Acute Visual Impairment due to Non Ischemic Central RetinalVein Occlusion Following Surgery for Fracture Femur: A Case report
S Philip, B Al Burwani, R Shenoy, D Deshmukh, M Saqueer, S Al Mahrooqi
central retinal vein occlusion, fluorescein angiography, non ischemic, optical coherence tomography
S Philip, B Al Burwani, R Shenoy, D Deshmukh, M Saqueer, S Al Mahrooqi. Acute Visual Impairment due to Non Ischemic Central RetinalVein Occlusion Following Surgery for Fracture Femur: A Case report. The Internet Journal of Ophthalmology and Visual Science. 2008 Volume 6 Number 2.
Visual loss following non ocular surgeries is an infrequent, but severe and disastrous complication, devastating to the patient and surgeon alike. Often, reported following major spinal and cardiac surgery, the most common causes are anterior and posterior -ischemic optic neuropathies, central retinal artery occlusion, central retinal vein occlusion, 6cortical blindness and miscellaneous (drug induced) . We report on a 21 year old otherwise healthy patient who presented with unilateral visual impairment in his left eye within 2 weeks post internal fixation surgery for fracture femur, and was found to have non ischemic central retinal vein occlusion.
A healthy young adult aged 21 years underwent an internal fiationfor fracture shaft of left femur sustained in a road traffic accident, under general anesthesia. The total duration of surgery was 110 minutes. Postoperative recovery was uncomplicated and the patient was sent home after 3days. Eight days later the patient presented to the ophthalmic emergency with history of blurred vision of 1 day duration in his left eye. Ophthalmic examination revealed a best corrected visual acuity of 6/6 in his right eye and 2/60 in his left eye. The anterior segment of right eye was normal. There was afferent puillary defect in the left eye. Intra ocular pressure both eyes was 12mmHg. Extraocularmuscle movements were normal. Fundus evaluation right eye revealed a normal looking fundus with cup disc ratio of 0.3. In the left eye, the disc was hyperemic with blurred margins; with soft exudates along the superior margin..The veins were dilated and tortuous.There were superficial hemorrhages scattered in the posterior pole and edema at the macula with vertical fan formation temporally (Fig-1)
Fundus fluorescein angiography showed normal flow of dye in the right eye. .In the left eye, the disc was hyperfluorescent. There were hypofluorescent areas corresponding with hemorrhages. (Fig 2).
On Optical coherence tomography, the macula in the left eye appeared edematous with a thickness of 940 µm. He was clinically and hematologically investigated.Cardiovascular, respiratory system,central nervous examination was normal.
Lab investigation revealed normal complete blood count, differential count,RBC and platelet count, Heamoglobin level, Hematocrit,MCV, MCH, MCHC, Erythrocyte sedimentation rate, C reactive protein, Coagulation profile, protein-C, protein-S, antithrombin Factor,Factor III, resistant factor to protein C, plasma homocysteine levels, luvidein factor, Blood glucose, lipid profile, electrolytes,rheumatoid factor, anticardiolipin factor, antiDNA factor, antinuclear factor, serological tests for TORCH, retrovirus, VDRL,and Mantoux test . Sickle dex test as negative.
Vascular catastrophies resulting in visual loss or impairment is not a novice following major surgeries and in older patients and is determined by preoperative, perioperative and post operative risk factors.(1,5) The most common cause is ischemic optic neuropathy,and the most common surgical procedure reported is prone spinal operations, though other surgeries were not free of the risk. Coexisting diseases increase the risk of developing this complication. However, a high frequency of occurrence in younger, healthier patients has been noted suggesting the role of intra operative physiologic variables such as edema formation and venous congestion as well as “normal” physiologic variation in ocular hemodynamics.(1, 3)
Retinal vein occlusion is a major cause of visual impairment in all age groups. It is more common in the elderly with an incidence of 0.8 to 2 %. Systemic hematological and local factors contribute to its development. The precise pathology is formation of intra luminal thrombus secondary to alteration in blood vessel wall and or blood constituents resulting in stagnation of blood low.(4,5)Our patient noted visual disturbance in the left eye approximately 11days after surgical intervention for fracture femur following a road traffic accident. He was found to have central retinal vein occlusion of the non ischemic type in the left eye. Despite extensive investigations no etiological factors could be identified. Central retinal vein occlusions with no explainable etiological factors have been reported to occur in children but not in adults so far (4, 5). Internal fixation of fracture femur probably precipitated the development of the vein occlusion in this patient. Perioperative visual loss (POVL) due to central vein occlusion following internal fixation of fracture femur has not been reported before. (1,2,3,4,5)