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Show Journal of Neuro- Ophthalmology 20( 4): 234- 235, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia Short Communications Central Retinal Artery Occlusion After a Local Anesthetic With Adrenaline on Nasal Mucosa Tarja H. Maaranen, MD, and Maija I. Mantyjarvi, MD The purpose of this article is to describe a 75- year- old patient with an acute central retinal artery occlusion after a local anesthetic with adrenaline on nasal mucosa. The local anesthetic was used in removing Jackson tubes from the left lacrimal canal. Occlusion of the central retinal artery related to nasal operations is a rare complication. In previous reports, retinal artery occlusions have been noted in connection with nasal submucosal injections of anesthetic and epinephrine. In our case, the use of anesthetic and adrenaline was superficial. Key Words: Adrenaline- Central retinal artery occlusion- Lidocaine- Local anesthetic. Loss of vision because of central retinal artery occlusion after an operation in the eye region is a rare but serious complication. Occlusion of central retinal artery has been reported after a nasal submucosal injection of local anesthetic with epinephrine ( 1) and in connection with nasal steroid injections ( 2). Also, superficial use of cocaine ( 3) and oxymethazoline hydrochloride ( 4) on the nasal mucosa has been reported to cause retinal artery occlusion. We describe a case in which intranasal lidocaine with adrenaline caused an acute central retinal artery occlusion and permanent loss of vision in our patient. The lidocaine and adrenaline were used superficially on the nasal mucosa. CASE REPORT A 75- year- old man had had disturbing lacrimation on the left side for a long time. In June 1998, a Jackson silicone tube was installed in the left lacrimal system under general anesthesia in the Eye Clinic of the Uni- Manuscript received July 7, 1999; accepted June 27, 2000. From the Department of Ophthalmology, University Hospital of Kuopio, Finland. Address correspondence and reprint requests to Tarja H. Maaranen, MD, Department of Ophthalmology, University Hospital of Kuopio, P. O. Box 1777, 70211 Kuopio, Finland. versity Hospital of Kuopio. At the time of this procedure, his visual acuity was normal OU, he did not complain of any visual disturbances, and there was no history of visual impairment in either eye. The Jackson tube was left in situ for 6 months. In November 1998, the patient revisited our clinic for the removal of the silicone tube. The patient still had normal visual acuity OU. The tube was cut, but it did not come out when the patient blew his nose, and the tube was not visible in the nose. The patient was sent to an otorhino-laryngologist, who put a cotton stick moistened with lidocaine hydrochloride ( 40 mg/ ml) and adrenaline hydrochloride ( 1 mg/ ml) into the left nostril for a few minutes. Thereafter, the tube was removed. About 20 minutes later, the patient noticed impairment of the visual acuity OS. The patient immediately came back to our clinic, and a typical acute central retinal artery occlusion was diagnosed OS. The patient could see only hand motions OS. The arterioles were strongly attenuated, and the retina was pale OS. The eye was treated with an anterior chamber paracentesis, 0.5 mg of nitroglycerine was given orally, and 500 mg of acetazol-amide was administered intravenously. However, visual acuity OS did not improve. The patient had a history of two cardiac infarcts, in 1973 and 1986. In 1992, he had a coronary bypass operation. Before this loss of visual acuity, the patient had no arrhythmia, chest pain, or transient ischemic attack ( TIA). An internist examined the patient, and no ischemic or other changes in the heart could be noticed; the patient did not have systemic arterial hypertension, and there was no significant narrowing in the cervical arteries in the ultrasonic examination. The blood count was normal. DISCUSSION A local anesthetic, lidocaine with adrenaline, was superficially used on the nasal mucosa in the removal of a Jackson tube. In two previous reports, superficial use of 234 RETINAL ARTERY OCCLUSION AND A LOCAL ANESTHETIC 235 vasoconstrictive agents has been reported to cause retinal artery occlusion. Wallace et al. ( 3) reported a case of central retinal artery occlusion 4 hours after intranasal administration of cocaine. In this case, vasospasm has been suggested as mechanism of retinal artery occlusion. Magargal et al. ( 4) reported a case in which chronic use of oxymetazoline hydrochloride caused a branch retinal artery occlusion. In our case, adrenaline probably caused vasoconstriction in the central retinal artery through the ethmoidal arteries. To our best knowledge, there are no previous reports of central retinal artery occlusions caused by superficial use of anesthetic and adrenaline. Savino et al. ( 1) reported four cases in which intranasal injection of a local anesthetic and epinephrine caused retinal artery occlusion. All of these patients had had nasal surgery under general anesthesia. Retinal artery occlusion was diagnosed several hours or days after the anesthesia. The mechanism of artery occlusion in these cases could have been surgical trauma, vasospasm, or embolism. In the current case, the mechanism is probably vasospasm, because the visual loss developed quickly after using lidocaine and adrenaline, and the retinal arterioles were strongly attenuated. Applying superficial anesthetic and adrenaline to the nasal mucosa can cause vasoconstriction in the retinal arteries. Older patients, such as in our case, can have some degree of arteriosclerosis narrowing the lumens of blood vessels. Even a small amount of vasoconstrictive agent can cause an occlusion in this situation. Thus, adrenaline should be avoided if possible or used with caution in nasal operations on older patients. REFERENCES 1. Savino PJ, Burde RM, Mills RP. Visual loss following intranasal anesthetic injection. J Neuro- ophthalmol 1990; 2: 140- 4. 2. Whiteman DW, Rosen DA, Pinkterton RMH. Retinal and choroidal microvascular embolism after intranasal corticosteroid injection. Am J Ophthalmol 1980; 89: 851- 3. 3. Wallace RT, Brown GC, Benson W, et al. Sudden retinal manifestations of intranasal cocaine and methamphetamine abuse. Am J Ophthalmol 1992; 2: 158- 60. 4. Magargal LE, Sanborn GE, Donoso LA, et al. Branch retinal artery occlusion after excessive use of nasal spray. Ann Ophthalmol 1985; 17: 500- 1. J Neuro- Ophthalmol, Vol. 20, No. 4, 2000 |
