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Vitreous Hemorrhage: A Rare Cause of Visual Change Following Subarachnoid Block for Cesarean Section
Abstract Number: F 69
Abstract Type: Case Report/Case Series
A healthy 34 yo G2P1 presented for repeat Cesarean Section. An uneventful spinal was placed in the sitting position using a 24 G Sprotte needle placed through an introducer. Spinal fluid was clear and velocity of flow through the needle appeared normal. The patient was given 11.25mg of hyperbaric marcaine, 25mcg of fentanyl, and .25 mg of duramorph.
Immediately on assuming the supine position with LUD, she complained of visual changes in her left eye. Limited ophthalmic exam showed nothing grossly abnormal. Following a T-4 sensory block, the patient underwent an uneventful C-section.
Visual changes persisted on arrival in PACU described as a “black spot” in the center of her visual field in the left eye with intact peripheral vision. Ophthalmology consult and exam revealed a best-corrected visual acuity of 20/20 right eye and 20/800 left eye. Intraocular pressures, pupils, and anterior segment were normal. Dilated fundus examination was within normal limits in the right eye and was remarkable in the left eye for a large central preretinal hemorrhage obscuring the view of the macula and part of the optic nerve. Preretinal hemorrhages were also scattered in the mid-periphery. The optic disc margins were sharp and retinal vessels were normal. No posterior vitreous detachment was present. Macular OCT and B scan ultrasound revealed no subretinal fluid or abnormality other than the preretinal hemorrhage. A head CT was within normal limits.
Discussion: Ocular complications following neuraxial anesthesia are extremely rare. There have been reports of vitreous hemorrhage following lumbar and caudal epidural steroid injection and epiduroscopy. A proposed mechanism is transmission of a sudden increase in cerebrospinal fluid pressure to the optic nerve sheath due to large volumes (20-10mL) injected obstructing intraocular venous return or rupture of retinal blood vessels(2). A sudden decrease in cerebrospinal fluid pressure following a therapeutic high volume LP may also lead to vitreous hemorrhage. The rapid decrease in intracranial pressure could cause traction on the optic nerve and/or associated venous structures, resulting in an occlusion of venous drainage and subsequent vitreous hemorrhage(3).
To our knowledge, this is the first report of vitreous hemorrhage following a spinal anesthetic. Findings suggest this may be a spontaneous vitreous hemorrhage due to Valsalva retinopathy. Pregnancy is known to exert several hormonal, immunological and hematologic changes that increase the risk of hemorrhage and Valsalva retinopathy(1). In this case Valsalva may have occured during patient positioning in an attempt to arch her back, or by taking a deep breath and holding it during needle placement.
Prognosis for this condition is generally good with 80% of cases having visual recovery between 6 weeks to 6 months(2).
1)J Med Case Reports, 2008,2:101
2)Pain Medicine, 2005;6:367-374
3)Am J of Emerg Med, 2008(5):633