A E R
Editor-in-Chief : Mohamad Said Maani Takrouri (KSA)
Open Access HTML Format
For entire Editorial Board visit : http://www.aeronline.org/editorialboard.asp
Anesthesia: Essays and Researches
Letters to Editor
Anaesthetic challenges in a patient with Axenfeld Rieger Syndrome Axenfeld Rieger Syndrome (ARS) is a rare autosomal dominant disorder (1 in 200,000) with variable morphology characterized by malformations of the anterior segment of the eye along with other abnormalities. Iris hypoplasia, iridocorneal adhesions, corectopia, polycornea, glaucoma are the usual ocular manifestations. [1] Craniofacial, dental, umbilical anomalies and congenital heart defects are also seen with ARS.[2,3] We report a case of a 3 year-old female child, a known case of ARS, who presented to us for examination under anesthesia (EUA) of both the eyes. The patient was a 3 year-old girl with no family history of ARS. She was first taken to ophthalmology clinic at 6 months of age when her parents noticed squinting of her eyes. Further workup confined the presence of glaucoma in both of her eyes. Slit lamp examination revealed a prominent Schwalbe’s line in all quadrants of both the eyes. There was no anomaly of the lens or fundus. A diagnosis of ARS was made. It was decided to take her up for EUA along with tonometry, refraction testing and fundus examination. Her preoperative investigations were all within normal limits. Examination revealed maxillary hypoplasia, thin upper lip, protruding lower lip and flattening of the mid face [Figures 1 and 2]. She also had hypodontia [upper two incisors and two canines were missing] for which fixed dentures had been put [Figure 3]. Rest of the systemic examination was normal though her electrocardiography showed clinically insignificant t wave inversion in leads V 1 – V3. She was taken up in OT and sedated with inj fentanyl 2 μg/kg and midazolam 0.02 mg/kg aided with a mixture of O2, N2O and sevoflurane via facemas. But as soon as plane of anesthesia was deepened, patient went into respiratory depression and mask ventilation became difficult. Her saturation dipped to 89% from 98%. Mandibular maneuvers did not improve mask ventilation, so a laryngeal mask airway #2 was inserted immediately and her SPO2 gradually improved. Her EUA was started and lasted for around 15-20 min. Her LMA was removed only when she was completely awake and she was shifted to recovery room where her stay for next 2 hours was uneventful. Axenfeld in 1920 first described a gray white circular line on the posterior surface of the cornea near the limbus, 108
Figure1: Maxillary hypoplasia and flattening of the mid face
Figure 2: Maxillary hypoplasia
with iris strands extending from the peripheral iris to this prominent line. He termed this condition as Axenfelds anomaly.[4] Rieger reported similar cases associated with other nonocular anomalies, with additional changes in iris and called it Rieger’s anomaly. ARS has been associated with mutations of the known genes PITX2 [the pituitary homeobox 2 gene] at 4q25[5] and FOXC 1 [the forkhad box C1 gene FKHLT] at 6p25.[6] Extraocular manifestations include maxillary hypoplasia, hypertelorism, telecanthus, hypodontia, oligodontia, microdontia. Other anomalies include those of pituitary
Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Letters
avoid any catastrophe occurring during the perioperative period, especially due to difficult airway.
ACKNOWLEDGMENT The Author would like to thank the patient for providing consent to use her photograph in this article.
Neha Baduni, Maitree Pandey, Manoj Kumar Sanwal, Meenakshi Verma
Department of Anaestheiology and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India Corresponding author: Dr. Neha Baduni, GH 12/183, Paschim Vihar, New Delhi, India. E-mail: [email protected]
Figure 3: Artificial dentures for missing teeth
gland, middle ear deafness, heart defects, hypospadias, short stature and mental retardation.[1] Anesthetic considerations include a detailed history to confirm the diagnosis, rule out any anesthetic complication (such as difficult mask ventilation or intubation) in any previous surgery. These patients might have a difficult airway due to facial anomalies, brachycephaly and maxillary hypoplasia. Therefore a detailed airway examination is mandatory along with preparation of the difficulty airway cart in the operation theatre. A complete cardiovascular workup to rule out congenital cardiac anomalies such as interatrial septal defects, semilunar valve stenosis or insufficiencies is advocated.[7] These patients might also have communicating hydrocephalus, psychomotor retardation or hypotonia. So preoperative councelling and maintenance of ICP (intra cranial pressure) in the perioperative period is required. To conclude ARS is a rare disorder with great genetic and morphologic variability. The concomitant occurrence of dental, craniofacial and cardiovascular anomalies can be quiet challenging even to an experienced anesthesiologist. Though EUA is a short procedure and does not require endotracheal intubation in most of the cases, an exhaustive and meticulous physical examination can
REFERENCES 1. 2. 3. 4. 5. 6. 7.
Shields MB, Buckley E, Klintworth GK,Thresher R.Axenfeld-Rieger syndrome. A spectrum of developmental disorders. Surv Ophthalmol 1985;29:387-409. Childers NK, Wright JT. Dental and craniofacial anomalies of Axenfeld- Rieger syndrome. J Oral Pathol 1986;15:534-9. Dressler P, Gramer E. Morphologie, familienanamnese und diagnosezeitpunkt bei 26 patienten mit Axenfeld-Rieger-syndrom und glaukom oder okulärer hypertension. Ophthalmologe 2006;103:393-400. Axenfeld T. Embryotoxon corneae posterius. Ber Dtsch Ophthalmol Ges 1920;42:301-2. Semina EV, Reiter R, Leysens NJ, Alward WL, Small KW, Datson NA, et al. Cloning and characterization of a novel bicoid-related homeobox transcription factor gene, RIEG, involved in Rieger syndrome. Nat Genet 1996;14:392-9. Mears AJ, Jordan T, Mirzayans F, Dubois S, Kume T, Parlee M, et al. Mutations of the forkhead/winged-helix gene, FKHL7, in patients with Axenfeld–Rieger anomaly. Am J Hum Genet 1998;63:1316-28. Gross S, Farnetani MA, Berardi R,Vivarelli R,Vanni M, Morgese G, et al. Familial Axenfeld-Rieger anomaly, cardiac malformations, and sensorineural hearing loss: A provisionally unique genetic syndrome? Am J Med Genet 2002;111:182-6. Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.103392
Quick Response Code
Intraoperative desaturation during thyroidectomy. Can endotracheal tube migration still be a cause? Sir, Intraoperative displacement of endotracheal tube (ET) can result in serious complications such as accidental extubation or endobronchial intubation.[1] Early recognition and repositioning of the ET are important.
Most of the existing case reports mention ET displacement during change in patient position or during laparoscopic surgeries[1] or during echocardiography probe placement. [2] We report a case of endobronchial migration of ET following mobilization of a large multinodular goiter. 109
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editor-in-Chief : Mohamad Said Maani Takrouri (KSA)
Open Access HTML Format
For entire Editorial Board visit : http://www.aeronline.org/editorialboard.asp
Anesthesia: Essays and Researches
Letters to Editor
Anaesthetic challenges in a patient with Axenfeld Rieger Syndrome Axenfeld Rieger Syndrome (ARS) is a rare autosomal dominant disorder (1 in 200,000) with variable morphology characterized by malformations of the anterior segment of the eye along with other abnormalities. Iris hypoplasia, iridocorneal adhesions, corectopia, polycornea, glaucoma are the usual ocular manifestations. [1] Craniofacial, dental, umbilical anomalies and congenital heart defects are also seen with ARS.[2,3] We report a case of a 3 year-old female child, a known case of ARS, who presented to us for examination under anesthesia (EUA) of both the eyes. The patient was a 3 year-old girl with no family history of ARS. She was first taken to ophthalmology clinic at 6 months of age when her parents noticed squinting of her eyes. Further workup confined the presence of glaucoma in both of her eyes. Slit lamp examination revealed a prominent Schwalbe’s line in all quadrants of both the eyes. There was no anomaly of the lens or fundus. A diagnosis of ARS was made. It was decided to take her up for EUA along with tonometry, refraction testing and fundus examination. Her preoperative investigations were all within normal limits. Examination revealed maxillary hypoplasia, thin upper lip, protruding lower lip and flattening of the mid face [Figures 1 and 2]. She also had hypodontia [upper two incisors and two canines were missing] for which fixed dentures had been put [Figure 3]. Rest of the systemic examination was normal though her electrocardiography showed clinically insignificant t wave inversion in leads V 1 – V3. She was taken up in OT and sedated with inj fentanyl 2 μg/kg and midazolam 0.02 mg/kg aided with a mixture of O2, N2O and sevoflurane via facemas. But as soon as plane of anesthesia was deepened, patient went into respiratory depression and mask ventilation became difficult. Her saturation dipped to 89% from 98%. Mandibular maneuvers did not improve mask ventilation, so a laryngeal mask airway #2 was inserted immediately and her SPO2 gradually improved. Her EUA was started and lasted for around 15-20 min. Her LMA was removed only when she was completely awake and she was shifted to recovery room where her stay for next 2 hours was uneventful. Axenfeld in 1920 first described a gray white circular line on the posterior surface of the cornea near the limbus, 108
Figure1: Maxillary hypoplasia and flattening of the mid face
Figure 2: Maxillary hypoplasia
with iris strands extending from the peripheral iris to this prominent line. He termed this condition as Axenfelds anomaly.[4] Rieger reported similar cases associated with other nonocular anomalies, with additional changes in iris and called it Rieger’s anomaly. ARS has been associated with mutations of the known genes PITX2 [the pituitary homeobox 2 gene] at 4q25[5] and FOXC 1 [the forkhad box C1 gene FKHLT] at 6p25.[6] Extraocular manifestations include maxillary hypoplasia, hypertelorism, telecanthus, hypodontia, oligodontia, microdontia. Other anomalies include those of pituitary
Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Letters
avoid any catastrophe occurring during the perioperative period, especially due to difficult airway.
ACKNOWLEDGMENT The Author would like to thank the patient for providing consent to use her photograph in this article.
Neha Baduni, Maitree Pandey, Manoj Kumar Sanwal, Meenakshi Verma
Department of Anaestheiology and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India Corresponding author: Dr. Neha Baduni, GH 12/183, Paschim Vihar, New Delhi, India. E-mail: [email protected]
Figure 3: Artificial dentures for missing teeth
gland, middle ear deafness, heart defects, hypospadias, short stature and mental retardation.[1] Anesthetic considerations include a detailed history to confirm the diagnosis, rule out any anesthetic complication (such as difficult mask ventilation or intubation) in any previous surgery. These patients might have a difficult airway due to facial anomalies, brachycephaly and maxillary hypoplasia. Therefore a detailed airway examination is mandatory along with preparation of the difficulty airway cart in the operation theatre. A complete cardiovascular workup to rule out congenital cardiac anomalies such as interatrial septal defects, semilunar valve stenosis or insufficiencies is advocated.[7] These patients might also have communicating hydrocephalus, psychomotor retardation or hypotonia. So preoperative councelling and maintenance of ICP (intra cranial pressure) in the perioperative period is required. To conclude ARS is a rare disorder with great genetic and morphologic variability. The concomitant occurrence of dental, craniofacial and cardiovascular anomalies can be quiet challenging even to an experienced anesthesiologist. Though EUA is a short procedure and does not require endotracheal intubation in most of the cases, an exhaustive and meticulous physical examination can
REFERENCES 1. 2. 3. 4. 5. 6. 7.
Shields MB, Buckley E, Klintworth GK,Thresher R.Axenfeld-Rieger syndrome. A spectrum of developmental disorders. Surv Ophthalmol 1985;29:387-409. Childers NK, Wright JT. Dental and craniofacial anomalies of Axenfeld- Rieger syndrome. J Oral Pathol 1986;15:534-9. Dressler P, Gramer E. Morphologie, familienanamnese und diagnosezeitpunkt bei 26 patienten mit Axenfeld-Rieger-syndrom und glaukom oder okulärer hypertension. Ophthalmologe 2006;103:393-400. Axenfeld T. Embryotoxon corneae posterius. Ber Dtsch Ophthalmol Ges 1920;42:301-2. Semina EV, Reiter R, Leysens NJ, Alward WL, Small KW, Datson NA, et al. Cloning and characterization of a novel bicoid-related homeobox transcription factor gene, RIEG, involved in Rieger syndrome. Nat Genet 1996;14:392-9. Mears AJ, Jordan T, Mirzayans F, Dubois S, Kume T, Parlee M, et al. Mutations of the forkhead/winged-helix gene, FKHL7, in patients with Axenfeld–Rieger anomaly. Am J Hum Genet 1998;63:1316-28. Gross S, Farnetani MA, Berardi R,Vivarelli R,Vanni M, Morgese G, et al. Familial Axenfeld-Rieger anomaly, cardiac malformations, and sensorineural hearing loss: A provisionally unique genetic syndrome? Am J Med Genet 2002;111:182-6. Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.103392
Quick Response Code
Intraoperative desaturation during thyroidectomy. Can endotracheal tube migration still be a cause? Sir, Intraoperative displacement of endotracheal tube (ET) can result in serious complications such as accidental extubation or endobronchial intubation.[1] Early recognition and repositioning of the ET are important.
Most of the existing case reports mention ET displacement during change in patient position or during laparoscopic surgeries[1] or during echocardiography probe placement. [2] We report a case of endobronchial migration of ET following mobilization of a large multinodular goiter. 109
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
