein which shows a very fast transit time. One day after his first presentation he shows a little retinal swelling, not present on initial exam. Bottom line, I sent him directly to neuro-ophth and he told me that he thought it was due to hypovolemia during the case. I spoke at length to all docs involved in his case and they swear no such thing took place during the procedure, which was very uneventful. The only thing that I found out later was about the positioning during the procedure. He may have been lying direcly on this eye during the 3 hr procedure. The neuro guy did not recommend any hypercoag work-up. This nice, father of a 2 year old is naturally upset, and I don't know quite what to say to him. I'm also a little afraid of being called as a witness if he decides to go litigious. As far as I can tell from my own research there are case reports of blindness following surgery, other than eye surgery, but it seems to be a rare complication. Has anyone else experienced this? Any thoughts on etiology?

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[EyeFormation]

I saw a case in residency of a lady in her 40's who underwent an ERCP who awoke with an orbital hemorrhage (tense orbit, rAPD, IOP in the high 30s--we never got a VA because she was still somewhat sedated). I think that she had liver disease with a co-existing coagulopathy. After canthotomy/cantholysis, her orbit decompressed nicely and she ended up 20/20. Maybe ERCPs are dangerous to vision!

 

[Retinamark]

Peri-operative visual loss is unfortunately not rare, and while there are some well recognized causes (ie hypotension / hypovolemia, and direct compression for eg) there are many cases with no identifiable cause

Dr Mark Werner at Mayo Clinic & the American Anesthetic Association have published a position statement on this issue, specifically directed at spine surgery, one of the more common causes, but also applicable to this situation
It's worth a read & has a good list of references.
Hope this helps....




Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery

(Approved by the ASA House of Delegates on October 25, 2005)

The purposes of this advisory are to enhance awareness of permanent impairment or total loss of sight associated with a spine procedure during which general anesthesia is administered and to reduce its frequency. The conditions addressed in this advisory are posterior ischemic optic neuropathy (PION), anterior ischemic optic neuropathy (AION) and central retinal artery occlusion (CRAO).

http://www.asahq.org/publicationsAndServices/practiceparam.htm#spine

 

[shiro1]

Thanks--I appreciate the link. Especially as I was asked to be present for a peer review of this situation. Unfortunately, he did not have ANY of the risk factors listed by this advisory.

 

[Andrew_Doan]

The only thing that I found out later was about the positioning during the procedure. He may have been lying direcly on this eye during the 3 hr procedure.

http://www.ncbi.nlm.nih.gov/entrez/..._uids=10872768&query_hl=1&itool=pubmed_docsum

J Spinal Disord. 2000 Jun;13(3):271-2. Related Articles, Links


Unilateral blindness as a complication of intraoperative positioning for cervical spinal surgery.

Manfredini M, Ferrante R, Gildone A, Massari L.

Department of Biomedical Sciences and Advanced Therapies, Section of Orthopaedics and Traumatology, University of Ferrara, Italy.

The authors report a case of unilateral blindness after surgical vertebral stabilization for C5-C6 subluxation. The blindness resulted from ischemia of the retina caused by prolonged compression of the eyeball on the surgical bed. This injury can be serious and irreversible, so it must be prevented by placing the patient in the proper position. The anesthetist must pay particular attention to avoid the consequences of possible intraoperative movement.

 

[shiro1]

Upon review of some articles and further questioning of the GI doc involved I think this guy had a CRAO related to head positioning during his proceedure done in a prone position. The peer review is tomorrow so I'll see if I can gain any more information.

Anyone have an idea about the etiology of the orbital findings of proptosis, decrease adduction and mild chemosis?

 

[nyeyes]

our neuro-op attg has told of us cases of PION after surg (spinal, GI, ext..), but would not expplain dec EOM's or proptosis

 

[eyestar]

Could it be Purtscher's retinopathy? seen esp. in acute pancreatitis, lupus, TTP, crf or trauma. Acutely, the optic nerve head and peripheral retina appear normal. But unilateral is kind of rare.

 

[shiro1]

To update: In positioning for the proceedure the patient was placed prone on a gel doughnut. He is very large, muscular and has a very stiff neck. The anesthesiologist noted that they would have to be very careful about his eyes, nose and airway during the proceedure. There is only one size doughnut in the OR. The entire proceedure including anesthesia care took about 3 hours due to excess puss and stent placement during the ERCP. No abnormalities in VS seen during proceedure.

I think he had a "temporary" CRAO due to external pressure directly on the eye for 3 hours. Afterwards, FANG showed good circulation through the CRA, but shutting it off for 3 hours was enough to cause irrevocable damage. Also, I read a case in which they felt there was medial rectus damage due to venous congestion and external pressure pushing the muscle up against the bony orbit. This may suggest an etiology for his EOM problems. He may have also had a PION which can also account for his large APD. In any case, all of this is conjecture and in the peer review the only conclusion that we came up with is that it rarely happens, but it does and it was most likely due to the difficult positioning. The OR has ordered different sized doughnuts for head positioning and take care now to avoid any direct pressure on an eye.

 

[7ontheline]

Could it be Purtscher's retinopathy? seen esp. in acute pancreatitis, lupus, TTP, crf or trauma. Acutely, the optic nerve head and peripheral retina appear normal. But unilateral is kind of rare.

Wouldn't there be lots of hemorrhages though?

 

[ryangeraets]

Sounds like it might be orbital compartment syndrome. There was an article earlier this year in Ophthalmology that sounded very much like the case you had described, and just recently there was a letter to the editor regarding the article that made me think of your post. Most of the other cases had some pain as well, but this diagnosis would explain the coexistent orbital findings (motility dysfunction, chemosis, etc) that your patient had along with the likely optic nerve dysfunction (?PION)
Hope this helps!

Ophthalmology. 2006 Jan;113(1):105-8