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Case Reports and Small Case Series
February 2000

Acute Bilateral Visual Loss Associated With Retinal Hemorrhages Following Epiduroscopy

Arch Ophthalmol. 2000;118(2):287-289. doi:

Acute bilateral visual loss associated with retinal hemorrhages following epidural steroid injection or gas myelography has been described.13 To our knowledge, we report the first case of acute bilateral visual loss associated with preretinal, retinal, and subretinal hemorrhages occurring after epiduroscopy, a diagnostic and therapeutic procedure that allows visualization of the spinal cord and epidural space in patients with chronic back pain.

Report of a Case

An 80-year-old woman whose medical history was significant only for chronic back pain and bilateral lower extremity weakness unresponsive to medical management underwent diagnostic epiduroscopy. The patient was brought to the operating room and placed in the prone position. Needle placement in the epidural space was confirmed with fluoroscopic guidance in 3 views. A guidewire was inserted and the scope apparatus was introduced. Visualization of the epidural space was allowed via saline instillation at a pressure not exceeding 60 mm Hg for a period of less than 5 minutes. Epiduroscopy was performed without complication under intravenous sedation; the patient's vital signs remained stable throughout the procedure. Immediately following the procedure, the patient noted acute visual loss in both eyes.

Ocular examination at that time revealed a best-corrected visual acuity of 5/200 OD and 3/200 OS. Intraocular pressures and pupils were within normal limits. Anterior segment examination was notable for well-positioned intraocular lenses. Dilated funduscopic examination was remarkable for multiple, round, preretinal, retinal, and subretinal hemorrhages involving the posterior pole and midperiphery in both eyes (Figure 1). The disc margins were sharp and the retinal vessels were of normal caliber. Fluorescein angiography revealed areas of blocked fluorescence corresponding to the hemorrhages seen clinically (Figure 2).

Figure 1.
Color fundus photographs of the right (left) and left (right) eyes demonstrate multiple retinal hemorrhages involving the posterior pole.

Color fundus photographs of the right (left) and left (right) eyes demonstrate multiple retinal hemorrhages involving the posterior pole.

Figure 2.
Fluorescein angiograms of the right (left) and left (right) eyes reveal that the hemorrhages are located both deep to and superficial to the retinal circulation.

Fluorescein angiograms of the right (left) and left (right) eyes reveal that the hemorrhages are located both deep to and superficial to the retinal circulation.

Six months later, best-corrected visual acuity had improved to 20/100 OD and 20/80 OS. The retinal hemorrhages had resolved spontaneously in both eyes (Figure 3); vision was limited secondary to nonexudative age-related macular degeneration.

Figure 3.
Color fundus photographs of the right (left) and left (right) eyes 6 months after epiduroscopy demonstrate resolution of the retinal hemorrhages.

Color fundus photographs of the right (left) and left (right) eyes 6 months after epiduroscopy demonstrate resolution of the retinal hemorrhages.

Comment

The occurrence of retinal hemorrhages in one or both eyes immediately after the injection of oxygen into the subarachnoid space during myelography or following epidural injection of corticosteroids has been described previously.13 To our knowledge, this is the first report of bilateral retinal hemorrhages occurring after epiduroscopy, a procedure involving placement of a fiberoptic scope into the epidural space with injection of saline for visualization of the spinal cord and subarachnoid space.

Increased cerebrospinal fluid (CSF) pressure during epiduroscopy may lead to retinal hemorrhages by 2 possible mechanisms. First, increased CSF pressure may be transmitted directly through the optic nerve sheaths to the retinal venous circulation.2 Alternatively, increased CSF pressure may result in decreased cerebral blood flow, which in turn stimulates a reflex increase in ophthalmic artery pressure with resultant venous collapse and rupture of capillaries.1

Acute visual loss associated with retinal hemorrhages is an uncommon but significant complication of epiduroscopy. Experimental evidence suggests that elevation of CSF pressure may be modulated by decreasing the rate and volume of epidural injection, potentially lowering the likelihood of this ocular complication.4 Patient education and informed consent are paramount when recommending this procedure, especially for patients with bleeding tendencies or compromised retinal circulation.

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Article Information

Reprints: Timothy G. Murray, MD, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136.

References
1.
Oberman  JCohn  HGrand  G Retinal complications of gas myelography. Arch Ophthalmol. 1979;971905- 1906Article
2.
Kushner  FHOlson  JC Retinal hemorrhage as a consequence of epidural steroid injection. Arch Ophthalmol. 1995;113309- 313Article
3.
Ling  CAtkinson  PLMunton  CGF Bilateral retinal haemorrhages following epidural injection. Br J Ophthalmol. 1993;77316- 317Article
4.
Usubiaga  JEUsubiaga  LEBrea  LMGoyena  R Effect of saline injections on epidural and subarachnoid space pressure and relation to postspinal anesthesia headache. Anesth Analg. 1967;46293- 296
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