Perioperative Posterior Ischemic Optic Neuropathy as a Rare Complication of Blepharoplasty

Abstract

Purpose: To report a case of visual loss to light perception in the right eye after upper and lower eyelid blepharoplasty. Design: Case report. Method: A 46-year-old man was referred 3 days after combined bilateral upper and lower lid blepharoplasty with visual acuity of light perception in the right eye. The fundus examination, fluorescein angiography and magnetic resonance imaging of the orbit were normal. Ocular motility was full in all directions of gaze. Result: The diagnosis of optic nerve damage was initially based on the relative afferent pupillary defect. The diagnosis of a perioperative posterior ischemic optic neuropathy was based on the Goldmann visual field examination and the subsequent optic atrophy. Central visual acuity, color vision as well as the visual field improved markedly within 3 months. Conclusion: Blindness is a rare but feared complication of blepharoplasty and is reported to occur in about 0.04% of cases. Although intraorbital hemorrhage is thought to be the leading cause for optic nerve damage in most of the patients with this devastating condition, we present a case with perioperative posterior ischemic optic neuropathy leading to visual loss after blepharoplasty. The mechanism leading to optic nerve damage in this patient may include compromised small arteries perfusing the optic disk due to direct mechanical compression and a probable vasoconstrictive activity of the anesthetic agent.

The primary vascular dysregulation syndrome: implications for eye diseases

“…Like retinal arterial occlusion and RVO, AION can occur in young subjects without any risk factors for atherosclerosis as well. We made the observations that the vast majority of these patients are PVD subjects and that the occlusions occur in most cases after major psychological stress [264,265] or, alternatively, are drug induced [266]. AION, however, can also be observed secondarily to other diseases (see ‘Secondary vascular dysregulation’) such as autoimmune diseases [267].…”

Ischemic Optic Neuropathy and Implications for Plastic Surgeons

“…Surprisingly, our review revealed many other procedures that were associated with this complication that included the following: bilateral upper and lower blepharoplasty, 22,23 orbital fracture repair, 24,25 endoscopic sinus surgery, 26,27 intranasal anesthetic injection, 28 and even one dental extraction. 29 Interestingly, PION followed mostly bilateral neck dissection and cases after oculoplastic surgery such as combined upper and lower blepharoplasty.…”

Neuropatia óptica isquêmica posterior como complicação pós-cirurgia de blefaroplastia

“…A paciente teve OVCR no olho contralateral mas não pós-cirurgia. A complicação de blefaroplastia que causa perda visual com fundo de olho normal, defeito pupilar aferente e perda difusa da sensibilidade central com preservação relativa do setor nasal inferior é a NOIP (9)(10)(11)(12)(13)(14) . A NOIP pós-blefaroplastia está associada a alterações orbitárias como hemorragias (12)(13)(14) , no caso a ressonância magnética era normal, levamos então a considerar o uso do anestésico local com vaso constritor, o qual promove a isquemia por comprometer as artéri-as principais responsáveis pela irrigação da parte orbitária do nervo óptico.…”

“…Em contato com o cirurgião plástico fomos informados da não utilização de vasoconstritor na anestesia local e que a reoperação foi realizada para remoção de coágulo da pálpebra inferior sem acesso a cavidade orbitária. A partir desse fato achamos que apesar de não haver hematoma intraorbitário a deformação anatômica provocada pela hemorragia externa pode ter aumentado transitoriaFigura 3: A) TCO na primeira semana pós-cirurgia mostrando espessura normal da camada de fibras nervosas; B) TCO no segundo mês com diminuição da camada de fibras nervosas nos quadrantes inferior e temporal (cor vermelha) (10) , onde o fator causal não foi encontrado. O que nos chamou atenção no artigo foi o padrão da campimetria visual muito semelhante ao nosso.…”