Abstract
The incidence of intraorbital hemorrhage in blepharoplasties is rare. The symptoms can be severe, such as orbital compartment syndrome and oculocardiac reflex. We describe a case of intraorbital hemorrhage manifested as sudden intraoperative arrhythmia and bradycardia during blepharoplasty surgery under local anesthesia and monitored anesthesia care. This should be considered a high-risk surgery for bleeding in ophthalmology and close hemodynamic monitoring is essential for immediate diagnosis. Also, a prompt response is of utmost importance to avoid loss of vision and to assure a positive outcome.
Keywords: Cardiac Arrhythmia; IntraorbitalHematoma; Oculoplastic Surgery; Local Anesthesia
Introduction
Blepharoplasty is considered a high-risk surgery for bleeding complications in ophthalmology, but the incidence of intraorbital hemorrhage is 55 per 100,000 [1]. Once an intraorbital hematoma occurs, the symptoms can be severe, such as orbital compartment syndrome, with consequent Retinal and visual loss, in addition to oculocardiac reflex, due to the stretching of the extraocular muscles and globe compression. Next, we describe a case of intraorbital hemorrhage associated with an oculocardiac reflex manifested as arrhythmia during blepharoplasty surgery under local anesthesia and monitored anesthesia care.
Case Report
Female patient, 62 years old, programmed to upper
blepharoplasty under local infiltration anesthesia, sedation and
monitored anesthesia care. Her personal medical history included
an antiphospholipid syndrome and a previous stroke in cerebellum,
with sequelae of convulsive episodes. At the moment of hospital
admission, she was in use of valproic acid and hydroxychloroquine.
Aspirin use had been interrupted seven days earlier. Physical
examination was unremarkable, blood pressure: 132x85 mmHg,
heart rate: 72 bpm, and normal electrocardiogram. Sedation and
monitored anesthesia care began with intravenous midazolam
(2.5mg), fentanyl (50mcg) and propofol (30mg), followed by
local infiltration in both upper lids with 10 mL of a 50% mixture
of 2% lidocaine and 0.5% bupivacaine with vasoconstrictor. The
procedure was initially performed on the left eye.
After the beginning of the second eye’s procedure, the patient
presented sinus bradycardia (heart rate: 30 bpm), followed by
ventricular extrasystoles, pain and proptosis in left eye, leading
to a diagnosis of intraorbital hematoma in the first operated
eye. Immediate surgical decompression was performed, with
drainage of a large amount of blood and an infusion of 20% mannitol was started. During drainage, she presented episodes of
bradycardia and psychomotor agitation, but remained conscious
and became hypertensive. At this moment, considering the
known etiology of the complication and the fact that the patient
remained hemodynamically stable, atropine was not administered.
Midazolam (2.5mg), fentanyl (50mcg), clonidine (75mcg) and
low dose ketamine (10mg) were administered, with resolution
of the condition. Dexamethasone (4mg), tenoxicam (40mg) and
ondansetron (4mg) were also administered. Since the operation on
the second eye had already begun, the surgeon chose to continue
the procedure, which resumed uneventfully. After completing the
surgical plan and resolving the left intraorbital hematoma, she
was referred to the post-anesthetic recovery room, where she
remained monitored and without complaints for two hours. She
was kept under observation in the ward and was discharged from
the hospital six hours later without further complications.
Discussion and Conclusions
Intraorbital hemorrhage during blepharoplasty is an extremely
rare complication and occurs due to surgical manipulation of the
orbital fat without adequate hemostasis [1]. The use of aspirin is
widely indicated in patients at risk for thromboembolic events
and its suspension can lead to a rebound effect due to increased
thromboxane A2 activity [2]. Therefore, aspirin suspension is not
recommended in low-risk ophthalmic surgeries, such as cataracts,
and even for medium-risk surgeries such as vitrectomy and
trabeculectomy, and continuation of therapy can be maintained
[3-5]. However, in the case of blepharoplasty, since it is a surgery
with a higher risk of bleeding, antiplatelet therapy should be
discontinued seven days before, as was done in this case. Despite
the low incidence, orbital hematoma during blepharoplasty may
be sufficient to produce orbital compartment syndrome, defined
by increased intraocular pressure with consequent compression
of the retinal artery and optic nerve. Visual loss occurs within
100 minutes if the condition is not properly treated. The most
common symptoms are pain, proptosis refractory to compression,
immobility of extraocular muscles, subconjunctival hemorrhage,
reduced visual acuity, diplopia and increased intraocular pressure
[6].
The most efficient treatment for orbital compartment syndrome
is achieved through cantotomy associated with lateral cantolysis,
preferably within 90 minutes after the trauma. Other measures
must be performed simultaneously, such as head elevation,
effective analgesia and antiemesis to improve the drainage of
aqueous humor and administration of hypertonic solution or
carbonic anhydrase inhibitor, in order to decrease the production
of aqueous humor and, consequently, reduce intraocular pressure
[6,7]. In the case reported, the signs presented by the patient, of
pain and proptosis, suggest an increase in intraocular pressure, and
treatment with mannitol and adequate hemostasis was sufficient to
resolve the condition. Also, clonidine administration was applied
as an adjunct to reduce intraocular pressure, as the stimulation
of peripheral α receptors promote vasoconstrictive effects in
the eye [8]. The oculocardiac reflex was first described in 1908
[9]. Triggering factors are compression of the globe or stretching
of the extraocular musculature. The reflex aference is provided
by stimulus of the trigeminal ophthalmic branch, and the vagal
efference via muscarinic cardiac fibers leads to bradycardia and
hypotension.
Other cardiac features of this reflex may manifest as
arrhythmias, cardiac blocks or even asystole. There may also be
an enhancement in gastric motility by intestinal parasympathetic
stimulation. In the present case, the oculocardiac reflex was
precipitated by the increase in intraocular pressure and stretching
of the extraocular musculature due to the acute rise in intraorbital
pressure. In blepharoplasties, the incidence of oculocardiac reflex
is high (40%) due to the stretching of the aponeurosis of the eyelid
levator muscle [10]. This muscle is strictly related to the superior
rectus muscle, so that its traction leads to the traction of the
superior rectus muscle. This does not seem to have been the cause
of the symptoms in the case reported, as the oculocardiac reflex
tends to fatigue. Thus, it is more common to occur during surgery
on the first eye, as previously published [10]. In this type of surgery,
atraumatic operative management prevents the appearance of the
trigeminovagal reflex. Compression of the globe should be avoided,
and the lifting of the eyelid muscle aponeurosis should be slow and
smooth [10].
Some authors suggest investigating patients susceptible to
vagal events in the pre-anesthetic evaluation; that is, patients
with a history of conduction blocks, vasovagal responses or in
chronic use of beta-blockers. These patients benefit from prior
administration of intravenous atropine [9,10]. Given the muscarinic
nature of the trigeminocardiac reflex, atropine is described as
first choice treatment. However, in this particular case, atropine
was not immediately considered, as bradycardia did not produce
signs and symptoms of low cardiac output. Instead, the patient
remained conscious and even exhibited hypertension. As such,
surgical decompression and other measures to lower intraocular
pressure were effective in addressing the etiology and offsetting
the symptoms. Even after resolution, close monitoring and follow
up should be ensured, as orbital hematoma symptoms may still
develop within the first 24 hours [11].
We present a case of sudden intraoperative arrhythmia and
bradycardia as manifestations of an oculocardiac reflex precipitated
by intraorbital hemorrhage as a complication of blepharoplasty.
This should be considered a high-risk surgery for bleeding in
ophthalmology and close hemodynamic monitoring is essential
for immediate diagnosis. Also, a prompt response is of utmost
importance to avoid loss of vision and to assure a positive outcome.
Conflict of Interest
The authors have declared that no competing interest exists.
Authors’ Contributions
CSG, LGM, and LCAL collected the patient’s information drafted this manuscript and made contribution to supervision and final approval, and DBM analyzed and interpreted the patient data, and final approval. All authors read and approved the final manuscript.
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