What Caused This Blurry Vision?

A 33-year-old white male presents for open reduction and internal fixation of right metacarpals 3 and 4 following a skiing accident. An ultrasound guided right supraclavicular nerve block was performed using ropivacaine 1% 20 mL mixed with lidocaine 2% with epinephrine (1:200,000) 20 mL. 

The patient began complaining of blurry vision. His wife who was present in the preoperative area noticed his right eyelid drooping. The anesthesiologist confirmed the presentation. 

(Answer and discussion on next page)

Answer: Horner’s syndrome induced by anesthetic

Jon Dylan Girard, MD

Dayton, Ohio

Horner’s syndrome is a result of disruption of sympathetic input from the stellate ganglion resulting in ipsilateral myosis, ptosis, and anhidrosis. This can occur from interruption of signals in the sympathetic pathway starting from the hypothalamus. Interruption of the signal at the level of the stellate ganglion can be from compression due to a tumor, carotid dissection, aneurysm, or cervical rib. It can also occur from surgery, trauma, anesthetics, or improper perioperative positioning. 

Horner’s syndrome has also been associated with cluster headaches. If from anesthetics, symptoms usually occur within 40 minutes and resolve within 2 hours. This occurs due to proximal migration of the anesthetic to the supraclavicular prevertebral area from site of injection.  

No treatment, other than re-assurance, is needed. Other complications that canoccur from supraclavicular nerve blocks include: infection, hematoma, vascular puncture, nerve injury, and diaphragmatic paralysis. 

In our case, the patient’s symptoms resolved after surgery and the physical exam returned to baseline.  

Reference

1. Walid T, Mondher A, Anis L, et al.  A Case of Horner's Syndrome following Ultrasound-Guided Infraclavicular Brachial Plexus Block.  Case Reports in Anesthiology.  2012; article ID 125346