Anesth Analg 2008; 107:1630-1631
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e3181839262
PATIENT SAFETY
Ocular Globe Luxation Under General Anesthesia
Steven R. Clendenen, MD*, and
David A. Kostick, MD
From the Departments of *Anesthesiology, and Ophthalmology, Mayo Clinic, Jacksonville, Florida.
Address correspondence to Steven R. Clendenen, MD, Mayo Clinic, JAB 4035, 4500 San Pablo Rd., Jacksonville, FL 32224. Address e-mail to clendenen.steven{at}mayo.edu.
Abstract
We present a case of ocular globe luxation after general anesthesia. Upon completion of the surgery, the upper eyelid was retracted to examine for conjunctival edema, which resulted in globe luxation. The posterior aspect of the globe was visualized and a small tethering white structure ("check ligament") was observed. The upper lid was retracted, and the globe easily repositioned into the orbit. Ophthalmic sequelae would not be anticipated if the episode of globe luxation is brief. Anesthesiologists should be aware of the risk factors associated with globe luxation and know how to appropriately treat this complication.
Ocular globe luxation is uncommon in the general population, and has never been reported in the anesthesia literature. Luxation of the globe occurs more commonly in patients with floppy eyelids, shallow orbits, or proptotic eyes.1,2 Luxation of the globe can lead to serious complications, such as traction on the optic nerve with subsequent nerve injury, or venous congestion with potential damage to the retina. We present a case of globe luxation after total hip arthroplasty and general anesthesia with no sequelae.
CASE DESCRIPTION
A 70-yr-old man with a history of degenerative joint disease of his left hip presented for a left total hip arthroplasty. His medical history was significant for obesity (148 kg, 161 cm), sleep apnea for 15 yrs (using continuous positive airway pressure 8.5 cm H2O at bedtime), and glaucoma. His surgical history included bilateral upper lid blepharoplasties. On physical examination, the patient was obese and had proptotic-appearing eyes.
The patient was taken to the operating room and appropriate monitors were applied. After induction of general anesthesia with 150 mg of propofol followed by 100 mg of succinylcholine, the patient's trachea was intubated, the endotracheal tube secured with tape, and the eyelids taped shut. The patient was positioned in the right lateral decubitus with axillary padding for protection. The patient underwent an uneventful left total hip arthroplasty with a total anesthetic duration of 180 min. Intraoperatively, he received 2200 mL of lactated Ringer's solution for maintenance and replacement of an estimated 400 mL blood loss. Upon completion of the surgery, the patient was placed in the supine position. The right (dependent) eyelid was gently retracted to examine for conjunctival edema, which resulted in immediate globe luxation. The "check ligament" (a small tethering white structure) was observed on the posterior aspect of the globe, which originates from the sheath of the lateral rectus muscle and attaches to the lateral canthal tendon and periosteum. The lids spontaneously closed with the eye prolapsed outside the orbit. Immediately upon luxation, the upper lid was retracted, and the globe was easily repositioned into the orbit by applying constant, gentle pressure. The patient was re-examined in the postanesthesia recovery room and reported no pain, discomfort, or decrease in vision. On ocular examination, the pupils were equal and reactive to light. The extra ocular movements were intact and symmetric. A repeat examination 24 h later was unchanged, and the patient recovered without other complications. Upon discharge from the hospital, he denied any history of globe luxation.
DISCUSSION
Although uncommon, globe luxation can occur after uneventful anesthesia. Therefore, the anesthesiologist must be familiar with this complication, and more importantly, must be prepared to treat it. Risk factors for globe luxation include African American race (Fig. 1), proptosis, shallow orbits, and floppy eyelid syndrome, which can occur with obesity.3–5 Although our patient had a history of glaucoma and upper lid blephroplasty surgery, these are not known to be risk factors for globe luxation. However, both obesity and proptosis placed the patient at risk for this rare complication.6–8 The most common cause of proptosis in adults is Graves' disease, but our patient had no signs or history of hyperthyroidism. In the absence of any known cause, proptosis is considered "physiologic," implying a mismatch between the orbital volume and globe size. If proptosis is identified preoperatively, patients should be asked if they have a history of globe luxation. If the concern about proptosis and the possibility of luxation are significant, referral to an ophthalmologist preoperatively should be considered. If prominent eyelid laxity (floppy eyelid syndrome) is identified preoperatively, surgical correction should be considered. If no treatable cause is identified, but there is still concern (because of risk factors or history), one should use eye shields during surgery. Care should be taken when securing endotracheal tubes with tape to avoid traction on the cheeks. If globe luxation does occur, the first priority is to reposition the globe in its original position. Typically, gentle retraction of the eyelids and gentle pressure applied to the globe will allow the eye to be repositioned without difficulty.9 If the anesthesiologist is unable to reposition the globe, an immediate ophthalmology consultation is indicated. Ophthalmic sequelae would not be anticipated if the episode of globe luxation is brief. Initial examination by the anesthesiologist includes pupil response, ocular motility, gross visual acuity, and assessment of eye pain. After the initial assessment, consultation by an ophthalmologist is appropriate. Initial examination by the ophthalmologist would include assessment of visual acuity, pupil response, ocular motility, intraocular pressure, and visualization of the optic nerve for spontaneous venous pulsations.
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Figure 1. (A) Prominent luxation of the left globe that was easily induced on elevating the floppy left upper eyelid. (B) Left lateral view demonstrates spontaneous globe luxation. Reprinted with permission from Alexandrakis G, Tse DT, Chang WJ. Spontaneous globe luxation associated with floppy eyelid syndrome and shallow orbits. Arch Ophthalmol 1999;117:138–9.
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CONCLUSION
Globe luxation may occur after uneventful general anesthesia. Anesthesiologists must be aware of the risk factors associated with globe luxation and know how to appropriately treat this complication.
Footnotes
Reprints will not be available from the author.
REFERENCES
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