Orbital infarction syndrome is a rare but devastating disorder resulting in sudden visual loss. A patient with orbital infarction syndrome due to orbital cellulitis after transcanalicular dacryocystorhinostomy with diode laser is described. A 55-year-old woman presented 3 days after transcanalicular dacryocystorhinostomy. Initial examination revealed significant eyelid swelling, marked proptosis, total ophthalmoplegia, and no light perception in the right eye. Fundus examination revealed ophthalmic artery occlusion. The clinical findings of the patient were consistent with orbital infarction syndrome. Clinical findings improved with antibiotic therapy, but visual acuity did not change.
From the Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Baris Yeniad, MD, Istanbul University, Istanbul Faculty of Medicine, Department of Ophthalmology, Capa-Sehremini, 34390, Istanbul, Turkey. E-mail: firstname.lastname@example.org
Received: December 20, 2011
Accepted: September 07, 2012
Posted Online: October 25, 2012
External dacryocystorhinostomy is the gold standard operation for the treatment of nasolacrimal duct obstruction. Recently, endonasal and transcanalicular dacryocystorhinostomy techniques have become the treatment of choice.1 Transcanalicular dacryocystorhinostomy with diode laser is a minimally invasive technique, but serious complications may be encountered with excessive laser energy, especially in inexperienced hands.2 We describe a patient with orbital infarction syndrome and sudden visual loss after transcanalicular dacryocystorhinostomy with diode laser.
A 55-year-old woman attended our clinic 3 days after transcanalicular dacryocystorhinostomy at another institution. Prior evaluation before referral revealed that she had developed eyelid edema, conjunctival hyperemia, chemosis, and pain in the right eye 2 days after the initial surgery. Topical and oral antibiotics were administered, but no improvement was noted. The patient experienced sudden vision loss 3 days postoperatively.
Initial examination revealed significant eyelid swelling, marked proptosis, and total ophthalmoplegia (Figure 1A). Visual acuity was 20/20 in the left eye and no light perception in the right eye. A fixed dilated pupil was noted. Fundus examination of the right eye revealed the presence of ophthalmic artery occlusion with optic disc edema, whitening of the retina, retinal hemorrhages, and attenuated retinal arterioles and venules (Figure 1B). A possible infectious chorioretinitis nasal to the optic disc was noted. Systemic evaluation was normal. Magnetic resonance images demonstrated marked proptosis, soft tissue edema, and thickening with opacification of the ethmoidal air cells in the right eye (Figures 1C–1D). Intravenous sulbactam/ampicillin, ciprofloxacin, and topical antibiotics were administered immediately after the diagnosis of orbital cellulitis. Over the next 2 weeks, there was a marked improvement in clinical findings (Figure 2); however, visual acuity did not improve.
Figure 1. (A) The patient with marked proptosis, eyelid edema, and purulent discharge. (B) Fundus photograph at initial examination reveals optic disc edema, attenuated arterioles and venules, preretinal and intraretinal hemorrhages, and retinal whitening. (C) Coronal contrast-enhanced T1-weighted magnetic resonance imaging demonstrates enhancement of orbital soft tissue and opacification of ethmoidal air cells. (D) Axial T1-weighted magnetic resonance imaging shows marked proptosis, soft tissue thickening, and edema.
Figure 2. (A) Fundus photograph at 3 months shows optic atrophy and obliterated vessels. (B) Fluorescein angiography shows diffuse window defects in the posterior pole and hypofluorescent focus nasal to the optic disc at 3 months. (C) Endoscopic examination reveals silicon tubes and scar tissue next to the middle turbinate. (D) The patient with slight ptosis and exotropia at 3 months.
Transcanalicular dacryocystorhinostomy with diode laser has low complication rates.1 The only serious complication reported is tissue necrosis and nasal cutaneous fistula.2
Dacryocystitis-induced orbital cellulitis is a rare but well-known entity.3 The rarity of orbital extension is attributed to the fact that the lacrimal sac is located in a preseptal region, and many anatomical structures act as a barrier to posterior extension of the infection. The infection in the lacrimal sac may spread posteriorly if the barriers are overcome. In our patient, possible causes included destruction of the orbital septum with excessive laser energy, collateral damage to the orbital structures, and injury to orbital vasculature during surgery. An undetected lacrimal or sinus infection may have played a role in the spread of infection into the orbital soft tissue following the destruction of the posterior barriers.
Mechanical compression of vascular structures due to orbital inflammation is reported to cause combined retinal artery and vein occlusions.4,5 Orbital infarction syndrome is a rare disorder characterized by ischemia of all intraorbital and intraocular structures. Increased orbital pressure or hypoperfusion of the ophthalmic artery and its branches leads to a collapse of the orbital arteries and veins, resulting in decreased orbital perfusion pressure and ischemia.6 Visual loss results from retinal infarction (due to central retinal artery hypoperfusion), anterior ischemic neuropathy, and choroidal ischemia (both due to compromised posterior ciliary arteries). Ophthalmoplegia results from impaired blood supply to the extraocular muscles.6 Ophthalmic artery occlusion, central retinal artery hypoperfusion, and ophthalmoplegia in our patient were consistent with orbital infarction syndrome.
Transcanalicular dacryocystorhinostomy with diode laser is a minimally invasive technique, but thorough understanding of relevant anatomical structures is important to prevent severe complications. Orbital infarction syndrome due to orbital cellulitis is a rare complication after transcanalicular dacryocystorhinostomy with significant damage to orbital and intraocular structures resulting in severe visual loss.
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