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ARTICLES
Year : 1978  |  Volume : 26  |  Issue : 2  |  Page : 40-41

Mydriasis following squint operation under retrobulbar anaesthesia


Institute of Ophthalmology, J.N. Medical College, Aligarh, India

Correspondence Address:
B S Goel
Institute of Ophthalmology, J.N. Medical College, Aligarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 721243

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How to cite this article:
Goel B S, Ahuja L. Mydriasis following squint operation under retrobulbar anaesthesia. Indian J Ophthalmol 1978;26:40-1

How to cite this URL:
Goel B S, Ahuja L. Mydriasis following squint operation under retrobulbar anaesthesia. Indian J Ophthalmol [serial online] 1978 [cited 2020 May 29];26:40-1. Available from: http://www.ijo.in/text.asp?1978/26/2/40/31475

The syndrome consisting of mydriasis, absent or inextensive light reflexes, extensive buts low constriction to true accommodation has most frequently been known following concus­sion of the globe[4]. Similar phenomenon has also been described following surgery for retinal detachment[5],[6] and following a corneal graft[1],[3]. The present case of irreversible mydriasis and cycloplegia following squint operation perfor­med under retrobulbar anaesthesia is being reported for the first time.


  Case Report Top


R.K., 18 years male was first seen in squint clinic in 1974 with the complaints of constant diplopia and devia­tion of the eyes since childhood. On examination there was no abnormal head posture. There was an alternating divergent squint of 13°, either eye fixing, with a slight restriction of movement of either eye on adduction and overaction on abduction. Hehad a crossed horizontal diplopia with occasional vertical element, greatest sepa­ration of images being on levoversion. Both pupils were normal in size and reaction. Corrected visual acuity (RE-4 Dsph, LE-3 .5 Dsph) was 6/5 in each eye. Forced duction test performed under general anaesthesia was negative. A 6 mm recession of right lateral rectus was done under general anaesthesia in May 1975. For the residual deviation, 8 mm left lateral rectus recession was performed under xylocaine anaesthesia (retrobulbar and facial block) in June 1976. The surgical procedure and the post operative period was uneventful.

Mydriasis in the left eye was noted during the post. operative phase. The left pupil was dilated (8 mm size) and was non reacting to direct light, accommodation, pilocarpine or eserine. Phenyl epherine 10% further dilated the pupil to 9 mm. The accommodation in the affected eye was poor as a result of which he had difficulty in reading and maintaining binocularity for near. His near vision with the left eye was J 6 which surprisingly did not improve with addition of convex lenses to his distant correction. The distant vision has been maintained at 6/5. There had been no change in the condition on subsequent examination two months later.


  Comments Top


The present case had a congenital bilateral medical rectus paresis with no other neuromus­cular deficiency or a musculo-facial anomaly. Bilateral recession of lateral recti improved the movements both clinically and as ascertained on Hess screen. The uniocular loss of accommo­dation, however, has caused difficulty-in reading and maintaining binocularity for near. The post-operative internal ophthalmoplegia as observed in this case is difficult to explain. Theoretically, such an event may occur follow­ing trauma to the nerves in their passage through the ocular tissues or as a result of direct damage to the iris tissue. Such a phenomenon is most unlikely following simple recession of the lateral rectus. The possibility leading to this condi­tion could be the involvement of ciliary gang. lion as a result of direct trauma by the injection needle or the effect of a possible retrobulbar haematoma. A damage to all the 10-12 short ciliary nerves by the retrobulbar injection seems impossible. Although there was no clinical evidence of a frank retrobulbar haemorrhage, a localised haematoma in or around the ciliary ganglion might have resulted in damage to the para-sympathetic supply though sparing the sympathetic fibres. An irreversible mydriasis and loss of accommodation as seen in this case is known following simple retrobulbar anaes­thesia. The cause remains a riddle. It is difficult to explain as to why he also did not improve for near vision with additional convex lenses also. On further follow up, it has been observed that the pupil size has returned to normal, pupillary reaction is restored and accommodation is normal. A full recovery ultimately was achieved in a year's time.


  Summary Top


A case of internal ophthalmoplegia follow­ing lateral rectus recession under retrobulbar anaesthesia is reported.

It is believed that the condition developed as a result of damage to the ciliary ganglion following retrobulbar injection, which is an extremely uncommon complication.

 
  References Top

1.
Alberth, B. and A. Schnitzler, 1971, Klin Mbl Augen-heilk, 1959, 330.  Back to cited text no. 1
    
2.
Alberth, B. and A. Schnitzler, 1917, Szemeszet, 108, 250.  Back to cited text no. 2
    
3.
Komuki, M. and Ohashi, K ; 1973, Acta. Soc. Ophthal. Jap. 77, 105.  Back to cited text no. 3
    
4.
Loewenfeld, I. E. and Thompson, H. S. 1967, Amer. Jour, Ophthal., 63, 46.   Back to cited text no. 4
    
5.
M. Yoshida ; 1971, Rinsho Ganka, 25, 2063.  Back to cited text no. 5
    
6.
Newsome, D.A. and Einaugher, R.B. 1971, Arch. of Ophthal., 86, 233.  Back to cited text no. 6
    




 

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