Posterior ischemic optic neuropathy: case report of a rare complication after general surgery

BACKGROUND: Posterior ischemic optic neuropathy (PION) is a rare cause of bilateral severe and bilateral visual loss. Three mechanisms for posterior ischemic optic neuropathy are recognized: arteritic, non-arteritic, and peri- or postoperative. We report a case of bilateral postoperative posterior ischemic optic neuropathy. HISTORY AND SIGNS: A previously healthy 51-year-old man complained of the sudden onset of visual loss and unformed visual hallucinations in both eyes, 24 hours after an uneventful lumbar spine surgery. Duration of surgery was 12 hours with 2.5 liters of blood loss. At the time of visual loss, anemia was 74 g/L. Ophthalmic examination revealed decreased visual acuity to count fingers and normal optic disc without swelling or hemorrhages in both eyes. THERAPY AND OUTCOME: Despite blood transfusion 2 days after visual loss, evolution was stable. One month later, visual acuity was 0.15 RE and 0.2 LE with severe dyschromatopsia. Pupils reacted sluggishly to light but briskly to convergence. Optic discs were diffusely pale. DISCUSSION: Peri- and postoperative posterior ischemic optic neuropathy is a rare but devastating complication of surgery performed at distance from the visual pathways and its vascularization. Risk factors include: spine surgery, peri-operative hypotension, anemia, facial edema. Early recognition of posterior ischemic optic neuropathy and rapid correction of hypotension and/or anemia might improve outcome of posterior ischemic optic neuropathy, which usually is poor.     

Posterior ischemic optic neuropathy after hemodialysis

PURPOSE: To report a case of visual loss from posterior ischemic optic neuropathy (PION) after hemodialysis. DESIGN: Observational case report. METHODS: Neuro-ophthalmic examination, neuro-imaging including computed tomography (CT) scan, magnetic resonance imaging (MRI) of the head and orbits, and magnetic resonance angiography (MRA) of the neck and cerebral vasculature, as well as electrophysiologic testing including electroretinogram (ERG) and visually evoked response (VER) were performed. RESULTS: Acute onset of painless bilateral no light perception vision with absent pupillary response to light and normal funduscopic examination occurred shortly after completion of hemodialysis. Computed tomography scan and MRA results were normal. Magnetic resonance imaging scan showed small vessel ischemic white matter changes. Electroretinogram results were normal and the VER was unrecordable. CONCLUSIONS: Visual loss after hemodialysis is a rare complication and is associated with anemia and hypotensive events. The visual loss is usually a result of anterior ischemic optic neuropathy. We were unable to find another instance in the literature of visual loss after hemodialysis resulting from PION.     

Posterior ischemic optic neuropathy due to Aspergillus fumigatus

A 35-year-old woman with metastatic breast cancer experienced acute monocular visual loss. Her fundus examination was normal. The patient died 48 h later, and autopsy demonstrated hematogenously disseminated aspergillosis. The retrobulbar optic nerve of the affected eye showed infarction due to massive embolization with Aspergillus fumigatus. Although the retrobulbar optic nerve is relatively resistant to ischemia, its meningeal derived blood supply may be occluded by massive showers of emboli.     

后部缺血性视神经病变27例分析

目的 通过回顾性研究,探讨后部缺血性视神经病变(posterior ischemic optic neuropathy,PION)的临床表现、诊断及治疗预后.方法 对27例(33只眼)PION患者进行常规眼部检查及全身检查,观察治疗前后视力、视野、眼前节及眼底体征变化.结果 治疗前所有患者均有不同程度视力下降和视野缺损,治疗后有29只眼视力有不同程度提高,视野缺损也有改善.有4只眼视力无明显改变,有效率为87.9%.结论 颈动脉供血不足是PION的重要致病凶素,早期诊断和积极治疗有助于视力改善.     

Posterior ischemic optic neuropathy. III. Clinical diagnosis

14 cases of posterior ischemic optic neuropathy (PION) were clinically analyzed, in whom we excluded known etiologies of optic nerve disturbances and confirmed the decreased blood supply to the posterior portion of the optic nerve. On the basis of our clinical findings, we have proposed the following criteria for the diagnosis of idiopathic PION: (1) sudden onset of unilateral visual disturbance in older patients; (2) normal optic disc, subsequently developing simple optic atrophy; (3) hypertensive and arteriosclerotic changes in the retinal vessels; (4) varying degrees of impaired vision, variable visual field defects; (5) associated systemic disease such as hypertension, diabetes mellitus, hyperlipemia, hypotension, etc.; (6) exclusion of other demonstrable causes of optic nerve disturbances, and (7) confirmation of abnormal hemodynamics in the posterior portion of the optic nerve by carotid angiography, ophthalmodynamography, ophthalmodynamometry and fluorescein fundus angiography.     

Posterior acute ischemic optic neuropathy (author's transl)

Posterior acute ischemic neuropathy is a new and distinct clinical entity. This syndrome associate unilateral visual disturbance with arcuate or altitudinal defect. Ocular ophthalmoscopic examination and fluorescein fundus angiography are normal at the onset of the disease. Later develop varied degrees of optic atrophy. Association with anterior optic acute ischemic neuropathy on the other eye is possible. Systemic lupus erythematosus, periarteritis nodosa, temporal arteritis, and arteriosclerosis are often involved. Study of three personal cases. Discussion on pathogenesis.     

Posterior ischemic optic neuropathy. I. Blood supply of the optic nerve

The blood supply of the posterior optic nerve was investigated in 10 monkeys after an injection of synthetic resin into the carotid arteries. The posterior intraorbital and intracanalicular optic nerves were supplied by a centripetal vascular system, formed by the pial vessels arising from the first branches of the ophthalmic artery. Superior and inferior vascular semicircles were detected in the intracanalicular optic nerve. The intracranial optic nerve was supplied by branches of the internal carotid artery, anterior cerebral artery and/or anterior communicating artery, and ophthalmic artery.     

Bilateral posterior ischemic optic neuropathy after spinal surgery

PURPOSE: To report the association between bilateral posterior ischemic optic neuropathy and spinal surgery. METHOD: Case report. RESULTS: After prone-position spinal surgery of 8 hours' duration, a 68-year-old woman was completely blind in both eyes. Moderate periorbital edema and temporal conjunctival chemosis were present bilaterally. Ophthalmic examination disclosed normal-appearing optic nerve heads, except for bilateral nasal fullness related to bilateral optic nerve drusen, and no retinal edema. Immediate cerebral arteriography, magnetic resonance imaging, and electroretinography were normal. Visual-evoked response was not detectable, and 7 weeks later, severe bilateral optic nerve head pallor developed. CONCLUSIONS: Severe selective hypoperfusion of the retrobulbar optic nerves may occur after spinal surgery. Pressure to the periorbital region may be a contributing factor.     

Anterior ischemic optic neuropathy following off-pump cardiac bypass surgery

Anterior ischemic optic neuropathy (AION) is a well-described cause of visual loss in patients who have undergone cardiac surgery with cardiopulmonary bypass. The etiology of AION following cardiac surgery with cardiopulmonary bypass is believed to be multifactorial. Microembolisation and pump-related platelet dysfunction have been considered risk factors for the development of AION following cardiac surgery with cardiopulmonary bypass. Currently, 10-15% of cardiac procedures are performed without cardiopulmonary bypass to reduce morbidity. To the best of our knowledge, this is the second report of a patient who underwent off-pump cardiac surgery and developed an AION postoperatively. The patient's potential risk factors were severe anemia, new onset of atrial fibrillation with rapid ventricular rate, hypotension postoperatively, a small optic disc, uncontrolled diabetes mellitus and a past medical history of hypertension and coronary artery disease.     

Anterior ischemic optic neuropathy after uncomplicated scleral buckling surgery

Background To report a case of non-arteritic anterior ischemic optic neuropathy (NAION) observed after uncomplicated scleral buckle placement.Methods A 57-year-old man presented with a rhegmatogenous retinal detachment of the left eye. He underwent uncomplicated scleral buckle placement and C₃F₈ injection. Perioperative intraocular pressures were normal.Results On postoperative day 24, fundus examination revealed swelling of the left optic nerve and features of an optic neuropathy (visual field defect, relative afferent pupillary defect). Fluorescein angiography did not reveal delayed choroidal filling. Review of systems and laboratory investigations were not consistent with giant cell arteritis.Conclusions Non-arteritic anterior ischemic optic neuropathy may develop after uncomplicated scleral buckling surgery.     

Bilateral posterior ischemic optic neuropathy after lumbar spine surgery

PURPOSE: To report a case of bilateral posterior ischemic optic neuropathy (PION) in a healthy young patient after lumbar spine surgery which was initially diagnosed as functional visual loss. DESIGN: Observational case report. PARTICIPANT: A 33-year-old woman who experienced visual loss in the immediate postoperative period after a lumbar spine fusion. TESTING: Serial visual field testing and fundus examinations, ERG. RESULTS: Bilateral PION was confirmed 2 months postoperatively with the development of bilateral optic disc pallor and a normal ERG. CONCLUSION: Young patients without vascular risk factors may develop bilateral PION after otherwise uncomplicated lumbar spine surgery. In subjects complaining of visual loss in the postoperative period who have a normal fundus and normal neuroimaging, a diagnosis of PION should be suspected, and close follow-up is warranted.     

Anterior ischemic optic neuropathy following off-pump cardiac bypass surgery

Anterior ischemic optic neuropathy (AION) is a well-described cause of visual loss in patients who have undergone cardiac surgery with cardiopulmonary bypass. The etiology of AION following cardiac surgery with cardiopulmonary bypass is believed to be multifactorial. Microembolisation and pump-related platelet dysfunction have been considered risk factors for the development of AION following cardiac surgery with cardiopulmonary bypass. Currently, 10-15% of cardiac procedures are performed without cardiopulmonary bypass to reduce morbidity. To the best of our knowledge, this is the second report of a patient who underwent off-pump cardiac surgery and developed an AION postoperatively. The patient's potential risk factors were severe anemia, new onset of atrial fibrillation with rapid ventricular rate, hypotension postoperatively, a small optic disc, uncontrolled diabetes mellitus and a past medical history of hypertension and coronary artery disease.     

Posterior ischemic optic neuropathy. II. Histopathology of the idiopathic form

The optic nerve and chiasm, obtained at autopsy, from 53 cases with clinical histories of cerebrovascular disturbances were histopathologically investigated, and ischemic changes in the posterior portion of the optic nerve were revealed in 12 cases. The progress of posterior ischemic optic neuropathy might be divided into necrotic, liquefactive and scar stages. The lesions were located in the transverse, peripheral, altitudinal and axial areas of the optic nerve. Occlusive changes of the vascular lumina due to atherosclerosis, arteriolosclerosis, capillosclerosis and emboli were demonstrated in association with the ischemic changes in the optic nerve parenchyma.     

Anterior ischemic optic neuropathy

AION is the most common acute optic neuropathy in patients over 50 and, although the diagnosis is often straightforward, our methods for managing the associated visual loss are inadequate. Analysis of the wealth of information gained from recent clinical studies may move us closer to an effective therapy.     

Embolic ischemic optic neuropathy

On examining the postmortem enucleated eyes of a 68-year-old man, we found the left eye had focal infarction 3 mm behind the lamina cribrosa caused by thromboembolic compromise of three discrete pial and pial-derived arterioles. The optic nerve had been destroyed focally, whereas the retinal and choroidal tissue supplied by a similarly occluded vessel had been preserved. We diagnosed nonarteritis ischemic optic neuropathy.