Anesth Analg 2002;95:1462-1463
© 2002 International Anesthesia Research Society
LETTERS TO THE EDITOR
Diagnosis of Acute Glaucoma in the Postoperative Period
Mitchel B. Sosis, MD PhD, and
Brian Cohen, OD FAAO
Campus Eye Group, Hamilton Square, New Jersey
To the Editor: We read with interest the recent report by Lentschener et al. (1) describing a 66-year-old woman with hyperopia who developed right-sided vision loss, erythema, and a bilateral frontal headache after a thyroidectomy performed under general anesthesia. A diagnosis of an anesthesia-related corneal injury was initially made, and the patient was treated with 10 mg of morphine administered subcutaneously.
In their report, the authors made no mention of even a basic diagnostic evaluation of the cornea, which can be done easily with fluorescein and a cobalt blue lamp—items that are generally available in any emergency department. In addition, pupillary testing is indicated whenever a patient reports vision loss and pain. In this case, the patient had a sluggish, mid-dilated pupil not diagnostic of a corneal abrasion. However, had there been a corneal abrasion, the patient’s treatment with morphine would have inappropriate because it simply would have masked any discomfort that she experienced. After the confirmation of a corneal abrasion, a patient should be treated with a topical antibiotic to prevent the development of a vision-threatening corneal ulcer (2).
In the case described, the patient’s increasing pain and erythema after 24 hours finally led to an ophthalmic examination, which revealed an elevated intraocular pressure. A diagnosis of narrow angle glaucoma was made.
It is important to note that patients with hyperopia (such as the patient described by the authors) have a higher incidence of a narrow iridocorneal angle because of the inherently small axial dimension of their eyes, which predisposes such patients to angle closure glaucoma.
The presence of a narrow iridocorneal angle would likely have been documented in the ophthalmic examination the patient underwent 1 year before surgery. It is unfortunate that the condition was not recognized at the time of surgery so that the use of drugs such as ephedrine, which may precipitate acute closed angle glaucoma, could have been avoided. Given the patient’s complaints, early ophthalmic consultation was indicated.
References
- Lentschener C, Ghimouz A, Bonnichon P, et al. Acute postoperative glaucoma after nonocular surgery remains a diagnostic challenge. Anesth Analg 2002; 94: 1034–5.[Abstract/Free Full Text]
- Cullom RD, Chang B, eds. The Wills eye manual. 2nd ed. Philadelphia: J B Lippincott, 1994:22–3.
Response
Claude Lentschener, MD,
Abdelmalek Ghimouz, MD,
Philippe Bonnichon, MD,
Christine Parc, MD, and
Yves Ozier, MD
University Paris V, Hôpital Cochin, Paris, France
In Response: We thank Drs. Sosis and Cohen for their interest in our case report (1). The authors point out issues of topical importance concerning both corneal injury and glaucoma cares, providing a contributive specialist opinion. However (and unfortunately), they misunderstood our message. Indeed, as announced in the title part of our manuscript, we report a diagnostic misadventure that could have been highly deleterious for the patient (1). An acute glaucoma following nonocular surgery was not diagnosed. Therefore, the appropriate treatment was delayed (1). Moreover, the patient was not aware that she had chronic angle-closure associated hyperopia (1).
Glaucoma and/or corneal injury are routine diagnoses in patients referred to an ophthalmology unit with only an eye complaint (2). Glaucoma is, however—as developed in the discussion part of our text and previously—an uncommon occurrence following nonophthalmologic surgery (1,3). We believe (and previous clinical reports confirm) that such a diagnostic misadventure could have occurred for other colleagues following nonocular surgery (3).
As do others, we strongly believe that clinical failures are of pedagogical value and should be published (4). In accordance with this statement, we reported our inappropriate clinical approach with a pedagogical goal. Letters to the Editor, if any, were expected to be on this pedagogical ground, in contrast with the letter from Drs. Sosis and Cohen.
References
- Lentschener C, Ghimouz A, Bonnichon P, et al. An acute postoperative glaucoma following non-ocular surgery. Still a diagnostic challenge. Anesth Analg 2002; 94: 1034–5.
- Cullom RD, Chang B, eds. The Wills eye manual. 2nd ed. Philadelphia: L. B. Lippincott, 1994:22–3.
- Fazio DT, Bateman JB, Christensen RE. Acute angle-closure glaucoma associated with surgical anesthesia. Arch Ophthalmol 1985; 103: 360–2.[Abstract/Free Full Text]
- Owens RC Jr, Ambrose PG. Torsades de pointes associated with fluoroquinolones. Pharmacotherapy 2002; 22: 663–8.[Web of Science][Medline]
This article has been cited by other articles:
|
|
|
|
 
F. T. Lytle and D. R. Brown
Appropriate Ventilatory Settings for Thoracic Surgery: Intraoperative and Postoperative
Seminars in Cardiothoracic and Vascular Anesthesia,
June 1, 2008;
12(2):
97 - 108.
[Abstract]
[PDF]
|
|
|
|
