Isolated transient diplopia and nystagmus after spinal anesthesia

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LETTER TO THE EDITOR

Isolated transient diplopia and nystagmus after spinal anesthesia Go¨kcen Basaranoglu • Leyla Saidoglu

Received: 25 July 2012 / Accepted: 3 February 2013 / Published online: 28 February 2013 Ó Japanese Society of Anesthesiologists 2013

Keywords

Spinal  Diplopia  Anesthesia

To the Editor: Postdural puncture headache (PDPH) is a common complication of spinal anesthesia. Tinnitus, diplopia, and photophobia may accompany PDPH. We report isolated diplopia and nystagmus without any other subjective symptom after spinal anesthesia. A 32-year-old man (ASA I), 165 cm in height and 65 kg in weight, was scheduled for elective unilateral varicose stripping. The laboratory evaluation and coagulation tests were in normal. We performed unilateral spinal anesthesia with a 22-gauge Quincke spinal needle at the L3–L4 interspace at the first attempt. We administered 2 ml hyperbaric 0.5 % bupivacaine. Spinal anesthesia developed to a T7–T8 level on the left side and L5 level on the right side. The surgery and anesthesia were uneventful, without any hypotensive period. However, 18 h later the patient complained of nystagmus and diplopia, which were observed during standing up and resolved when resuming the supine position. These findings could be consequent to cerebrospinal fluid (CSF) leakage. The optic nerve, fundus, globe motion, and thickness of macula were normal, and his pupils were isochoric. Binocular and horizontal diplopia occured. Nystagmus was present when the patient looked toward the G. Basaranoglu (&) Bezmialem Vakif University, Medical Faculty, Department of Anesthesiology and Reanimation, Soganli mah Alper sok yuvam apt no= 1/20 B. Evler, Istanbul, Turkey e-mail: [email protected] L. Saidoglu Kanuni Sultan Su¨leyman Hastanesi, Istanbul, Turkey

right. Direct, indirect light reflex, and cranial computerized tomography examination were normal. The patient was given caffeine 50 mg and theophylline medication per os three times per day. On the fourth postoperative day, diplopia was decreased. After 7 days, diplopia and nystagmus were completely resolved. In the differential diagnosis of diplopia cornea, lens, muscle, optic nerve, and brain problems must be considered. Myasthenia gravis, Guillain–Barre´ syndrome, multiple sclerosis, and other muscle disorders for the differential diagnosis of diplopia were excluded with neurological consultation. Our patient had no history of neurological or psychological disorder and subdural hematoma. The patient had no previous medical history suggesting diplopia and there was no symptom of neurological disease, e.g., myasthenia gravis. The early theophylline–caffeine combination may have had the effect of increasing CSF. It was interesting for us why headache was not concomitant with diplopia and nystagmus. Although there are already several case reports about diplopia available in the literature, diplopia and nystagmus without PDPH is a very rare and uncommon complication of spinal anesthesia [1–5]. Using large-bore spinal needless for spinal anesthesia