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Show Central Retinal Artery Occlusion Caused by Fat Embolism Following Endoscopic Sinus Surgery Ko Eun Kim, MD, Seong Joon Ahn, MD, Se Joon Woo, MD, Namju Kim, MD, Jeong-Min Hwang, MD Abstract: Endoscopic sinus surgery (ESS) can lead to a variety of ophthalmic complications. Central retinal arterial occlusion (CRAO) is one such complication, usually due to orbital compartment syndrome. We report a case of CRAO following endoscopic sinus surgery as a result of fat embolism. Journal of Neuro-Ophthalmology 2013;33:149-150 doi: 10.1097/WNO.0b013e31828657d6 © 2013 by North American Neuro-Ophthalmology Society A43-year-old man reported visual loss in his right eye after awakening from general anesthesia for endoscopic sinus surgery (ESS). Routine intranasal injection of epinephrine mixed with lidocaine was used to reduce bleeding and no associated cardiovascular side effects were reported during the FIG. 1. A. Eye movements show right exotropia with inability to adduct the right eye. B. Right fundus shows central retinal artery occlusion. C. Intraarterial fat emboli (arrow). D. Impaired arterial perfusion seen on fluorescein angiogram due to embolic material (arrow). E. Coronal orbital computed tomography reveals fracture (arrow) of the medial wall of the right orbit. F. Contrast-enhanced T1 axial magnetic resonance imaging with fat suppression shows right ethmoid sinusitis and a torn right medial rectus muscle. Department of Ophthalmology (KEK, SJA, SJW, NK, J-MH), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea; and Department of Ophthal-mology (KEK), Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea. The authors report no conflicts of interest. Address correspondence to Se Joon Woo, MD, Department of Ophthalmology, Seoul National University Bundang Hospital, #300, Gumi-dong, Bundang-gu, Seongnam, Gyeonggi-do 463-707, Korea; E-mail: sejoon1@snu.ac.kr Kim et al: J Neuro-Ophthalmol 2013; 33: 149-150 149 Photo Essay Section Editor: Timothy J. McCulley, MD Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. procedure. During ESS, lamina papyracea was breached with direct injury to the right medial rectus and the procedure was stopped immediately. Five hours later, visual acuity was light perception, right eye, and 20/20, left eye. Intraocular pressure was 12 mmHg in the right eye. There was mild periorbital swelling and ecchymoses of the right upper and lower eyelids, and a large right exotropia with complete loss of adduction of the right eye (Fig. 1A). Subconjunctival hemorrhage was noted in the right eye on slit-lamp examination and the right pupil was dilated and nonreactive to light. The right fundus revealed a cherry red spot in the macula, pale and with exten-sive retinal edema, and diffuse retinal arterial narrowing (Fig. 1B). Yellow-colored fat emboli were seen within the retinal artery (Fig. 1C). Examination of the left eye was unremark-able. Neurological, physical, and laboratory findings were all within normal limits. Fluorescein angiography (FA) of the right eye revealed a filling defect, due to emboli noted in the proximal retinal artery (Fig. 1D). In addition, there were marked filling delays in the retinal arteries combined with flow inter-ruption of several arterial branches. Optical coherence tomography revealed diffuse thickening of the inner retinal layers and a central foveal thickness of 388 mm in the right eye, compared with 294 mm in the left eye. Kinetic visual field examination showed a diffuse visual field loss in the right eye, with vision preserved only in an inferonasal island. Computed tomography demonstrated a right medial orbital wall fracture with a small amount of retrobulbar hemorrhage (Fig. 1E), while magnetic resonance imaging revealed disruption of the right medial rectus muscle (Fig. 1F). The right optic nerve was normal in appearance and no intra-cranial abnormalities were detected. After 6 months, vision in the right eye remained light perception and the right exotropia was unchanged with complete loss of adduction. The fat emboli were no longer visible on fundus examination and FA showed normal retinal arterial perfusion. While the frequency of ophthalmic complications following ESS is low (1,2), when they occur, they may have devastating consequences. Rene et al (3) reported a case of unilateral blindness following ESS in which direct optic nerve damage occurred in combination with central retinal arterial occlusion (CRAO). This was presumed to have occurred because of ophthalmic arterial spasm. A recognized cause of CRAO following ESS is the orbital compartment syndrome resulting from orbital hemorrhage (2-6). Patients generally present with pain, proptosis, tense eyelids, perior-bital edema, subconjunctival hemorrhage, and external ophthalmoplegia. We assume that the fat emboli from adjacent damaged bones or retrobulbar fat were released into the circulation leading to occlusion of the central retinal artery. Although pharmacomechanical thrombolysis was not performed in this case, it may be considered as a therapeutic option (7). ACKNOWLEDGMENT We thank Dr. Jae Hyoung Kim for his effort in selecting the best magnetic resonance imaging and computed tomography images. REFERENCES 1. May M, Levine HL, Mester SJ, Schaitkin B. Complications of endoscopic sinus surgery: analysis of 2108 patients- incidence and prevention. Laryngoscope. 1994;104: 1080-1083. 2. Bhatti MT. Neuro-ophthalmic complications of endoscopic sinus surgery. Curr Opin Ophthalmol. 2007;18:450-458. 3. Rene C, Rose GE, Lenthall R, Moseley I. Major orbital complications of endoscopic sinus surgery. Br J Ophthalmol. 2001;85:598-603. 4. Sharp HR, Crutchfield L, Rowe-Jones JM, Mitchell DB. Major complications and consent prior to endoscopic sinus surgery. Clin Otolaryngol Allied Sci. 2001;26:33-38. 5. Bhatti MT, Stankiewicz JA. Ophthalmic complications of endoscopic sinus surgery. Surv Ophthalmol. 2003;48:389-402. 6. Buus DR, Tse DT, Farris BK. Ophthalmic complications of sinus surgery. Ophthalmology. 1990;97:612-619. 7. Park SJ, Woo SJ, Park KH, Hwang JM, Hwang GJ, Jung C, Kwon OK. Partial recovery after intraarterial pharmacomechanical thrombolysis in ophthalmic artery occlusion following nasal autologous fat injection. J Vasc Interv Radiol. 2011;22: 251-254. 150 Kim et al: J Neuro-Ophthalmol 2013; 33: 149-150 Photo Essay Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
