Perioperative visual loss in ocular and nonocular surgery

Branch Retinal Artery Occlusion Following Rhinoplasty: A Case Report

Central retinal artery occlusion (CRAO) is a sudden and vision-threatening condition with catastrophic consequences unless managed immediately by reestablishing the retinal circulation. Even though CRAO is a common ocular disorder, it is a very rare complication after non-ocular surgeries; only a few cases have been reported in the literature. Cardiac and spine surgeries are considered the most common causes of postoperative vision loss. In this case report, we present the case of a young female patient diagnosed with central retinal artery occlusion after a septoplasty. This is considered the first reported case in the Kingdom of Saudi Arabia. Branch retinal artery occlusion (BRAO) and CRAO are possible complications of otorhinolaryngology procedures, and both otorhinolaryngologists and ophthalmologists should be aware of these possible complications.

The Incident of Multiple Skin Necrosis and Unilateral Vision Loss Post Liposuction: A Case Report

For many years, people with excess weight around specific body parts who wanted to improve their shape or establish symmetry to achieve their ideal body image chose liposuction. As with any intervention, there is a chance of complications and unfavorable outcomes with liposuction. As a late result of the procedure, skin necrosis, infection, and hematoma are some of the known complications of such a procedure. Other known complications include damage to surrounding structures like nerves, vasculature, or perforating body viscera. This study aimed to report an eventful and unwanted result of a common and relatively safe cosmetic procedure. A 31-year-old Saudi female presented to the emergency room (ER) with right unilateral vision loss, bruises, and burning pain involving the upper limbs, thighs, abdomen, back, and flanks after having liposuction and rhinoplasty two weeks ago in a private clinic overseas. Multiple investigations were obtained to investigate her blindness, which showed a right upper branch of retinal vein occlusion. She was treated conservatively with daily wound dressings and analgesics. After five days, the patient returned with infected wounds and clinical deterioration, necessitating multiple excisions, debridement, and grafting. She eventually recovered and was discharged in good health. Herein, we report a rare case of unilateral blindness and multiple skin necrosis following liposuction of the abdomen and thigh. Debridement and skin grafting were the ideal treatment strategies.

Effect of different surgical positions on intraocular pressure: a cross-sectional study

Background

Intraoperative intraocular pressure (IOP) elevation is a risk factor for postoperative blindness. Surgical position is associated with intraoperative IOP elevation. In China, there are few studies on the effect of various surgical positions on intraoperative IOP. This study was conducted to explore IOP change and its related factors in four common surgical positions in China.

Methods

This was a cross-sectional observational study. A total of 325 surgical patients who had non-ocular surgery from January 2019 to December 2019 in the hospital, were enrolled in this study. During their surgeries for general anesthesia, these participants were placed in lithotomy position/lateral position/prone position/supine position according to their surgery requirement. IOP was measured by icareTA03 handheld portable tonometer at 9 different time points from admission to exiting the operation room. And general information, postural position, and surgery information were collected through a uniform questionnaire. Multivariate analysis was performed to explore the related factors of IOP change.

Results

IOP of both eyes on lithotomy position, lateral position, and supine position showed statistical differences by ANOVA test at each time point (p < 0.05). IOP of both eyes in the prone position before exit from the operating room was significantly higher than IOP 10-min after anesthesia (p < 0.01). IOP under different postural angles showed statistical differences (F value = 4.85, P < 0.05), and the larger the head-down angle, the higher the IOP. IOP on the compressed side in the lateral position was higher than that on the non-compressed side (p < 0.01). In the multivariate linear regression analysis adjusted by other factors, postural position and baseline IOP were associated with IOP difference between before and after surgery (p < 0.01).

Conclusion

IOP in the four surgical positions showed different change patterns with the surgical process and position change. Nurses should assist the surgeon to reduce the head-down angle without interfering with the surgical operation and strengthen the inspection of IOP on patients with long-time surgery, to avoid intraoperative rapid IOP changes.

Bilateral central retinal artery occlusion: An exceptional complication after frontal parasagittal meningioma resection

Background:

Central retinal artery occlusion (CRAO) is a rare acute disease associated with great morbidity. It is reported as a complication of surgical procedures, but rarely associated with brain surgery and no reports before due to parasagittal meningioma resection.

Case Description:

We present the case of a 41-year-old female who underwent surgery for a parasagittal meningioma and developed a bilateral CRAO as an acute postoperative complication. Most common causes, such as cardiac embolism, carotid pathology and coagulation problems, were discussed and all clinical and neuroradiological exams performed were reported.

Conclusion:

Bilateral CRAO as results of brain surgery is extremely rare; however, if it occurs, it should be early recognized and treated to minimize its high morbidity.

Cortical Blindness after Cervical Spine Surgery in Supine Position - A Rare Case Report and Review of the Literature

We report the first case of perioperative visual loss due to cortical blindness after supine cervical spine surgery. A 46-year-old female presented with severe right-sided brachialgia of 1½ years' duration. Her magnetic resonance imaging (MRI) (cervical spine) showed severe right foraminal stenosis at C5–6. She underwent C5–6 anterior cervical discectomy and fusion. Nine hours after surgery, during a routine postoperative round, the patient complained of complete bilateral visual loss. The fundus examination and pupillary light reflex were normal. MRI of the brain showed the posterior cerebral artery infarct with hypoplasia of the left vertebral artery. She was transferred to the neurointensive care unit where antiplatelet treatment was started along with heparin. Her vision slowly began to improve, and at the end of 1 year, she had a reasonable visual acuity in both eyes. It is now standard practice in our institution to check patients' vision immediately after surgery.

Ocular complications of perioperative anesthesia: a review

Ocular complications associated with anesthesia in ocular and non-ocular surgeries are rare adverse events which may present with clinical presentations vacillating between easily treatable corneal abrasions to more serious complication such as irreversible bilateral vision loss. In this review, we outline the different techniques of anesthetic delivery in ocular surgeries and highlight the incidence and etiologies of associated injuries. The changes in vision in non-ocular surgeries are mistaken for residual sedation or anesthetics, therefore require high clinical suspicion on part of the treating ophthalmologists, to ensure early diagnosis, adequate and swift management especially in surgeries such as cardiac, spine, head and neck, and some orthopedic procedures, that have a comparatively higher incidence of ocular complications. In this article, we review the literature for reports on the clinical incidence of different ocular complications associated with anesthesia in non-ocular surgeries and outline the current understanding of pathophysiological processes associated with these adverse events.

Anterior Ischaemic Optic Neuropathy following Liposuction in a Patient with Optic Disc Drusen

Ischaemic optic neuropathy (ION) following non-ocular surgeries is a rare but devastating complication. Spine and cardiovascular surgical procedures are well known to be accompanied by this complication. ION after liposuction surgery is gaining attention during the past decades due to the escalating demand for this procedure. We report a case of unilateral anterior ION (AION) after abdominoplasty and liposuction in an eye with optic disc drusen (ODD), which has not been reported previously. The presence of ODD is not only an independent risk factor for AION in young patients, but could also be the underlying cause of the ischaemic insult to the optic nerve head in haemodynamically unstable patients.

Posterior ischemic optic neuropathy: Perioperative risk factors

Perioperative posterior ischemic optic neuropathy (PION) is a rare but devastating condition. Visual impairment is commonly bilateral, profound, and irreversible. The most frequently associated triggering events are spine surgeries, other orthopedic surgeries, cardiac bypass surgeries, and radical neck dissection. The etiology is multifactorial. The most commonly reported risk factors are severe and prolonged hypotension, anemia, hemodilution, orbital and periorbital edema, direct orbital compression by prone position, and abnormal autoregulation. This review discusses the current literature on perioperative PION and includes a study conducted by our group to investigate the perioperative risk factors of PION in order to better understand the pathogenesis and help identify high-risk patients. Our results provide further corroborating evidence that PION is associated with spinal, cardiovascular, and abdominal surgeries, longer duration of procedure, and facial edema. Anemia and chronic hypertension are frequent risk factors. Treatment for perioperative PION is uncertain and depends largely on the immediate reversal of hemodynamic alterations. Hence, it is important to identify patients at risk and accordingly take prophylactic measures to prevent its occurrence. Optimizing hemoglobin levels, hemodynamic status, and tissue oxygenation is crucial.

Central Retinal Artery Occlusion After Nasosinal Surgery - an Insight

Objective

To describe a case of central retinal artery occlusion (CRAO) after nasosinal surgery and subject's subsequent response to hyperbaric oxygen therapy (HBOT).

Design

Observational case report.

Results

We describe a subject with diagnosed CRAO after septoplasty, bilateral inferior turbinate reduction and balloon sinuplasty, who was given hyperbaric oxygen treatment after four days of onset of CRAO with an improvement in visual acuity and visual field.

Conclusion

Even though CRAO has been rarely reported after ENT procedures and HBOT has been previously described for the treatment, this is the case report where hyperbaric oxygen was given after four days of onset, with a possible improvement.

A case report of optic neuropathy following dacryocystorhinostomy in a 57-year-old female patient with May-Hegglin anomaly

Background

We report a rare case of optic neuropathy following dacryocystorhinostomy (DCR) in a 57-year-old female patient with May-Hegglin anomaly.

Case presentation

The patient was presented with sudden onset of vision loss for the left eye after DCR under general anesthesia. Her best corrected visual acuity was light perception in the left eye. Relative afferent pupillary defect was detected in her left eye. Magnetic resonance imaging of the orbit revealed an hyperintensity at the intra-orbital segment of the left optic nerve on T2-weighted image and Flair image. The patient was diagnosed with acute postoperative optic neuropathy and treated with methylprednisolone. Although her vision partially improved, she was left with a visual field defect in the left eye.

Conclusions

In patients with hematologic diseases, postoperative vision loss can occur following even minor surgery under general anesthesia, such as DCR. Therefore, preoperative counseling regarding the risk of visual loss should be given to high-risk patients.

Systematic Review and Meta-Analysis of Prone Position on Intraocular Pressure in Adults Undergoing Surgery

BACKGROUND

Patients undergoing surgery in the prone position may be at risk for postoperative vision loss associated with increased intraocular pressure. The purpose of this systematic review and meta-analysis is to estimate the magnitude of the increase in intraocular pressure at specific perioperative time points in adult patients. The research question to be addressed is "What is the magnitude of the increase in intraocular pressure at specific perioperative time points in adults undergoing surgery in the prone position?"

METHODS

Comprehensive search strategies were used to identify nine eligible studies (N = 229). Standardized mean difference effect sizes were calculated for two intraoperative time points.Time points for meta-analysis were selected to achieve the greatest number of comparisons for analysis at each time point. Prediction intervals for each time point were also calculated to show the dispersion of true effect sizes around the mean.

RESULTS

Meta-analysis showed that intraocular pressure increased significantly between induction of anesthesia and up to 10 minutes of prone position (T1: standardized mean difference [d] = 2.55; P < .001) and continued to increase significantly until the end of the prone position (T2: d = 3.44; P = .002).

CONCLUSIONS

Intraocular pressure increases of this magnitude demonstrate the need for implementing interventions to reduce the risk for postoperative vision loss in patients undergoing surgery in the prone position.

CLINICAL RELEVANCE

Implementing preoperative ophthalmologic examinations for patients undergoing surgery in the prone position may help to reduce the risk for ocular injury. Intraoperative interventions that can be implemented to reduce or mitigate the increase in intraocular pressure include implementing a 5- to 10-degree reverse Trendelenburg prone position, reducing the amount of time the patient is in the prone position, considering staged procedures, monitoring intraocular pressure, providing periodic position changes or rest periods, preventing pressure on the eye, and administering specific medications or anesthetics.

Unilateral Vision Loss without Ophthalmoplegia as a Rare Complication of Spinal Surgery

Postoperative visual loss is an extremely rare complication of nonocular surgery. The most common causes are ischemic optic neuropathy, central retinal artery occlusion, and cerebral ischemia. Acute visual loss after spinal surgery is even rarer. The most important risk factors are long-lasting operations, massive bleedings, fluid overload, hypotension, hypothermia, coagulation disorders, direct trauma, embolism, long-term external ocular pressure, and anemia. Here, we present a case of a 54-year-old male who developed acute visual loss in his left eye after a lumbar instrumentation surgery and was diagnosed with retinal artery occlusion.

Optic Nerve Enhancement and Restricted Diffusion in Postoperative Visual Loss

Postoperative visual loss is rare and most often due to posterior ischemic optic neuropathy. We describe optic nerve MR imaging of a 37-year-old man with postoperative visual loss due to posterior ischemic optic neuropathy after complicated aortic aneurysm surgery. MR demonstrated restricted diffusion and focal enhancement of both optic nerves. Combined restricted diffusion and focal enhancement is a unique MR imaging feature with postoperative vision loss.

Ophthalmic Artery Occlusion Following Facial Sclerosing Therapy

Purpose:

To describe a case of ophthalmic artery occlusion and complete ophthalmoplegia after intralesional injection of a sclerosing agent into a subcutaneous hemangioma on the forehead.

Case Report:

A 16-year-old girl underwent direct injection of 3 mL of sodium tetradecyl sulfate (Fibrovein) emulsion 1% (10 mg/mL) with a 23-gauge needle into a subcutaneous hemangioma on the forehead. Immediately after the injection, she developed sudden loss of vision and lid swelling of the left eye. Her visual acuity in the left eye became no light perception. Her left eye also developed a dilated pupil, ptosis, and complete external ophthalmoplegia. Funduscopy of the left eye revealed signs of central retinal artery occlusion. Magnetic resonance imaging of the orbit showed thickening of the medial and lateral rectus muscles of the left eye. Magnetic resonance venography of the brain was normal with no evidence of cavernous venous thrombosis. After 3 months, her ptosis and ophthalmoplegia resolved but her visual acuity remained no light perception.

Conclusion:

Persistent total visual loss should be kept in mind as a disastrous complication of sclerosing therapy in a patient with facial hemangioma.

The Effect of Perioperative Fluid Management on Intraocular Pressure during Gynecologic Laparoscopic Pelvic Surgery

Purpose

Visual loss is a devastating perioperative complication that can result from elevated intraocular pressure (IOP). The Trendelenburg position during surgery increases IOP. The purpose of this study was to quantify IOP changes in patients undergoing laparoscopic hysterectomy, at different time points and body positions throughout the procedure, and to compare fluctuations of IOP during the perioperative period according to two fluid management protocols.

Methods

Thirty women scheduled to undergo elective gynecologic laparoscopic pelvic surgery were randomly allocated to receive a liberal or restrictive fluid management protocol. IOP, mean arterial pressure, heart rate, exhaled tidal volume, end-tidal CO₂, and ocular perfusion pressure were assessed prior, during, and postsurgery, at 8 time points altogether.

Results

Mean changes in IOP were similar for the two protocols; the peak IOP was at the steep (peak) Trendelenburg position. For each protocol, IOP correlated positively with mean arterial pressure, and mean blood pressure correlated with ocular perfusion pressure.

Conclusion

IOP was elevated during laparoscopic pelvic surgery and particularly at the steep Trendelenburg position. No differences were found in any of the parameters examined according to a liberal or restrictive fluid management protocol.

Hyperhomocysteinemia in bilateral anterior ischemic optic neuropathy after conventional coronary artery bypass graft: a case report

Background

The incidence of anterior ischemic optic neuropathy after coronary artery bypass graft procedures ranges from 1.3 to 0.25%. The mechanisms of anterior ischemic optic neuropathy after cardiovascular procedures remain undefined but many systemic and related-to-surgery risk factors could underlie anterior ischemic optic neuropathy. In this case, we report a rare presentation of a bilateral anterior ischemic optic neuropathy after coronary artery bypass graft and speculate on the preoperative hyperhomocysteinemia as an independent risk factor for anterior ischemic optic neuropathy.

Case presentation

A 56-year-old white man, a tobacco smoker with type 2 diabetes and coronary artery disease, underwent a conventional coronary artery bypass graft with extracorporeal circulation. In spite of ongoing anti-aggregation, antithrombotic, and vasodilator therapy, 10 days after the surgery he complained of severe bilateral visual loss. Funduscopy and fluorescein angiography revealed a bilateral anterior ischemic optic neuropathy. Analysis of preoperative laboratory tests revealed hyperhomocysteinemia.

Conclusion

Hyperhomocysteinemia could increase the risk of ocular vascular damage and bilateral ocular involvement in patients who have undergone conventional coronary artery bypass graft.

Postoperative posterior ischemic optic neuropathy (PION) following right pterional meningioma surgery

Postoperative visual loss (POVL) is an unpredictable complication of nonocular surgeries. Posterior ischemic optic neuropathy (PION) is particularly feared in spinal surgeries in the prone position. We report a rare case of PION occurring after surgery for a pterional meningioma and discuss the various factors implicated in POVL.

How to avoid perioperative visual loss following prone spinal surgery

Background:

In a prior article, “Perioperative visual loss (POVL) following prone spinal surgery: A review,” Epstein documented that postoperative visual loss (POVL) occurs in from 0.013% to 0.2% of spine procedures performed in the prone position. POVL is largely attributed to ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), cortical blindness (CB), direct compression (prone pillows/horseshoe, eye protectors), and rarely, acute angle closure glaucoma.

Methods:

Risk factors for ION include prolonged surgery, extensive fusions, anemia, hypotension, hypovolemia, diabetes, obesity, use of the Wilson frame, male sex, and microvascular pathology. CRAO may result from improper prone positioning (e.g., eye compression or rotation contributing to jugular/venous or carotid compression), while CB more typically results from both direct compression and obesity.

Results:

Several preventive/prophylactic measures should limit the risk of POVL. The routine use of an arterial line and continuous intraoperative monitoring document intraoperative hypotension/hypovolemia/anemia that can be immediately corrected with appropriate resuscitative measures. Application of a 3-pin head holder completely eliminates direct eye compression and maintains the neck in a neutral posture, thus avoiding rotation that can contribute to jugular/venous obstruction and/or inadvertent carotid compression. In addition, elevating the head 10° from the horizontal directly reduces intraocular pressure.

Conclusions:

The best way to avoid POVL following prone spine surgery is to prevent it. Routine use of an arterial line, intraoperative monitoring, a 3-pin head holder, and elevation of the head 10° from the horizontal should limit the risk of encountering POVL after spinal procedures performed in the prone position.

Perioperative visual loss following prone spinal surgery: A review

Background:

Postoperative visual loss (POVL) following prone spine surgery occurs in from 0.013% to 1% of cases and is variously attributed to ischemic optic neuropathy (ION: anterior ION or posterior ION [reported in 1.9/10,000 cases: constitutes 89% of all POVL cases], central retinal artery occlusion [CRAO], central retinal vein occlusion [CRVO], cortical blindness [CB], direct compression [horseshoe, prone pillows, and eye protectors Dupaco Opti-Gard]), and acute angle closure glaucoma (AACG).

Methods:

Risk factors for ION include prolonged operative times, long-segment spinal instrumentation, anemia, intraoperative hypotension, diabetes, obesity, male sex, using the Wilson frame, microvascular pathology, decreased the percent of colloid administration, and extensive intraoperative blood loss. Risk factors for CRAO more typically include improper positioning during the surgery (e.g., cervical rotation), while those for CB included prone positioning and obesity.

Results:

POVL may be avoided by greater utilization of crystalloids versus colloids, administration of α-2 agonists (e.g., decreases intraocular pressure), avoidance of catecholamines (e.g., avoid vasoconstrictors), avoiding intraoperative hypotension, and averting anemia. Patients with glaucoma or glaucoma suspects may undergo preoperative evaluation by ophthalmologists to determine whether they require prophylactic treatment prior to prone spinal surgery and whether and if prophylactic treatment is warranted.

Conclusions:

The best way to avoid POVL is to recognize its multiple etiologies and limit the various risk factors that contribute to this devastating complication of prone spinal surgery. Furthermore, routinely utilizing a 3-pin head holder will completely avoid ophthalmic compression, while maintaining the neck in a neutral posture, largely avoiding the risk of jugular vein and/or carotid artery compromise and thus avoiding increasing IOP.

Are Preexisting Retinal and Central Nervous System-Related Comorbidities Risk Factors for Complications Following Robotic-Assisted Laparoscopic Prostatectomy?

Purpose:

To assess whether retinal and central nervous system (CNS) comorbidities are risk factors for complications following robotic assisted laparoscopic prostatectomy (RALP).

Materials and Methods:

A retrospective review of our RALP database identified 1868 patients who underwent RALP by a single surgeon between December 10, 2003-March 14, 2014. We hypothesized that patients with preexisting retinal or CNS comorbidities were at a greater risk of suffering retinal and CNS complications following RALP. Perioperative complications and risk of recurrence were graded using the Clavien and D'Amico systems, respectively.

Results:

40 (2.1%) patients had retinal or CNS-related comorbidities, of which 15 had a history of retinal surgery and 24 had a history of cerebrovascular accident, aneurysm and/or neurosurgery. One additional patient had a history of both retinal and CNS events.

Patients with retinal or CNS comorbidities were significantly older, had elevated PSA levels and CCI (Charlson Comorbidity Index) scores than the control group. Blood loss, length of stay, surgical duration, BMI, diagnostic Gleason score and T-stage were not statistically different between groups.

No retinal or CNS complications occurred in either group. The distribution of patients between D'Amico risk categories was not statistically different between the groups. There was also no difference in the incidence of total complications between the groups.

Conclusions:

RALP-associated retinal and CNS complications are rare. While our RALP database is large, the cohort of patients with retinal or CNS-related comorbidities was relatively small. Our dataset suggests retinal and CNS pathology presents no greater risk of suffering from perioperative complications following RALP.

[Bilateral amaurosis after spinal trauma]

This article presents the case of a 72-year-old male patient who suffered severe trauma of the spinal column. The patient developed persistent, bilateral, complete blindness after prolonged emergency neurosurgical treatment in a prone position. A bilateral surgical posterior ischemic optic neuropathy (PION) was diagnosed, which is a rare but severe complication of prolonged non-ocular surgery with circulatory stress. The massive, mostly bilateral, irreversible visual loss up to complete blindness leads to severe and permanent impairment of affected patients.

Posterior Reversible Encephalopathy Syndrome Resolving Within 48 Hours in a Normotensive Patient Who Underwent Thoracic Spine Surgery

Posterior reversible encephalopathy syndrome (PRES) usually manifests with severe headaches, seizures, and visual disturbances due to uncontrollable hypertension. A patient (age in the early 60s) with a history of renal cell cancer presented with lower-extremity weakness and paresthesias. Magnetic resonance imaging (MRI) of the thoracic spine revealed a T8 vertebral body metastatic lesion with cord compression at that level. The patient underwent preoperative embolization of the tumor followed by posterior resection and placement of percutaneous pedicle screws and rods. Postoperatively, the patient experienced decreased visual acuity bilaterally. Abnormal MRI findings consisted of T2 hyperintense lesions and fluid-attenuated inversion recovery changes in both occipital lobes, consistent with the unique brain imaging pattern associated with PRES. The patient’s blood pressure was normal and stable from the first day of hospitalization. The patient was kept on high-dose steroid therapy, which was started intraoperatively, and improved within 48 hours after symptom onset.

Visual Field Defect after Cardiac Surgery: The Striking Role of Interdisciplinary Collaboration

Perioperative visual loss (POVL) is a potentially devastating complication that can occur following ocular or nonocular surgery. The leading causes of this disease are retinal vascular occlusions, ischemic optic neuropathies, and cortical blindness. POVL pathogenesis is strictly influenced by surgery, anesthesia, and patients' comorbidities. We report of a 55-year-old caucasian man who presented with complaints of sudden painless loss of vision and unilateral campimetric deficit. We recorded a preserved visual acuity but at fundus examination a bilateral ischemic optic neuropathy (ION) was suspected. Our hypothesis was supported by uncommon and peculiar visual field defects and a history of cardiovascular surgery shortly before was a striking data. When we examined his medical records we found strong accordance with what is reported in literature to be risk factors for postoperative ION development. He presented intraoperative hypotension, anemia, and hypothermia, he was older than 50 years, and surgery lasted for more than five hours. We are currently monitoring his visual acuity and visual fields which remain unchanged. As there is no proved therapy for such severe adverse events, we recommend intraoperative check of blood pressure, blood loss, and body temperature, associated with repeated eye checks and patients' interview.

Perioperative visual loss with non-ocular surgery: case report and review of literature

Perioperative visual loss (POVL), a rare but devastating complication, has been reported after spine, cardiac, and head-neck surgeries.The various causes include ischemic optic neuropathy, central or branch retinal artery occlusion, and cortical blindness. The contributory factors described are microvascular diseases and intraoperative hemodynamic compromise. However, the exact association of these factors with post-operative blindness has not yet been confirmed. A case of POVL with caesarian section surgery is being presented. The visual loss occurred due to a combined occlusion of central retinal artery and vein.The causes, presentation, and risk factors of POVL after non-ocular surgery are being discussed.

Postoperative vision loss after reverse shoulder arthroplasty

We report a case which highlights the rare but devastating complication of postoperative vision loss (POVL) in orthopaedic surgery. Though documented previously, it has not been reported in shoulder arthroplasty surgery of which we present the first case. The aetiology of POVL is difficult to elucidate due to its elusive nature. We explain the risks associated with regional blocks used for such surgery and how this may be related to POVL. We must be vigilant of the possible causes of POVL as curative treatment is often not possible and hence must take preventative measures which we have recommended. Fortunately, the patient fully recovered at 10 months postoperatively with excellent function of her reverse shoulder arthroplasty.

Temporary postoperative visual loss associated with intracerebral hemorrhage after laparoscopic appendectomy: a case report

Postoperative visual loss (POVL) after non-ophthalmic surgery is rare, with a reported incidence ranging from 0.013 to 0.2%. Most perioperative visual loss is associated with spine operations and cardiac bypass procedures. The most common cause of POVL is ischemic optic neuropathy. However, there are no previous reports of postoperative visual loss after laparoscopic appendectomy. A 43-year-old female with no underlying disease underwent laparoscopic appendectomy; the operation was completed in one hour and her blood pressure was stable during the perioperative period. In the post-anesthetic care unit, the patient complained of nausea and headache, but she did not complain of any unusual visual symptoms. Approximately one hour after arriving at the ward, the patient complained of visual disturbance. Neurologic examination revealed left homonymous hemianopsia, and subarachnoid hemorrhage and intracerebral hemorrhage were found in the occipital area on brain MRI.

Surgical errors and risks - the head and neck cancer patient

Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice.

To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur.

Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.

Cortical blindness following spinal surgery: very rare cause of perioperative vision loss

A 38-year-old man was operated with posterior spinal decompression and pedicle screw instrumentation for his L2 fracture with incomplete neurological deficit. In the recovery, he complained of blindness in both eyes after twelve hours. Computed tomographic scan and magnetic resonance angiography revealed bilateral occipital lobe infarcts. He remained permanently blind even after three years follow-up. Though rare, perioperative vision loss is a potential complication following spine surgery in prone position. We report a rare occurrence of cortical blindness following lumbar spine surgery.

Raised intraocular pressure (IOP) and perioperative visual loss in laparoscopic colorectal surgery: a catastrophe waiting to happen? A systematic review of evidence from other surgical specialities

BACKGROUND

Case reports of healthy patients experiencing total perioperative visual loss (POVL) after elective laparoscopic surgery, including colorectal resection, are appearing increasingly frequently in the literature. We reviewed the literature exploring the relationship between patient positioning and intraocular pressure (IOP) across all surgical specialties. This was then applied to the potential risk of developing POVL in patients undergoing laparoscopic colorectal surgery.

METHODS

A systematic review of the relevant literature was performed to identify all studies exploring the relationship between intraocular pressure and patient positioning.

RESULTS

Eight relevant studies on both elective patients and healthy non-anaesthetised volunteers in the spinal, neurosurgical and urological fields were identified which explore the changes in IOP according to patient positioning. These all reported significant rises in IOP in both head-down positioning and prone positioning, and the strongest effects were seen in those patients placed in combined head-down and prone position (such as prone jackknife). Rises in IOP were time-dependent in all studies.

CONCLUSIONS

Patients undergoing laparoscopic colorectal surgery in a prolonged head-down position are likely to experience raised IOP and thus are at risk of POVL. Those having a laparoscopic abdominoperineal excision with prone positioning for the perineal component are probably those in the greatest danger. Surgeons need to be aware of this under-recognised but potentially catastrophic complication.

Visual loss after spine surgery

Incidence of perioperative visual loss ranges from 0.06% to 0.2% with the most common cause as ischemic optic neuropathy. We report one-year follow up of a 50-years-old hypertensive housewife who underwent lumbar decompression and fusion for degenerative scoliosis, but woke up with painless unilateral visual loss. Fundus examination was normal. Her visual acuity improved from initial finger counting close to face to finger counting at 3 m at 1 year. Identification of high risk patients may help in appropriate preoperative counselling, prevention and early recognition of this devastating complication.