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November 2007

Pneumocephalus Following Macular Hole Repair

Arch Ophthalmol. 2007;125(11):1583-1584. doi:10.1001/archopht.125.11.1583

Vitreoretinal surgery inherently contains some of the most challenging surgical cases in ophthalmology. Owing to the complex nature of these surgical cases, several complications can arise. We describe an outcome of macular hole repair not previously reported to our knowledge.

An 80-year-old woman had a stage 3 macular hole in the left eye. Her ocular history included pseudophakia bilaterally and glaucoma controlled with timolol. The level of glaucomatous damage was not quantified and was noted as advanced per the referring physician. One month after the initial diagnosis, the patient was taken to the operating room and had repair of the macular hole with injection of perfluoropropane gas. The amount and concentration of gas injected were not provided by the primary retinal surgeon. There were no complications during the case. The postoperative intraocular pressure was 25 mm Hg OS. The patient was instructed to keep face down for proper positioning of the gas. On the first postoperative day, her left eye was noted to have no light perception and she had severe headache. The intraocular pressure at this time was normal per the primary surgeon. One week postoperatively, the left eye was still noted to have no light perception; severe headaches, nausea, and vomiting persisted. The intraocular pressure was 60 mm Hg OS. Anterior chamber paracentesis was performed, which decreased her intraocular pressure and alleviated her nausea and vomiting. Later that night, the patient became acutely confused and neurologically decompensated. She was evaluated in an emergency department. Brain computed tomography showed gas extending from the eye through the optic nerve parenchyma and inferior to the chiasm as well as posteriorly into brain tissue up to the level of the lateral ventricles (Figure 1). At this time, she was referred to the Neuro-Ophthalmology Service and later to the Neurosurgery Service at the University of Illinois at Chicago Hospital. No surgical intervention was deemed necessary at that time. Short-interval clinical follow-up and serial computed tomographic scans were recommended. Computed tomography 2 months later showed dissipation of gas from the brain. As the gas dissipated, the patient's neurological status returned to normal. Her left eye remained with no light perception and there was no view to the optic nerve due to phthisis of the eye (Figure 2).