Postoperative Visual Loss: Anatomy, Pathogenesis, and Anesthesia Considerations
Visual loss after surgery is a poorly understood phenomenon with risk factors similarly found in vascular pathogenesis. Outcomes vary, ranging from full recovery to permanent blindness. Because the incidence is so rare, it has been difficult to identify best practice risk prevention strategies and management to minimize or even eliminate visual loss after surgery. This review, therefore, summarizes understanding of anatomy, pathogenesis, and anesthesia considerations related to visual loss after surgery. To facilitate further exploration of the subject, the American Society of Anesthesiology (ASA) Committee on Professional Liability established the ASA Postoperative Visual Loss (POVL) Registry in 1999, which is a database that includes detailed patient and surgical information on related cases. The findings from this task force are also summarized in this manuscript and conclude that there are no specific patient characteristics that would identify a patient as high risk; however, risk is deemed higher when procedures are prolonged and involve an anticipated large volume of blood loss. In summary, patients who are to undergo higher-risk procedures should be kept at a neutral spine with the head kept at or above the level of the heart. Serial hematocrits should be checked, and central venous pressure monitoring can be used to monitor volume status. Volume resuscitation can be done with colloids, crystalloids, and blood products to maintain euvolemic states. Since there is a large medicolegal consideration with vision loss, surveyed patients have overwhelmingly preferred to have the risk of POVL discussed with them face-to-face prior to the day of surgery. In this regard, the more severe injury to the visual pathway correlates with increase in payment when injury is brought to suit.
KeywordsVision loss after anesthesia Ophthalmologic injuries Anterior and posterior ischemic optic neuropathy Cortical blindness
- 2.Givner I, Jaffe N. Occlusion of the central retinal artery following anesthesia. Arch Ophthalmol. 1950;43(2):197–201. https://doi.org/10.1001/archopht.1950.00910010204001.CrossRefGoogle Scholar
- 4.Williams EL. Postoperative blindness. Anesthesiol Clin North Am. 2002;20(3):605–22, viii. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12298309.
- 5.American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on perioperative visual loss. Anesthesiology. 2012;116(2):274–85.CrossRefGoogle Scholar
- 6.Kels BD, Grzybowski A, Grant-Kels JM. Human ocular anatomy. Clin Dermatol. 2015;33(2):140–6. https://doi.org/10.1016/j.clindermatol.2014.10.006.CrossRefPubMedGoogle Scholar
- 17.Roth S. Postoperative blindness. In:Miller’s anesthesia. 7th ed. Philadelphia: Churchill Livingstone/Elsevier; 2010.Google Scholar
- 24.Stern WH, Archer DB. Retinal vascular occlusion. Annu Rev Med. 1981;32(1):101–6. https://doi.org/10.1146/annurev.me.32.020181.000533.CrossRefPubMedGoogle Scholar
- 25.Fraser SG, Adams W. Interventions for acute non-arteritic central retinal artery occlusion. In: Fraser SG, editor. Cochrane Database of Systematic Reviews. Chichester: Wiley; 2009. p. CD001989. https://doi.org/10.1002/14651858.CD001989.pub2.
- 26.Incandela L, Cesarone MR, Belcaro G, Steigerwalt R, De Sanctis MT, Nicolaides AN, Griffin M, Geroulakos G, Ramaswami G. Treatment of vascular retinal disease with pentoxifylline: a controlled, randomized trial. Angiology. n.d. 2002;53(Suppl 1):S31–4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11865833.
- 27.Werner D, Michalk F, Harazny J, Hugo C, Daniel WG, Michelson G. Accelerated reperfusion of poorly perfused retinal areas in central retinal artery occlusion and branch retinal artery occlusion after a short treatment with enhanced external counterpulsation. Retina. 2004;24(4):541–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15300074.CrossRefGoogle Scholar
- 28.Schumacher M, Schmidt D, Jurklies B, Gall C, Wanke I, Schmoor C, Maier-Lenz H, Solymosi L, Brueckmann H, Neubauer AS, Wolf A, Feltgen N, EAGLE-Study Group. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology. 2010;117(7):1367–1375.e1. https://doi.org/10.1016/j.ophtha.2010.03.061.CrossRefPubMedGoogle Scholar
- 36.http://depts.washington.edu/asaccp/projects/postoperative-visual-loss-registry, Postoperative Visual Loss Registry | ASA Closed Claims Project, Postoperative Visual Loss Registry, July 16, 2017.
- 37.Uppal M, Posner K, Roth S. Visual loss complicating surgery: review of 21 cases. Anesthesiology. 2000;93:A-1136.Google Scholar
- 38.Posner KL. The POVL Study Group: a national sample of variation in blood pressure and anemia severity in spinal fusion surgery. Anesthesiology. 2009;111:A1013.Google Scholar
- 39.Lee L, Posner KL, Domino KB. Trends in injuries to the visual pathways and medicolegal payments from the closed claims project database. Anesthesiology. 2013:A2058. https://depts.washington.edu/asaccp/sites/default/files/pdf/Click%20here%20for_2.pdf.
- 40.Marcus L. Plant, the decline of “Informed consent”, 35 Wash. & Lee L. Rev. 1978;91:91. http://scholarlycommons.law.wlu.edu/wlulr/vol35/iss1/3.
- 41.Marcus L. Plant, the decline of “Informed consent”, 35 Wash. & Lee L. Rev. 1978;91:94. http://scholarlycommons.law.wlu.edu/wlulr/vol35/iss1/3.
- 42.Corda DM, Dexter F, Pasternak JJ, Trentman TL, Nottmeier EW, Brull SJ. Patients’ perspective on full disclosure and informed consent regarding postoperative visual loss associated with spinal surgery in the prone position. Mayo Clin Proc. 2011;86(9):865–8. https://doi.org/10.4065/mcp.2011.0279.CrossRefPubMedPubMedCentralGoogle Scholar
- 43.Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak. J Neurosurg Spine, 25(5):586–590. Thejns.org. http://thejns.org/action/showCitFormats?doi=10.3171%2F2016.4.SPINE1623#.