Glycopyrrolate Induced Bilateral Angle Closure Glaucoma after Cervical Spine Surgery
We present a case of a 59-year-old male with hepatitis B, hypertension, and benign prostatic hypertrophy treated by 5α-reductase inhibitor. The patient was admitted to the hospital for cervical spine laminectomy. He was diagnosed with cervical disc disease involving C4-C5, C5-C6, and C6-C7 causing severe neck pain and paresthesia radiating to both upper and lower limbs. His past surgical history included surgical excision of multiple lipomas under general anesthesia with no reported complications. Ophthalmic history was significant for mild bilateral hyperopia (+1.50D).\nOn the day of surgery the patient was not premedicated. The vital signs upon induction were as follows: blood pressure 110/70 mmHg; heart rate 80 beats/min; O2 saturation 97% on room air. Two intravenous lines and a radial arterial line were inserted prior to induction. Intravenous midazolam (Dormicom; Hameln Pharmaceutical, Germany) 2 mg IV and (Fentanyl; Hameln Pharmaceutical, Germany) intravenous fentanyl 50 mcg were administered. While awake, nasal intubation was performed after bilateral superior laryngeal nerve block, transtracheal block, and topical anesthesia. After preoxygenation, intravenous induction was administered with Propofol (Diprivan; Frenius Kabi, Germany) 200 mg, Rocuronium (Esmeron; Organo, Netherland) 50 mg, Fentanyl 250 μg, Midazolam 1 mg, and Xylocaine (Lidocaine Hydrochloride; Hameln Pharmaceutical, Germany) 100 mg. Dexamethasone (Dexamed; Medochemie LTS, Cyprus) 16 mg was given intravenously after induction. Both eyes were covered with eye pads and taped. The patient was moved intoa prone position. The head was stabilized with a horseshoe head rest and the anesthesiologist made sure that no pressure was applied on the eyes or forehead. Remifentanil (Ultiva; GSK, Italy) and cisatracurium (Nimbex; GSK, Italy) intravenous infusions were started.\nThroughout the procedure, vital signs were maintained within the following limits: Systolic blood pressure 100–130 mmHg; diastolic blood pressure 50–80 mmHg; heart rate 50–70 beats/ min; O2 saturation 99–100%; temperature 35.7–36.7°C. Four liters of lactated Ringers were infused intraoperatively that lasted 5 h and 30 min. After the laminectomy was performed, the patient was reversed back to the supine position. Muscle relaxants were reversed with neostigmine (Prostigmine; Valeant, Switzerland) 0.05 mg/kg (4.5 mg) and glycopyrrolate (Robinul; American Regent Inc, USA) 0.01 mg/kg (0.9 mg). The patient was extubated fully awake and cooperative and was transferred to the recovery room in stable condition.\nIn the early postoperative period, the patient had no ocular complaints. Approximately 12 h following recovery from general anesthesia he developed progressive bilateral frontal headache associated with nausea that persisted despite analgesics. CT scan of the brain ordered by the orthopedics service was normal. Twenty-four hours postoperatively, he started complaining of bilateral blurring of vision along with headache at which time the ophthalmology service was consulted.\nOphthalmic examination indicated Snellen visual acuity of 20/100 in both eyes. There was corneal edema bilaterally with an intraocular pressure of 65 mmHg in each eye. Reaction to light was sluggish in both pupils. The anterior chambers were shallow and gonioscopy revealed bilateral plateau iris occluding the trabecular meshwork 360°. Both irises were pigmented dark-brown. No lens thickening was observed bilaterally. The patient was diagnosed with bilateral AACG with plateau iris syndrome. Acetazolamide (Diamox; Sigma Pharmaceuticals Ltd, New Zealand) 500 mg PO and intravenous Mannitol (500 cc over 40 min) were administered and the patient was instructed to instill topical antiglaucoma drops including dorzolamide hydrochloride–timolol maleate (Cosopt; Merck, USA) and bimatoprost (Lumigan; Allergan, USA) ophthalmic solution. On follow up over the next 12 h, visual acuity improved to 20/35 bilaterally with significant decrease in corneal edema. The intraocular pressure decreased to 21 mmHg in the right eye and 14 mmHg in the left eye, respectively. The anterior chambers remained shallow, hence peripheral iridotomies at 10 and 12 o’clock were performed on both eyes. The patient was returned for 1 month follow-up and his vision was 20/20 in both eyes with an IOP of 13 mmHg and 15 mmHg in the right and left eyes, respectively. Peripheral iridotomies were patent bilaterally.