British Journal of Radiology (2004) 77, 1057-1058
© 2004 British Institute of Radiology
doi: 10.1259/bjr/86898521
Orbital emphysema: an unusual complication of balloon dacryocystoplasty
R Ajit, FRCS(Ed)1,
C Inkster, FRCOphth1,
J Tuck, FRCS, FRCR2 and
P Mortzos, MBChB1
Departments of 1 Ophthalmology and 2 Radiology, Royal Bolton Hospital, Minerva Road, Bolton BL4 0JR, UK
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Abstract
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Balloon dacryocystoplasty is a procedure used in the treatment of partial nasolacrimal duct obstruction. A case of orbital emphysema following one such procedure is reported here. The risk factors associated with this rare event are highlighted.
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Introduction
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Balloon dacryocystoplasty (DCP) is a minimally invasive radiological procedure for the treatment of obstruction of the nasolacrimal duct in patients with symptomatic epiphora [1]. This procedure involves an antegrade insertion of a guidewire through the lacrimal drainage system under fluoroscopic control and subsequent retrograde balloon dilatation of the obstruction performed via a nasal approach using a small vessel angioplasty balloon [2]. Reported technical and clinical success rates vary between 59% and 93% [2–4]. No major complications have been reported to date [5]. We report a case of orbital emphysema following one such procedure. As far as we could ascertain, this complication has not been reported previously in the literature.
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Case report
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A 69-year-old woman was scheduled for dacryocystography for epiphora due to nasolacrimal duct (NLD) obstruction. Her past medical history included severe chronic obstructive pulmonary disease with prolonged intake of oral steroids. She subsequently underwent bilateral dacryocystography and a left sided DCP. The procedure was uneventful and a control dacryocystogram performed after DCP showed an improved NLD lumen.
Several hours after the procedure she developed a sudden onset of swelling and bruising around the left eye. This worsened the following day. She presented to the emergency clinic on the third post-operative day with persistent swelling and poor vision.
On examination, her uncorrected visual acuity was restricted to hand movements in the left eye. There was severe periorbital swelling, chemosis and injection of the conjunctiva with crepitus on palpation. There was no afferent pupillary defect and examination of the fundus showed a normal disc. A diagnosis of orbital emphysema was made (Figure 1
). This was confirmed by CT of the orbit and skull, which showed extensive orbital and subcutaneous emphysema with air in the infratemporal fossa and subconjunctivally. No fluid collection was noted (Figure 2).
Oral amoxicillin with clavulanic acid 375 mg was prescribed for 5 days. Her ocular condition improved over the next few days and her Snellen visual acuity improved to 6/9. The swelling subsided completely over the next 4 weeks. She had residual epiphora but she declined any further intervention.
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Discussion
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Balloon DCP has been advocated as a safe and effective procedure for partial NLD obstruction [2–4].
The technique involves widening of the puncta and introduction of a cannula into one of the canaliculi, preferably the upper canaliculus. A steerable 0.18 micro-guidewire is advanced through the cannula into the lacrimal sac. There are a number of different techniques used for passage of the guidewire and its retrieval. The technique employed in our unit is a hybrid of some of these techniques. A 3 mm transluminal angioplasty balloon is then introduced over the wire from a nasal approach. Dilatation with pressures between 6 and 8 atmospheres for 30 s to 2 min is performed at the site of obstruction [5].
Complications so far reported include self-limiting nasal bleeds, pain during the procedure, extravasation of contrast, headache, blurred vision, and iatrogenic false passage with no residual effects [4, 5].
We suggest that the mechanism of delayed orbital emphysema in our case could have been due to raised intranasal pressure on sneezing, forcing air through a disrupted ethmoidal air cell in an already thinned out bony anatomy. This might have led to accumulation of air in the retro-orbital space and the infratemporal fossa through the infraorbital foramina and pterygopalatine fossa. Prolonged steroid intake may have been contributory to thinning of the bone [6]. Appropriate treatment with antibiotics and avoidance of blowing of the nose allowed satisfactory resolution of this complication.
Our case highlights that side effects with significant clinical consequences can occur even with a procedure that is perceived as relatively safe, in a patient with contributory risk factors such as long-term steroid intake. This could have provided a mechanism for the unusual complication of orbital emphysema in our patient. Patients undergoing balloon DCP should be warned of this complication and asked to report to the hospital for urgent treatment of this condition if it ensues.
Received for publication March 23, 2004.
Revision received July 15, 2004.
Accepted for publication August 9, 2004.
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References
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Abstract
Introduction
