Ocular Rosacea or Corneal Abrasion After General Anesthesia?

Andrew Germanovich, DO1, Arjang Khorasani, MD1, Harold Sy, MD2, N. Nick Knezevic, MD, PhD1

1Department of Anesthesiology, 2Department of Ophthalmology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA

DiscussionAbstract

References

Rosacea• unknown etiology, affects primarily chin, nose, cheeks and glabella• erythema, telangiectasias, flushing, papules and pustules• exacerbated by heat, spicy foods, hot drinks, alcohol, emotional stimuli, heat, cold or strong winds1

• most prevalent in the middle age group of Northern Europeans2 Ocular Rosacea• common in 50% of patients with facial rosacea3

• no correlation between severity of ocular rosacea and severity of facial rosacea•Symptoms: eye irritation, dryness, blurry vision, corneal ulceration, perforation or secondary infection.4

Introduction

Case Description

• A 75 year old man scheduled for elective surgical repair of right inguinal and umbilical hernia• PMH – DM and HTN; Allergies: None• PE: facial telangiectasias, MPII, CTAB, RRRAnesthetic Course:• Premed: 1 mg of midazolam.; PreO2 - 10L O2 via FM 2 min • Induction: 2 mg/kg of propofol, 100 mcg of fentanyl, 0.6 mg/kg of rocuronium; Eyes were taped shut• Patient was manually ventilated for 90 sec. prior to intubation , PAP < 20 cmH2O• The trachea was intubated and extubated without difficulty • PostOp O2 provided via FM at 10 L/min immediately after the procedure, during transport and PACU• One hour later the patient started to complain of an increasing burning sensation in his right eye, associated with blurry vision, dryness, and severe itching• Corneal abrasion was suspected and the patient was taken to the eye clinicOphthalmologic consultation: • Right lower palpebra erythematous and edematous; the conjunctiva injected, no corneal abrasion• Additional directed history - prior episodes of identical right eye symptoms following exposure to high airflows from cooling fans or automobile vents• Patient stated that during facemask oxygenation he felt a stream of oxygen gas blowing in both eyes• Diagnosis – Ocular Rosacea, based on dermatologic findings of rosacea and clinical ophthalmologic exam (Picture 1) • Treatment – lubricant eye drops, and symptoms improved within minutes• Home Rx – 50 mg of doxycycline QD for a month; use of compresses twice a day, and lid scrubs at bedtime; artificial tears QID; and avoidance of rosacea triggers such as nicotine, caffeine, alcohol, and spicy foods was advised.

1. Buechner SA. Dermatology 2005; 210: 100-82. Chamaillard M, et al. Arch Dermatol 2008; 144: 167-713. Wilkin J, et al. J Am Acad Dermatol 2002; 46: 584-74. Akpek EK, et al. Ophthalmology 1997; 104: 1863-75. Warner ME, et al. Anesthesiology 2002; 96: 855-96. Wilkin JK. Arch Dermatol 1994; 130:359-62

We report a patient who developed blurry vision, episcleritis, blepharitis and conjunctivitis following general anesthesia. Corneal abrasion, as the most common eye injury related to general anesthesia was suspected. Ophthalmologic consultation was obtained and excluded corneal abrasion. The patient had exacerbation of ocular rosacea induced by gas leakage during bag mask ventilation or during spontaneous breathing via face mask before or after anesthesia.

Picture 1. A photograph of the patient after treatment (with written permission) . Note telangiectasias on the patient’s nose, cheeks and forehead. Also note the patient’s residual blepharitis and conjunctivitis in the right eye.

Recommendations

• Application of eye lubrication as soon as possible after induction of anesthesia and during the postoperative period.• Minimize gas leakage from the facemask during the perioperative period.• Although patients can be prophylactically treated with lubricating eye drops, they should still be examined by an ophthalmologist. • Patients with ocular rosacea require detailed examination and a follow up treatment plan to prevent serious complications.6

• Corneal abrasion is the most common eye injury related to general anesthesia• It is often attributed to facemasks, tape or other foreign objects • 4.2% of patients complain of eye symptoms following anesthesia for non-ocular surgery.5 • Instances of blurry vision after anesthesia occasionally occur without evidence of corneal abrasion. • Ocular rosacea can precede facial rosacea and present with blurry vision, blepharitis and conjunctivitis.• We believe that this case is an exacerbation of acute ocular rosacea, induced by the leakage of gas from the face mask, causing eye irritation. • This gas leakage was possible during bag mask ventilation or during spontaneous breathing via facemask before or after anesthesia. • During mask ventilation in majority of instances air leak occurs in right upper side of the mask.