Transcript Style E 24 by 48 - Advocate Health Care

Ocular Rosacea or Corneal Abrasion After General Anesthesia?
Andrew Germanovich,
Department of Anesthesiology,
1
1
DO ,
Arjang Khorasani,
2Department
1
MD ,
Harold Sy,
2
MD ,
N. Nick Knezevic, MD,
1
PhD
of Ophthalmology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA
Abstract
Case Description
Discussion
We report a patient who developed
blurry vision, episcleritis, blepharitis and
conjunctivitis
following
general
anesthesia. Corneal abrasion, as the
most common eye injury related to
general anesthesia was suspected.
Ophthalmologic
consultation
was
obtained
and
excluded
corneal
abrasion. The patient had exacerbation
of ocular rosacea induced by gas
leakage during bag mask ventilation or
during spontaneous breathing via face
mask before or after anesthesia.
• A 75 year old man scheduled for elective surgical repair of right inguinal and umbilical hernia
• PMH – DM and HTN; Allergies: None
• PE: facial telangiectasias, MPII, CTAB, RRR
Anesthetic Course:
• Premed: 1 mg of midazolam.; PreO2 - 10L O2 via FM 2 min
• Induction: 2 mg/kg of propofol, 100 mcg of fentanyl, 0.6 mg/kg of rocuronium; Eyes were taped shut
• Patient was manually ventilated for 90 sec. prior to intubation , PAP < 20 cmH2O
• The trachea was intubated and extubated without difficulty
• PostOp O2 provided via FM at 10 L/min immediately after the procedure, during transport and PACU
• One hour later the patient started to complain of an increasing burning sensation in his right eye,
associated with blurry vision, dryness, and severe itching
• Corneal abrasion was suspected and the patient was taken to the eye clinic
Ophthalmologic consultation:
• Right lower palpebra erythematous and edematous; the conjunctiva injected, no corneal abrasion
• Additional directed history - prior episodes of identical right eye symptoms following exposure to high
airflows from cooling fans or automobile vents
• Patient stated that during facemask oxygenation he felt a stream of oxygen gas blowing in both eyes
• Diagnosis – Ocular Rosacea, based on dermatologic findings of rosacea and clinical ophthalmologic
exam (Picture 1)
• Treatment – lubricant eye drops, and symptoms improved within minutes
• Home Rx – 50 mg of doxycycline QD for a month; use of compresses twice a day, and lid scrubs at
bedtime; artificial tears QID; and avoidance of rosacea triggers such as nicotine, caffeine, alcohol, and spicy
foods was advised.
• Corneal abrasion is the most common eye injury
related to general anesthesia
• It is often attributed to facemasks, tape or other
foreign objects
• 4.2% of patients complain of eye symptoms
following anesthesia for non-ocular surgery.5
• Instances of blurry vision after anesthesia
occasionally occur without evidence of corneal
abrasion.
• Ocular rosacea can precede facial rosacea and
present with blurry vision, blepharitis and
conjunctivitis.
• We believe that this case is an exacerbation of
acute ocular rosacea, induced by the leakage of gas
from the face mask, causing eye irritation.
• This gas leakage was possible during bag mask
ventilation or during spontaneous breathing via
facemask before or after anesthesia.
• During mask ventilation in majority of instances air
leak occurs in right upper side of the mask.
Introduction
Rosacea
• unknown etiology, affects primarily
chin, nose, cheeks and glabella
• erythema, telangiectasias, flushing,
papules and pustules
• exacerbated by heat, spicy foods, hot
drinks, alcohol, emotional stimuli, heat,
1
cold or strong winds
• most prevalent in the middle age
group of Northern Europeans2
Ocular Rosacea
• common in 50% of patients with facial
3
rosacea
• no correlation between severity of
ocular rosacea and severity of facial
rosacea
•Symptoms: eye irritation, dryness,
blurry
vision,
corneal
ulceration,
perforation or secondary infection.4
Picture 1. A photograph of the patient after treatment (with
written permission) . Note telangiectasias on the patient’s nose,
cheeks and forehead. Also note the patient’s residual blepharitis
and conjunctivitis in the right eye.
References
1. Buechner SA. Dermatology 2005; 210: 100-8
2. Chamaillard M, et al. Arch Dermatol 2008; 144: 167-71
3. Wilkin J, et al. J Am Acad Dermatol 2002; 46: 584-7
4. Akpek EK, et al. Ophthalmology 1997; 104: 1863-7
5. Warner ME, et al. Anesthesiology 2002; 96: 855-9
6. Wilkin JK. Arch Dermatol 1994; 130:359-62
Recommendations
• Application of eye lubrication as soon as possible
after induction of anesthesia and during the
postoperative period.
• Minimize gas leakage from the facemask during the
perioperative period.
• Although patients can be prophylactically treated
with lubricating eye drops, they should still be
examined by an ophthalmologist.
• Patients with ocular rosacea require detailed
examination and a follow up treatment plan to prevent
serious complications.6