A 46-year-old obese male with a mechanical aortic valve with increasing dyspnoea for less than ordinary physical activity underwent to an urgent transoesophageal echocardiogram (TEE) because of the suspect of prosthetic valve thrombosis. At time of examination, the patient was normotensive with an INR of 5 (on Coumadin). The TEE was easily performed under conscious sedation with midazolam as for our standard practice for TEE. About 15 min after the end of procedure, during the recovering time, the patient manifested proptosis and diplopia. The cardiologist quickly performed an orbital ultrasound, showing a hyperechoic formation located in the superomedial orbital region limiting the movements of the eye as shown in Panel A [the image shows a transverse section of the ocular bulb recorded with a linear probe, posteriorly is visible the retrobulbar haematoma as a rounded formation of 3 cm maximum diameter (as indicated by the arrow)].
The diagnosis was later confirmed by nuclear magnetic resonance imaging as reported in Panel B [the image shows a T2 sequence, coronal plane, at the ocular bulbs level with the haematoma visible in the superomedial region of the ocular cavity (as indicated by the arrow)].
The introduction of the probe caused multiple gag reflexes with Valsalva-like manoeuvers. The increase in arteriovenous pressure gradients during these manoeuvers possibly led to vascular lesions in the retrobulbar region, resulting in blood extravasation. The treatment of this rare complication is complex and may require surgical intervention on a delicate region. In literature, there are no reported cases of retrobulbar haematoma following a TEE to date. At present, ‘drug-induced coagulopathy’ (see also NOAC) is a relative contraindication to perform a TEE, especially in urgency.
The data underlying this article are available in the article and in Supplementary material online.
Author notes
Conflict of interest: None declared.
