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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
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.
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