Medicine

Diplopia as a complication of local anesthesia: A case report

Fanny Koumoura, DDSVGeorge Papageorgiou,
Dipiopia caused by iocai anestbesia at the superior posterior alveolar narve for the removai of the maxiilary third molar is a rare compiication. The dipiopia is due to facial paisy of the oculomotor muscles ot the globe.Thispaper describes the case Ota 22-year-oid woman, in whom dipiopia was observed atter an overail uncompiicated removai of the semi-impacted third moiar. Possibie causes of the anesthetic effects are reported. The most accepted expianation is that the anesthetic diffuses on the abducent nerve in the cavernous sinus. The necessary actions fhaf the dental surgeon musf perform are reported. (Quintessence tnt 2001:32:232-234) Key words: abducent nerve, cavernous sinus, dipiopia, impacted third molar, infrafemporai fossa, iaterai recfus muscie, iocai anesthesia

he local anesthesia that is frequently used in dental practice is occasionally accompanied by some complicafions tbat are either systemic (beadache, syncope, failure of tbe anesthesia, nausea)' or local (bematoma, facial palsy, anemic skin zones). Tbus, during tbe administration of regional anestbesia to tbe second branch of tbe trigeminal nerve, several unusual sensory or motor disorders may occur, such as blanching of tbe cheek or amaurosis, or ophthalmoplegia, resulfing in diplopia.Diplopia is a disturbance of eye movement, resulting in double images at a certain position, caused by tbe suppression of tbe oculomotor muscles that control tbat posifion. Tbe suppression is caused by eitber injury to the III, IV, and VI cranial nerves that innervate tbose muscles or direct injuries to tbe muscles themselves.^ An indireet effect on one of tbe ocular muscles may occur during anestbesia of tbe maxillary nerve via tbe greater palatine eanal,'' tbe infratemporal fossa, or tbe infraorbital sulcus.^
CASE REPORT

Maxiiiofaciai Surgery Department for the removal of the semi-impacted maxillary left third molar. The patient had no apparent health problems, and the tootb was situated in a perpendieular posifion [B class per Archer). A solution of artieaine hydrochloride v/itb epinepbrine bydrochloride was injected, and the tooth was elevated uneventfully. Immediately after the removal of the tooth, the patient complained of "double vision"; no other symptoms or signs were manifested. The ensuing orthoptic evaluafion revealed tbat the patient was seeing double only at tbe outer left positions of her eyes. Gradually, her vision improved and recovery was completed approximately 2 bours later, requiring no further treatment.

DISCUSSION

The patient in this report experienced postoperative dipiopia. The 22-year-oid woman attended the
'Maxiliolaciai Sjrgeon and Associate Director, Maxiiiofaciai Department, General Peripherie Accidents iHospital ("KAT'), Kifissia, Athens, Greece 'Maxiiiofaciai Sjrgeor, General Periplieric Accidents Hospilai ("KAT"), Kifissia, Athens, Greece. Reprint requests; Or Fanny Koumoura, 21 Eveipidcn Street, Athens 113 62, Greece. E-maii: dpap@hol.gr This paper was presented al the 18tti Parhellenic Dentai Ccngress, Athens Greece. October 26,1998.

The superior posterior alveolar nerves etnerge from the maxillary nerve before entering the maxilia. The maxillary nerve is a brancb of tbe trigeminal cranial nerve. For tbe removal of maxillary third molars, anesthetic solution is usually deposited bebind the maxillary tuberosity near wbere tbe superior posterior alveolar nerve passes tbrougb tbe pterygozygomatic and infratemporal fossae. The pterygozygomatic fossa and its continuity, the infratemporal fossa, are located in the space bounded by the zygomatic arch, the maxillary tuherosity, the zygomatie process of the maxilla, and the greater wing of the sphenoid bone, Tbis space contains several vessels and nerves, including the internal maxillary and middle meningeal arteries, the pterigoid venous plexus, and the third brancb of tbe trigeminal nerve. Tbe bilateral fossae communicate througb tbe inferior

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Fig 1 Possibie routes of affectation of oouiomotor muscles, (a] difect diffusion through the soft tissues; (b) venous routes via the cavernous sinus; (c) arterial route via an abnormai course; (d) arteriai route iattie middle meningeai artery.

Fig 2 Cavernous sinus and cranial nerves in transverse section: (a) internal carotid arrery; (b] oculomotor nerve; (c) troctilear nerve, (d] abducent nerve, (e ophthaimic nerve; (f maxiliary nerve; (g) spiienoid sinus; (in seila turcioa.

orbital fissures with their respective orbital fossae, where the oculomotor muscles are located. In the case of regional anesthesia, the anesthetic solution can diffuse into the ocular muscles causing subsequent diplopia.- The reported cause is by direct diffusion of the solution through the soft rissues or even the connective tissue along the nerves and the vessels (Fig la).' The possibility of anesthetic solution penetraring the orbital fossa via an anatomical defect of the maxillary sinus wall was also considered.^ The suggestion of arterial diffusion was also discussed (Fig lc). The anesthetic solufion enters through the superior posterior alveolar artery, which is running through a specific anomalous anatomical course, and reaches the oculomotor muscles.^ We can consider a second artedal course (Fig Id) to be from the entrance of the solution at the superior part of the internal maxillary artery to the middle meningeai artery, which has an anastomotic link with the lacrymal branch of the ophthalmic atlery, and to the muscles. In this latter suggesfion, however, several other symptoms such as dizziness and sensitivity of the eyelids exist.^ Finally, according to the venous diffusion concept (Fig lb), the anesthetic solution from the pterygozygomatic-infratemporal fossa enters the pterygoid venous plexus, and via emissary veins through the ovoid, the lacerum, or the sphenoid foramina reaches the cavernous sinus of the cranial base, where it soaks the
Quintessence Internaticnal

abducent nerve (VI cranial nerve),' causing neuroparalysis of the lateral rectus muscle. This muscle is solely innervated by the abducent nerve, and in the case of interruption of its function, the result is diplopia at the lateral posifion of the eye.*" The patient's diplopia was initially attributed to the direct spread through the surrounding tissues. If this is the case, the patient should see a double image at multiple posifions because the anesthetic that enters the inferior orbital fissure should affect all the muscles of the orbital fioor. For example, affectation of the inferior rectus and inferior oblique muscles creates diplopia in more than one position of the eye. This case, however, specifically concerned the lateral position, which is controlled by the lateral rectus muscle and its nerve, tbe abducent nerve. Consequently, it seems that the anesthetic affected the abducent nerve because it is impossible to specifically affect the lateral rectus muscle only. Indeed, the abducent nerve, running supedicially on the lateral wall of the cavernous sinus (Fig 2), lateral to the internal carotid artety, is separated by the dura mater from the rest of the oculomotor nerves. These nerves, the oculomotor, trochlear (III and IV cranial nerves), and tdgemlnal (ophthalmic and maxillary) nerves, are thus protected when the anesthefic enters the sinus." Consequently, the venous spread of the anesthetic and the isolated effect on the abducent nerve is the most likely explanation in this case.
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 Koumoura/Papageorgiou

CONCLUSION

- ADVANCED

Few case reports are mentioned in the world literature concerning diplopia. In tiie instance of diplopia, we must reassure tbe patient by expiaining tbe transient nature of tbe problem, tbat its duration lasts as long as tbe anesthesia. As soon as this compiication appears, an examination must be performed to assess eye mobility, pupil reaction, and the visual acuity, in order to determine tbe probable cause and to prevent the possibility of furtber damage.

REMOVABLE PARTIAL DENTURES

James S. Brudvik, DDS, FACP

REFERENCE 1. Hidding J, lihoury R General complications in dental local anesthesia. Deutsche Zahnarztliche Zeitschrift 1991:46: 834-836. 2. Goldenherg AR. Transient diplopia from a posterior alveolar injection. J Endod 1990;16:550-551. 3. Rubin M. Trocblear nerve palsy simulating an orbital blowout fracture. J Maxillofac Surg 1992:50:1238-1239. 4. Sved AM, Wong JD, Donkor P, Horan J, Rix L, Curtin ), Vickers R. Complications associated with maxillary nerve block anaesthesia via the greater palatine canal. Aust Dent J 1992:37:340-345. 5. Apinhasamit W. Diplopia following infiltration injection of the upper canine tooth (a case report]. J Dent Assoc Thai 1983:33:113-118. 6. Wrinkler T, Von Wowern N, Odont L, Sittniann S. Retrieval of an upper third molar from the infratemporal space. J Oral Surg 1977 ;35:130-I32. 7 Marinho R. Abducent nerve palsy following dental local analgesia. BrDentJ 1995:179:69-70.

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