Vision loss following tranexamic acid injection during an elective sinus surgery

Intravenous tranexamic acid (TXA) is commonly used preoperatively to reduce surgical bleeding; however, its antifibrinolytic effects may increase the risk of thromboembolism. When retinal vessels are involved, urgent ophthalmologic evaluation is essential to preserve vision.

A 19-year-old female developed acute vision loss in the right eye following elective endoscopic sinus surgery during which intravenous tranexamic acid was administered to reduce intraoperative blood loss. Funduscopic examination revealed an atypical thrombus within the central retinal artery, and fluorescein angiography confirmed a branch retinal artery occlusion (BRAO). Anterior chamber paracentesis was unsuccessful in dislodging the thrombus. She subsequently underwent hyperbaric oxygen therapy and was started on aspirin. Although her visual acuity improved and the thrombus resolved, she continued to demonstrate visual field defects, delayed arterial filling, and marked loss of contrast sensitivity.

Our case illustrates a rare but serious retinal vascular event occurring following intraoperative use of tranexamic acid. Additionally, other perioperative use of vasoconstrictors such as intranasal epinephrine may have contributed. Prompt diagnosis of retinal complications with a dilated funduscopic exam can allow for potentially vision-saving treatments, such as hyperbaric oxygen therapy. With an increase in indications for tranexamic acid use and a wider trend of adoption among surgeons, it is imperative that each patient be carefully assessed for thrombotic risk. Importantly, potential drug interactions, including concurrent use of local injections of vasoconstricting medications, should be taken into account to reduce the chance of irreversible vision loss.