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| CLINICAL NOTE |
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| Year : 1999 | Volume
: 1
| Issue : 2 | Page : 97-99 |
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Blindness after surgery of the paranasal sinuses
Laila M Al-Telmessani
Department of Otolaryngology, King Faisal University Al-Khobar, Saudi Arabia
| Date of Web Publication | 16-Jun-2020 |
Correspondence Address:
FRCS Ed Laila M Al-Telmessani
Consultant ENT Surgeon King Fahd Hospital of the University P.O. Box 2208 Al-Khobar 31952
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/1319-8491.286870
In this communication we report two cases of blindness in two male patients who were referred to our hospital with the diagnosis of blindness after having undergone endoscopic ethmoidectomies on the same day.There were clinical signs of orbital hemorrhage in both patients. C.T. scan studies confirmed ethmoid sinus surgery.The optic nerves were intact.The blindness persisted six months after the date of diagnosis.
Keywords: blindness, orbital haematoma, surgery of the paranasal sinuses
How to cite this article:
Al-Telmessani LM. Blindness after surgery of the paranasal sinuses. Saudi J Otorhinolaryngol Head Neck Surg 1999;1:97-9 |
| Introduction | |  |
Sinusitis is one of the commonest diseases of the paranasal sinuses worldwide,Saudi Arabia being no exception.Surgical extirpation of the paranasal sinuses is frequently performed by otolaryngologists.
The anatomic proximity of the orbit to the adjacent paranasal sinuses renders its contents vulnerable to trauma during sinus surgery.[1] Blindness is one of the most distressing complications in otolaryngology and head and neck surgery. [2] It is due to either direct damage to the optic nerve or retrobulbar hematoma. [1] Orbital hemorrhage is the most frequently reported ophthalmic complication of paranasal sinus surgery and may result in blindness if not treated promptly.[3] It is well known that orbital hematoma will increase orbital pressure and reduce the blood supply to and from the eye.[1] If orbital hematoma is treated aggressively blindness associated with it can be reversed as the retina or optic nerve can only tolerate ischemia for 60-90 minutes. [2] This is a report of two cases of orbital haematoma with resultant blindness. To our knowledge and after computerized literature search, this is the first report of blindness post endoscopic sinus surgery in the Kingdom of Saudi Arabia.
| Case Reports | | |
First Case
A 26 year old Saudi male was referred to our hospital with left eye blindess which followed a submucous resection of the septum. The blindness was observed on the same postoperative day.
Examination revealed left eye ecchymosis, exode- viation, lower eye lid hematoma, non-reactive pupil with no light perception. The optic disc and macula were normal. Endoscopic examination of the nose revealed large septal perforation and small polyps in the left ethmoid region with blood clots which suggested surgical intervention to left ethmoid. Computerized tomogram showed dehes- cence in the lamina paprycea [Figure 1]. Magnetic Resonance Image (MRI) showed an edematous intact optic nerve [Figure 2]. Patient was treated with steroids but without improvement. | Figure 1: Axial CT Scan showing a clacified foreign body surrounded by mocosal thickening located in the right nasal fosseae with adjacent maxillary sinusitis .No bone destruction
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 | Figure 2: Axial CT Scan showing a clacified foreign body surrounded by mocosal thickening located in the right nasal fosseae with adjacent maxillary sinusitis .No bone destruction
Click here to view |
Second Case
A 30-year-old Pakistani male who had allergic rhinitis and nasal polyposis for which he has had two surgeries in Pakistan. The third surgery (intranasal ethmoidectorny) and in the immediae postoperative period he developed right eye ecchymosis, proptosis, lid hematoma and no light perception. He was sentto our hospital on the 3rd postopertaive day. Examination revealed right eye ecchymosis, exodeviafion, eye lids hematoma, non-reactive pupil and no light perception. The optic disc and macula were normal. Computerized tomography showed soft tissue density in the right ethmoid and frontal sinuses with dehescence of lamina paprycea and an intact optic nerve. He was treated with Prednisolone 80mg orally per day for 2 weeks with no improvement. On six months follw up the patientis right blindness persisted.
| Discussion | | |
Literature review revealed only eighteen cases of blindness after surgery of the paranasal .Orbital complications are associated more commonly with ethmoid and sphenoid surgery. [1],[2],[3],[4]
Two mechanisms for blindness that occur during ethmoid or sphenoid surgery are apparent: (1) direct damage to the optic nerve or its blood supply and (2) retrobulbar haematoma with increased orbital pressure which compromises vascular supply and drainage to and from the eye. [1] Stankeiwicz,1987 [2] reported one case of temporary blindness occurring as a result of an expanding orbital haematoma. The same author in 1989 reported four cases of blindness after intranasal ethmoidectomies, one of them was temporary while the other three were permanent. [1]
Maniglia,1989 [3] reported ten cases of blindness after ethmoid and sphenoid surgery and two of them were bilateral. Sozeri,1993 [4] reported a case of reversible blindness due to orbital haemorrhage occurring after intranasal ethmoidectomy
The majority of the cases of blindness secondary to surgery of the paranasal sinuses whether permanent or temporary were found to be due to orbital haematoma. Only three reported cases, two by Maniglia [3] and one by Bulls[5] in 1990 were secondary to transection of the optic nerve.
The development of endosocpic sinus surgery has stimulated interest in this type of surgical practice. It has also drew our attention to the fact that ethmoid surgery regardless of the technique employed has its potential dangers. [6] As surgeons in our part of the world started the practice of endosocpic sinus surgery, complications were to appear.
In both cases, the patients were not well informed about the type of surgery and the possible complications. An informed concent is necessary and every patient should be aware of the possible comlpica- tions, especially orbital and itracranial. [3]
Both’ of our patients developed symptoms of orbital haematoma e.g. lid edemam ecchymosis, chemo- sis, pupil dilatation and lastly proptosis and decrease of acuity of vision.But it was not dignosed intraoperatively and when diagnosed postoperatively, proper management was lacking.
Orbital bleeding may result in blindness if not treated promptly.[3] It can be difficult to differentiate direct optic nerve injury from retrobulbar haematoma. Therefore, management requires that the ophthalmologist and otolaryngologist cohort very closely together until the nature of the injury is determined.[1]
The surgical procedure should be stopped and eye massage should be started immediately to reduce eye pressue. The eye is gently massaged with the hand open aand the fingers together. Within a few minutes, the tense, hard eye relaxes and proptosis is reduced. The procedure can be repeated while waiting for the diuretic to work. The two main diuretics used are acetazolamide and mannitol. [1],[2],[5],[7] Electrolytes have to be monitered closely.
There is no literature supporting the benefits of ste- riod treatment for retrobulbar haematoma.[1]
If intensive medical management has proved unsuccessful after 30-60 minutes, then surgical orbital decompression should be performed starting with lateral canthotomy and catholysis by an ophthalmologist.
The patient should be monitered in the operating room with a schiotz tonometer and if the orbital pressure is not reduced, medial decompression should be undertaken.
The patients should be admitted to the intensive care unit and the eye should be checked frequently for proptosis,vision, papillary changes and increasing eye pain.
Early intraoperative recognition and prompt medical treatmenr could reverse blindness or prevent it as has been reported by Stankiewcz,1989; Sozeri,1993 and Bulls, 1990. [1],[4],[5]
Ophthalmic complications of sinus surgery are uncommon but when ther occur, they may result in considerable morbidity. Orbital haemorrhage is the most frequently reported ophthalmic complication of sinus surgery and may result in blindness if not treated promptly.[3],[4]
Training and experience plus knowledge of the ethmoid anatomy are of paramount importance for successful surgery with minimal complications. The early recognition of the complication and its appropriate management can help to decrease the relative severity of the complication.[6] The key to management is to move step by step in an organized fashion until vision loss is reveresed or all options have been exhausted.[1] Finally, we believe that reporting, major complications of sinus surgery espicially orbital ones, is of great importance so that otolaryngologists will gain a greater insight into the problem and all possible measures to prevent it.
Acknowledgement
I am greatly indebted to Professor Hashim Yagi for his help. I also wish to thank Mr. Gordon Ntow of the Medical Photography Department of King Fahd Hospital of the University for the preparation of the prints.
| References | | |
| 1. | Stankiewicz James A. Blindness and intranasal endoscopic ethmoidectomy, prevention and management. Otolaryngol Head Neck Surg 1989;101:320-329.  |
| 2. | Stankiewicz James A. Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 1987;97:1270-1273. |
| 3. | ManigIia JJ. Fatal and major complications secondary to nasal and sinus surgeiy. Laryngoscope 1989;99:276-283. |
| 4. | Sozeri B,Ataman H, Guvsel B. Blindness after intranasal ethmoidectomy. Rhinology 1993;31:85-87. |
| 5. | Bulls DR. Ophthalmic complications of sinus surgery. Ophthalm 1990;97:612-619. |
| 6. | Sogg A, Eichel B. Ethmoid surgery complications and their avoidance. Ann Otorhinolaiyngol 1991; 100: 722-724. |
[Figure 1], [Figure 2]
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