Transient Blindness & Squint during S.M.R. Operation

K. CI. CADRE, S. A. GOKtIALE, K. B. BHAROAVA, T. M. SHA~.

Retinal arterial spasm is one of the common causes of arterial occlusion. The predisposing factor is vasomotor instability which may manifest as migraine, menstrual disturbance, Raynaud's disease etc. In many eases, how- ever, no evidence of vascular or organic disease can be found. I t has been reported in dogs following adrenalin injection (Redslop, 1926; Cohen & Bothman, 1927). I t has also been precipitated by inhalation of tobacco smoke or by procedures like antral wash (Hirsch, 1920; K. E. Weiss, 1921; Swett, 1935). The spasm usually subsides without leaving any permanent damage. This is a report of transient blindness and paralytic squint occuring after injection of 2 % xylocaine with adrenaline, presumably due to arterial spasm.

K. G. Gadre I-~on. Professor & I-Iead of the E.N.T. Department. S. A. Gokhale I-Ion. Assistant Prof. of Ophthalmology. K. B. Bhargava Hon. Associatlatc Professor of E.N.T. T. M. Shah, Tutor in E.N.T. Lokmanya Tilak Municipal Medical College & Hos-

pital, Sion, Bombay-400 022.

Case Report

A male medical student (V.M.) aged 25 years was taken up for an S.M.R. operation on 18th Jan., 1978 under local anaesthesia. With hardly 3 ml of xylocaine with adrenaline having been injected into the nasal septum on the right side he complained of blindness of the right eye. On examination the right pupil was semidilated and very slug- gishly reacting to light and the right eye was markedly divergent. The medial rectus was completely paralysed and the inferior and superior recti were partially paralysed. The left eye was normal. During examination of the right eye, vision rapidly improved and he started complaining of diplopia. By the time the opthalmoscope was brought the vision was almost normal and the fundus also was nor- mal. Within five minutes the eye became normal and diplopia, had disappeared. On enquiry, he did not give history of any vascular disturbance in the past. The blood-pressure was normal. He made an unevent ful recovery.

It was lucky that the operation was being conducted under local anaesthesia. If the in- jection of adrenaline was given with the patient under general anaesthesia probably

the ocular effect would not have come to notice, and might have permanently endangered his eye sight.

Due to fear of having a similar episode on injecting the septum on the left side, the operation was abandoned.

Discuss ion

The most likely explanation of this episode is a spasm of retinal and orbital arteries due to adrenaline in the xylocaine injection. The effect is likely to be local rather than systemic because:

1. The other eye was not involved. 2. The patient did not complain of other

disturbances like palpitation. 3. The arteries on the medial side of the

right orbit were involved. Hence the medial rectus was completely pamlysed and the superior and inferior recti were partially paralysed resulting in a diver- gent squint and diplopia.

References Cohen & Bothman (1927), Hiresh (1920) Redslop

(1926), Swelt (1935) & Weris (1921) quoted by Duke Elder, Text Book of Ophthalmology.

Canine Fossa Puncture Aen~n~ AHAD, ABDUL RASHID~ ~V~OHAMMAD SAmQ

There are sufficient side effects of the in- ferior meatus technique of maxillary sinus lavage, like bleeding, pain and synco.pal attack, thus an alternative route with mamm- al complications might be of some interest. Canine fossa approach has been tried in a series of 40 patients of chronic maxillary sinusitis. To compare the side effects met with, the two routes, were tried on the same patient. The (L) maxillary antrum was approached through canine fossa while the (R) antrum was irrigated through the inferior meatus in all the 40 patients taken up for the present study.

Technique o f canine fossa puncture

Canine fossa was infiltrated with 3 ml. of I per cent xylocainc. 5 mts. after the infiltra- tion of local anaesthetic, the canine fossa was punctured with a trocar and canula, keeping the tip at an angle of 90 degrees with the surface, which makes it less likely to slip.

Abdul Ahad Asstt. Prof. E.N.T. Govt. Medical college, Srngar. Abdul Rashld Reglstt'ar, E.N.T. Govt. Medical college

Srinagar. Mohammad Sadiq Rcglstrar, E.N.T. Govt. Ngcdical

college, 8ringar.

Discuss ion

I t is quite obvious from the observations that canine fossa approach has got very few side effects as compared to the inferior meatus technique. Only 10 patients (25 per cent) felt pain with canine fossa approach while with inferior meatus technique all the 40 patients (100 per cent) noticed pain. The two procedures having been performed in the same patient eliminated the individual varia- tion of pain threshold.

With canine fossa route only 5 patients (12"5 per cent) had bleeding in contrast to 28 patients (70 per cent) having bleeding with the inferior meatus technique of proof puncture. Bleeding is usually annoying to the patient and another disadvantage of the bleeding is that the blood gets mixed with the antral wash out thereby masking the true nature of the discharge. With canine puncture no patient got a syncopal attack while with the inferior meatus approach five patients had syncopal attacks. Petersen (1973) also observed fewer side effects with canine fossa approach in a series of 25 patients, but his series lacked the presence of a control group. There are various other disadvantages of inferior meatus proof puncture which may limit the utilisation of this valuable procedure.

(I) Considerable delay while waiting for topical anaesthetic to take effect, this usually takes 15 minutes or longer.

Gibb (1968) observed that copious nasal secretions of mucus or pus may impair the efficiency of the anaesthetic agent by (a)

covering mucous membrane with a protective film, (b) diluting analgesic agent, (c) lowering the pH of nasal secretions which prevents the normal break down of the anaesthetic agent.

(2) Inferior meatus may be difficult to anaesthetise when the aperture between inferior turblnate and meatus is narrow.

(3) The angle between the tip of the trocar and bone is acute which makes it likely to slip causing mueosal tears which adds to bleeding and pain.

(4) Topical anaesthetics are more toxic on an equal volume basis than infiltration anaesthetics.

(5) I t is difficult to adopt the inferior meatus route in cases of severe deflection of the nasal septum.

Canine fossa puncture has several advan- tages over the classical inferior meatus route. Anaesthesia is faster, less toxic and more effective, thus conserving time and re- ducing pain and bleeding. The tip of troear is applied to canine fossa at an angle of 90 degrees which makes it less likely to slip. There is no danger of the canula going into the orbit or the cheek during this technique, as can happen with inferior meatus approach.

References 1. Gibb, A. G. (1968). Inflitratlon analgesia in antral

puncture. Archives of Otolaryngology : U: 113-114. 2. Peterscn, R. J. (1973L Canine fossa puncture.

l.~yngosr 85: 369-371.

104 I n d i a n J o u r n a l o f O t o l a r y n g o l o g y V o l u m e 30, No . 2, J u n e 1978