Eye Problem Following Foot Surgery -- Abducens Palsy as a Complication of Spinal Anesthesia

Kamil Cagri Kose, MD; Oguz Cebesoy, MD; Engin Karadeniz, MD; Sinan Bilgin, MD

Disclosures

October 17, 2005

Case Report

A 38-year-old man presented to our clinic with a 4-year history of pain and deformity of the first metatarsophalangeal joint of his left foot. His examination revealed a left hallux valgus with ulceration of the skin overlying the bunion deformity. His hallux valgus angle was 34 degrees and the intermetatarsal angle was 8° on the AP x-ray. The joint was congruent and there was no evidence of arthrosis. Correction via modified Chevron procedure with a capsuloperiosteal flap was planned and performed with the patient under spinal anesthesia. The patient's medical history was insignificant regarding systemic illnesses and was accepted as ASA1 class before to the application of anesthesia.

Spinal anesthesia was administered in one attempt through the L2-L3 intervertebral space while the patient was in a lateral recumbent position with a 22-gauge Quincke-type spinal needle with no complications. The CSF was clear without visible blood. The analgesia lasted for 2 hours postoperatively and after that period analgesic medication was continued with nonsteroidal anti-inflammatory drug injections and oral paracetamol tablets every 6 hours. The patient's general condition (neurologic status, vital signs, hemodynamics) was stable during the preoperative and postoperative periods. He was given 1500 cc isotonic NaCl IV solution during the operation. His urine output was not monitored.

On the first postoperative day, the patient experienced a severe headache that did not respond to the standard nonsteroidal analgesic medication and hydration. His daily oral fluid intake was approximately 2000 mL. Despite his headache, he was not told to lie down or keep a recumbent position until the end of the second postoperative day. During the second postoperative day, he experienced nausea and vomited 3 times. The nausea and vomiting did not respond to antiemetic medication, but responded well when the patient was placed on his back on the third postoperative day.

On the fourth postoperative day, the patient's nausea ceased completely, but he complained of diplopia (double vision), and his examination revealed bilateral strabismus. When he was told to make a lateral gaze after covering one of his eyes; he was unable to do this procedure with both of his eyes. His overall condition, vital signs, and neurologic status were normal. An ophthalmology consult was obtained. Bilateral abducens nerve palsy was diagnosed, which was clinically evident but the optic disc and field of vision were normal. He was given intermittent eye closure and lateral gaze exercises. Cranial magnetic resonance imaging (MRI), which was obtained to exclude an intracranial pathology, was normal.

The patient was given nonsteroidal anti-inflammatory medication and steroids to decrease neural edema (prednisolone 16-mg tablet decreased to half by 2-day intervals and stopped on the eighth day). The disorder did not respond to this treatment.

The patient returned to work after 9 weeks. His diplopia was minimized at the end of sixth week but did not resolve completely until the end of the ninth week. At that time, he still had mild strabismus. His strabismus had decreased to a minimal level at the end of 16th week and completely resolved at the end of 6 months.

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