Acute angle-closure glaucoma after total knee replacement surgery: case report and literature review

¹Department of Anesthesia and Critical Care, Habib Bourguiba Hospital, Sfax Tunisia, ²Department of Orthopedic Surgery, Habib Bourguiba Hospital, Sfax, Tunisia

^&Corresponding author
Salma Ketata, Department of Anesthesia and Critical Care, Habib Bourguiba Hospital, Sfax, Tunisia

Introduction    

Acute angle closure glaucoma (AACG) after non ocular surgery is a rare complication of general anesthesia. However, in case of delayed diagnosis, it may lead to blindness. Immediate diagnosis and appropriate treatment should be done to prevent visual loss [1]. We present a case of acute angle closure glaucoma after total knee replacement surgery under general anesthesia in a monophtalmus patient. In this case, the most likely trigger was the use of atropine and nefopam.

Patient and observation     

Patient information: a 65-year-old monophtalmus man (ASA physical status I, BMI =28,36 kg cm^-2) with knee arthrosis was scheduled for a total knee replacement surgery under general anesthesia. The preoperative assessment was unremarkable. General anesthesia was induced with IV propofol (3 mg kg^-1), Fentanyl (3µg kg^-1), and cisatracurium (0.15 mg kg^-1) to facilitate tracheal intubation (size 7.5 oral cuffed tracheal tube). Mechanical ventilation was used. Anesthesia was maintained with a mixture of air and oxygen (50%:50%) supplemented with isoflurane 1 to 1.5 minimum alveolar concentration, Fentanyl and cisatracrium reinjections as needed. Anesthesia lasted almost 3 hours. The patient received 8 mL kg^-1 h^-1 crystalloid infusion during the surgery. The act has occurred with hemodynamic stability. IV paracetamol (1g) and IV nefopam (20 mg) were administered 30 minutes before the end of the surgery and every 6 hours for postoperative pain relief. neostigmine and atropine were injected at the end of surgery for decurarization. No additional drugs were administered.

Clinical findings: on the first postoperative day, the patient complained of a reduced visual acuity associated with periorbital pain and nausea.

Diagnostic assessment: slit lamp examination revealed lid edema and conjunctival hyperemia. The iris showed fixed and mid-dilated pupil. Gonioscopic examination showed a narrow angle. Intraocular pressure was 30 mm Hg (normal intraocular pressure is 12-20 mm Hg).

Diagnosis: the diagnosis of acute angle closure glaucoma was made and in case of delayed diagnosis or absence of treatment, it may lead to blindness.

Therapeutic interventions: medical treatment included IV mannitol 20%, tunolol and pilolol eye drops and acetazolamide pills was given to the patient.

Follow-up: the next day, the intraocular pressure was normalized, and visual acuity was completely recovered.

Patient perspective: the patient did not claim any adverse reaction to the treatment and was satisfied with the result.

Informed consent: the patient did finally give his consent.

Discussion     

This case illustrates unilateral AACG most likely related to general anesthesia. The development of AACG requires the coexistence of both a predisposed eye (eye with a narrow anterior chamber angle) and a pupillary block. A pupillary block may appear in different circumstances such as the use of mydriatic agents or a mydriatic situation. Usual risk factors for postoperative AACG are a genetic predisposition, female gender, shallow anterior chamber depth or hypermetropia, increased lens thickness, small corneal diameter, and increased age [2]. Additionally, precipitating factors have been described. There are pharmacologic manipulations of the pupil (Table 1), producing a partially or fully dilated pupil, and emotional factors. These 2 conditions are frequent in the context of general anesthesia [3]. Thirty-six cases of AACG related to anesthesia have been published. The gender distribution is 1 male for 3 females, with a mean age of 63 years (58-64 interquartile range). There were 27 unilateral and 9 bilateral cases. The main identified precipitating factors for the development of AACG were the stress and the use of atropine (80%) or scopolamine. Nine cases (25%) were related to ephedrine use.

In the present case, 3 possible triggering factors which are the stress, the use of atropine for decurarization and nefopam for postoperative analgesia could be incriminated. Nefopam, which is a non-opioid analgesic that inhibits reuptake of serotonin, norepinephrine and dopamine [4], is contraindicated in patients with known angle closure glaucoma because of its parasympatholytic effects. Atropine, which is used to relax the ciliary muscle and dilate the pupil, has long-acting anticholinergic action, and can induce AACG [5]. Moreover, the perioperative period carries the risk of psychological stress. However, general anesthesia and postoperative events often mask the first symptoms. The presence of hypotension or anemia, may enhance ischemic optic neuropathy, which is a much more frequent cause of postoperative vision loss than AACG, but in contrast with AACG, its prognosis is often poor [6,7]. The published cases of AACG are summarized in Table 2 [8-24]. The purpose of this observation is to insist on good preoperative patients´ evaluation. The search for preexisting eye damage would be necessary in a programmed functional surgery. In our case, in front of the existence of monophtalmia, a specialized ophthalmological examination should have been required. In fact, the preoperative diagnosis of glaucoma could change the choice of anesthetic technique and used drugs.

Conclusion     

Acute angle closure glaucoma is a rare cause of postoperative visual impairment. The use of mydriatic drugs such as atropine on predisposed individuals may precipitate this acute event, therefore physicians´ awareness is required in order to quickly initiate the treatment.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Salma Ketata, Rahma Derbel, Imen Zouche, Omar Ketata. Data collection: Salma Ketata, Rahma Derbel, Hichem Kolsi, Ahlem Bousabbeh. Manuscript drafting: Salma Ketata, Omar Ketata Manuscript revision: Salma Ketata, Imene Zouche, Rania Dammak, Hichem Kolsi, Ahlem Bousabbeh. All authors read and approved the final version of the manuscript.

Tables     

Table 1: classification of drugs inducing acute angle closure glaucoma by administration route

Table 2: previously published cases of perioperative acute angle closure glaucoma

References