Korean J Ophthalmol.  2008 Jun;22(2):133-136. 10.3341/kjo.2008.22.2.133.

Choroidal Ischemia and Serous Macular Detachment Associated with Severe Postoperative Pain

• Jung JW
• Lee DY
• Nam DH

• KMID: 1099009
• DOI: http://doi.org/10.3341/kjo.2008.22.2.133

Abstract

To report the association of a unilateral serous macular detachment with severe postoperative pain. A 71-year-old woman presented with a sudden decrease in vision in the right eye, seven days after a total knee replacement arthroplasty. The patient's history was unremarkable except for a severe pain greater than the visual analog scale of 8 points for about 2 days after surgery. Retinal examination showed a well differentiated serous detachment that was about 3.5 disc diameter in size and located in the macular area. Fluorecein angiography and indocyanine green angiography showed delayed perfusion of the choriocapillaris without leakage points in the early phase and persistent hypofluorescence with pooling of dye in the subretinal space in the late phase. There was a spontaneous resolution of the serous detachment and the choroidal changes with residual pigment epithelial changes. Severe postoperative pain may influence the sympathetic activity and introduce an ischemic injury with a focal, choroidal vascular compromise and secondary dysfunction of overlying RPE cells in select patients.

Keyword

Choroidal ischemia; Pain; Serous retinal detachment; Total knee replacement arthroplasty

MeSH Terms

Aged
*Arthroplasty, Replacement, Knee
Choroid/*blood supply
Coloring Agents/diagnostic use
Female
Fluorescein Angiography
Humans
Indocyanine Green/diagnostic use
Ischemia/diagnosis/*etiology
Pain Measurement
*Pain, Postoperative
Retinal Detachment/diagnosis/*etiology
Serum
Vision Disorders/etiology

Figure

• 

  Fig. 1 Fundus photographs at the first visit show a serous elevation of the macular area in the right eye.

• 

  Fig. 2 Fluorescein angiogram of right eye performed at the first visit (A) Early phase shows choroidal hypoperfusion (white arrow) and serous detachment (black arrow) without a leakage point, (B)(C) mid and late phases show pooling of the dye in the subretinal space without a leakage point.

• 

  Fig. 3 Indocyanine green angiography angiogram performed at the first visit. (A) Early phase shows delayed perfusion of the choriocapillaris without a leakage point, and (B) late phase shows persistent hypofluorescence (arrow) with slow filling of neurosensory detachment without a focal source of leakage. (C), (D) show no disturbance of the posterior pole in the left eye.

• 

  Fig. 4 Follow-up examination 6 months following the first clinic visit shows complete resolution of the serous detachment of macula. (A) Early phase fluorescein angiogram shows three hyperfluorescent spots (arrow), not seen on previous exam, and (B) late phase fluorescein angiogram shows one of the points leaking slightly and two fade out slowly. Horizontal (C) and vertical (D) crosshair scan of optical coherence tomography at fovea and the leakage point show no serous detachment or pigment epithelium detachment.

Reference

1. Cogan DG. Ocular involvement in disseminated intravascular coagulopathy. Arch Ophthalmol. 1975. 93:1–8.

2. Valluri S, Adelberg DA, Curtis RS, Olk RJ. Diagnostic indocyanine green angiography in preeclampsia. Am J Ophthalmol. 1996. 122:672–677.

3. Wolfensberger TJ, Tufail A. Systemic disorders associated with detachment of the neurosensory retina and retinal pigment epithelium. Curr Opin Ophthalmol. 2000. 11:455–461.

4. Lowder CY, Gutaman FA, Zegarra H, et al. Macular and paramacular detachment of the neurosensory retina associated with systemic diseases. Trans Am Ophthalmol Soc. 1981. 79:347–370.

5. Fine SL, Berger JW, Maguire MG, Ho AC. Age-related macular degeneration. N Engl J Med. 2000. 342:483–492.

6. Fastenberg DM, Ober RR. Central serous choroidopathy in pregnancy. Arch Ophthalmol. 1983. 101:1055–1058.

7. Iida T, Yannuzzi LA, Spaide RF, et al. Cystoid macular degeneration in chronic central serous chorioretinopathy. Retina. 2003. 23:1–7.

8. Yannuzzi LA, Shakin JL, Fisher YL, Altomonte MA. Peripheral retinal detachments and retinal pigment epithelial atrophic tracts secondary to central serous pigment epitheliopathy. Ophthalmology. 1984. 91:1554–1572.

9. Pertovaara A. Noradrenergic pain modulation. Prog Neurobiol. 2006. 80:53–83.

10. McGrath B, Elgendy H, Chung F, et al. Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth. 2004. 51:886–891.