Branch retinal artery occlusions after balloon sinuplasty due to formation of a traumatic pseudoaneurysm in the internal carotid artery and embolization treatment

Purpose: To describe a case of multifocal branch retinal artery occlusions due to a traumatic internal carotid artery pseudoaneurysm and endovascular treatment after a balloon sphenoid sinuplasty procedure. Observations: A 62-year-old female with no significant past medical history underwent an elective outpatient balloon sinuplasty of the right frontal sinus and bilateral sphenoid sinuses. Shortly after the balloon sinuplasty device was inflated in the left sphenoid sinus, acute, severe, pulsatile bleeding was encountered from the posterior wall of the sinus. The patient underwent emergent catheter angiography and a traumatic pseudoaneurysm was noted in the left internal carotid artery that required endovascular embolization. After the procedures, the patient's visual acuity was 20/40 in the right eye and 20/200 in the left eye. The pupil exam revealed a left relative afferent pupillary defect. Visual field testing showed a central scotoma and an inferior nasal quadrant defect in the left eye. On fundus exam, there were multiple retinal emboli seen with ischemic retinal whitening in the left superior macular and superior temporal segments consistent with multifocal branch retinal artery occlusions in the left eye. Conclusions and Importance: The dilation of paranasal sinuses using a balloon instrument is a fairly new technique in the surgical management of chronic sinonasal inflammatory disease, and serious adverse effects have not been widely reported. To our knowledge, this is the first case of multifocal branch retinal artery occlusions due to a traumatic internal carotid artery pseudoaneurysm and endovascular treatment after balloon sinuplasty to be reported in the English language ophthalmic literature.