DOI: 10.1097/IOP.0b013e3181b397df
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PMID: 19966668
Issn Print: 0740-9303
Publication Date: 2009/09/01
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Excerpt
The patient missed her next-day appointment and presented 8 days later with a large medial subconjunctival hemorrhage OS, 3 mm of left proptosis, a left relative afferent pupillary defect, 30 Δ of exotropia, limitation of horizontal motility, and no light perception visual acuity OS, but the fundus was normal. On questioning, the patient mentioned that she had sudden severe pain in the left eye on the same day while at home with sudden loss of vision, but she did not seek treatment. Urgent CT of the orbit showed a large medial wall fracture OS with blood filling most of the maxillary and ethmoid sinuses and incarceration of the medial rectus in the fracture site; there was minimal blood in the orbit (Fig.). The patient was diagnosed to have lost vision in the left eye secondary to a retrobulbar hematoma.
The trend toward minimally invasive surgery is becoming ever more popular in ophthalmology, and lacrimal surgery is no exception. Ideally, EN-DCR should be a step further down the road beyond endoscopic techniques toward achieving the goal of minimal access surgery because it requires a significantly less steep learning curve and less instrumentation.1
The cause of vision loss in our patient remains a dilemma. We initially thought that an accidental large tear of the periobita allowed blood to trickle and collect behind the eye, and that the nasal pack that was placed prevented the collected blood from oozing out, forcing its way in the orbit. The traumatic nature of the procedure evidenced by the large medial wall fracture on CT lent further support to our initial hypothesis.
It should be noted, however, that the scarcity of blood behind the eye on CT belies our theory, and the location of the fracture well posterior to the lacrimal sac fossa also suggests alternative explanations. Because of poorer visualization of anatomic landmarks inherent in this technique, it seems more logical to assume that the surgeon could have committed an error locating the proper site of bone removal, injuring the medial rectus in this way, which slowly bled in the orbit causing a compartment syndrome. Alternatively, a vascular spasm or indirect injury to the posterior orbital circulation, due to local diffusion of the anesthetics or to undue stretch on the medial rectus muscle, respectively, cannot be completely ruled out.2
Whether limited visualization from an intransal nonendoscopic approach, or surgeon error can be blamed for this complication is not clear. The surgeon (M.E.) has a relatively large experience with DCR, particularly EN-DCR, which leaves us more inclined to accept the first possibility that the lack of an endoscope might have precluded accurate assessment of the anatomic landmarks and led to grave intraoperative judgment errors.
It may be foolish to make sweeping conclusions from a single case report, but because different problems have been reported with EN-DCR despite the obvious fact that the procedure is not widely practiced,1,3 and because a computerized literature search using Medline did not reveal any published references for blindness after alternative DCR techniques, we think that despite its simplicity, short operating time, and lack of sophisticated instrumentation, the complications of EN-DCR should not be neglected.
