Postoperative Visual Loss
Differential Diagnosis
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Corneal abrasion
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Ischemic optic neuropathy (ION)
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Central/branch retinal artery occlusion (CRAO, BRAO)
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Cortical blindness secondary to visual field stroke
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Transient ischemic attack (TIA)
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Acute glaucoma
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Expansion of intraocular vitrectomy gas bubble (nitrous oxide)
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TURP glycine toxicity
Risk Factors
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External eye compression from improper patient positioning
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Retrobulbar hemorrhage due to vascular injuries following sinus/nasal surgery
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Retinal microemboli associated with open-heart surgery
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Prone positioning
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Lengthy spinal fusion surgery, ↓ arterial pressure, ↑ blood loss, anemia, high volume crystalloid resuscitation
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Cardiothoracic, instrumented spinal fusion surgeries, head & neck, nose or sinus surgeries
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Systemic vascular risk factors: hypertension, diabetes, atherosclerosis, hyperlipidemia, smoking, obesity, obstructive sleep apnea & hypercoagulability
Management
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Immediate normalization of vital signs & metabolics
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Urgent ophthalmology consultation +/- neurology consultation
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CRAO:
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Ocular massage to dislodge clot
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Localized hypothermia to affected eye
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Acetazolamide (500mg IV)
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Inhaled CO2 (mixture of 95% oxygen & 5% carbon dioxide)
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Anterior chamber paracentesis
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Intraarterial fibrinolysis
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ION:
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Elevate head of bed
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Correct volume depletion & blood loss
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Restore BP to normal range
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Potential benefit from acetazolamide, mannitol, furosemide
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Steroids, hyperbaric oxygen controversial
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Surgeon to bedside for multidisciplinary debriefing with patient & family
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Call CMPA for counselling around disclosure & documentation