Eye Injuries after Nonocular Surgery: A Study of 60,965 Anesthetics from 1988 to 1992

Background: Eye injuries after anesthesia, although infrequent, may result in visual impairment. Previous studies have not defined the risk factors associated with these injuries. To study the cause of these injuries and to determine incidence data, the authors reviewed the records from a 4.5-y period of patients who sustained eye injuries after anesthesia and nonocular surgery.

Methods: The records were surveyed of 60,965 patients who underwent anesthesia for nonocular surgery at our institution from January 1988 to July 1992. Eye injuries were identified by examining several sources of information, including quality improvement data, postoperative visits or telephone calls, and examination of medical records of postoperative patients who required an ophthalmology consultation. Records were reviewed to determine the types and causes of eye injuries. Logistic regression, with univariate and multivariate analysis, was used to identify the importance of possible risk factors.

Results: Of 34 patients who sustained eye injuries (0.056%), the most common was corneal abrasion (n = 21). Other injuries were conjunctivitis, blurred vision, red eye, chemical injury, direct trauma, and blindness. Independent factors associated with a higher relative risk of eye injury were long surgical procedures (odds ratio, 1.16 per hour of anesthetic care; CI, 1.1 to 1.3), lateral positioning during surgery (odds ratio, 4.7; CI, 2 to 11), operation on the head or neck (odds ratio, 4.4; CI, 2.2 to 9.0), general anesthesia (odds ratio, 3.0; CI, 2.2 to 38), and surgery on a Monday (odds ratio, 2.7; CI, 1.4 to 5.3). In only 21% of cases was a specific cause of injury identified.     

The frequency of perioperative vision loss.

The frequency of perioperative vision loss, especially for spinal surgery, has been increasing recently. We undertook a retrospective study to determine the frequency of this outcome in a large surgical population receiving general or central neuraxis regional anesthesia for noncardiac procedures from 1986 to 1998. Specific criteria were used to separate cases in which the surgical procedure likely directly contributed to the vision loss. Vision loss was present if any part of the visual field was affected. Initial database screening found 405 cases of new-onset vision loss or visual changes in 410,189 patients who underwent 501,342 anesthetics and who survived at least 30 days after their final procedures. Two hundred sixteen of these patients regained full vision or acuity within 30 days. Of the 189 patients who developed vision deficits for longer than 30 days, 185 underwent ophthalmologic or neurologic procedures in which ocular or cerebral tissues were surgically damaged or resected. The remaining 4 patients (1 per 125,234 overall; 0.0008%) developed prolonged vision loss without direct surgical trauma to optic or cerebral tissues. In this large study population of noncardiac surgical patients, including those who underwent spinal surgical procedures, the frequency of perioperative vision loss persisting for longer than 30 days was very small. IMPLICATIONS: Vision loss and blindness after surgery and anesthesia is a very rare event. In this study, only one per 125,234 patients undergoing noncardiac surgery developed vision loss persisting for longer than 30 days.     

Erblindung nach nichtophthalmologischen Eingriffen

Perioperative visual loss (POVL) after nonocular surgery is a rare but unexpected event and represents a devastating complication. It is most often associated with cardiac, spinal as well as head and neck surgery. The etiology of POVL remains incompletely understood. Any portion of the visual system may be involved, from the cornea to the occipital lobe. The most common site of permanent injury is, however, the optic nerve itself and ischemia is the most often presumed mechanism. Multiple factors have been proposed as risk factors for POVL, including long duration in the prone position, decreased ocular perfusion pressure, excessive blood loss and anemia, hypotension, hypoxia, excessive fluid replacement, elevated venous pressure, head positioning and a patient-specific vascular susceptibility which may be anatomic or physiologic. However, the risk factors for any given patient or procedure may vary. The underlying specific pathogenesis of these neuro-ophthalmic complications remains unknown and physicians should be alert to the potential for loss of vision in the postoperative period. This review updates readers on the incidence, suspected risk factors, diagnosis and treatment of POVL in the setting of nonocular surgery.     

Postoperative blindness

This chapter discusses the cases of postoperative blindness reported in the literature and the theories that attempt to explain the mechanisms involved. Although uncommon, alterations in vision and blindness after anesthesia for major surgical procedures, particularly cardiopulmonary bypass or spine surgery, are well documented, with an incidence varying between 0.05% and 1%. Accurate incidence data are unavailable because it is not known what percentages are reported. However, the large number of case reports over many years has provided some significant information. Although sustained compression of the eye is an important cause, postoperative visual loss may also occur, in an unrelated manner, because of ischemic optic neuropathy, central retinal artery or vein occlusion, or cortical blindness.     

Perioperative visual loss after nonocular surgery

Although rare, a change in visual acuity after surgery for nonocular procedures has devastating consequences. Increased recognition and discussion of this complication is reported in recent literature, most notably following spinal and cardiac surgery. Various pathologies may be responsible for perioperative visual loss (POVL), including ischemic optic neuropathy, retinal vascular occlusion, and cortical blindness. Here we review the incidence of the problem, the anatomy and physiology of the ocular circulation, variants of POVL, and proposed predisposing factors. Potential perioperative methods to prevent this complication are discussed, and suggested treatment modalities are presented.     

Ischemic optic neuropathy following spine surgery

Perioperative visual loss (POVL) is a devastating injury that has been reported infrequently after nonocular surgery. The most common cause of POVL is ischemic optic neuropathy (ION). Increasing numbers of cases of ION are being reported after spine surgery, but the etiology of postoperative ION remains poorly understood. After a MEDLINE search of the literature, we reviewed published case reports of ION, specifically those reported after spine surgery performed with the patient in the prone position. Most of the cases involved posterior ION (PION, n = 17), and the remainder anterior (AION, n = 5). Most patients had no or few preoperative vascular disease risk factors. All except one PION and 2 of 5 AION cases reported symptom onset within the first 24 hours after surgery. Visual loss was frequently bilateral (40% of AION, 47% of PION cases). Mean operative time exceeded 450 minutes. The lowest average intraoperative mean arterial blood pressure was 64 mm Hg and the mean lowest intraoperative hematocrit was 27%. The average blood loss was 1.7 L for AION and 5 L for PION patients. PION patients received an average of 8 L of crystalloid solution and 2.2 L of colloid intraoperatively. This compilation of case reports suggests that a combination of prolonged surgery in the prone position, decreased ocular perfusion pressure, blood loss and anemia/hemodilution, and infusion of large quantities of intravenous fluids are some of the potential factors involved in the etiology of postoperative ION. However, levels of blood pressure and anemia intraoperatively were frequently at levels considered acceptable in anesthesia practice. The etiology of postoperative ION remains incompletely understood. Potential strategies to avoid this complication are discussed.     

Ischemic optic neuropathy after lumbar spine surgery

Ischemic optic neuropathy is the most common cause of visual complications after non-ophthalmic surgery. The incidence has varied in different case series, but prone-position spine surgery appears to be involved in most of the reports. We present the case of a 47-year-old woman who developed near total blindness in the left eye following lumbar spine fusion surgery involving the loss of 900 mL of blood. An ophthalmic examination including inspection of the ocular fundus, fluorescein angiography, and visual evoked potentials returned a diagnosis of retrolaminar optic neuropathy. Outcome was poor.     

Case series: Monocular visual loss associated with subarachnoid hemorrhage secondary to ruptured intracranial aneurysms

PURPOSE: To describe variations in the presentation of monocular visual loss associated with intracranial aneurysm rupture. The clinical course, possible etiologies and management of visual loss in three patients are described. CLINICAL FEATURES: The first patient developed Terson's syndrome (vitreal hemorrhage associated with raised intracranial pressure secondary to subarachnoid hemorrhage). Following aneursymal clipping, her postoperative management was conservative and there was no improvement in visual acuity. The second patient underwent surgical clipping of internal carotid aneursysms and sustained visual loss subsequent to surgical dissection and temporary clipping around the optic nerve and anterior choroidal artery. The vessel subsequently thrombosed. Potential contributing factors to visual loss in this case included intraoperative hypotension and anemia. This patient received anti-platelet medications, and experienced subsequent improvement in visual acuity to 6/9. A third patient underwent a right orbito-frontal keyhole craniotomy with the cranial flap retracted across the orbit. Elevated intraocular pressure secondary to external orbital compression may have compromised retinal and choroidal perfusion. This patient also developed vasospasm of both anterior cerebral arteries which resolved partially with papaverine therapy. Hypertension-hypervolemia therapy was instituted, with subsequent partial recovery of visual acuity in her right eye. CONCLUSION: Perioperative monocular visual loss associated with intracranial aneurysm repair is an infrequent occurrence, and clinical presentations may be quite variable. The primary pathophysiological mechanisms are intraocular hemorrhage and ischemia of ocular structures, including the optic nerve. Early detection, via regular fundoscopic examination and treatment aimed at decreasing intraocular pressure and augmenting ocular perfusion may improve outcomes.     

Vision salvage after resection of a giant meningioma in a patient with a loss in light perception

Clinical approaches to the surgical management of optic chiasm compression stress quick action, as several case series have demonstrated minimal vision restoration following aggressive decompression in patients presenting more than 3 days after the onset of blindness. The authors here report the case of a 48-year-old woman who presented with near-complete binocular vision loss but regained visual function following surgical removal of a giant planum-tuberculum meningioma, which was performed 8 days after a documented loss in light perception. The interval between the patient's vision loss and successful vision-restoring decompressive surgery is the longest recorded to date in the literature. This case shows the importance of aggressive decompression of mass lesions despite extended intervals of optic nerve dysfunction.     

Clinical diagnosis and treatment of intraorbital wooden foreign bodies

Purpose: The intraorbital wooden foreign body is often misdiagnosed or missed on computed tomography (CT) scan, due to the invisible or unclear images. The residual foreign bodies often occur during surgical removal. The clinical manifestations, imaging features and treatment of intraorbital wooden foreign bodies were discussed in this study. Method: We retrospectively analyzed 14 cases of intraorbital wooden foreign bodies managed at our hospital between January 2007 and May 2015. All patients underwent orbital CT examination before surgery, and surgery was performed under general anesthesia with orbital wound debridement and suture, as well as exploration and removal of wooden foreign bodies. Results: At first, 11 cases underwent removal of foreign bodies, including 1 case with incomplete removal and then receiving a secondary surgery. Foreign bodies were not found in three cases with preoperative misdiagnosis and orbital MRI found residual foreign bodies in the orbit. Operations were performed via primary wound approach in eight cases, conjunctival approach in two cases, and anterior orbitotomy in four cases. Postoperatively, one case was complicated with eye injuries, three cases with ocular muscle injuries, eight cases with visual loss, and eight cases with orbital abscess. The length of foreign bodies ranged from 1.8 cm to 11.0 cm. The maximum of four foreign bodies were removed at the same time. Conclusion: Because the imaging of orbital wooden foreign bodies is complex and varied, MRI should be combined when they are invisible on CT scan. At the same time injuries trajectory and clinical manifestations of patients should be taken into account. Surgical exploration should be extensive and thorough, and foreign bodies and orbital abscess must be cleared.     

Unilateral visual field defect due to optic nerve compression by sclerotic internal carotid artery: a case report

A case of unilateral visual field defect due to optic nerve compression by a sclerotic internal carotid artery was reported. A 71-year-old woman was admitted to our department because of constricted visual field of the right eye. MRI showed elevation of the right optic nerve compressed by an internal carotid artery. The right carotid angiography revealed elevation and distortion of the C1-2 portion. Frontal craniotomy was carried out and the optic nerve was visualized on this side. The right optic nerve was found to have been compressed by the sclerotic internal carotid artery. The optic canal was then unroofed. The post-operative course was uneventful. The visual field was improved. When last seen 6 months after surgery, her visual field remained in the improved condition. Nasal field abnormalities are most frequently encountered in retinal and anterior optic nerve pathology. Our success in improving the visual field disturbance may be accounted for by the fact that the preoperative period was short and the operation was performed before atrophy of ocular fundi occurred. Nasal field loss caused by intracranial lesions of the optic pathway is rare. It is probably impossible to determine degree of the symptomatology caused by direct-pressure compression as opposed to that caused by ischemia secondary to occlusion of small arterial supply branches. Vascular compressive neuropathy of optic nerve should not be diagnosed simply by the radiological finding of the optic nerve dislocation. However, optic nerve compression by surrounding arteries should be remembered as one of the possible causes of visual field defect which needs to be treated surgically.     

Swelling of the tongue after intraoperative monitoring by transesophageal echocardiography]

Tongue swelling after surgery is a rare but potentially lethal postoperative complication. This is a case report of a 62-yr-old patient who developed tongue swelling after intraoperative monitoring by transesophageal echocardiography. The patient underwent replacement of the descending aorta with an interposition graft under cardiopulmonary bypass. A transesophageal echocardiography (TEE) probe was inserted after the induction of general anesthesia. Surgery and anesthesia were uneventful. After the surgical procedure, the TEE probe was removed. At that time, marked swelling of the tongue was noted. However, there was no diffuse edema in the neck, face, supraglottic structures or the larynx. The tongue swelling was thought to have been caused by local mechanical compression of the tongue with the TEE probe. The tongue returned to normal size the next day. Care should be taken to prevent the occurrence of this complication during and after TEE examination under general anesthesia.     

Endonasal transsphenoidal surgery under local anesthesia for elderly patient with pituitary tumor: case report

We present a surgical case under local anesthesia of an 88-year-old woman suffering from visual disturbance caused by pituitary adenoma. Magnetic resonance (MR) imaging showed a large pituitary tumor with suprasellar extension compressing the chiasmatic nerve. Neither she nor her family would agree to surgical therapy. However, when we proposed surgery under local anesthesia, they accepted it. Partial removal of the tumor via the endonasal transsphenoidal approach was carried out, uneventfully. The nasal surface was infiltrated with 4%-Xylocaine prior to the ordinary xylocaine injection to the nasal mucosa. The patient did not complain of any pain associated with the surgical procedure, including saline injection to the subarachnoid space through spinal drainage. The postoperative course was fine except for the temporarily appearance of diabetes insipidus. Postoperative MR imaging showed complete relief of compression to the chiasmatic nerve. Her visual field was improved dramatically. Endonasal transsphenoidal surgery under local anesthesia is thought to be one of the most useful methods of choice, especially in cases of elderly patient with pituitary tumor.     

Case with postoperative acute angle-closure glaucoma

A 59-year-old man who had undergone biopsy of cervical lymph node under general anesthesia developed an attack of acute angle-closure glaucoma the night after the surgery. He had had no eye symptoms before. He complained of visual disorder, nausea, eye pain, and dizziness after the surgery. His intraocular pressure in the right eye was high (69 mmHg), and an ophthalmologist diagnosed it as acute angle-closure glaucoma. Dropping lotion in the eyes and the intravenous administration were not effective. His intraocular pressure decreased immediatery after laser iridotomy, and his symptoms improved. When the symptoms of eye pain and visual impairment appeared after the surgery, we should take acute angle-closure glaucoma into consideration and treat it as soon as possible.     

The electroretinogram during orbital compression following intraorbital regional block for cataract surgery

The electroretinogram (ERG) is a transient biopotential that reflects the electrical response of the distal retina to phototimulation. Disturbances in retinal circulation produce characteristic abnormalities in the ERG wave form. The objective of this study was to investigate the changes in the ERG produced by combined retrobulbar and peribulbar injections of a large volume (8 ml) of local anaesthetic, followed by ocular compression. Electroretinogram recordings were obtained from skin electrodes placed on the infero orbital ridge in response to stroboscopic flash stimulation in 34 adult patients undergoing cataract surgery: (a) prior to regional anaesthesia (baseline condition); (b) within one minute after regional anaesthesia of the orbit (block condition); (c) after ten minutes of orbital compression with a Honan’s device at 30 mmHg. (compression condition); (d) and five minutes after removal of orbital compression (recovery condition). The ERG implicit times of both a- and b-wave increased (P < 0.001) after anaesthetic block. The amplitude of the a- and b-waves also decreased (P < 0.001) immediately following anaesthetic block and continued to decrease following application of the compression device (P < 0.01). Following removal of ocular compression the amplitude of the b-wave increased (P < 0.01). Only the a-wave implicit time (P < 0.005) decreased with release of ocular compression. These findings are compatible with the ERG changes of transient retinal ischaemia produced by ocular compression.     

Blindness and basal ganglia hypoxia as a complication of Le Fort I osteotomy attributable to hypoplasia of the internal carotid artery: a case report.

Le Fort I osteotomy is used as a surgical procedure for correction of maxillofacial deformities. The common complications of this procedure are hemorrhage and infection, with incidence of 6% to 9%. Blindness associated with Le Fort I osteotomy was reported in 8 patients. An 18-year-old female complained of loss of sight in the left eye after recovery from hypotensive general anesthesia. The visual field of the left eye was dark and only perceived some movement. She presented with motor dysfunction and regressive behavior 2 weeks later as a result of hypoxia of bilateral basal ganglia. Two months later, her visual acuity recovered gradually and regressive behavior improved. Carotid angiography showed congenital hypoplasia of the left internal carotid artery. We suspected that hypoplasia could cause hypoxia of the central nervous system.     

Positioning patients for spine surgery: Avoiding uncommon position-related complications

Positioning patients for spine surgery is pivotal for optimal operating conditions and operative-site exposure. During spine surgery, patients are placed in positions that are not physiologic and may lead to complications. Perioperative peripheral nerve injury (PPNI) and postoperative visual loss (POVL) are rare complications related to patient positioning during spine surgery that result in significant patient disability and functional loss. PPNI is usually due to stretch or compression of the peripheral nerve. PPNI may present as a brachial plexus injury or as an isolated injury of single nerve, most commonly the ulnar nerve. Understanding the etiology, mechanism and pattern of injury with each type of nerve injury is important for the prevention of PPNI. Intraoperative neuromonitoring has been used to detect peripheral nerve conduction abnormalities indicating peripheral nerve stress under general anesthesia and to guide modification of the upper extremity position to prevent PPNI. POVL usually results in permanent visual loss. Most cases are associated with prolonged spine procedures in the prone position under general anesthesia. The most common causes of POVL after spine surgery are ischemic optic neuropathy and central retinal artery occlusion. Posterior ischemic optic neuropathy is the most common cause of POVL after spine surgery. It is important for spine surgeons to be aware of POVL and to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters. Modification of risk factors extrinsic to the patient may help reduce the incidence of PPNI and POVL.     

Relaxing incisions with compression sutures to reduce astigmatism after epikeratoplasty

Relaxing incisions with compression sutures were performed in seven eyes with high astigmatism following epikeratoplasty for keratoconus and in one case of posttraumatic aphakia. Mean preoperative keratometric astigmatism was 7.64 +/- 2.51 diopters (range 5.50 D to 13.00 D) in the epikeratoplasties for keratoconus and about 10.00 D in the hyperopic epikeratoplasty. The surgical procedure consisted of a free-hand dissection perpendicular to the steeper meridian along the scar between the edge of the epikeratoplasty lenticule and the recipient cornea, with an additional incision into the recipient stroma to an approximate depth of 80%. Following the incisions, compression sutures were added 90 degrees away in the flatter meridian. After surgery, the net decrease in keratometric astigmatism was 6.50 D +/- 2.90 D (range 5.00 to 13.00 D) in the eyes with epikeratoplasty for keratoconus and 6.50 D in the eye with hyperopic epikeratoplasty. Uncorrected visual acuity improved in six eyes and remained unchanged in two eyes. Spectacle-corrected visual acuity improved in every eye and contact-lens-corrected visual acuity improved in seven eyes and was unchanged in one eye. This procedure, already employed for astigmatism correction after penetrating keratoplasty, was effective in decreasing astigmatism after epikeratoplasty.     

Spinal cord ischemia following thoracotomy without epidural anesthesia

PURPOSE: Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. CLINICAL FEATURES: A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5-6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5-6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. CONCLUSION: In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population.     

Awareness during general anesthesia for head and neck surgery--a case report

We report a second case of awareness during general anesthesia with sevoflurane supplemented with fentanyl. A 58-year-old man, weighing 61 kg, underwent an 8.8-hour operation for a malignant tumor of the right mandible. His right eye was guarded with ointment but kept open for observation of facial movement following muscle stimulation by the surgeon. The intraoperative course and emergence from anesthesia were otherwise uneventful. The patient became agitated in the recovery room and could recall his visual memory during the operation. We speculated contribution of visual input through the open eye and/or the effects of cranial bone oscillation during the surgery to his intraoperative awareness.