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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 96-97

Deep vein thrombosis due to continuous prone positioning after retinal detachment surgery


1 Department of Ophthalmology, Chang Gung Memorial Hospital–Chiayi, Puzih City, Taiwan
2 Department of Ophthalmology, Chang Gung Memorial Hospital–Chiayi, Puzih City; Department of Medicine, Chang Gung University College of Medicine, Tao-Yuan, Taiwan

Date of Web Publication14-May-2016

Correspondence Address:
Evelyn Jou-Chen Huang
Department of Ophthalmology, Chang Gung Memorial Hospital, Number 6, Section West, Chai-Pu Road, Puzih City, Chaiyi County 61363
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.1016/j.tjo.2015.05.002

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  Abstract 


In March 2014, a 56-year-old woman without previous underlying disease underwent encircling scleral buckling, 20-gauge pars plana vitrectomy, cryotherapy around a retinal tear, and gas-fluid exchange with 15% perfluoropropane flush for upper rhegmatogenous retinal detachment of the left eye. However, she developed progressive left leg swelling, pain, warmth, and redness, associated with difficulty in elevating her left leg after continuously maintaining a prone head position when either lying down or sitting for 2 days. When she arrived at the emergency room, she had an elevated D-dimer level. After undergoing Doppler ultrasound imaging, she was diagnosed as having deep vein thrombosis of the left leg. She received anticoagulation therapy with enoxaparin and warfarin overlapping for 7 days. The edema, pain, and paresthesia of her left leg were relieved. However, because of the risk of bleeding with anti-coagulation drug usage, the patient needed to be monitored for 6 months. Prone positioning for gas tamponade is important for anatomic and functional success in retinal detachment surgery; however, timely walking and rest between periods of continuous prone positioning should be encouraged to prevent deep vein thrombosis and other impaired circulation-related complications.

Keywords: deep vein thrombosis, prone positioning, retinal detachment surgery


How to cite this article:
Wang CP, Huang EJ, Kuo CN, Lai CH. Deep vein thrombosis due to continuous prone positioning after retinal detachment surgery. Taiwan J Ophthalmol 2016;6:96-7

How to cite this URL:
Wang CP, Huang EJ, Kuo CN, Lai CH. Deep vein thrombosis due to continuous prone positioning after retinal detachment surgery. Taiwan J Ophthalmol [serial online] 2016 [cited 2021 Aug 1];6:96-7. Available from: https://www.e-tjo.org/text.asp?2016/6/2/96/204298


  1. Introduction Top


Prone positioning for gas tamponade after retinal detachment is important for retinal reattachment. Ophthalmologists always tell these patients to maintain the prone position as much as possible for 1–2 months if gas remains in the posterior chamber. However, maintaining a prone position continuously is very difficult for some patients, who may change to a seated prone position with hips and knees flexed and the head on a table. Sitting for long periods of time, as when driving or flying, could lead to blood clot formation in the legs because of lack of movement of the calf muscles, and may result in deep vein thrombosis (DVT) and pulmonary embolism (PE), which is fatal. In this paper, we report a case of leg DVT resulting from continuous seated prone positioning after retinal detachment surgery. Ophthalmologists should reinforce the importance of adequate movement of the legs and body repositioning when long-term prone positioning is required.


  2. Case report Top


A 56-year-old woman was referred to our emergency room for sudden onset of left leg swelling early that morning, which was accompanied by soreness and an inability to elevate the leg. She denied having fever, headache, dyspnea, chest pain, abdominal pain, or lower extremity cold or numb sensations. Two days earlier, she had undergone retinal detachment surgery with encircling buckling, trans plana vitrectomy, cryotherapy, and fluid gas exchange with 15% perfluoropropane. As suggested for better tam-ponade effect, she maintained prone positioning as long as possible whether lying down or seated. However, after sitting motionless in a prone position with leg flexion for 6 hours, severe swelling of the left leg developed, with pain and erythema [Figure 1]. In the emergency room assessment, laboratory tests showed D-dimer elevation (>10,000 ng/mL). A venous duplex ultrasound revealed a thrombus with total occlusion of the left common femoral vein, superficial femoral vein, profunda femoral vein, and popliteal vein. Her right lower extremity veins were patent. Left leg DVT was suspected, and she was admitted for further evaluation and management.
Figure 1: The patient's left leg shows swelling, pain, and warmth and redness that is accompanied by difficulty elevating her leg after continuous prone positioning.

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She was administered anticoagulation therapy, with enoxaparin (by subcutaneous injection) and warfarin overlapping. The monitored prothrombin time/international normalized ratio (PT/INR) value was low, and the warfarin dose was increased. After two days, enoxaparin was discontinued with a PT/INR value of 1.42. There was no deficiency in antithrombin III, protein C, protein S, or plasmin-ogen. After 1 week on anticoagulation therapy, her left leg swelling and pain were gradually relieved, and she was discharged. However, anticoagulants had to be continued for 6 months. This therapy is associated with an increased risk of bleeding.


  3. Discussion Top


Ophthalmologists advise patients who undergo retinal detachment surgery with air tamponade to maintain a prone position after surgery as much as possible for 1 –2 months or until there is no remaining air in the posterior chamber. However, in this patient, DVT developed as a result of being in a continuous seated prone positioning for 6 hours. Deep vein thrombosis and its sequelae such as PE can be severe or fatal. However, these consequences are preventable.[1] Patients should be advised that appropriate exercise during prone positioning is important to prevent such complications.

Deep vein thrombosis may arise spontaneously or may be caused by trauma, surgery, or prolonged bed rest.[2] Patients have an increased risk of DVT who have antithrombin deficiency,[3] lupus anticoagulant,[4] previous DVT,[5] or cancer,[6],[7] or patients who use oral contraceptives or are on hormone replacement therapy.[2],[8] Before retinal detachment surgery is performed, a patient should undergo a careful perioperative evaluation to assess the clinical situation and the possible need for prophylaxis in specific high-risk patients.[9]

Deep vein thrombosis is a clinical challenge for doctors because it can develop in any section of the venous system; however, it arises most frequently in the deep veins of the leg.[1] In our patient, DVT developed because of motionless prone positioning with her knee flexed for 6 hours. There are reports of DVT developing in a fiberglass mold maker after 6 weeks of working in a kneeling po-sition,[10] and in a patient maintaining a prone position after spine surgery with a central venous catheter in place.[11]

Anticoagulation treatment for DVT is useful, but it impairs the blood’s ability to clot, which results in an increased risk ofbleeding. Ophthalmologists have a role in preventing the development of DVT in patients who need prone positioning.

Deep vein thrombosis resulting from prone positioning after retinal detachment is rare but preventable. Appropriate exercise and rest during continuous prone positioning are suggested as preventative measures.



 
  References Top

1.
Kyrle PA, Eichinger S. Deep vein thrombosis. Lancet. 2005;365:1163–1174.  Back to cited text no. 1
    
2.
Kearon C, Kovacs MJ, Julian JA. Deep vein thrombosis. Lancet. 2005;366:118. author reply 119–120.  Back to cited text no. 2
    
3.
Sakata T, Okamoto A, Mannami T, Matsuo H, Miyata T. Protein C and anti-thrombin deficiency are important risk factors for deep vein thrombosis in Japanese. JThromb Haemost. 2004;2:528–530.  Back to cited text no. 3
    
4.
Chung WS, Lin CL, Chang SN, Lu CC, Kao CH. Systemic lupus erythematosus increases the risks of deep vein thrombosis and pulmonary embolism: a nationwide cohort study.JThromb Haemost. 2014;12:452–458.  Back to cited text no. 4
    
5.
Young L, Ockelford P, Milne D, Rolfe-Vyson V, McKelvie S, Harper P. Post-treatment residual thrombus increases the risk of recurrent deep vein thrombosis and mortality. JThromb Haemost. 2006;4:1919–1924.  Back to cited text no. 5
    
6.
Zwicker J, Connolly G, Carrier M, Kamphuisen P, Lee A. Catheter-associated deep vein thrombosis of the upper extremity in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost. 2014;12:796–800.  Back to cited text no. 6
    
7.
Tagalakis V, Levi D, Agulnik JS, Cohen V, Kasymjanova G, Small D. High risk of deep vein thrombosis in patients with non-small cell lung cancer: a cohort study of 493 patients. JThorac Oncol. 2007;2:729–734.  Back to cited text no. 7
    
8.
Douketis JD, Julian JA, Kearon C, Anderson DR, Crowther MA, Bates SM, et al. Does the type of hormone replacement therapy influence the risk of deep vein thrombosis? A prospective case-control study. J Thromb Haemost. 2005;3: 943–948.  Back to cited text no. 8
    
9.
Bosson JL, Labarere J, Sevestre MA, Belmin J, Beyssier L, Elias A, et al. Deep vein thrombosis in elderly patients hospitalized in subacute care facilities: a multicenter cross-sectional study of risk factors, prophylaxis, and prevalence. Arch Intern Med. 2003;163:2613–2618.  Back to cited text no. 9
    
10.
van Beeck JL, Versfeld K, Ehrlich R. Deep vein thrombosis following prolonged kneeling: a case report. Occup Med (Lond). 2014;64:305–307.  Back to cited text no. 10
    
11.
Cho JK, Han JH, Park SW, Kim KS. Deep vein thrombosis after spine operation in prone position with subclavian venous catheterization: a case report. Korean J Anesthesiol. 2014;67:61–65.  Back to cited text no. 11
    


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