Circulatory Failure in the Central Retinal Artery during Medial Orbital Wall Blow-out Fracture Repair

Purpose: We report a case of visual impairment due to circulatory failure in the central retinal artery during blow-out fracture repair.Case summary: A 16-year-old male with no underlying disease was diagnosed with a trapdoor type medial orbital wall blow-out fracture after a motorcycle accident and underwent blow-out fracture repair. During the surgery, his left eye was nearly completely dilated. Postoperatively, the visual acuity in the left eye was hand motion and there was ptosis of the left upper eyelid. Concerned with the possibility of orbital implant compression, computed tomography was performed immediately and a second operation was performed. However, there was no direct compression originating from the intraocular implant or any signs of active bleeding. The following day, optical coherence tomography and fluorescein angiography revealed a cherry-red spot on the central fovea with edema of the inner retinal layer and delayed arterial circulation. Under a diagnosis of incomplete central retinal artery occlusion, the patient was treated with intraocular pressure-lowering eye drops and intravenous mannitol. Despite prompt intervention, the visual acuity of the left eye did not improve beyond 0.04 at the 2-year follow-up.Conclusions: When there is visual impairment and pupillary dilation after blow-out fracture repair, we should consider not only compressive factors but also the possibility of central retinal artery occlusion or circulatory failure. In such cases, retinal examinations should be done to assess the retinal blood flow and enable early detection of any complications allowing prompt appropriate intervention.