Acute Cardiovascular Response to Ophthalmic Phenylephrine During Plaque Radiotherapy Insertion

To report a case of an acute rise in blood pressure and acquired cardiac arrhythmia resulting from excessive topical phenylephrine exposure intraoperatively during the surgical insertion of a radioactive plaque for choroidal melanoma.

Observational case report with literature review.

A 56-year-old asymptomatic man with a diagnosis of choroidal melanoma of the right eye underwent routine plaque radiotherapy placement. Due to delayed dilation, additional topical 10% phenylephrine drops were placed on the eye after limited conjunctival peritomy. Shortly thereafter, the patient experienced an acute hypertensive episode with a cardiac arrhythmia and confusion due to the excess phenylephrine used that pooled on the ocular surface. The patient was successfully treated by the anesthesia team and found to have no chronic cardiac conditions. The choroidal melanoma was also successfully treated.

Additional mydriatic agents may be used with caution in the postincision setting, but should be thoroughly rinsed to prevent adverse cardiac events, particularly phenylephrine. Open communication is critical between the surgical and the anesthesia team prior to the addition of phenylephrine drops.