Scribd Logo
Upload

Welcome to Scribd!

  • 189 views

    Postoperative Blindness After Spine Surgery in The Prone Position

    Uploaded by

    widget_13
    The document discusses postoperative blindness that can occur after spine surgery performed in the prone position. Potential causes discussed include direct pressure to the eye causing issues like central retinal artery occlusion, as well as more indirect causes like prolonged surgery, blood loss, hypotension, and fluid management issues that could lead to ischemic optic neuropathy. While the exact causes are unclear and likely multifactorial, the literature suggests preventing postoperative vision loss may involve careful patient positioning and monitoring, maintaining adequate fluid status and blood pressure, and considering staged procedures for high risk patients.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd

    Postoperative Blindness After Spine Surgery in The Prone Position

    Uploaded by

    widget_13
    189 views17 pages
    The document discusses postoperative blindness that can occur after spine surgery performed in the prone position. Potential causes discussed include direct pressure to the eye causing issues like central retinal artery occlusion, as well as more indirect causes like prolonged surgery, blood loss, hypotension, and fluid management issues that could lead to ischemic optic neuropathy. While the exact causes are unclear and likely multifactorial, the literature suggests preventing postoperative vision loss may involve careful patient positioning and monitoring, maintaining adequate fluid status and blood pressure, and considering staged procedures for high risk patients.

    Original Description:

    Postoperative Blindness After Spine Surgery in the Prone Position

    Original Title

    Postoperative Blindness After Spine Surgery in the Prone Position

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document discusses postoperative blindness that can occur after spine surgery performed in the prone position. Potential causes discussed include direct pressure to the eye causing issues like central retinal artery occlusion, as well as more indirect causes like prolonged surgery, blood loss, hypotension, and fluid management issues that could lead to ischemic optic neuropathy. While the exact causes are unclear and likely multifactorial, the literature suggests preventing postoperative vision loss may involve careful patient positioning and monitoring, maintaining adequate fluid status and blood pressure, and considering staged procedures for high risk patients.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    189 views17 pages

    Postoperative Blindness After Spine Surgery in The Prone Position

    Uploaded by

    widget_13
    The document discusses postoperative blindness that can occur after spine surgery performed in the prone position. Potential causes discussed include direct pressure to the eye causing issues like central retinal artery occlusion, as well as more indirect causes like prolonged surgery, blood loss, hypotension, and fluid management issues that could lead to ischemic optic neuropathy. While the exact causes are unclear and likely multifactorial, the literature suggests preventing postoperative vision loss may involve careful patient positioning and monitoring, maintaining adequate fluid status and blood pressure, and considering staged procedures for high risk patients.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 17

    Postoperative Blindness after Spine Surgery in the Prone Position

    Richard Ng June 21, 2011

    A Bad Day at the Office


    15 y/o M with scoliotic deformity after ASIA A C5 level injury at age 4 PSIF from T2 Pelvis Patient positioned prone, head held by pins in halo EBL 4000cc, 8 hour operation Extubated POD5: bilateral complete blindness Neurology & ophthamology consults -> posterior optic ischemic neuropathy At 6 months, return of light Samdani et al. Vision Loss After Spinal Fusion for Scoliosis in a Child With Spinal Cord Injury. J Spinal perception & shapes < 3ft Cord Med. Nov 2009;32(5):591594

    A rare complication

    What are the causes of postoperative vision loss (POVL) after spine surgery in the prone position? How do we prevent it?

    Incidence

    POVL in non-ophthalmic surgery:


    0.056%: eye injury over 60,965 cases from 1988-1992 (Roth et al., Anesth., 1996) 0.0008%: vision loss >30 days in 410,189 noncardiac pts from 1986-1998 at Mayo Clinic (Warner et al., Anesth Analg, 2001) Estimated 0.07% for cardiac surgery, <1/10000 (0.001%) for appendectomy (Shen et al. Anesth Analg, 2009)

    Incidence

    POVL in spine surgery:

    0.094%: 4,728,815 cases of laminectomy/discectomy/spinal fusion in US NIS database from 1993-2002 (Patil et al. Spine, 2008)

    Highest incidence was scoliosis at 0.28%

    0.03%: spinal fusion in 465,345 discharges from 1996-2005 US NIS database (Shen et al. Anesth Analg, 2009) Smaller series ranging from 0.09% to 0.2%

    Pathophysiology

    Cortical Blindness

    Infarction of visual pathways in brain Normal pupillary reflex, normal fundoscopy

    Retinal Artery Occlusion (central vs branch)


    External compression or emboli CRAO: Afferent pupil defect, retinal edema, cherry red spot

    Ischemic Optic Neuropathy (ION)


    Anterior versus Posterior Afferent pupil defect, optic disc edema, subsequent atrophy

    Cortical Blindness

    Stroke of visual pathways


    Incidence: 0.014% (1.4 / 10000) in spinal fusion

    More common than in cardiac surgeries! (Shen et al.)

    Much more common in patients < 18 (4.3/10000) versus patients > 18 (0.12-0.25/10000) Patil et al. showed that non-CRAO, non-ION visual loss 5.8 times more prevalent in age <18 vs 1844. Limited literature related to spine surgery Thought to be caused by embolism or sustained profound hypotension resulting in infarction (Williams, Anesthesiology Clin N Am, 2002)

    Retinal Vascular Occlusion

    Central Retinal Artery Occlusion

    ? Due to external compression due to positioning Increased IOP -> occlusion of retinal artery Case of CRAO with OptiGard goggles

    Branch Retinal Artery Occlusion

    Microemboli thru right to left shunt

    the Eyes: An Old Complication with a New Vein Anesth Analg, 2007 Central Retinal Mechanism,

    Roth et al. Visual Loss in a Prone-Positioned Spine Surgery Patient with the Head on a Foam Headrest and Goggles Covering Katz and Karlin, Visual Field Defect After Posterior Spine Fusion, Spine, 2005.

    Retinal Vascular Occlusion

    Incidence:

    Retinal vascular occlusion: 0.6/10000 in spinal fusion (Shen et al) CRAO: 0.001% (0.1 / 10000) (Patil et al.)

    All cases of CRAO reported in ASA Postoperative Vision Loss Registry were unilateral (Lee et al., Multiple 2006)reports Anesth, case relating to horseshoe headrests

    A small turn in the patients head may result in pressure to the globe

    Hollenhorst et al. Unilateral blindness occurring during anesthesia for neurosurgical operations. AMA Arch Ophthalmol 1954 Grossman and Ward. Central Retinal Artery Occlusion After Scoliosis Surgery with a Horseshoe Headrest. Spine, 1993. Bekar et al. Unilateral Blindness due to Patient Positioning During Cervical Syringomyelia Surgery: Unilateral Blindness After Prone Position. J

    Ischemic Optic Neuropathy

    Anterior ION

    Posterior ION

    Anterior = in the eye (optic disc) Perfusion pressure affected by MAP and IOP

    Posterior = optic nerve in orbit behind globe (retrobulbar) Less blood flow than in anterior portion, less autoregulation

    Ischemic Optic Neuropathy

    Incidence:

    Patil et al.: ION incidence of 0.006% over all spine cases, 0.02% in spinal fusion scoliosis surgeries. Chang et al. (John Hopkins): ION incidence of 0.028% in 14,000 patients Most cases are PION and are frequently bilateral (>50% in Lee et al.)

    Patil et al. used risk-adjusted multivariate analysis to identify Hypotension (OR 10.1), Peripheral Vascular Disease (OR 6.3) Anemia (OR 5.9), and Blood Transfusion (OR 4.3) as strongest risk factors for ION in 271 patients
    Hypotension and Anemia not specific to intraoperative hypotension or anemia

    Prone Positioning

    Prone positioning has been shown to increase intraocular pressure (IOP) in anesthetized patients (Cheng et al, Anesth, 2001)

    20 patients without eye disease had spine surgery prone IOP followed with Tono-pen

    Supine: 13 1 mmHg Prone: 27 2 mmHg Prone at end of case (average 320 min): 40 2 mmHg Supine at end of case: 31 2 mmHg

    Unclear how much intraoperative fluids / edema contributed to increase in IOP over duration of surgery

    Literature

    Case Series:

    Cheng et al. Neurosurg, 2000: Survey sent out, 24 patients reported.


    2 cases CRAO despite head held in pins 12/24 patients had hematocrit > 30%, and 5/24 had EBL<500cc

    American Society of Anesthesiologists Postoperative Visual Loss Registry: 93 spine cases 1999-2005, (Lee et. al., Anesthesiology, 2006)

    89% of cases were ION (60% PION), 11% of cases CRAO No clear association with anesthetic agent, hypotension, hematocrit 94% of cases > 6 hours

    Literature

    Case-Control Series:

    Myers et al. Spine, 1997: 37 cases of POVL after spine surgery through survey and review of recent cases.

    Matched to control group for age, type of surgery, number of levels, instrumentation Relative to control group, affected group had increased blood loss and longer surgery No difference in hematocrit or blood pressure

    Holy et al. Anesth, 2009: 17 cases of ION after any surgery, 1998-2005

    Each case matched to two controls for age and surgery. 4/17 were spine surgeries. No statistically significant correlation with EBL, intraop hypotension, hematocrit, surgical time, hypothermia, vasopressors

    Literature

    Literature Reviews:

    Roth et al, Perioperative visual loss: what do we know, what can we do?, Brit J Anesth, 2009.

    In summary, much is unknown about the pathogenesis of perioperative ION

    Gill et al, Postoperative visual loss associated with spine surgery, Eur Spine J, 2006. 7 studies, 102 cases

    The etiology of postoperative visual loss is probably multifactorial, however, patients with a large amount of blood loss producing hypotension and anemia along with prolonged operative times may be causing a greater risk in developing visual disturbances.

    Lee et al, Postoperative Ischemic Optic Neuropathy, Spine, 2010. 19 studies

    The overall strength of evidence to identify predictors of postoperative ischemic optic neuropathy is Very Low, that is, any estimate of effect is very uncertain. The overall strength of evidence for current recommended preventative measures is also Very Low,

    Summary

    Causes:

    Direct pressure to eye Multifactorial


    Prone positioning ?Prolonged operation ?Blood loss ?Hypotension ?Fluid Replacement

    Prevention
    Recommendations of ASA Task Force on Perioperative Blindness (2006) Consider informing patients of risk of perioperative visual loss. Use colloids along with crystalloids to maintain euvolemia. Position the head at the level of heart or higher, and in a neutral position, when possible. Consider staging prolonged procedures in highrisk patients. And appropriate positioning and frequent eye checks in the prone position may CRAO and other direct eye injuries from globe compression

    You might also like