Deterioration of glaucoma after carotid endarterectomy

Abstract

A 64-year-old man with a long history of untreated diabetes mellitus had suffered from visual disturbance in his right eye. Neovascular glaucoma in the right eye and diabetic retinopathy in both eyes were found, and ischemic ocular syndrome was suspected for the right eye. Neuroimaging revealed severe stenosis of the right internal carotid artery. He was first treated for diabetes and glaucoma, and then, after these conditions were stabilized, right carotid endarterectomy (CEA) was carried out. Although the operation was uneventful, he suffered from headache and his right sight was blurred on the day after surgery. Right intraocular pressure was markedly increased, and corneal edema and increased iris neovascularization were also recognized. Intensive ophthalmologic care was carried out, but his right vision worsened and was eventually lost. Ocular ischemia causes not only neovascularization of the iris, which leads to insufficient resorption of the aqueous humor, but also insufficient production of the aqueous humor. After CEA, production of the humor is immediately activated, but the resorption capacity does not change, which results in an extraordinary increase in intraocular pressure. Neurosurgeons should be aware that CEA not only improves or avoids worsening of vision in patients with ischemic oculopathy, but can also rarely cause paradoxical devastating visual deterioration.