Postoperative Ptosis and Diplopia Induced by the Intraoperative Application of Bone Wax

Bone wax is a hemostatic agent well used by neurosurgeons to prevent bleeding from bone. However, several complications involving bone wax have been reported, such as ptosis, infection, paraplegia, osteohypertrophy, edema, pain, granuloma formation, allergic reaction, and thrombosis.

A 47-year-old female patient presented to our neurosurgery department complaining of headache and vomiting. Subarachnoid hemorrhage from a ruptured aneurysm was detected on computed tomography (CT), and we performed emergent clipping of the ruptured aneurysm. During the maneuvers of craniotomy, the frontal base was slightly opened and bone wax of 6.7 × 3.5 × 5.7 mm was used to prevent bleeding from the bone edge and also to cover the opened site of the frontal base. Postoperatively, the patient started to complain of right ptosis and vertical diplopia. A CT image revealed that the bone wax in the right orbit was compressing the superior rectus muscle and the levator palpable muscle, which was thought to be the cause of the clinical symptoms. Removal of the bone wax was performed on postoperative day 21, after the patient surpassed the spasm period after subarachnoid hemorrhage without aggravation of neurologic deficits. Postoperative CT image confirmed removal of the bone wax in the orbit. The right ptosis and diplopia improved partially after the second operation.

The authors report a case with complications of ptosis and diplopia after the use of bone wax. Bone wax should be used minimally to the extent possible to avoid an unexpected harmful event.