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Editor,—Subperiosteal orbital haematoma as a complication during endoscopic sinus surgery is not well known to ophthalmologists.
It has the potential to increase intraocular pressure and subsequently cause blindness by optic nerve compression with central retinal artery occlusion.1
We report a case of a 13 year old boy who developed bilateral subperiosteal haematoma after bilateral endoscopic sinus surgery.
A 13 year old boy was referred for evaluation of decreasing visual acuity 3 days after bilateral endoscopic sinus surgery for pansinusitis.
He complained of blurred vision in both eyes, diplopia, and anhidrosis of the left side of his face. There was moderate swelling of the left upper eyelid. His best corrected visual acuity was 20/30 in the right and 20/40 in the left eye. Both pupillary responses showed sluggish reactions. Upward movement of left eye was limited, with inability to supraduct more than 30 degree past the midline because of pain. In the primary position he had a 5 prism dioptre left hypodeviation. Slit lamp examination, funduscopic examination, and confrontation visual field tests were normal in both eyes. Intraocular pressure by applanation was 14 mm Hg in both eyes. An orbital computed tomography (CT) scan demonstrated soft tissue swelling consistent with subperiosteal haematoma in both orbits (Fig 1). The patient had no history of systemic diseases such as coagulopathy or bleeding disorder.
Treatment with systemic antibiotics and coagulant was tried, to promote the spontaneous absorption of the subperiosteal haematoma and prevent other complications, because of the patient’s fear of more surgery.
Ten days after the sinus surgery, anhidrosis of the left side of the face persisted and left eye visual acuity decreased to 20/200. At that time, visual evoked potential (VEP) showed evidence of optic nerve damage in both eyes with prolonged latency and decreased amplitude. Follow up orbital CT revealed no decrease in the amount of blood present.
The same day an emergency operation was performed to evacuate the subperiosteal haematoma by bilateral sub-brow incision; the blood was evacuated through a periosteal incision.
The day after the operation his anhidrosis was resolved and visual acuity in both eyes recovered to 20/20 in 2 weeks. Orbital CT 2 weeks after operation demonstrated clearing of the subperiosteal haematoma (Fig 2).
Because of the relatively low complication rate from endoscopic surgery of the paranasal sinuses, orbital injury only occasionally presents to the ophthalmologist. These orbital complications include injury to the nasolacrimal duct, orbital emphysema, diplopia, orbital haematoma, and temporary or permanent blindness.2 The most devastating complication is blindness resulting from optic nerve compression by haematoma or direct injury to the nerve itself. If injury of the anterior ethmoidal artery occurs during the ethmoidectomy, it may be difficult to control the bleeding owing to the contraction of the vessel into the orbit.
The pathogenesis of subperiosteal orbital haematoma is (1) traumatic tearing of an orbital vessel, (2) rupture of a subperiosteal vessel secondary to increased venous pressure transmitted by valveless orbital veins from congested sinus mucosa, or (3) erosion of a vessel by orbital extension of an infectious process. Its frequent occurrence in the roof of the orbit may be related to the loose attachment of the periosteum in this area.3
In this case, it was thought that the subperiosteal haematoma was caused by avulsion injury to the posterior ethmoidal arteries during endoscopic sinus surgery. There was no fat protrusion or anterior ethmoidal artery injury during surgery.
Herniation of the orbital fat is an important sign, indicating entry to the lamina papyracea during the removal of the polypoid tissue from the ethmoidal sinus.2 If there is a suspicion of orbital bleeding, the patient should be observed for signs of increased intraorbital pressure such as pain, swelling of the eyelid, ecchymosis of the eyelid, proptosis, restriction of the eyeball movements, pupillary reaction, and diminished vision by the ophthalmologist in the recovery room.
Interestingly, this patient had anhidrosis of the left side of the face. The authors could not find any reports on anhidrosis associated with subperiosteal haematoma. Sweating over the ipsilateral side of the face is lost with sympathetic interruption below the bifurcation of the carotid artery, where the facial sweat fibres leave the artery.
Anhidrosis in this patient may be related to injury of sympathetic fibres in the optic foramen by pressure of a subperiosteal haematoma.
This case reports an unusual but dangerous simultaneous bilateral orbital complication of endoscopic sinus surgery and its treatment.