We describe a unique case of retrobulbar ocular hematoma requiring urgent release after tenecteplase (TNK) administration for acute stroke.

Major surgery within the prior 14 days is considered a contraindication for TNK administration, but there are no well-defined guidelines on what surgeries are classified as major or invasive. Additionally, little information is known about complications from TNK administration after minor or less invasive surgeries, including ocular procedures.

Clinical case.

A 74-year-old female presented with acute onset left facial droop and left-sided weakness with last known well 2 hours prior, with NIH stroke scale of 8. She had notable stroke risk factors of hypertension, chronic kidney disease, tobacco use, and prior stroke. She also recently had bilateral blepharoplasty surgery on her eyelids two days prior. After shared decision-making between the patient and ER providers, the patient was administered TNK. On arrival to the intensive care unit, she was bleeding from both eyes with significant periorbital edema, ecchymosis, and inability to open either eye. Examination revealed left retrobulbar hematoma with compartment syndrome requiring a left lateral cathotomy and catholysis with ongoing increased intraocular pressures. Visual acuity, visual fields, and color saturation were all significantly impaired in both eyes, but started to improve throughout her hospitalization. Magnetic resonance imaging showed a small right thalamocapsular stroke.

Our case report describes ocular complications of administering TNK after bilateral blepharoplasty surgery in a patient presenting with acute stroke. Ocular surgeries are typically considered minor but can still have debilitating complications from surgical site bleeding after TNK administration. This case showcases the importance of weighing the risks and benefits of minor surgery complications when administering TNK for acute stroke.