FRONTIERS IN MEDICAL CASE REPORTS - Volume 3; Issue 3, (May-Jun, 2022)

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Corneal Abrasion After Radical Thyroidectomy: A Case Report

Author: Huixian Cheng, Liangbin Cao, Yan Lu, Yongquan Chen, Manlin Duan

Category: Medical Case Reports

Abstract:

Corneal abrasion during radical thyroidectomy is a rare complication and is infrequently addressed in the literature. Here, we present the case of a young female patient who underwent radical thyroidectomy with general anesthesia. During the operation, the eyes were being naturally closed without protection measures, and corneal abrasion of the left eye occurred after the operation. The lesion had completely resolved with no sequelae after treatment. Therefore, preventive measures and attentive care may help reduce the incidence of corneal abrasion in patients undergoing radical thyroidectomy.

Keywords: General Anesthesia, Corneal Abrasion, Eye Injury

DOI URL: http://dx.doi.org/10.47746/FMCR.2022.3306

Full Text:

Introduction

Corneal abrasion (CA) is the most common ocular complication in patients undergoing non-ocular surgery under general anesthesia, with a variable incidence rate of 0.01% to 0.33% (Deljou et al., 2019; Porter et al., 2022; Segal et al., 2014). Although rare, most corneal abrasions heal without significant long-term complications. Perioperative CA accounts for a lower proportion of anesthesia claims, but the average amount of compensation is larger (Yu et al., 2010). While relatively benign, CA may lead to delays in discharge from the hospital due to the need for ophthalmology consultation and further treatment. It can also result in a decrease in patient satisfaction surrounding the hospital stay. Here, we present a report of one patient who sustained perioperative CA during a radical thyroidectomy performed with general anesthesia. It is hoped that more doctors will realize that effective preventive measures and careful care can help reduce the incidence of CA after anesthesia surgery.

Case Presentation

A 33-years-old female patient, ASA I, underwent left thyroidectomy with thyroisthmectomy, bilateral central lymph node dissection, left functional neck lymph node dissection, left thyroidectomy with thyroisthmectomy and bilateral recurrent laryngeal nerve exploration under general anesthesia. The past medical history of the patient and standard examination before the surgery were unremarkable. There were no past ocular problems noted.

The anesthesia and operation process were smooth, and the vital signs were stable during the operation. During anesthesia, the patient's double eyelids were closed naturally without relevant protective measures. The total operating time (from opening to close of the wound) was 4 hours. And almost 4 and half hours total time for anesthesia. The patient recovered well after the operation, with a Steward score of 6, and was safely returned to the ward.

Two hours after returning to her hospital room, the patient complained of obvious foreign body sensation in the left eye, and an ophthalmologist was consulted. The ophthalmologist's examination revealed obvious swelling of the left eyelid, hyperemia of the bulbar conjunctiva, exfoliation of the corneal epithelium, round pupil, sensitive light reflex, and no obvious abnormalities in eye movement. A left eye CA was documented, and levofloxacin eye drops and calf blood deproteinized extract ophthalmic gel were prescribed. The patient recovered completely after two days without sequelae.

Discussion

CA is the most common ophthalmologic complication during general anesthesia for non-ocular procedures. When the corneal epithelium is removed from the underlying basal membrane, a surface defect of the corneal epithelium can result (Malafa et al., 2016). There are two main mechanisms of perioperative corneal injury: direct mechanical injury of corneal epithelium and dry injury of cornea exposed to air for a long time (Deljou et al., 2019). General anesthesia diminishes the patient’s normal eyelid reflexes and causes the eyelids to not close completely, resulting in dry cornea. Over the years, multiple case reports have reported CA in different surgeries, during total joint arthroplasty (Young et al., 2021), after an intraoperative wake-up test during spinal surgery (Yanagidate and Dohi, 2003), and routine gastrointestinal endoscopy (Dixon et al., 2019), and so on. The precise mechanism of corneal injury is unknown in most cases. There is a need for further research to better elucidate the etiology of CA during the perioperative period.

Segal, et al. (2014) found that the use of oxygen masks during transport was an important risk factor. Incomplete closure of the lid exposes the epithelial surface and makes the cornea prone to abrasion. In this case, the patient's double eyelids were closed naturally without relevant protective measures. During the operation, it is difficult to observe corneal exposure due to the shielding of the sterile sheet. It is not clear whether there is CA caused by mechanical compression. Therefore, patients should have the eyelids secured in the closed position directly after anesthesia induction for protection.

The characteristics associated with the injury were longer duration of anesthesia and non-supine surgical position, both of which have been previously described (Deljou et al., 2019; Malafa et al., 2016). Other risk factors associated with CA include advanced age of the patient, head/neck procedures, Trendelenburg position, prolonged surgery (>60 minutes), perioperative anemia, and intraoperative hypotension (Malafa et al., 2016; Moos and Lind, 2006). A case-controll study results suggest that the extended period of time that patients are anaesthetised for longer surgical procedures predisposes to perioperative CA. When patients are anaesthetised for longer surgeries, they are at higher risk for tear film deficiency, mechanical corneal exposure and subsequent CA (Carniciu et al., 2017). In this case, there are several risk factors, including neck surgery, longer surgery and anesthesia time, special surgical posture (to fully expose the thyroid gland, raise the patient's shoulder, equivalent to Trendelenburg position) and unfixed eyelids during operation, which increase the risk of CA. It is essential surgeons and anesthesiologists work as a team to limit the operative time, optimize intraoperative conditions, and ensure patient safety, to impact patient outcomes positively.

Long-term adverse effects of CA are uncommon, but it is a major cause of postoperative distress. Symptoms include pain, blurry vision, tearing, redness, photophobia, and sensation of a foreign body (Kaye et al., 2019). Given the known risk factors associated with perioperative CA, eye protection is necessary to reduce the number of ocular adverse events. Methods of protecting the eyes during general anesthesia include manual eye closure, adhesive tape on the eyelids, and the use of ointment or eye drops (Kaye et al., 2019). Nevertheless, no single prevention method is 100% effective.

Prevention of CA is crucial and is optimized when all perioperative providers are adequately educated in eye care. In a study by Martin, et al. (2009) increased awareness of perioperative corneal injury among anesthesiologists, combined with improved educational measures, was associated with a significant reduction in the incidence of CA. In 2022, Porter, et al. that the use of simple, standardized perioperative and perioperative CA prevention, diagnosis, and treatment protocols can consistently reduce perioperative CA occurrence. Moreover, the decreased number of CA cases was sustained for 2 consecutive years (Porter et al., 2022). Surgeons and anesthesiologists should recognize this avoidable complication and take precautions to protect the eyes during surgery.

Conclusion

CA during radical thyroidectomy is a rare complication and is infrequently addressed in the literature. Preventive measures and attentive care may help reduce the incidence of CA in patients undergoing radical thyroidectomy.

Consent: The patient has given permission for publication of her clinical details.

Conflict of Interest: The author declares that there are no conflicts of interest regarding the publication of this article.

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