A 73-year-old man with acute orbital swelling following cataract surgery
Digital Journal of Ophthalmology 2007
Volume 13, Number 8
August 28, 2007
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Conor Mulholland | The Royal Victoria Hospital, Belfast

A 73 year-old man presented for planned post-operative day 1 examination following phacoemulsification and placement of intraocular lens in the right eye. He complained of right upper and lower eyelid swelling and an inability to open the right eye. The surgery had been carried out under sub-Tenon's local anesthesia. The surgical record noted high “positive pressure” during surgery and a corneal wound suture was used but there were no intraoperative complications.

His past ocular history was notable for an uncomplicated cataract extraction with placement of an intraocular lens in the left eye 6 months prior. He had no significant past medical history.

The visual acuity was 6/9 (with assisted elevation of the eyelid) on the right and 6/6 on the left. There was marked periorbital swelling, 2mm of proptosis and restricted eye movements on the right. Pupillary reactions were normal. Color vision was normal. Anterior segment examination showed marked conjunctival hyperemia and chemosis. The anterior chamber was quiet. Examination of the fundus and optic disc was normal.

Figure 1
Attempted upgaze showing limited elevation of the right eye

Figure 2
Attempted leftgaze showing limited adduction of the right eye

Figure 3
Attempted downgaze showing limited depression of the right eye

Figure 4
Lid swelling and ptosis

Ancillary Testing
Radiographic Studies
Computed Tomography of orbits showed diffuse edema of orbital tissues but no evidence of retrobulbar hemorrhage and no focal lesion.

Allergen Testing
Cutaneous allergen patch testing showed hypersensitivity to hyalouronidase.

The patient was admitted for observation including serial testing of visual acuity, pupillary responses and color vision. Oral antihistamines were prescribed.

Differential Diagnosis
1. Retrobulbar hemorrhage

Retrobulbar haemorrhage is a well recognized but rare complication of cataract surgery. The incidence is estimated at between 0.44% and 1.7% with retrobulbar local anesthetic blocks,(1, 2, 3) but is lower with Sub-Tenon's anesthesia.(5) It can present with acute proptosis, periocular ecchymosis, restricted eye movements and loss of vision. However in this case computed tomography scanning of orbits showed diffuse orbital edema but no evidence of hemorrhage.

2. Orbital cellulitis

Orbital cellulitis is another rare complication of cataract surgery and can present with lid swelling, proptosis and restricted eye movement.(6) However it would also be expected to be associated with headache, pyrexia and systemic upset.

3. Hypersensitivity reaction

Cutaneous allergen patch testing in this case demonstrated hypersensitivity to hyaluronidase. Of note hyaluronidase had been added to the local anesthetic mix for the affected right eye but had been omitted when the fellow left eye had been operated upon uneventfully 6 months previously.

4. Endophthalmitis

Acute endophthalmitis following cataract surgery may also present with lid swelling but in the absence of any intraocular inflammation or reduction in vision this diagnosis can be excluded.

5. Nerve palsy and/or extraocular muscle injury

Periocular anesthesia may be associated with nerve palsies leading to impaired ocular motility. In particular the oculomotor nerve is often affected by periocular anesthesia. However this effect is short-lived and not associated with the proptosis and periocular swelling seen in this case. Direct injury to extraocular muscles may also impair ocular motility but would be associated with restriction of movement in the direction of action of the affected muscle, and would again not be associated with the proptosis, periocular swelling and diffuse edema seen in this case.

Diagnosis and Discussion
This case report describes an unusual case of acute orbital swelling following cataract surgery caused by hypersensitivity to hyaluronidase, a component of the sub-Tenon’s local anesthetic mix. Hypersensitivity was confirmed on cutaneous patch testing.

The presentation in this case was similar to that described in a previous case series of hypersensitivity reactions to hyaluronidase following peribulbar anaesthetic for cataract surgery.(7) The typical presenting features in this case series were proptosis, peribulbar erythema and itching, restriction of extraocular muscle function, conjunctival chemosis, pain and itch. The management in this case involved observation and oral anti-histamines. Complete resolution occurred over the following 7 days.

1. Edge KR, Nicoll JMV. Retrobulbar haemorrhage after 12,500 retrobulbar blocks. Anesth Analg 1993; 76: 1019-22
2. Ruben S. The incidence of complications associated with retrobulbar injection of anaesthetic for ophthalmic surgery. Acta Ophthalmologica 1992; 70: 836-8
3. Cionni RJ, Osler RH. Retrobulbar haemorrhage. Ophthalmology 1991; 98: 1153-5
4. Rahman I. Ataullah S. Retrobulbar hemorrhage after sub-Tenon's anesthesia. Journal of Cataract & Refractive Surgery 2004; 30(12):2636-7
5. Konstantatos. Anticoagulation and cataract surgery: a review of the current literature. Anaesthesia & Intensive Care 2001; 29(1): 11-8
6. Hofbauer JD, Gordon LK, Palmer J. Acute orbital cellulitis after peribulbar injection. American Journal of Ophthalmology 1994; 118(3): 391-2.
7. Leibovitch I, Tamblyn D, Casson R and Selva D. Allergic reaction to hyaluronidase: a rare cause of orbital inflammation after cataract surgery. Graefe's Archive for Clinical and Experimental Ophthalmology 2006; 244(8): 944-949