Intra-arterial Thrombolysis for Branch Retinal Artery Occlusion and Anterior Ischemic Optic Neuropathy (AION) Occurring After Orbital Floor Fracture Surgery - A Case Report and Literature Review

以動脈內注射血栓溶解劑治療眼窩底骨折術後併發視網膜分支動脈阻塞及前部缺血性視神經病變的患者－個案報告及文獻回顧

曾文楷(Wen-Kai Tseng) ； 蘇亦昌(I-Chang Su) ； 汪宜樺(I-Hua Wang) ； 李建智(Jian-Jr Lee)

《臺灣整形外科醫學會雜誌》 27卷3期 (2018/09) Pp. 231-242

摘要

Background: Facial bone fracture-related blindness may be associated with the fracture injury or with the consequent operation. Most of the cases of post-operative blindness following facial bone fracture occur among patients with orbital floor fracture. Retrobulbar hemorrhage, increased intra-ocular pressure, and vascular compromise are possible mechanisms of blindness. Occlusion of the retinal artery and/or its branches and ischemic optic neuropathy can impair visual acuity. No evidence-based treatment protocol has been established yet for this complication. Aim and Objectives: We report a case of left eye blindness occurring after an operation to fix an orbital floor fracture; the patient was successfully treated with intra-arterial thrombolysis. We review the literature to elaborate the possible mechanisms of blindness and to describe the current treatment. Materials and Methods: A 69-year-old man with no known systemic disease fell in the bathroom. Results of an examination using head and neck computer tomography (CT) revealed left eye orbital floor fracture. His visual acuity was not affected. Orbital floor reconstruction with a bio-absorbable plate was performed smoothly one week after trauma. The following morning, the patient complained of shadow that was hindering his vision. Then, the patient developed near-total blindness (OS). Results of an urgent orbital CT examination showed the plate was positioned correctly and the ophthalmic artery was intact. Fundus photography revealed an injected disc with disc edema and whitening of the cilioretinal artery area. Cilioretinal artery occlusion and anterior ischemic optic neuropathy (AION) were suspected. Intra-arterial thrombolysis was performed in a hybrid operation room (Artis Zeego, Siemens AG, Forchheim, Germany). Results: Results of follow-up fluorescein angiography showed no arterial perfusion delay. During the out-patient follow-up, the patient’s visual field improved by 60-70%. His visual acuity also increased from light sensation to 20/30 (OS) 7 months later. Conclusion: Intra-arterial thrombolysis with urokinase can restore vision following its loss due to cilioretinal artery occlusion and AION. However, the potential adverse effects of thrombolysis, including hemorrhagic stroke and surgical site bleeding, should be carefully assessed.

關鍵字

orbital floor fracture ； intra-arterial thrombolysis ； cilioretinal artery occlusion ； anterior ischemic optic neuropathy

並列摘要

背景：眼窩底骨折的病人可能併發突發的視力喪失，睫狀體視網膜動脈阻塞及前部缺血性視神經病變是其中一個可能原因，目前並沒有研究報告指出此類病人該如何治療。目的及目標：藉由報告一個以動脈內注射血栓溶解劑治療眼窩底骨折術後併發睫狀體視網膜動脈阻塞及前部缺血性視神經病變的個案，探討此類病人可能發生原因及治療上的選擇。此外，也針對整形外科中常造成視力影響的填充物注射做討論。材料及方法：一位六十九歲男性因跌倒被送入急診，電腦斷層顯示左側眼窩底骨折，在可吸收骨板重建後發生左側視力喪失，眼科檢查診斷為睫狀體視網膜動脈阻塞及前部缺血性視神經病變，經會診神經外科後，施行動脈內注射血栓溶解劑治療。結果：術後除左眼瘀青擴大外患者無其他不適，追蹤七個月後病人左眼視力恢復到0.7且視野也恢復六至七成。結論：眼窩底骨折術後若併發睫狀體視網膜動脈阻塞及前部缺血性視神經病變造成的視力喪失，可以考慮以動脈內注射血栓溶解劑治療；但病人的臨床狀況及相關風險必須仔細評估及告知。