PETER SAVINO AND HELEN DANESH-MEYER, EDITORS
The Operation Was a Success, but the Patient
Anne E. Semmer, BS,
Michael S. Lee, MD,
Mehran Taban, MD,
Scott Smith, MD,
and Gregory Kosmorsky, DO
Department of Ophthalmology,
Department of Neurology,
Department of Neurosurgery, University of Minnesota,
Minneapolis, Minnesota; and
Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio
(In keeping with the format of a clinical pathologic conference,
the abstract and key words appear at the end of the article.)
A 71-year-old African American woman presented
with vision loss in her left eye after trabeculectomy
with mitomycin C and retrobulbar anesthesia. She
noticed severe visual impairment in the operated
eye when she removed her eye shield the morning
after surgery. She denied any visual changes in her
right eye. Prior to surgery, visual acuity was 20/30
OD and 20/25 OS.
Past medical history included psoriasis, hyperten-
sion, and Graves disease, for which she took
lopressor and levoxyl. Ocular history was signiﬁcant
for left eye traumatic angle-recession glaucoma with
poorly controlled intraocular pressures (IOP) de-
spite maximal medical therapy. Preoperative IOP
ranged from 35--40 mm Hg in the left eye. Visual
ﬁeld testing showed shallow, early inferior arcuate
defects in both eyes. She also had bilateral moderate
cataracts, bilateral posterior vitreous detachments,
and an old inferior hemispheric retinal vein
occlusion with cystoid macular edema OD.
Her best corrected visual acuity after surgery was
20/25 OD and 20/400 OS. She had a left relative
afferent pupillary defect. Examination of the right
eye was unchanged from previous examinations.
The left eye IOP was 10 mm Hg. Slit-lamp examina-
tion revealed a well-formed bleb and a deep anterior
chamber with 1þ cell. The retinal vessels appeared
normal. The macula appeared opaciﬁed with
possible retinal thickening. No hemorrhages were
observed. The optic nerves were not swollen, and
each had a cup-to-disk ratio of 0.3 (Fig. 1).
What is your impression?
What tests would you order?
COMMENTS BY GREGORY KOSMORSKY, DO
This 71-year-old woman had undergone a major
intraocular procedure, and her vision was altered
dramatically by the ﬁrst postoperative day. When an
individual loses vision in the immediate postopera-
tive period, the most likely causes will be related to
the surgery. In this case, an undocumented pressure
rise that compromised the blood ﬂow of the optic
nerve needs to be considered. Dr Lee tells us that
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