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Anesthesiology:
Case Reports

A Unique Case of Subconjunctival Hemorrhage in a Patient Undergoing Decompressive Lumbar Laminectomy

Obray, Jon B. M.D.*; Long, Timothy R. M.D.†; Wass, C. Thomas M.D.‡

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EYE injury after nonocular surgery is rare, with an incidence of approximately 0.06%. 1 To elucidate the frequency of eye injury, Roth et al.1 surveyed the records of 60,965 patients undergoing nonocular surgery. They observed that 34 patients sustained eye injury (e.g., corneal abrasion, conjunctivitis, blurred vision, red eye, chemical injury, direct trauma, eyelid hematoma, permanent visual loss) during the perioperative period. 1 Of these, corneal abrasion and blindness were the most and least commonly reported injuries, respectively. 1 Of additional interest, Gild et al.2 reported that 3% of all claims in the American Society of Anesthesiologists Closed Claims Database were due to ocular injury. Further, they reported that the payment frequency for eye injury claims was significantly greater than for non–ocular-related injuries. 2 Taken together, although perioperative eye injury is rare, it can result in serious patient morbidity. We present a unique case in which we observed subconjunctival hemorrhage after uneventful general anesthesia for decompressive lumbar laminectomy.
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Case Report

A 67-yr-old woman with American Society of Anesthesiologists physical status III and a 3-week history of left foot drop secondary to severe lumbar spinal stenosis was scheduled to undergo surgical decompression and fusion of the L4–L5 disk space. Preoperative medical examination revealed an obese patient (weight, 120 kg; body mass index, 47 kg/m2) with a history of gastroesophageal reflux disease and deep venous thrombosis after a previous pregnancy. Her current medications included famotidine and acetaminophen as needed. She was allergic to penicillin and had no previous anesthesia-related complications.
General anesthesia was induced with intravenous fentanyl, propofol with lidocaine, and succinylcholine. Cricoid pressure was applied. After induction of general anesthesia, the patient's eyes were taped shut before atraumatic orotracheal intubation. In addition to standard American Society of Anesthesiology monitors, right internal jugular vein and right radial arterial artery catheters were placed. She was positioned prone on a Jackson table with her face carefully positioned in a Gentletouch® 7” Headrest Pillow (Orthopedic Systems, Inc., Union City, CA) with a T-shaped cutout for the eyes, nose, and mouth. Her orbits and abdomen were noted to be pressure-free after prone positioning and throughout the surgical course. Anesthesia was maintained with inhaled isoflurane and nitrous oxide plus intravenous oxymorphone and vecuronium.
Hemodynamically, she was stable throughout surgery, with brief episodes of hypertension (maximum systemic blood pressure, 195/100 mmHg) during laryngoscopy and emergence. Both episodes of hypertension were promptly treated with intravenous esmolol and hydralazine. Blood loss was estimated to be 900 ml. She received 500 ml hetastarch, 2,800 ml lactated Ringer's solution, and 425 ml intraoperatively salvaged blood. Central venous pressure measurements ranged from 7 to 13 mmHg during surgery. Urinary output was 900 ml.
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At the conclusion of surgery (after being prone for approximately 6 h), the patient was returned to the supine position, and the eye tapes were removed. Because the patient appeared somnolent, we elected to assess the level of narcosis by evaluating the magnitude of pupillary miosis. However, while doing this, we observed what seemed to be severe scleral injection or subconjunctival hemorrhage in her left eye (fig 1). The orbit was devoid of overt trauma, and the eye was free of purulence and lacrimation. It deserves mention that these findings were observed before emergence from general anesthesia. That is, the patient had not coughed or strained during use of the endotracheal tube.
Subsequently, the patient underwent uneventful extubation, and an ophthalmology consultation was obtained in the postanesthesia recovery room. The ophthalmologist reported subconjunctival hemorrhage of the left eye with intact visual acuity, normal intraocular pressures, and normal funduscopic examination. The ophthalmologist's conclusion was subconjunctival hemorrhage of unclear etiology that would resolve spontaneously. In a follow-up telephone interview 2 weeks after surgery, the patient reported complete resolution of her subconjunctival hemorrhage without long-term sequelae.
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Discussion

We report a case of atraumatic perioperative subconjunctival hemorrhage. To elucidate the uniqueness of the current case, we performed an extensive search of the medical literature and were unable to find previously cited cases of perioperative subconjunctival hemorrhage. Although this physical finding is extremely distressing at first glance, the downstream implications are typically of little, if any, consequence. That is, the usual clinical course of subconjunctival hemorrhage is that of spontaneous resolution without long-term sequelae.
Subconjunctival hemorrhage results from tearing of small vessels bridging the potential space between the episcleral and conjunctival tissues. These events are usually spontaneous and unilateral in nature. Other causes include extremes of patient positioning (e.g., head-down vertical inversion), blunt trauma (e.g., a patient rubbing their eye postoperatively), vigorous coughing (e.g., paroxysms associated with pertussis infection) or sneezing, Valsalva maneuver (e.g., bearing down during labor or in patients with bulimia), systemic hypertension, ocular amyloidosis, aspirin intoxication, and acute conjunctivitis. 3–8
After an extensive ophthalmologic evaluation, we were unable to determine the etiology of subconjunctival hemorrhage in our patient. Potential etiologies include prone positioning and transient systemic hypertension. Patients undergoing spinal surgery are often placed in the prone position for extended periods of time. In the healthy patient, this is probably without consequence; however, in the patient with retinal vascular abnormalities, macular degeneration, ocular hypertension, glaucoma, and other similar disorders, this may contribute to serious postoperative ocular complications. Because the current patient's abdominal region was free of pressure during prone positioning, we doubt that her obesity was a causative factor. Specifically, care was taken to ensure that her abdomen was free of compression, thereby avoiding thoracic and ocular vascular congestion.
Fortunately, subconjunctival hemorrhage usually resolves spontaneously over 2 or 3 weeks with no long-term sequelae. Nonetheless, appropriate ophthalmologic examination is indicated to rule out the possibility of concurrent and more serious ocular injuries. In the current patient, ophthalmologic examination revealed no significant change in visual acuity and normal intraocular pressure, and she recovered from this event without adversity.
In summary, we present a unique case of perioperative subconjunctival hemorrhage. Despite the unsightly physical appearance of this disorder, long-term sequelae rarely occur. Nonetheless, careful ophthalmologic examination is essential to rule out more serious pathology.
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References

1. Roth S, Thisted RA, Erickson JP, Black S, Schreider BD: Eye injuries after nonocular surgery. A nesthesiology 1996; 85: 1020–7

2. Gild WM, Posner KL, Caplan RA, Cheney FW: Eye injuries associated with anesthesia: A closed claims analysis. A nesthesiology 1992; 76: 204–8

3. Fukuyama J, Hayasaka S, Yamada K, Setogawa T: Causes of subconjunctival hemorrhage. Ophthalmologica 1990; 200: 63–7

4. Paysse EA, Coats DK: Bilateral eyelid ecchymosis and subconjunctival hemorrhage associated with coughing paroxysms in pertussis infection. J Am Assoc Pediatr Ophthalmol Stabismus 1998; 2: 116–9

5. Weinstein HD, Halabis JA: Subconjunctival hemorrhage in bulimia. J Am Optom Assoc 1986; 57: 366–7

6. Lee HM, Naor J, DeAngelis D, Rootman DS: Primary localized conjunctival amyloidosis presenting with recurrence of subconjunctival hemorrhage. Am J Ophthalmol 2000; 129: 245–7

7. Black RA, Bensinger RE: Bilateral subconjunctival hemorrhage after acetylsalicyclic acid overdose. Ann Ophthalmol 1982; 14: 1024–5

8. Wright PW, Strauss GH, Langford MP: Acute hemorrhagic conjunctivitis. Am Fam Physician 1992; 45: 173–8

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