Successful management of central retinal artery occlusion and optic nerve injury postendoscopic sinus surgery with combined hyperbaric oxygen and intravenous steroids

Ramesh Murthy; Nikhil Beke; Aratee Palsule; Manisha Deshmukh

doi:10.4103/jcor.jcor_55_18

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Year : 2019 | Volume : 7 | Issue : 3 | Page : 124-126

Successful management of central retinal artery occlusion and optic nerve injury postendoscopic sinus surgery with combined hyperbaric oxygen and intravenous steroids

Ramesh Murthy¹, Nikhil Beke¹, Aratee Palsule¹, Manisha Deshmukh²
¹ Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
² Department of Internal Medicine, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

Date of Submission	26-Jun-2018
Date of Acceptance	25-Mar-2019
Date of Web Publication	11-Dec-2019

Correspondence Address:
Ramesh Murthy
Axis Eye Clinic, Kumar Millenium, Shivteerth Nagar, Paud Road, Kothrud, Pune - 411 038, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_55_18

Abstract

Functional endoscopic sinus surgery, especially ethmoidal surgery, carries a risk of orbital injury because of the close relation between the orbit and the sinuses. For central retinal artery occlusion (CRAO), hyperbaric oxygen therapy has shown good outcome. Intravenous steroids are prescribed for cases of optic nerve injury. We describe a case of combined optic nerve injury and CRAO following endoscopic sinus surgery which was managed successfully with good recovery of vision with multimodal therapy with a combination of intravenous methylprednisolone and hyperbaric oxygen

Keywords: Central retinal artery occlusion, endoscopic sinus surgery, hyperbaric oxygen

How to cite this article:
Murthy R, Beke N, Palsule A, Deshmukh M. Successful management of central retinal artery occlusion and optic nerve injury postendoscopic sinus surgery with combined hyperbaric oxygen and intravenous steroids. J Clin Ophthalmol Res 2019;7:124-6

How to cite this URL:
Murthy R, Beke N, Palsule A, Deshmukh M. Successful management of central retinal artery occlusion and optic nerve injury postendoscopic sinus surgery with combined hyperbaric oxygen and intravenous steroids. J Clin Ophthalmol Res [serial online] 2019 [cited 2023 Mar 23];7:124-6. Available from: https://www.jcor.in/text.asp?2019/7/3/124/272709

Sinus surgery aimed at removing diseased sinus mucosa and enhancing aeration of the sinuses has been in vogue to treat a variety of conditions. Transnasal endoscopic sinus surgery, especially ethmoidal surgery, poses a great risk of orbital injury especially in the hands of the inexperienced endoscopic surgeon owing to the close relation between the orbit and the sinuses.^[1] We describe a case of combined optic nerve injury and central retinal artery occlusion (CRAO) following endoscopic sinus surgery which was managed successfully with good recovery of vision with intravenous methylprednisolone and hyperbaric oxygen.9. Hadanny A, Maliar A, Fishlev G, Bechor Y, Bergan J, Friedman M, et al. Reversibility of retinal ischemia due to central retinal artery occlusion by hyperbaric oxygen.

Case Report

A 43-year-old woman presented to us with complaints of sudden-onset painless visual loss in her right eye a few hours after an endoscopic sinus surgery with septoplasty. Vision in her right eye was perception of light and accurate projection. Her left-eye vision was 6/6, and examination was within normal limits. Extraocular movements were normal without any proptosis. There was a subconjunctival hemorrhage on the temporal aspect of the bulbar conjunctiva in the right eye. Anterior-segment evaluation revealed relative afferent pupillary defect (Grade 3) in her right eye. Fundus evaluation after pupillary dilatation showed normal disc with pale retina and prominent opacification of the retina in periarteriolar region with cherry red spot. The retinal periphery was normal [Figure 1]a. The left eye's fundus was within normal limits. With a suspicion of right eye CRAO with optic nerve injury, an urgent magnetic resonance imaging and computed tomography (CT) scan were performed [Figure 2]. This showed diffuse right-eye optic nerve edema in the intraconal segment, a break in the lamina papyracea with medial bony displacement, and herniation of the orbital fat through the defect. Review of her operative notes revealed that she had undergone uncinectomy and middle meatal antrostomy. Erosion of the lamina papyracea was noted with prolapse of the orbital fat during the surgery.

Figure 1: (a) Fundus evaluation after pupillary dilatation on the same day of surgery shows normal disc with pale retina and prominent opacification of the retina in periarteriolar region with cherry red spot suggestive of central retinal artery occlusion. (b) Fundus fluorescein angiography performed shows delayed perfusion of the retinal arterioles with intact choroidal circuit and disc perfusion

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Figure 2: (a) T1-weighted axial magnetic resonance imaging scan image at the level of the mid orbit shows the presence of diffuse right-eye optic nerve edema in the intraconal segment, a break in the lamina papyracea with medial bony displacement, and herniation of orbital fat through the defect. (b) Computed tomography scan coronal view shows the presence of a breach in the inferomedial wall of the right-eye orbit with mild herniation of the orbital fat

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On the same day, she was administered injection methylprednisolone 1 g intravenous once a day which was given for 3 days and was also started on sublingual nitroglycerin with blood pressure and electrocardiogram monitoring. The next day, she underwent fundus fluorescein angiography which showed delayed perfusion of the retinal arterioles with intact choroidal circuit and disc perfusion [Figure 1]b. Visually evoked potential performed on the same day revealed delayed P100 latency, suggesting an anterior optic nerve pathway lesion [Figure 3]b. She also received hyperbaric oxygen at 2 atmospheric pressure for 90 min a day under the supervision of an internist for 10 days. After 10 days, her best-corrected visual acuity in the right eye was 6/12. Retinal examination revealed disc pallor in her right eye [Figure 4]a. Repeat fundus fluorescein angiography revealed improved perfusion of the retinal arteriolar circuit and adequate disc perfusion [Figure 4]b. At the 4^th month follow-up, her vision was 6/12 in her right eye, but she continued to have defective color vision, contrast and visual field [Figure 3]a.

Figure 3: (a) Visual field examination (30–2 perimetry) reveals the presence of severe constriction of the visual field in the right eye. (b) Visually evoked potential examination shows the presence of delayed P100 latency

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Figure 4: (a) Fundus photograph done 2 months after the episode shows the presence of diffuse disc pallor, more temporally, and the rest of the retina appears normal. (b) Fundus fluorescein angiography shows normal arterial and venous perfusion

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Discussion

The orbit is at greatest risk during endoscopic sinus surgery as the lamina papyracea is extremely thin, sometimes absent, and forms a near-imperceptible boundary during sinus surgery.^[2] The risk of damage is greater when the tissue is diseased or mechanized systems are used for sinus debridement. Mechanized systems extract tissue rapidly and do not provide any tactile feedback, thus predisposing to inadvertent orbital entry.^[3] Optic nerve injury can be direct or indirect due to instrumental damage or tissue or fat prolapse into the orbit from the ethmoidectomy site. Aerated posterior ethmoidal cells, called Odoni cells, can also be present close to the optic nerve, putting it at greater risk of injury.^[4]

These problems can be averted by performing a good CT scan, identifying the areas of disease preoperatively, and looking for anatomical variants. Early intraoperative location of the lamina papyracea, measures to reduce intraoperative bleeding, and good surgical technique can reduce the incidence of complications. Intraorbital hemorrhage can be due to direct injury to a vessel or trickling of blood from the sinuses into the orbit medially which can cause rapid onset of proptosis and loss of vision. Traction on an orbital vessel can also cause intraorbital hemorrhage. A transected ethmoidal artery can also retract into the orbit and bleed, leading to severe proptosis. It is best to keep the eye uncovered during endoscopic sinus surgery. Any movement of the eyeball indicates traction on the orbital fat with inadvertent orbital entry. Other indications of intraorbital hemorrhage include sudden proptosis or bruising of the lids or sudden swelling of the lids.

Observing the pupil is also important during surgery. Pupil dilation during surgery indicates either ischemia or damage to the pupillomotor nerves or optic nerve. Severe orbital hemorrhage leads to compressive optic neuropathy with subconjunctival hemorrhage, rapidly increasing proptosis, and a tense orbit. Diplopia indicates either muscle entrapment or muscle injury.^[1],[5]

Hyperbaric oxygen therapy (HBOT) includes the inhalation of 100% oxygen at pressures >1 atmosphere absolute to enhance the amount of oxygen dissolved in the body tissues. During HBOT, the arterial oxygen tension exceeds 2000 mmHg, nearly 20–30 times the amount of oxygen dissolved in the plasma.^[6] Normally, about 60% of the retina's oxygen consumption is supplied by the choroidal circulation, but with HBOT, nearly 100% of the oxygen to the retina can be supplied by the choroidal circulation.^[7] The mechanism of HBOT is to increase the oxygen to the ischemic tissue till reperfusion occurs. HBOT is approved by the US Food and Drug Administration for the treatment of CRAO.^[6] HBOT can increase the amount of oxygen dissolved in plasma from 0.32 to 6 ml oxygen/100 ml, which is almost 17-fold more than breathing room air.^[8] HBOT is useful provided the ischemic macula has not developed the irreversible anoxic change in the form of a cherry red spot.^[9] HBOT can oxygenate the ischemic, yet not fully necrotic retina, reverse the preinfarction, and significantly improve the visual outcome.^[9] However, in our patient, in spite of ischemia and the presence of a cherry red spot, we managed to recover satisfactory vision. In our patient, HBOT was used to treat the ischemic retina and methylprednisolone for the optic nerve injury with good outcome. Thus, in our patient, identification of the presence of more than one mechanism of injury and their treatment individually with two modalities resulted in a good visual recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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