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Show Jmiriml of Neiim- Ophlhalmolofiy 19( 3): 176- 179, 1999. © 1999 Lippincott Williams & Wilkins, Inc., Philadelphia Posterior Optic Nerve Infarction After Lower Lid Blepharoplasty Catriona D. Good, Lorraine M. Cassidy, Ivan F. Moseley, and Michael D. Sanders We describe a case of acute and total loss of vision after lower lid blepharoplasty. This major complication followed minor cosmetic surgery. Magnetic resonance imaging ( MRI) showed posterior segmental infarction of the optic nerve, a finding not previously demonstrated. Key Words: Blepharoplasty- Blood supply- Complication- Oplic nerve- Optic nerve infarction- Visual loss. CASE REPORT A 68- year- old woman had carbon dioxide laser therapy and lower lid blepharoplasty for bags under her eyes and wrinkles. The surgery was carried out under local anesthetic and sedation as a day case. Transconjunctival injections of Lignocaine 2% ( International Medication Systems ( UK) Ltd, Surrey, England) with adrenaline were performed bilaterally. Incisions were made through the conjunctiva into the fat bags using a C02 laser. Haemostasis of large blood vessels was secured with diathermy, the fat was excised, and the lower lids allowed to return to their natural position. Afterwards, periocular resurfacing of wrinkles was performed using the Feathertouch technique. Immediately after the procedure there was slight oozing of blood from the left lower lid margin, which settled, and the patient was discharged 2 hours later. Later that night she had marked swelling and bruising around both eyes and was unable to open her right eye. The next day she experienced rapid, complete visual loss from the right eye, which had been normal preopera-tively. Examination revealed marked bilateral periorbital swelling and subconjunctival hemorrhages more marked on the right ( Fig. 1). In the right eye, there was no light perception and the pupil was fixed and semidilated. The left eye acuity was 6/ 6 and ocular examination was normal. Magnetic resonance imaging ( MRI) performed 5 days after surgery showed mixed signal in the right lower lid on Tl- weighted images, compatible with the known Manuscript received March 8, 1999; accepted April 22, 1999. From the Departments of Neuroradiology ( CDG, IFM) and Ncuro-ophthalmology ( LMC, MDS), The National Hospital for Neurology and Neurosurgery, London, England. Address correspondence and reprint requests to Dr. Catriona Good, Lysholm Department of Neuroradiology, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, England. hemorrhage ( Fig. 2A). There was no major hematoma in the right orbit, but there were two small pockets of hemorrhage in the retrobulbar fat on the right side and the fat appeared diffusely swollen and inhomogeneous, suggesting diffuse edema or congestion ( Figs. 2B and C). There was no proptosis and the optic nerve was not displaced. The axial T2- weighted images ( Fig. 3A) showed clearly defined high signal in a segment of the optic nerve starting 13 mm behind the eye and extending posteriorly for 7 mm. The anterior and posterior margins were orthogonal to the long axis of the nerve. Coronal images ( Fig. 3B) confirmed that the full thickness of the nerve was involved. The remainder of the anterior optic pathway appeared completely normal. Contrast medium was not given. DISCUSSION Visual loss is a rare but well- documented complication of blepharoplasty ( 1), although previous reports have not documented MRI changes within the optic nerve localizing the site of damage. In a national survey of 3,000 ophthalmologists in the United States performing blepharoplasties ( 98,514,000 lid procedures), the frequency of blindness as a complication was found to be 0.04% ( 2). Visual loss after blepharoplasty is well described in the literature, but the mechanism has not been elucidated. The most likely factor is increased intraorbital pressure and vascular compromise consequent on hemorrhage or edema within the orbit induced by operative manipulation ( 3). During the operation, the fat is removed from the orbit and blood can ooze from the cut surface of the fat. The hemorrhage may be venous or more likely arteriolar and may depend on the fascicular arrangement of the orbital compartments. Pockets of blood, edema, and air may be trapped within the fascial planes, elevating the orbital pressure so that perfusion of the pial network around the optic nerve is impaired. Therefore, MRI may show only a modest amount of blood within the orbit. Hemorrhage may also spread along the periosteum toward the back of the orbit and compress the optic nerve in the orbital apex, although we saw no evidence of this in our case. Alternative mechanisms for visual loss have been suggested and these include compromise of the central reti- 176 POSTERIOR OPTIC NERVE INFARCTION 177 FIG. 1. Photographs taken 5 days after cosmetic lower lid blepharoplasty. Note the dense extensive subconjunctival hemorrhage in the right eye and smaller foci of hemorrhage in the left eye. Marked bilateral lower lid and upper malar bruising and skin crusting ( with permission of D. Kaisy). nal artery ( 4- 6) or vein ( 7) with ischemia of the anterior optic nerve or acute angle- closure glaucoma in susceptible individuals ( 3). The critical duration of impaired perfusion needed to cause permanent blindness varies and depends on the degree of orbital hemorrhage and the rapidity and degree of increased intraorbital pressure, but probably ranges from l to 4 hours. Some recovery can be expected if reperfusion occurs within I to 1.5 hours ( 6). The visual morbidity can be minimized with early diagnosis and surgery to open up the fascial layers ( 8). Hislop et al. proposed a protocol for the management of patients with retrobulbar hemorrhage in an attempt to reduce the incidence of blindness ( 5). In 1988, a technique was introduced for upper and lower lid blepharoplasty that combined the advantages of a transconjunctival approach and CO, laser as the only cutting tool ( 9). This was aimed at reducing complications attributable to hemorrhage; however, removal of orbital fat is an essential part of the surgery and results in hemorrhage irrespective of the incisional instrument. In our case, there was infarction of the posterior portion of the intraorbital optic nerve with sparing of the anterior and intracanallicular portions. MRI demonstrated two tiny pockets of hemorrhage within the retrobulbar fat and diffuse edema in the right orbit ( Figs. 2A- C). The clearly defined area of increased signal within the right optic nerve on the axial T2- weighted images was situated behind the entrance of the central retinal artery, which pierces the dura 12 mm behind the optic disc. This portion of the nerve is supplied by peripheral centripetal arteries of the pial plexus with no axial centrifugal system except for a short recurrent branch extending back from the central retinal artery for 2 to 3 mm in approximately 20% of the population ( 10). This contrasts with the anterior optic nerve, which receives a centrifual supply from the central retinal artery and a centripetal supply from the pial plexus. The intracanallicular portion is supplied by separate branches of the ophthalmic artery, which form semicircles on the upper and lower surfaces of the optic nerve. The pial supply is relatively deficient within the optic canal ( 10). In our case, there was marked subconjunctival hemorrhage with only small pockets of blood in the retrobulbar fat, but this was associated with marked edema or congestion of the intraorbital fat. We suggest that this caused increased intraorbital pressure and compromise of the centripetal pial plexus with consequent infarction of the posterior portion of the intraorbital optic nerve. The anterior and canallicular portions of the optic nerve, with alternative blood supplies, were not compromised. Unfortunately immediate attempts to decompress the optic nerve were not made in this case. Despite the newer surgical techniques that arc designed to prevent retrobulbar hemorrhage, blindness is J Neuro- Ophtlmlmol, Vol. 19, No. .1, /< W 178 C. D. GOOD ETAL. FIG. 2. A: Coronal T1- weighted ( 400/ 10) magnetic resonance image demonstrating high signal subacute hemorrhage in the right lower lid. B: Coronal fast spin echo T2- weighted ( 3000/ 102) image with fat saturation, showing increased signal in the edematous, swollen retro orbital fat within the right orbit with normal signal return from both anterior optic nerves. C: Axial T1- weighted ( 400/ 10) image with fat saturation, showing two small pockets of hyperintense hemorrhage within the intermediate signal of the edematous orbital fat. J Ncum- Opllllmlmol, Vol. 19. No. .1, 1999 POSTERIOR OPTIC NERVE INFARCTION 179 FIG. 3. A: Coronal fast spin echo 12- weighted image ( 3000/ 102) with fat saturation demonstrating full thickness high signal within the right posterior optic nerve and normal signal from the left optic nerve. B: Axial fast spin echo T2- weighted ( 3000/ 102) image with fat saturation demonstrating the edematous retro orbital fat and a clearly defined area of high signal in a segment of the posterior right optic nerve. still a risk alter blepharoplasty and patients need to be carefully monitored in the postoperative period to detect critical increased intraorbital pressure. REFERENCES 1. Waller RR. Is blindness a realistic complication of blepharoplasty procedures'? Ophthalmology l978; 85: 730- 5. 2. De Merc M, Wood T, Austin W. Eye complications with blepharoplasty or other eyelid surgery. A national survey. Plast Reconstr Surg 1974; 53: 634- 7. 3. Hcpler RS, Sugimura Gl, Straatsma BR. On the occurrence of blindness in association with blepharoplasty. Pla. st Reconstr Surg 1976; 57: 233- 5. 4. Ord RA, Post- operative retrobulbar haemorrhage and blindness complicating trauma surgery. Br J Oral Surg 1981; 19: 202- 7. 5. Hislop WS, Dutton GN, Douglas PS. Treatment of retrobulbar haemorrhage in accident and emergency departments. Br ./ Oral Maxillofac Surg 1991 ; 29( 2): 77- 9. " 6. Anderson RL, Edwards JJ. Bilateral visual loss after blepharoplasty. Ann Plast Surg l980; 5( 4): 288- 92. 7. Kelly PW, May DR. Central retinal artery occlusion following cosmetic blepharoplasty. Br J Ophthalmol 1980; 64: 918- 22. 8. Callahan M. Prevention of blindness after blepharoplasty. Ophthalmology 1983; 90: 1047- 51. 9. David LM. The laser approach to blepharoplasty../ Dermatol Surg Oncol 1988; 14: 741- 6. 10. Isayama Y, Hiramatsu K, Asakura S, Takahashi T. Posterior isch-aemic optic neuropathy. 1. Blood supply of the optic nerve. Oph-thalmologica 1983; 186: 197- 203. ./ Nnim- Oplulwlmol, Vol. 19, No. .1 1W9 |
