Anterior ischemic optic neuropathy: a complication after systemic inflammatory response syndrome

Preservation of Vision after Early Recognition of Anterior Ischemic Optic Neuropathy in a Patient with Sepsis

Non-arteritic ischemic optic neuropathy (NAION) can rarely occur in the setting of sudden vascular compromise, especially in patients with a "disk-at-risk" appearance. Anemia and hypotension are believed to be the main precipitators of shock-induced NAION. Early recognition of this phenomenon can prevent further visual loss and result in partial visual recovery. We here present a 56-year-old patient who developed NAION characterized by optic disc edema in both eyes and visual loss in the left eye secondary to hypotension in the setting of septic shock. He received aggressive blood pressure management (stopping all his anti-hypertensives, hydration, and midrodrine) which resulted in stabilization of vision in the right eye and likely prevented further visual loss in the left eye.

Posterior ischemic optic neuropathy following a major burn injury and review of the literature

Posterior ischemic optic neuropathy following burns is a rare but devastating condition that can result in total bilateral visual loss. Numerous treatment modalities have been trialed, yet there is no effective therapy to delay or reverse the disease. Hence, it is imperative for burns surgeons to be aware of the potential risk factors and have a high index of suspicion right from the outset to prevent this outcome. Here, we discuss the case of a patient that developed posterior ischemic optic neuropathy subsequent to a major burn injury. We also present a literature review on optic neuropathies following burns to describe the etiology, clinical signs, and potential management.

Integration of ophthalmology in ocular trauma to improve patient care: A narrative review

Introduction

Ocular trauma can cause significant morbidity and is a leading cause of unilateral blindness. In multi-trauma, life- and sight-threatening injuries can co-occur causing increased complexity in the assessment and management of ocular injuries as the competing priorities in the severely injured must be balanced. We conducted a narrative review to determine how ophthalmology may be further integrated into a trauma service and/or the organisation of an ocular trauma service.

Methods

The literature was reviewed via EMBASE, MEDLINE, CINAHL and Google Scholar utilising comprehensive search strategies and keyword searches. Our review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Results

The search yielded 437 articles, 30 studies met selection criteria and were included in the review. The included literature comprised guidelines, observational studies and reviews of registry data from Australia, England, the United States, Singapore, Iran and Israel.

Conclusion

The Australian Trauma Model has clear guidelines for referral of trauma patients to ensure appropriate care of the severely injured. However, there are no clear guidelines for the integration of ophthalmology into trauma. Therefore, early referral to ophthalmology and streamlining of referral pathways of specialist care would improve the care of patients with ocular trauma.

Left orbital compartment syndrome and right anterior ischemic optic neuropathy in a patient with severe burns despite non-aggressive fluid resuscitation

INTRODUCTION

Ophthalmological complications such as orbital compartment syndrome (OCS) and ischemic optic neuropathy are rare complications in patients with burns and have been described in patients where aggressive fluid resuscitation was performed. While OCS requires urgent surgical intervention, no current treatment is established to treat, or prevent, ischemic optic neuropathy in patients with burns.

METHODS

The authors report a case of a 38-year-old woman with flame burns including the periorbital regions who developed OCS on the left side and anterior ischemic optic neuropathy (AION) on the right side despite non-aggressive fluid resuscitation. Immediate lateral canthotomy combined with inferior cantholysis was performed on the left side.

DISCUSSION AND CONCLUSION

OCS and AION need to be considered as potential complications even in critically ill patients with facial burns who do not receive aggressive fluid resuscitation. Whether an early surgical intervention will lower the risk of AION development is, however, speculative.

LAY SUMMARY

Ophthalmological complications such as orbital compartment syndrome and ischemic optic neuropathy are rare complications in patients with burns and have been described in patients where aggressive fluid resuscitation was performed. We present a case of a critically ill patient with severe facial burns who developed orbital compartment syndrome on the left side and anterior ischemic optic neuropathy on the right side even though our patient did not receive aggressive fluid resuscitation.Our case is particular because both of these rare complications are seen in a single patient and neither received aggressive fluid resuscitation. The fact that the patient did not develop ischemic optic neuropathy on the side where the lateral canthotomy was performed (only on the side where the patient had orbital compartment syndrome), this case might raise the discussion of whether an early surgical intervention might lower the risk of ischemic optic neuropathy development in patients with facial burns.

Orbital Compartment Syndrome Following Major Burn Resuscitation: A Case Series and Survey of Practice Patterns

Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.

Waking Up Blind in the ICU: A Case Report of Ischemic Optic Neuropathy in a Burn Patient

The objective of this report is to analyze and summarize the current literature of ischemic optic neuropathy (ION), a rare complication in severe burn and trauma victims, while presenting an urban burn center's experience with the condition. This is an unfortunate condition and this report will raise awareness to a potential complication in the burn patient population as well as in critically ill patients in other settings.

We present the case of a 27-year-old healthy male patient admitted to our Burn Center with 85% total body surface area (TBSA) full-thickness burns sustained in a house fire. The patient had a complicated hospital course but improved over time and was weaned off of prolonged ventilation and sedation. Subsequently, he complained of bilateral blindness. A fundoscopic examination demonstrated bilateral pale optic nerves with sparing of the remaining peripheral retina consistent with ION. The patient suffered complete bilateral vision loss. He had multiple factors that could have instigated the development of ION, including several episodes of septicemia, hypovolemic shock and severe adult respiratory distress syndrome (ARDS) with refractory hypoxemia requiring a prolong ventilation support and vasopressor therapy. 

Due to the advancement of the treatment of acute burns, the survival rate of patients that once would have succumbed to their burn injury, is increasing. With these new achievements, we are facing new challenges and complications. ION has a significant impact on the quality of the patient’s life. The early diagnosis will not necessarily translate into a benefit for these patients as no treatment has been proven successful. Extensive retrospective and prospective studies are necessary to identify and treat this patient population.

A Young Man With Severe and Disabling Complications of Septic Shock

A young man had severe septic shock with multiorgan failure due to necrotizing fasciitis caused by group A streptococcus after endoscopic repair of a preperitoneal inguinal hernia. He was treated with surgical exploration and antibiotics and resuscitated with fluids, vasopressors, and inotropic agents. He survived this critical illness, but when he woke up from sedation, his vision was lost in both eyes. Ophthalmological evaluation revealed minimal peripapillary retinal hemorrhages without signs of papillary edema. Visually evoked potentials were negative. Magnetic resonance imaging did not show a cause of the visual damage. The patient had bilateral ischemic optic neuropathy diagnosed. Two weeks later, unilateral sudden deafness also developed. The acquired blindness and hearing loss were unchanged after more than 1 year and seem to be permanent, severely disabling this young survivor of septic shock.

A case series: bilateral ischemic optic neuropathy secondary to large volume fluid resuscitation in critically ill burn patients

Ischemic optic neuropathy (ION) in the trauma setting is a rare and devastating condition associated with systemic hypotension, massive volume resuscitation, and sepsis. The objective of this case series is to highlight a potential correlation between severe burn and ischemic optic neuropathy. We present three patients with total body surface area (TBSA) thermal injury burns ranging from 57 to 68% treated at the North Carolina Jaycee Burn Center that developed bilateral ischemic optic neuropathy during their hospital stay. Each patient required greater than 25 L of crystalloid fluid within 24 h after admission, suffered multiple bouts of sepsis, and required extended pressor support. We postulate that ischemic optic neuropathy develops as a result of the interplay between the patient's systemic pathophysiology, i.e. shock, sepsis and the continued need for large volume fluid resuscitation. Current treatments of ION have not proven to be effective, except for possibly limiting fluid resuscitation. In the few cases of refractory burn shock, the incidence of this condition is unlikely to be readily improved. However, it is important for clinicians to be aware of this devastating complication and consider early ophthalmology involvement in the care of severely burned patients.

Uncommon ophthalmologic disorders in intensive care unit patients

Ophthalmologic complications are frequently encountered in intensive care unit (ICU) patients (Grixti et al. Ocul Surf 2012;10(1):26-42). However, eye care is often overlooked in the critical care setting or just limited to the ocular surface because treatment is focussed on the management of organ failures. Lack of awareness about other less common intraocular sight-threatening conditions may have a devastating effect on the patient's vision. To identify specific, frequently missed uncommon ocular disorders in ICU, a literature review using the keywords "Intensive Care," "Eye care," "ITU," "ICU," "Ophthalmological disorders," "Eye disorders" was performed. The databases of CINAHL, PuBMed, EMBASE, and Cochrane library were searched. The higher quality studies are summarized in the table with statements of methodology to clarify the level of evidence. The most prevalent ophthalmologic disorders identified in critically ill subjects include exposure keratopathy, chemosis, and microbial keratitis. In addition, uncommon eye disorders reported in ICU include metastatic endogenous endophthalmitis, acute primary angle closure, ischemic optic neuropathy, pupil abnormalities, vascular occlusions, and rhino-orbital cerebral mucormycosis. Early diagnosis and effective treatment will help to prevent visual loss.

A case report and brief review of the literature on bilateral retinal infarction following cardiopulmonary bypass for coronary artery bypass grafting

Postoperative visual loss is a devastating perioperative complication. The commonest aetiologies are anterior ischaemic optic neuropathy (AION), posterior ischaemic optic neuropathy (PION), and central retinal artery occlusion (CRAO). These appear to be related to certain types of operation, most commonly spinal and cardiac bypass procedures; with the rest divided between: major trauma causing excessive blood loss; head/neck and nasal or sinus surgery; major vascular procedures (aortic aneurysm repair, aorto-bifemoral bypass); general surgery; urology; gynaecology; liposuction; liver transplantation and duration of surgery. The non-surgical risk factors are multifactorial: advanced age, prolonged postoperative anaemia, positioning (supine v prone), alteration of venous drainage of the retina, hypertension, smoking, atherosclerosis, hyperlipidaemia, diabetes, hypercoagulability, hypotension, blood loss and large volume resuscitation. Other important cardiac causes are septic emboli from bacterial endocarditis and emboli caused by atrial myxomata. The majority of AION cases occur during CPB followed by head/neck surgery and prone spine surgery. CPB is used to allow coronary artery bypass grafting on a motionless heart. It has many side-effects and complications associated with its use and we report here a case of bilateral retinal infarction during routine coronary artery bypass grafting in a young male patient with multiple risk factors for developing this complication despite steps to minimise its occurrence.

Perioperative visual loss: what do we know, what can we do?

Perioperative visual loss (POVL), a rare, but devastating complication, can follow non-ocular surgery. Highest rates of visual loss are with cardiac and spine surgery. The main causes of visual loss after non-ocular surgery are retinal vascular occlusion and ischaemic optic neuropathy. This review updates readers on the incidence, suspected risk factors, diagnosis, and treatment of POVL due to these conditions.

[Loss of vision after non-ophthalmic surgery: systematic review of the literature on incidence, pathogenesis, treatment and prevention]

BACKGROUND AND GOAL

Postoperative loss of vision is a rare, but devastating complication after non-ocular surgery. It can occur partially or completely and may involve one or both eyes. Since its etiology has not yet been solved, the purpose of this review was to extract potential causes from the case collections reported to propose prophylactic measures.

METHODS

A literature search was performed using the "Pubmed" database of the US National Library of Medicine. MeSH terms and combinations used were: blindness, postoperative complications, ischemic optic neuropathy, not ophthalmological surgical procedures, not neurosurgical procedures. Additionally, the results of the interim analysis of the postoperative visual loss (POVL) registry of the ASA were considered.

RESULTS

The incidence of permanent loss of vision after non-ophthalmologic surgery is reported to be 0.0008%. However, it is elevated up to 0.11% after cardiac and 0.08% after spine surgery. Risk factors seem to be perioperative anemia, arterial hypotension and prone position, but also pre-existing diseases such as arteriosclerosis. Thus hemodynamic stabilization or correction of anemia may be successful in therapy.

CONCLUSION

Patients with pre-existing arteriosclerotic disease scheduled for spine or cardiac surgery, but also for bilateral neck dissection should be informed preoperatively about the rare possibility of POVL. Postoperatively any visual changes should be immediately referred to an ophthalmologist and treated accordingly.

Elevated Orbital Pressure: Another Untoward Effect of Massive Resuscitation after Burn Injury

BACKGROUND

Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury.

METHODS

We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures.

RESULTS

Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027).

CONCLUSIONS

Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.

Blindness in the Intensive Care Unit: Possible Role for Vasopressors?

Blindness caused by ischemic optic neuropathy in the hospital setting occurs perioperatively and in critically ill patients, but its etiology remains ill defined. We describe four critically ill patients who developed blindness within 1 mo of one another. Three cases occurred outside of the operative arena. Potential risk factors for the development of ischemic optic neuropathy, such as use of vasopressors, venous congestion, and hypotension, are described.

Acute visual loss in a child with autosomal recessive polycystic kidney disease: case report and review of the literature

Acute visual loss secondary to ischemic optic neuropathy in children is extremely rare. The causes are usually hypotension or anemia. We describe the clinical course of a 9-year-old boy with a functional renal transplant who presented to the emergency room hemodynamically stable after waking up with complete bilateral loss of vision (no light perception). Examination showed that he had suffered massive nocturnal blood loss from esophageal varices secondary to portal hypertension. The patient's end-stage renal disease was secondary to autosomal recessive polycystic kidney disease (ARPKD), an entity comprised of renal cysts and hepatic fibrosis. Ophthalmologic findings in ARPKD are rarely cited in the literature. A literature search revealed 3 other cases of sudden visual loss reported in nonophthalmologic journals in patients with ARPKD. Funduscopic examination showed bilateral optic nerve head pallor and swelling with associated flame hemorrhages. The fact that this patient already had mildly pale nerves on presentation, along with hemodynamically compensated blood pressure and pulse, suggested chronic as well as acute ischemia. Based on our findings and other reported cases in the literature, ophthalmologic examinations may be indicated in all patients with ARPKD.