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Ulnar neuropathy as a complication of retinal detachment surgery and face-down positioning.
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MedLine Citation:
PMID:  21941499     Owner:  NLM     Status:  PubMed-not-MEDLINE    
PURPOSE: To report a case of bilateral ulnar neuropathy as an extraocular complication following retinal detachment surgery and face-down positioning.
METHODS: Case report.
RESULTS: Bilateral hypoesthesia and numbness of the 4th and 5th finger started 2 weeks after vitrectomy for retinal detachment and face-down positioning. Due to progressive symptoms 6 months later, unilateral ulnar nerve decompression at the elbow was performed.
CONCLUSIONS: This case report demonstrates that strict face-down positioning bears the risk of ulnar neuropathy.
Dimitrios Brouzas; Nikolaos Gourgounis; Stavroula Davou; Eleni Loukianou; Ilias Georgalas; Chryssanthi Koursandrea
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Publication Detail:
Type:  Journal Article     Date:  2011-08-02
Journal Detail:
Title:  Case reports in ophthalmology     Volume:  2     ISSN:  1663-2699     ISO Abbreviation:  Case Rep Ophthalmol     Publication Date:  2011 May 
Date Detail:
Created Date:  2011-09-23     Completed Date:  2011-11-10     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101532006     Medline TA:  Case Rep Ophthalmol     Country:  Switzerland    
Other Details:
Languages:  eng     Pagination:  243-5     Citation Subset:  -    
1st Department of Ophthalmology, University of Athens Medical School, Athens, Greece.
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Journal ID (nlm-ta): Case Report Ophthalmol
Journal ID (publisher-id): COP
ISSN: 1663-2699
Publisher: S. Karger AG, Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34,
Article Information
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Copyright © 2011 by S. Karger AG, Basel
collection publication date: Season: May-Aug Year: 2011
Electronic publication date: Day: 2 Month: 8 Year: 2011
pmc-release publication date: Day: 2 Month: 8 Year: 2011
Volume: 2 Issue: 2
First Page: 243 Last Page: 245
ID: 3177803
PubMed Id: 21941499
DOI: 10.1159/000330692
Publisher Id: cop0002-0243

Ulnar Neuropathy as a Complication of Retinal Detachment Surgery and Face-Down Positioning
Dimitrios Brouzas*
Nikolaos Gourgounis
Stavroula Davou
Eleni Loukianou
Ilias Georgalas
Chryssanthi Koursandrea
1st Department of Ophthalmology, University of Athens Medical School, Athens, Greece
Correspondence: *Dimitrios Brouzas, MD, 10 G. Papandreou Str., GR-16231 Byron-Athens (Greece), Tel. +30 10 7652 909, E-Mail


Face-down positioning after silicone or gas tamponade for retinal surgery is an established practice mainly for upper retina beaks and posterior pole surgery. The use of long-acting gases for conventional retinal surgery and vitrectomy is subjected to some restrictions regarding gas concentration, altitude [1], airplane travel [2, 3, 4], and general anesthesia [5]. However, no guidelines for surgeons exist concerning the duration of face-down positioning. Strict face-down positioning after use of long-acting gas or silicone tamponade bears the risk of ulnar neuropathy [6, 7, 8]. This case report draws attention to this risk.

Case Report

A 57-year-old, overweight woman presented to the eye casualty department complaining of flashing lights, floaters, and decreased visual acuity in the left eye. Best-corrected decimal visual acuities were 10/10 OD and 7/10 OS. Fundus examination revealed an upper temporal bullous rhegmatogenous retinal detachment emanating from a hole along the border of a lattice degeneration. A 23-gauge vitrectomy with 16% SF6 gas tamponade was performed. The patient was instructed to assume a face-down position for 10 days.

Two weeks later, she was complaining of hypoesthesia and numbness along the left 4th and 5th finger, as well as hypoesthesia, numbness, and a burning sensation along the right 4th and 5th finger. An appointment with the orthopedic clinic was arranged for her, and a bilateral ulnar nerve neuropathy was diagnosed. Six months later, a surgical intervention with decompression of the right ulnar nerve at the elbow was performed due to progressive deterioration of symptoms (fig.1).

One year later, she still complained of bilateral hypoesthesia and numbness in the 4th and 5th fingers and ‘weak grip’ in the right hand.


In 1996, Ciulla et al. [6] reported 2 cases of ulnar nerve palsy after maintaining a face-down position for 2-4 weeks after vitrectomy with intraocular perfluorooctane. One of the patients underwent surgical decompression of the nerve at the elbow. In 1999, also Holekamp et al. [7] reported 7 cases of ulnar neuropathy during the immediate postoperative period after vitrectomy with fluid gas exchange for macular hole surgery followed by at least 1 week of strict face-down positioning. All patients had persistent symptoms during a follow-up period ranging from 3 to 24 months.

In 2004, Salam et al. [8] reported another case of bilateral ulnar neuropathy at the elbow confirmed by reduced conduction velocities in nerve conduction studies with minimal recovery during a follow-up period of 10 months.

In our case, the postoperative instructions included 10 days face-down positioning, and the symptoms started 2 weeks after surgery. The patient was overweight, and it is possible that the pressure on the bent elbow during face-down positioning was therefore increased.


As there are no specific guidelines for surgeons, patients must be instructed to minimize the time spent with their elbows in a flexed position to avoid any undue pressure on the elbows during face-down positioning. Moreover, patients should be made aware of warning signs of any early ulnar nerve damage symptoms, such as hypoesthesia, numbness, and a burning sensation in the 4th and 5th fingers.

1. Ferrini W,Pournaras J,Wolfensberger T. Expansion of intraocular gas bubbles due to altitude: do meteorological factors play a role?Klin Monbl AugenheilkdYear: 201022731231420408083
2. Gandorfer A,Kampik A. Expansion of intraocular gas due to reduced atmospheric pressure. Case report and review of the literatureOphthalmologeYear: 20009736737010892283
3. Kokame GT,Ing MR. Intraocular gas and low-altitude flightRetinaYear: 1994143563587817030
4. Lincoff H,Weinberger D,Stergiu P. Air travel with intraocular gas. II. Clinical considerationsArch OphthalmolYear: 19891079079102730410
5. Kodjikian L,Fleury J,Garweg J,Rouberol F,Gambrelle J,Burillon C,Grange JD. Blindness after nitrous oxide anesthesia and internal gas tamponadeJ Fr OphtalmolYear: 20032696797114631282
6. Ciulla TA,Frederick AR Jr,Kelly C,Amrein R. Postvitrectomy positioning complicated by ulnar nerve palsyAm J OphthalmolYear: 19961227397408909221
7. Holekamp NM,Meredith TA,Landers MB,Snyder WB,Thompson JT,Berman AJ,Williams S. Ulnar neuropathy as a complication of macular hole surgeryArch OphthalmolYear: 19991171607161010604664
8. Salam A,Harrington P,Raj A,Babar A. Bilateral ulnar nerve palsies: an unusual complication of posturing after macular hole surgeryEyeYear: 200418959714707983

Article Categories:
  • Published: August 2011

Keywords: Key Words Face-down positioning, Ulnar neuropathy, Vitrectomy complications.

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