Fatal Air Embolism after Choroidal Melanoma Endoresection without Air Infusion: A Case Report

Abstract

<b><i>Background:</i></b> The aim of this study was to report 2 cases of pulmonary air embolism developing several hours after choroidal melanoma endoresection without the use of air infusion during the surgery, with fatality in 1 patient. <b><i>Methods:</i></b> The method of this study was case report. <b><i>Participants:</i></b> Two patients with large choroidal melanomas who collapsed several hours after endoresection without air infusion as a result of pulmonary air embolism. <b><i>Results:</i></b> A 72-year-old man collapsed 4 h and 30 min after endoresection without air infusion. Computerized tomography angiography confirmed air embolism. The patient died after 86 min of cardiopulmonary resuscitation. A 41-year-old woman collapsed 5 h and 30 min after endoresection, performed without air infusion and with close monitoring, which included right internal jugular vein catheterization intraoperatively. Transthoracic and transesophageal echography, performed preoperatively, intraoperatively, and postoperatively, revealed air embolism only after collapse occurred. Imaging showed the embolism to be biventricular because of patent foramen ovale. The patient was treated promptly with extracorporeal membrane oxygenation and mechanical ventilation, which resulted in a full recovery. <b><i>Conclusions:</i></b> Air embolism can develop after endoresection for choroidal melanoma, despite avoiding air infusion. Further studies are needed to understand how this occurs. Special measures are indicated to detect this complication and to treat it promptly and effectively.

Anatomical and functional outcomes after endoresection and adjuvant ruthenium brachytherapy for uveal melanoma: a single center case series

“…Ruschen et al hypothesized that a gas embolism was due to the entry of per uorooctane into the bloodstream with the formation of gas bubbles in the pulmonary circulation, and the association with an increased vapor pressure of per uorooctane 54 . In our case we always used per uorodecalin, which has been reported to enter circulation during endoresection without systemic complication 55 .…”

“…Previously, air was used to atten the retina in this surgical procedure, however, this method was abandoned after the report of intraoperative and early postoperative death caused by air embolism 41,42 . It is known that air embolism can develop after endoresection for choroidal melanoma, despite avoiding air infusion 54,55 . Ruschen et al hypothesized that a gas embolism was due to the entry of per uorooctane into the bloodstream with the formation of gas bubbles in the pulmonary circulation, and the association with an increased vapor pressure of per uorooctane 54 .…”

Operative Complications of Posterior Uveal Melanoma Surgery

“…82 In addition, fatal air emboli have been reported to occur secondary to exposure of the choroidal circulation. [83][84][85] Exoresection Via Partial Lamellar Sclerouvectomy Exoresection is a procedure meant to remove ciliary body or choroidal melanomas from an external approach using a lamellar scleral flap, allowing the overlying retina to remain intact and protecting the eye from radiation complications while avoiding enucleation. The technique was described in the 1960s 86,87 and was used more commonly in the 1980s and 1990s, primarily for anteriorly located lesions.…”

“…Another significant concern is pulmonary embolus development, which has been reported postoperatively following endoresection in patients under 50 and is thought to be caused in part by hypotensive anesthesia 82. In addition, fatal air emboli have been reported to occur secondary to exposure of the choroidal circulation 83–85…”

Grundlagen der Vitrektomie unter Verwendung intraokularer Tamponaden – ein chirurgischer Basiskurs

“…Since decalin has lower vapor pressure, this is probably less of a problem than it is with octane, which has a significantly higher vapor pressure and can, due to warming up in the systemic circulation, lead to significant evaporation with air embolism, with fatal consequences 20 . In principle, this problem can be prevented through cauterization and by severing the affected vorticose veins 21 .…”