different causes of vision loss after surgery guidelines to prevent vision loss after surgery

1. POSTOPERATIVE
VISION LOSS (POVL)
PRESENTED BY :
DR.ANKITA MADAN

2.  Partial or complete vision loss of vision occuring after
general anaesthesia for nonocular surgery.
 Uncommon complication
 Associated more with cardiac surgery or procedures on
the spine done in prone position.

3. PATHOPHYSIOLOGY
 Ischemia to visual pathway particulary the optic
nerve and the retina.
 Major source of blood supply of retina and optic
nerve is the Opthalmic artery branch of internal
carotid artery.
 Branches : Central retinal artery and long and
short posterior arteries – blood supply of retina

5. Posterior portion of optic nerve more susceptible to poor perfusion in
presence of hypotension due to comparatively less vascular supply.

7. CAUSES OF POVL
 Ischemic optic neuropathy (ION)
 Central retinal artery occlusion (CRAO)
 Cortical blindness
 Posterior reversible encephalopathy syndrome
(PRES)

8. VISION LOSS AFTER SPINAL
SURGERY
 Anterior ischemic optic neuropathy
 Posterior ischemic optic neuropathy
 Retinal vascular occlusion

9. ISCHEMIC OPTIC NEUROPATHY(ION)
Irreversible painless loss of vision
Spontaneously without any warning signs
Usually seen after cardiac surgery , spine
surgery , head and neck surgery , orthopedic
joint procedures and surgery on nose or
sinuses.

10. Two types - anterior or posterior ION
AION –Most commonly after cardiac
surgery
PION –After spine surgery in prone
postion or radical neck dissection.

12. MECHANISM FOR ION
 Increased venous pressure in the globe and
interstitial edema during prone position
 Increase in intraocular pressure
 Compression of vessels supplying optic nerve
 Hypoxia of optic nerve

13. RETINAL ISCHAEMIA
 CENTRAL RETINAL ARTERY OCCLUSION
decreases blood supply to the entire retina
 BRANCH RETINAL ARTERY OCCLUSION
affects only a portion of the retina.
 Following ocular trauma , embolic phenomenon
following carotid surgery and vasospastic
episodes.
 In spine surgery , it is due improper patient
positioning and external compression of eye.

14. POVL AFTER CARDIAC
SURGERY
 Risk factors :
 Lower postoperative haematocrit
 Presence of clinically significant vascular diseae
 Long duration of CPB
 Red cell transfusions
 Use of other blood components

15. POVL AFTER HEAD AND NECKSURGERY
 ION after neck dissection
 CRAO after neck and nasal or sinus surgery
 Orbital hemorrhage from blunt trauma during the
procedure

16. PERIOPERATIVE VISUAL LOSSIN OTHERSURGERIES
 After robotic and laparoscopic surgeries especially
after laparoscopic nephrectomies and robotic
prostatectomies.
 During robotic prostatectomy, patient in steep
trendelenburg position for a prolonged time and co2
insufflation of the abdomen increases the CVP , the
intrathoracic pressure and the intraocular pressure.

17. OTHER CAUSES OF POVL
CORTICAL BLINDNESS
 Result of decreased perfusion to the occipital
cortex due to hypoperfusion and embolic
phenomenon.
 Normal light reflex and fundoscopic examination.
 Prevention by maintaining normal perfusion
pressure and hematocrit of about 30%.

18. POSTERIORREVERSIBLE ENCEPHALOPATHY
SYNDROME (PRES)
 SEIZURES
 HEADACHE
 VOMITING
 VISION DEFECTS
 DECREASED LEVEL OF CONSCIOUSNESS.

19. Reported after severe hypertension ,
chemotherapy , immune suppression ,
renal disease , vasculitis and eclampsia ,
lumbar spine fusion , hysterectomy and
video assisted thoracoscopic surgery .
Treatment is symptomatic.

20. ASA PRACTICE ADVISORY
 Inform patients undergoing spine surgery of long
duration and expected excessive blood lossabout
small and unpredictable risk of POVL.
 Systemic BP to be monitored in high risk patients.
Deliberate hypotension should be practiced on case
by case basis.
 Central venous pressure must be monitored in high
risk patients.

21. To maintain hematocrit of above 28%
Use of vasopressors on case by case basis.
During positioning , direct compression on eyes
must be avoided and head should be maitained
in neutral position at the level or higher than the
level of heart.

22. Staging of surgical procedure must be given
consideration in high risk patients.
Vision must be tested of high risk patients for
POVL immediately after they are awake and
ophthalmology opinion must be taken urgently if
there is any concern.
Optimization of Hb level , hemodynamic status
and oxygenation may be addressed

23. THANKS 