Dear Sir,
We read with interest the article titled “Acute visual loss with ophthalmoplegia after spinal surgery: Report of a case and review of literature” by Mukherjee and Alam.[1] Authors have mentioned about ischemic damage to optic nerves due to raised intraocular pressure (IOP) as a possible mechanism for loss of vision in the immediate postoperative period following prolonged surgery. We appreciate the authors’ effort and the research work. We would like to highlight a few points regarding glaucomas due to acid base imbalance. Factors which increase IOP are hypoxia, metabolic alkalosis and respiratory acidosis, and increased central venous pressure (coughing, straining, increased intrathoracic pressure, trendelenburg positions, and valsalva maneuver).[2] Pharmacological or metabolic process that increases choroidal blood volume will increase IOP. Mechanically ventilated patients with chronic lung disease (posthypercapnia syndrome) develop metabolic alkalosis. Respiratory acidosis is caused by depressed central respiratory drive and acute paralysis of the respiratory muscle. Assisted ventilation is required in children undergoing treatment for respiratory acidosis.[3] The prevalence[4] of pupillary block glaucoma increases with age. However, it can occur at any age, including rare cases in childhood.[5] Atropine and adrenaline are common drugs used in general anesthesia, which may precipitate acute angle closure glaucoma in predisposed patients.[4]
To conclude, IOP monitoring should be performed in children undergoing intensive care treatment following either head injury or major head and neck surgery. Torchlight, fluorescein strip, topical anesthetic eye drops, direct ophthalmoscope, measuring tape, plastic rule (exophthalmometer), and tonometer (Schiotz or Tonopen) should be available in pediatric Intensive Care Unit.
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References
- 1.Mukherjee B, Alam MS. Acute visual loss with ophthalmoplegia after spinal surgery: Report of a case and review of the literature. Indian J Ophthalmol. 2014;62:963–5. doi: 10.4103/0301-4738.143951. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Matthes K, Anjolie E, Wang LE, Anderson TA. 1st ed. New York: Oxford University Press; 2015. Pediatric Anesthesiology. A Comprehensive Board Review. [Google Scholar]
- 3.Paul VK, Bagga A. Ghai Essential Pediatrics. 8th ed. New Delhi: CBS Publishers Pvt. Ltd; 2013. [Google Scholar]
- 4.Allingham RR, Damji KF, Freedman S, Moroi SE, Rhee DJ. Shield's Textbook of Glaucoma. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2011. [Google Scholar]
- 5.Deshpande N, Shetty S, Krishnadas SR. Pupillary-iris-lens membrane with goniodysgenesis: A case report. Indian J Ophthalmol. 2006;54:275–6. doi: 10.4103/0301-4738.27957. [DOI] [PubMed] [Google Scholar]