|Year : 2023 | Volume
| Issue : 1 | Page : 59-61
Successful management of delayed hyaluronidase hypersensitivity after subtenon's anesthesia during the COVID-19 pandemic: A rare case report
Bharat Gurnani1, Kirandeep Kaur2
1 Consultant Cataract, Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry, India
2 Consultant Cataract, Pediatric Ophthalmology and Strabismus Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry, India
|Date of Submission||30-Dec-2021|
|Date of Decision||03-Feb-2023|
|Date of Acceptance||07-Feb-2023|
|Date of Web Publication||20-Mar-2023|
Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry - 605 007
Source of Support: None, Conflict of Interest: None
Subtenon's block is commonly used to achieve akinesia, analgesia, and anesthesia for ophthalmic surgeries. This case study detailed a rare hypersensitivity report in a 65-year-old female who had underwent manual small incision cataract surgery under subtenon's anesthesia (STA) in the left eye. On postoperative day 1, she presented with acute onset proptosis, periorbital edema, conjunctival chemosis, and restriction of extraocular movements. The pupillary reaction and dilated fundus examination were normal. A differential diagnosis of orbital cellulitis, Mucormycosis, and hyaluronidase hypersensitivity (HH) was considered. Since the patient was afebrile, and pupillary reactions, ENT, neurological, and fundus examination were normal, the diagnosis was narrowed down to delayed HH. The patient was managed with a 1 cc IV injection of dexamethasone once a day for 3 days, along with routine postoperative drugs. As per detailed literature review, this is probably a second case report of delayed HH post-STA.
Keywords: COVID-19 pandemic, dexamethasone, hyaluronidase hypersensitivity, lignocaine, subtenon's block
|How to cite this article:|
Gurnani B, Kaur K. Successful management of delayed hyaluronidase hypersensitivity after subtenon's anesthesia during the COVID-19 pandemic: A rare case report. Indian J Pharmacol 2023;55:59-61
|How to cite this URL:|
Gurnani B, Kaur K. Successful management of delayed hyaluronidase hypersensitivity after subtenon's anesthesia during the COVID-19 pandemic: A rare case report. Indian J Pharmacol [serial online] 2023 [cited 2023 May 29];55:59-61. Available from: https://www.ijp-online.com/text.asp?2023/55/1/59/372172
| » Introduction|| |
Subtenon's anesthesia (STA) is a commonly employed technique for majority ophthalmic surgery because of the potential advantage of low risk of globe perforation and other complications. The first description came in 1884 by Turnbull and later by Swan in 1956. Hyaluronidase has a depolymerizing action and acts on hyaluronic acid present in the intracellular connective tissue. It is mixed with local anesthetics while administering regional anesthesia to facilitate infiltration in the orbital area. This report is about a rare and interesting case of delayed hyaluronidase hypersensitivity (HH) after subtenon's block given for manual small incision cataract surgery (MSICS). The patient was successfully managed postoperatively. As per the detailed literature review, delayed HH after STA has rarely been reported.
| » Case Report|| |
A 65-year-old female complained of defective vision in the left eye (oculus sinister [OS]) for the past 6 months. She gave a history of right eye (oculus dexter [OD]) cataract surgery 3 months back. The systemic history was not significant. She underwent a COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) test that was found to be negative, following a febrile episode a month back. She had also taken both doses of the COVID-19 vaccine (Covishield) before the surgery. The preoperative corrected distant visual acuity (CDVA) in OD was 20/20 and in the OS was 20/200. The intraocular pressure (noncontact tonometry) was 14 mmHg in both eyes (oculus uterque-OU). The slit-lamp anterior segment examination revealed pseudophakia in OD and a grade 3 nuclear sclerotic cataract in the left eye, and the rest of the examination was unremarkable. The fundus examination in OU was normal. The patient was admitted for OS MSICS with intraocular lens implantation (IOL) under STA. At our institute, STA is used routinely for MSICS, as we have found a low complication rate compared to peribulbar and retrobulbar anesthesia. Before the surgery, pupillary dilatation was achieved with the help of 0.8% tropicamide and 5% phenylephrine. A senior ophthalmologist administered STA using 3 ml 2% lignocaine hydrochloride mixed with 1:100,000 adrenaline and 500 IU hyaluronidase. A perfect anesthesia was achieved, and no adverse effects were observed. The patient underwent an uneventful MSICS with IOL implantation. Twelve hours postsurgery on the next postoperative day, the patient complained of pain, redness, and swelling in OS. OS examination revealed mild axial proptosis, periorbital edema, upper lid tenderness, conjunctival chemosis with a tight orbit, and restriction of extraocular movements [Figure 1]. The pupillary reaction and fundus examination were normal. The CDVA was 20/40 in OS. A differential diagnosis of orbital cellulitis, Mucormycosis, and HH was considered. On further questioning, systemic history was normal. The patient was afebrile, with no signs and symptoms suggestive of COVID-19 disease. A complete blood count, erythrocyte sedimentation rate, diabetic profile, and lipid profile were normal. Since the patient was afebrile, pupillary reaction and fundus examination were normal, the possibility of orbital cellulitis was ruled out.
|Figure 1: Digital slit-lamp images depicting sequence of events: (a) Proptosis (more prominent), lid edema, chemosis in the left eye of the patient after administration of local anesthesia suggestive of delayed hyaluronidase hypersensitivity. (b) Postoperative day 1 picture showing diffuse conjunctival chemosis in the left eye. (c) Postoperative day 2 picture in primary gaze depicting gradual resolution of proptosis, lid edema, chemosis. (d) Postoperative day three picture in up-gaze depicting total resolution of lid edema and chemosis. (e) Postoperative day three picture in right gaze depicting total resolution of lid edema and chemosis. (f) Postoperative day three picture in left gaze depicting total resolution of lid edema and chemosis|
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In orbital Mucormycosis condition, the visual acuity would be reduced due to involvement of optic nerve, and cause altered mental function. Further, the infection could spread to the brain, otologic involvement can occur and fundus may reveal signs of central retinal vein and artery occlusion. Since the visual acuity, neurological examination, ear, nose, and throat evaluation, and fundus examination were normal, the possibility of Mucormycosis was also ruled out. An intradermal test with lignocaine and hyaluronidase was performed. The site of hyaluronidase injection showed an immediate hypersensitivity reaction with wheal and erythema. The response disappeared within a few minutes, confirming HH. She received IV steroid, dexamethasone 1 cc (4 mg/ml) once a day for 3 days along with topical antibiotic gatifloxacin (0.5%) and dexamethasone (0.1%) combination in tapering doses (4/3/2/1 times/day for 1 week each). The patient responded well with rapid reduction of lid edema, conjunctival chemosis, and improvement in extraocular movements. Since the patient was improving with treatment, radiological investigations such as computed tomography (CT) scan and magnetic resonance imaging were deferred. Complete resolution of proptosis, lid edema, and chemosis was observed after 3 days. The patient was successfully discharged on the 4th postoperative day and was advised for follow-up review after 15 days [Figure 2].
|Figure 2: Flowchart depicting the timeline of clinical events and the treatment on each postoperative day|
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| » Discussion|| |
STA is a commonly used regional anesthesia for cataract surgery. Lignocaine and hyaluronidase mixture is the most frequently used anesthetic due to rapid onset of action and quicker recovery post block. Hyaluronidase assists in the diffusion of anesthetic agents to the periorbital structures during ophthalmic surgery (e.g., retrobulbar block, STA, and peribulbar block). Hyaluronidase breaks down the hyaluronic acid present in connective tissues. It also causes a transient rise in intraocular pressure, reduces myotoxicity, and alleviates the incidence of postoperative strabismus. HH is a rare entity and can masquerade orbital infection and inflammation. It can be immediate as well as delayed. The first case of immediate HH was reported by Kirby et al. The patient had periorbital edema and conjunctival chemosis as the common ocular manifestations. The first case of HH after STA was reported by Musa et al. This was an IgE mediated delayed HH after 36 h of STA.
In our case, the patient developed proptosis, lid edema, chemosis, and restriction of extraocular movements on the 1st postoperative day 1, which mimicked orbital cellulitis and Mucormycosis during the COVID-19 pandemic. The absence of systemic symptoms, history of negative RT-PCR, two doses of COVID-19 vaccination, and prompt response to dexamethasone confirmed HH after ruling out other possibilities. This is a documented second case reported with a unique and rare presentation of delayed HH after STA. This case report provides insights into delayed HH after STA, and the treating ophthalmologist and pharmacologists must be aware of this rare entity. HH can also occur after routine cataract surgery as a delayed response, and this possibility should not be overlooked while treating the patient.
| » Conclusion|| |
This case report highlights the adverse reaction to hyaluronidase after STA, which was successfully managed after meticulous evaluation. In such scenarios, the possibility of orbital cellulitis, retrobulbar hemorrhage, and Mucormycosis during the COVID-19 pandemic should be kept in mind. After ruling out other differentials, HH can be successfully managed with systemic corticosteroids preventing irreversible ocular sequelae. The main impact of this case report is to provide a clinical perceptive knowledge about differentials, prompt diagnosis and effective treatment in managing will help achieve an excellent visual outcome in patients presenting with HH.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Puducherry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Guise P. Sub-Tenon's anesthesia: An update. Local Reg Anesth 2012;5:35-46.
Buhren BA, Schrumpf H, Hoff NP, Bölke E, Hilton S, Gerber PA. Hyaluronidase: From clinical applications to molecular and cellular mechanisms. Eur J Med Res 2016;21:5.
Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases 2017;5:307-23.
Kirby B, Butt A, Morrison AM, Beck MH. Type I allergic reaction to hyaluronidase during ophthalmic surgery. Contact Dermatitis 2001;44:52.
Musa F, Srinivasan S, King CM, Kamal A. Raised intraocular pressure and orbital inflammation: A rare IgE-mediated allergic reaction to sub-Tenon's hyaluronidase. J Cataract Refract Surg 2006;32:177-8.
[Figure 1], [Figure 2]