Bilateral orbital infarction syndrome after bifrontal craniotomy.

Report of a Case. A 24-year-old man experienced multiple cranial fractures leading to brain contusion and free intracranial air after a motor vehicle crash. Because of persisting rhinoliquorrhea 3 months later, the endocranium was sealed. Preoperative visual acuity was 20/20 OU. After bicoronal skin incisions, a dermal and a galea-periostal flap were dissected to the supraorbital rim without wrapping them in gauze. Both flaps were retracted inferiorly while resting on the patient’s eyes. During the procedure, the patient’s heartbeat stopped for a few seconds; it was corrected with 0.5 mg of atropine. One hour after extubation, the patient complained about reduced vision. Immediate ophthalmologic examination revealed recognition of hand movements, normal intraocular pressures, conjunctival chemosis, and complete bilateral ophthalmoplegia (Figure 1). Pupils were insensitive to light. Ophthalmoscopy showed occlusion of both central retinal arteries, causing retinal edema and a cherry red spot (Figure 2A). An intravenous application of acetazolamide and heparin sodium was started immediately, followed by isovolemic hemodilution. Magnetic resonance imaging and magnetic resonance angiography showed normal intracranial arteries and edematous ocular muscles. Two days later, fluorescein angiography revealed normal retinal and choroidal perfusion (Figure 2B and C). After 4 months, eye movements had normalized and both eyes showed optic atrophy and pigmentary retinopathy (Figure 2D). Visual acuity remained unchanged.