Korean J Ophthalmol.  2015 Aug;29(4):233-240. 10.3341/kjo.2015.29.4.233.

Iatrogenic Central Retinal Artery Occlusion Following Retrobulbar Anesthesia for Intraocular Surgery

• Jung EH
• Park KH
• Woo SJ

• KMID: 2363767
• DOI: http://doi.org/10.3341/kjo.2015.29.4.233

Abstract

PURPOSE
To present clinical features of central retinal artery occlusion (CRAO) following retrobulbar anesthesia for intraocular surgery.
METHODS
This observational case series describes 5 consecutive patients with acute CRAO following retrobulbar anesthesia for intraocular surgery. Data collected for this study included subject characteristics, retrobulbar anesthesia technique, treatment type, initial and final best-corrected visual acuity, and other ophthalmologic examinations.
RESULTS
Mean subject age was 67.0 +/- 8.2 years (range, 53 to 72 years). All patients had one or more vascular risk factors (e.g., hypertension, cerebral infarction, carotid artery stenosis) and presented with acute vision loss 1 day after uneventful intraocular surgery (cataract surgery in 2 eyes and vitrectomy in 3 eyes). All 5 patients received retrobulbar anesthesia during surgery, 4 of which involved the use of a sharp needle. No immediate complications were noted during intraocular surgery. Final visual prognosis was poor (from finger count to no light perception) although intraocular thrombolysis was attempted in 3 patients.
CONCLUSIONS
Iatrogenic CRAO is a potential complication of retrobulbar anesthesia for intraocular surgery in elderly patients with vascular risk factors. Unfortunately, this complication can lead to severe vision loss. We conclude that retrobulbar anesthesia for intraocular surgery should be performed with great care and special consideration for elderly patients with vascular risk factors.

Keyword

Cataract; Intraocular surgery; Retinal artery occlusion; Retrobulbar anesthesia; Vitrectomy

MeSH Terms

Aged
Anesthesia/*adverse effects/methods
Anesthetics, Local/administration & dosage/*adverse effects
Female
Fluorescein Angiography
Follow-Up Studies
Fundus Oculi
Humans
*Iatrogenic Disease
Male
Middle Aged
Ophthalmologic Surgical Procedures/*adverse effects
Orbit
*Postoperative Complications
Retinal Artery Occlusion/diagnosis/*etiology
Retrospective Studies
Visual Acuity
Anesthetics, Local

Figure

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  Fig. 1 Images of patient 1 who underwent cataract surgery (phacoemulsification and posterior chamber intraocular lens implant) with retrobulbar anesthesia. (A) Fundus photograph showing a cherry-red spot. (B) Fluorescein angiogram showing decreased choroidal perfusion and delayed filling of the retinal artery and vein. (C) Internal carotid angiogram showing stenosis of the right ophthalmic artery (arrow) and a tortuous proximal ophthalmic artery.

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  Fig. 2 Images of patient 2 who underwent vitrectomy, endolaser, and intravitreal air injection for proliferative diabetic retinopathy vitreous hemorrhage. (A) Fundus photograph obtained 3 days after intraarterial thrombolysis. A cherry-red spot, retinal edema, and multiple retinal hemorrhages are apparent. (B) Spectral domain optical coherence tomography image obtained 3 days after intra-arterial thrombolysis. Increased reflectivity and inner retinal thickness (including the central macula), along with decreased outer retina reflectivity, are apparent. (C) Internal carotid angiogram showing severe stenosis of the right cervical internal carotid artery (arrow) and the ophthalmic artery.

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  Fig. 3 Images of patient 3, who presented with severe visual decline resulting in no light perception after vitrectomy with retrobulbar anesthesia for proliferative diabetic retinopathy and vitreous hemorrhage. All images were taken 7 days after surgery. (A) A cherry-red spot and severe arterial narrowing and sclerosis are observed in the fundus photograph. (B) Early-phase (2 : 11) fluorescein angiogram showing poor arterial filling. (C) Increased reflectivity and thickness of the inner retina are apparent in spectral domain optical coherence tomography. (D) Standard electroretinogram (ERG) in the left eye showing decreases in both scotopic and photopic wave amplitude.

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  Fig. 4 Images of patient 4, who underwent vitrectomy under retrobulbar anesthesia for treatment of epiretinal membrane. Preoperative best-corrected visual acuity was 20 / 32 in the right eye. One day following surgery, best-corrected visual acuity was at the level of "hand motion" in his right eye. (A) Fundus photograph 1 day after surgery, showing a cherry red spot and marked inner retinal edema in the macula. (B) Early-phase (20 seconds after fluorescein injection) fundus fluorescein angiography 13 days after surgery, showing a mild delay in arteriovenous transit time and multiple patchy capillary nonperfusion in the posterior pole. (C) Goldmann visual field test obtained 5 months after surgery, indicating the presence of a central scotoma.

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  Fig. 5 Images of patient 5, who underwent cataract surgery (phacoemulsification and posterior chamber intraocular lens implant) under retrobulbar anesthesia and presented with visual decline 1 day after surgery. (A) Fundus photograph 1 day after surgery, showing a typical cherry red spot in the right eye. (B) Increased retinal reflectivity and internal retinal thickness are apparent in spectral domain optical coherence tomography. (C) Transfemoral cerebral angiogram performed 1 day after surgery, showing no definitive occlusion in the ophthalmic artery (arrow) or cerebral arteries.

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