Visual Disturbances Caused by Massive Musculoskeletal and Mediastinal Emphysema After Hip Arthroscopy
Samuel Thomas1, Adeela Alizai1, Mark Walsh1, Marium Ansari2, Duffy Monahan1, Haneefa Raza1, Aida Ansari2, Yusuf Raza1, Hala Ansari1, Jeffery Bao3, Syed Raza1
1Department of Emergency Medicine, Saint Joseph Regional Medical Center, 2Indiana University School of Medicine, 3Royal College of Surgeons in Ireland
Objective:
To describe massive gas entry into the body during hip arthroscopy as an uncommon occurrence that caused pneumomediastinum, gas tracking through the fascial planes and skull base, and infiltration of gas into the ciliary body, leading to transient visual disturbances.
Background:
A 19-year-old cross country runner underwent arthroscopy of the right hip for a labrum tear. After sitting up for a four-hour drive, the patient noted significant crepitations of her lower extremities associated with numbness and tingling over her hands and feet, along with visual disturbances.
An emergency department exam revealed crepitations of the lower extremities, abdomen, chest, and neck. The patient reported blurred vision and an inability to read. Uncorrected bilateral visual acuity was 20/20 for distance vision but 20/100 for near vision. Pupils were not reactive to light, did not accommodate to near target, and were mid-dilated at 5 mm.
Results:
CT scan of the lower extremities and chest revealed massive subcutaneous emphysema involving the lower extremities, abdomen, chest, and neck, with pneumoperitoneum and pneumomediastinum.
The patient received four hyperbaric oxygen treatments (HBOT). By the third treatment, near visual acuity was 20/20. However, far visual acuity was now 20/50. This disappeared one week after discharge.
Conclusions:
The patient’s presentation with lack of accommodation to near target and non-reactive dilated pupils was brought about by the penetration of gas around the eye. It is proposed that small bubbles either disrupted contractility of the ciliary muscles, causing an inability of the zonules to relax and thicken the crystalline lens, disrupting the near triad, or caused paresis of the iris sphincter muscle, resulting in partial mydriasis. Additionally, HBOT is known to cause “myopic shift” by causing changes in protein function of the crystalline lens and a transient increase in refractive index and temporary shift toward myopia.
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