Postoperative Visual Loss

 

 

Differential Diagnosis

 

  • Corneal abrasion 

  • Ischemic optic neuropathy (ION)

  • Central/branch retinal artery occlusion (CRAO, BRAO)

  • Cortical blindness secondary to visual field stroke

  • Transient ischemic attack (TIA)

  • Acute glaucoma

  • Expansion of intraocular vitrectomy gas bubble (nitrous oxide)

  • TURP glycine toxicity

 

 

Risk Factors

 

  • External eye compression from improper patient positioning

  • Retrobulbar hemorrhage due to vascular injuries following sinus/nasal surgery

  • Retinal microemboli associated with open-heart surgery

  • Prone positioning

  • Lengthy spinal fusion surgery,  arterial pressure,  blood loss, anemia, high volume crystalloid resuscitation

  • Cardiothoracic, instrumented spinal fusion surgeries, head & neck, nose or sinus surgeries

  • Systemic vascular risk factors: hypertension, diabetes, atherosclerosis, hyperlipidemia, smoking, obesity, obstructive sleep apnea & hypercoagulability

 

Management

 

  • Immediate normalization of vital signs & metabolics

  • Urgent ophthalmology consultation +/- neurology consultation

  • CRAO:

    • Ocular massage to dislodge clot

    • Localized hypothermia to affected eye

    • Acetazolamide (500mg IV)

    • Inhaled CO2 (mixture of 95% oxygen & 5% carbon dioxide)

    • Anterior chamber paracentesis

    • Intraarterial fibrinolysis

  • ION:

    • Elevate head of bed

    • ​Correct volume depletion & blood loss

    • Restore BP to normal range

    • Potential benefit from acetazolamide, mannitol, furosemide 

    • Steroids, hyperbaric oxygen controversial

  • Surgeon to bedside for multidisciplinary debriefing with patient & family

  • Call CMPA for counselling around disclosure & documentation