Portal de Periódicos da CAPES

Delayed retrobulbar hemorrhage following Baerveldt glaucoma drainage implant surgery

2012; Elsevier BV; Volume: 47; Issue: 4 Linguagem: Inglês

10.1016/j.jcjo.2012.03.006

1715-3360

Ashley Brissette, Kelly D. Schweitzer, Chaim M. Bell,

Dermatologic Treatments and Research

A 60-year-old female presented to the emergency eye clinic on the third day after an uneventful 350 mm2 Baerveldt glaucoma drainage implant (GDI) insertion in the inferonasal quadrant of the right eye. Surgery had been performed with topical lidocaine gel and subconjunctival lidocaine, without retrobulbar injection of anesthetic. The patient complained of sudden onset of bleeding from the right eye, as well as ecchymosis of the right upper and lower eyelids. She had neither recent exposure to drugs or alternative therapies with anticoagulant properties, nor had she experienced any trauma since surgery. She did not have a history of hypertension or medical conditions associated with an increased risk of bleeding. Her past ocular history included right Ahmed GDI surgery 8 months previous, and left Ahmed and Baerveldt GDI surgeries in 2009. On postoperative (postop) day 1, right eye intraocular pressure (IOP) measured 7 mm Hg. The implant was stable, and there were no signs of periorbital or subconjunctival hemorrhage. At presentation (postop day 3), visual acuity was 20/70− right eye, and IOP measured 53 mm Hg. External examination showed periorbital swelling, eyelid ecchymosis, and 3 mm proptosis of the right eye. Retropulsion was 4+ on the right and 1+ on the left. Right eye movement was markedly restricted in all fields of gaze. Anterior segment examination showed a formed anterior chamber, 360° subconjuctival hemorrhage, and blood leaking from the conjuctival wounds. Posterior segment examination showed no choroidal effusion or hemorrhage. The patient was diagnosed with a retrobulbar hemorrhage causing orbital compartment syndrome. Emergency lateral cathotomy and catholysis were performed, followed by immediate systemic acetazolamide and topical IOP lowering medications (dorzolamide, timolol, brimonidine, and bimatoprost). At discharge 8 hours later, IOP measured 19 mm Hg. The next morning, IOP was 19 mm Hg and visual acuity measured 20/50. Retropulsion had decreased to 2+. Computed tomography confirmed moderate proptosis of the right globe and very minimal streaky increased attenuation within the intraconal fat of the right orbit consistent with a resolving retrobulbar hemorrhage (Fig. 1 and Fig. 2). Three months later, the patient's vision improved to 20/25, the GDI tube remained in excellent position, and the IOP measured 8 mm Hg in the right eye.Fig. 2Computed tomography of head. Left asterisk and arrow shows previous Ahmed glaucoma drainage implant placement. Right arrow indicates minimal increased attenuation within the intraconal fat and evidence of retrobulbar hemorrhage.View Large Image Figure ViewerDownload (PPT) Retrobulbar hemorrhage is an ocular emergency that can cause devastating effects if not promptly assessed and treated. Because the orbit is confined by bone or the orbital septum in all directions, bleeding into this fixed space causes increased intraorbital volume and pressure.1Johnson D. Schweitzer K. Ophthaproblem S.S. Can you identify this condition? Retrobulbar hemorrhage.Can Fam Phys. 2009; 55: 605-607PubMed Google Scholar Retrobulbar hemorrhage most commonly occurs after facial trauma, surgery to the orbit, or retrobulbar injection.2Winterton J.V. Patel K. Mizen K.D. Review of management options for a retrobulbar hemorrhage.J Oral Maxillofac Surg. 2007; 65: 296-299Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Delayed retrobulbar hemorrhages after insertion of alloplastic orbital implants have been described with suggested mechanisms including displacement of the implant,3Gupta S. Aakalu V.K. Ahmad A.Z. Late-onset orbital hematoma secondary to alloplastic orbital implant mimicking transient ischemic attacks.Ophthal Plast Recontr Surg. 2011; 27: e18-e20Crossref PubMed Scopus (10) Google Scholar low grade chronic irritation, or rupture of a thin-walled vessel surrounding the capsule of the implant.4Gilhotra J.S. McNab A.A. McKelvie P. O'Donnell B.A. Late orbital haemorrhage around alloplastic orbital floor implants: a case series and review.Clin Exp Ophthalmol. 2002; 30: 352-355Crossref PubMed Scopus (42) Google Scholar Etiologic similarities that may exist with our case include contact between the GDI or surgical instruments and an inferior vessel. The delayed onset may indicate migration of the device in the early postoperative period or lysing of a clot that had initially formed at the time of surgery. A literature review revealed only one case of a mild delayed retrobulbar hemorrhage associated with the use of an Ahmed GDI that did not require surgical intervention.5Chan C.H. Lai J.S. Shen S.Y. Delayed retrobulbar haemorrhage after Ahmed glaucoma implant: a case report.Eye (London England). 2006; 20: 494-495Crossref PubMed Scopus (8) Google Scholar To our knowledge, our case is the first description of severe delayed retrobulbar hemorrhage requiring emergency canthotomy and cantholysis following Baerveldt GDI insertion, and the first occurring in the absence of a retrobulbar injection.