Branched Retinal Artery Occlusion After Rhinoplasty
Title: Branched Retinal Artery Occlusion After Rhinoplasty
Author (s): Sahil Aggarwal BS; William R Barlow JR MD; Rebekah H. Gensure, MD PhD; Paul Bernstein MD, PhD
Photographer: Becky Weeks
Description of Images: 1) Fundus photograph of the left eye demonstrating retinal whitening and retinal edema adjacent to the fovea. 2) Humphrey Visual Field of the left eye showing a near complete superior altitudinal defect. 3) Optical Coherence Tomography showing mild edema of the inner retinal with corresponding shadowing of outer retinal details and mild edema seen on the thickness map of the left eye. 4) Fluorescein Angiography (FA) of the left eye, showing the progression from early filling (A) to late (D) delayed perfusion in the inferior macula and peripapillary areas of the retina.
Keywords/Main Subjects: rhinoplasty, branched retinal artery occlusion, visual field defect
Diagnosis: Branched retinal artery occlusion
Unilateral vision loss after nasal surgery is rare and is typically caused by retinal embolism secondary to intraoperative injection of local anesthetic agents into the nasal mucosa. Here, we present the case of a patient whose routine septoplasty was complicated by a branched retinal artery occlusion.
A 41-year-old female with a history of a deviated septum presented with sudden vision loss in the left eye that began after an elective septoplasty 3 days earlier. After waking from surgery, she noted no light perception in the left eye which she attributed to possible swollen eyelids. Her vision slowly returned over the next 72 hours; however, she continued to have poor vision in the superior visual field in the left eye. On examination, visual acuity was 20/20 bilaterally; fundus photography demonstrated retinal whitening of the inferior retina with retinal edema (Figure 1). Humphrey Visual Field (HVF) testing showed a superior altitudinal defect in the left eye (Figure 2). This pattern of retinal changes corresponded to the visual field defect. Optical Coherence Tomography (OCT) of the macula showed an inferior area of mild edema with shadowing in the areas of edema that obscure the macular details, compared to the adjacent peripheral non-edematous retina (Figure 3). Fluorescein angiogram was performed and showed a mild, partial obstruction in the suspected inferior branch retinal arteriole with late hypofluorescence/delayed perfusion of the corresponding capillary bed (Figure 4). The patient was admitted to the neurology stroke service 4 days after surgery to rule out a vaso-occlusive etiology. Echocardiography, Magnetic Resonance Imaging (MRI) of the brain, and Computed Tomography (CT) scans of the orbits and head and neck region were all within normal limits. A complete coagulopathy panel was also normal. The patient was discharged on aspirin with a stable but unchanged superior visual field defect in the left eye that was presumed to be a rare surgical complication of rhinoplasty.
Otolaryngologic surgeries are not commonly associated with visual complications postoperatively. While visual changes and ophthalmoplegias have been documented in endoscopic sinus surgeries owing to iatrogenic damage to the orbit1, ophthalmic complications of nasal airway surgeries are rare. In this case, a routine septoplasty for deviated septum was complicated by a unilateral branched retinal artery occlusion. While the mechanism for this devastating outcome is less understood, there are several possibilities. The most likely cause in this case is a decrease in perfusion to the retina secondary to anesthetic and epinephrine injection into the nasal mucosa. Inadvertent flow of these substances into the branches of the ophthalmic artery may lead to vasospasm and ischemia to the retina.2-4 Other potential etiologies include direct damage to the optic nerve or an orbital fracture,5 both of which are unlikely in this case given the lack of findings associated with these conditions on examination and imaging results.
Management of a retinal occlusive crisis following nasal surgery involves a thorough ophthalmic examination. If a central or branched retinal arterial is confirmed, this represents a true neuro-ophthalmologic emergency, and prompt evaluation by a stroke service is warranted. As with any retinal artery occlusion, timely evaluation and treatment may improve visual outcomes. Specific treatment modalities are controversial, but up to 90% of untreated patients with BRAO achieve a final visual acuity of greater than 20/40, and peripheral visual field defects improve in approximately half of all cases.6
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Faculty Approval by: Griffin Jardine, MD
Disclosure (Financial or other): None to disclose.