Blindness due to anterior ischemic optic neuropathy in a burn patient

Orbital Compartment Syndrome in Severe Burns: Predictive Factors, Timing, and Complications of Intervention

PURPOSE

Severe burn patients require high-volume fluid resuscitation, which increases risk for orbital compartment syndrome (OCS). We aimed to understand surgeons' practice patterns and to examine risk factors for OCS, timing of lateral canthotomy and cantholysis (LCC), and complications of intervention.

METHODS

A survey of American Society of Ophthalmic Plastic and Reconstructive Surgery and North American Society of Academic Orbital Surgeons' practice patterns in burn patients was undertaken. In addition, a retrospective analysis was conducted of 107 patients with burns greater than 20% total body surface area at 1 institution from January 1, 2009, to June 1, 2018. Patients with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis, frostbite, or no ophthalmologic consultation were excluded. Risk factors for OCS, timing of LCC, and complications of the intervention were examined.

RESULTS

In the survey, 37 of 54 respondents had treated burn patients, of which 29 followed no protocol. Threshold intraocular pressure for intervention varied widely, and nearly all reported having seen complications from LCC in burn patients. For the retrospective analysis, 107 patients met criteria, of which 22 (20.6%) required LCC. Renal failure, inhalation injury, eyelid burns, higher total body surface area, elevated lactate, increased number of escharotomies, and greater total fluid required were significantly associated with the clinical decision that the patient was at risk for OCS requiring LCC. Fluid resuscitation in excess of the Ivy Index (250 ml/kg) increased odds of LCC 8.6 times. Average time of LCC was 15.8 hours after burn. LCC patients experienced higher rates of complications including eyelid retraction, exposure keratopathy, and corneal ulceration.

CONCLUSIONS

Severe burn patients should be monitored closely by an ophthalmologist during the first 48 hours for signs of OCS. Further studies should aim to recommend protocols guiding evaluation and intervention.

Preservation of Vision after Early Recognition of Anterior Ischemic Optic Neuropathy in a Patient with Sepsis

Non-arteritic ischemic optic neuropathy (NAION) can rarely occur in the setting of sudden vascular compromise, especially in patients with a "disk-at-risk" appearance. Anemia and hypotension are believed to be the main precipitators of shock-induced NAION. Early recognition of this phenomenon can prevent further visual loss and result in partial visual recovery. We here present a 56-year-old patient who developed NAION characterized by optic disc edema in both eyes and visual loss in the left eye secondary to hypotension in the setting of septic shock. He received aggressive blood pressure management (stopping all his anti-hypertensives, hydration, and midrodrine) which resulted in stabilization of vision in the right eye and likely prevented further visual loss in the left eye.

Acute Bilateral Blindness in the Setting of Sudden Onset of Bilateral Proptosis and Ophthalmoplegia: A Case Report With Literature Review

PURPOSE OF REVIEW

Acute bilateral blindness has an extensive differential diagnosis that requires a careful history and physical examination to narrow down. In this article, we discuss the pathophysiology and radiographic findings of each possible diagnosis for acute bilateral blindness.

RECENT FINDINGS

Visual pathology with respect to bilateral blindness can be broadly broken down into 3 anatomic categories: media (i.e., the anterior and posterior chamber of the eye), retina, and neural visual pathway. Possible causes of rapid onset bilateral blindness include bilateral occipital infarcts, endogenous bacterial endophthalmitis, orbital cellulitis, orbital compartment syndrome, cavernous sinus thrombophlebitis, thyroid disease, and bilateral nonarteritic ischemic optic neuropathy.

SUMMARY

In this case, we present a patient with acute onset of bilateral blindness, in addition to bilateral ophthalmoplegia, proptosis, and orbital chemosis. We believe that this rare case of acute bilateral blindness is thought provoking and aids in the understanding of the differential diagnosis and underlying pathophysiology of visual loss.

Posterior ischemic optic neuropathy following a major burn injury and review of the literature

Posterior ischemic optic neuropathy following burns is a rare but devastating condition that can result in total bilateral visual loss. Numerous treatment modalities have been trialed, yet there is no effective therapy to delay or reverse the disease. Hence, it is imperative for burns surgeons to be aware of the potential risk factors and have a high index of suspicion right from the outset to prevent this outcome. Here, we discuss the case of a patient that developed posterior ischemic optic neuropathy subsequent to a major burn injury. We also present a literature review on optic neuropathies following burns to describe the etiology, clinical signs, and potential management.

Left orbital compartment syndrome and right anterior ischemic optic neuropathy in a patient with severe burns despite non-aggressive fluid resuscitation

INTRODUCTION

Ophthalmological complications such as orbital compartment syndrome (OCS) and ischemic optic neuropathy are rare complications in patients with burns and have been described in patients where aggressive fluid resuscitation was performed. While OCS requires urgent surgical intervention, no current treatment is established to treat, or prevent, ischemic optic neuropathy in patients with burns.

METHODS

The authors report a case of a 38-year-old woman with flame burns including the periorbital regions who developed OCS on the left side and anterior ischemic optic neuropathy (AION) on the right side despite non-aggressive fluid resuscitation. Immediate lateral canthotomy combined with inferior cantholysis was performed on the left side.

DISCUSSION AND CONCLUSION

OCS and AION need to be considered as potential complications even in critically ill patients with facial burns who do not receive aggressive fluid resuscitation. Whether an early surgical intervention will lower the risk of AION development is, however, speculative.

LAY SUMMARY

Ophthalmological complications such as orbital compartment syndrome and ischemic optic neuropathy are rare complications in patients with burns and have been described in patients where aggressive fluid resuscitation was performed. We present a case of a critically ill patient with severe facial burns who developed orbital compartment syndrome on the left side and anterior ischemic optic neuropathy on the right side even though our patient did not receive aggressive fluid resuscitation.Our case is particular because both of these rare complications are seen in a single patient and neither received aggressive fluid resuscitation. The fact that the patient did not develop ischemic optic neuropathy on the side where the lateral canthotomy was performed (only on the side where the patient had orbital compartment syndrome), this case might raise the discussion of whether an early surgical intervention might lower the risk of ischemic optic neuropathy development in patients with facial burns.

Orbital Compartment Syndrome Following Major Burn Resuscitation: A Case Series and Survey of Practice Patterns

Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.

Waking Up Blind in the ICU: A Case Report of Ischemic Optic Neuropathy in a Burn Patient

The objective of this report is to analyze and summarize the current literature of ischemic optic neuropathy (ION), a rare complication in severe burn and trauma victims, while presenting an urban burn center's experience with the condition. This is an unfortunate condition and this report will raise awareness to a potential complication in the burn patient population as well as in critically ill patients in other settings.

We present the case of a 27-year-old healthy male patient admitted to our Burn Center with 85% total body surface area (TBSA) full-thickness burns sustained in a house fire. The patient had a complicated hospital course but improved over time and was weaned off of prolonged ventilation and sedation. Subsequently, he complained of bilateral blindness. A fundoscopic examination demonstrated bilateral pale optic nerves with sparing of the remaining peripheral retina consistent with ION. The patient suffered complete bilateral vision loss. He had multiple factors that could have instigated the development of ION, including several episodes of septicemia, hypovolemic shock and severe adult respiratory distress syndrome (ARDS) with refractory hypoxemia requiring a prolong ventilation support and vasopressor therapy. 

Due to the advancement of the treatment of acute burns, the survival rate of patients that once would have succumbed to their burn injury, is increasing. With these new achievements, we are facing new challenges and complications. ION has a significant impact on the quality of the patient’s life. The early diagnosis will not necessarily translate into a benefit for these patients as no treatment has been proven successful. Extensive retrospective and prospective studies are necessary to identify and treat this patient population.

A case series: bilateral ischemic optic neuropathy secondary to large volume fluid resuscitation in critically ill burn patients

Ischemic optic neuropathy (ION) in the trauma setting is a rare and devastating condition associated with systemic hypotension, massive volume resuscitation, and sepsis. The objective of this case series is to highlight a potential correlation between severe burn and ischemic optic neuropathy. We present three patients with total body surface area (TBSA) thermal injury burns ranging from 57 to 68% treated at the North Carolina Jaycee Burn Center that developed bilateral ischemic optic neuropathy during their hospital stay. Each patient required greater than 25 L of crystalloid fluid within 24 h after admission, suffered multiple bouts of sepsis, and required extended pressor support. We postulate that ischemic optic neuropathy develops as a result of the interplay between the patient's systemic pathophysiology, i.e. shock, sepsis and the continued need for large volume fluid resuscitation. Current treatments of ION have not proven to be effective, except for possibly limiting fluid resuscitation. In the few cases of refractory burn shock, the incidence of this condition is unlikely to be readily improved. However, it is important for clinicians to be aware of this devastating complication and consider early ophthalmology involvement in the care of severely burned patients.

The management of eyelid burns

Eyelid involvement is common in facial burns. Ocular sequelae, including corneal ulceration, are usually preventable and secondary to the development of eyelid deformities, exposure keratopathy, and rarely, orbital compartment syndrome. Early ophthalmic review and prophylactic ocular lubrication is mandatory in burns involving the eyelids. Early surgical intervention, often requiring repeat procedures, is indicated if eyelid retraction causing corneal exposure occurs. Permanent visual impairment is rare with such prompt management. No binding aphorisms exist regarding the tissue used for eyelid reconstruction, with each case requiring an individual approach based on available skin. This review article covers the principles of ophthalmic management in addition to intermediate and long-term management of eyelid burns.

Elevated Orbital Pressure: Another Untoward Effect of Massive Resuscitation after Burn Injury

BACKGROUND

Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury.

METHODS

We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures.

RESULTS

Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027).

CONCLUSIONS

Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.