Perioperative Vision Problems

Vision problems can occur during the perioperative period. These problems can vary in severity, from temporary blurriness to permanent blindness. Although uncommon and unforeseen, clinicians are increasingly aware of perioperative visual changes as a possible outcome of surgery and anesthesia.

The occurrence of perioperative vision loss, particularly in spinal surgery, is thought to be on the rise. Mayo Clinic researchers conducted one of the initial retrospective studies to characterize the frequency of visual disturbances (determined through visual field testing) after surgery. Among 410,189 patients who underwent 501,342 anesthetics and survived at least 30 days post-procedure, 405 cases of new-onset vision loss or visual changes were identified. Of these, 216 patients regained full vision or acuity within 30 days. Among the 189 patients who experienced vision deficits lasting longer than 30 days, 185 had undergone ophthalmologic or neurologic procedures involving surgical damage or resection of ocular or cerebral tissues. The remaining 4 patients (1 in 125,234 overall) experienced prolonged vision loss without direct surgical trauma to optic or cerebral tissues. The study’s most significant finding was the very low incidence of vision loss in this large surgical population, with only 1 case per 118,783 patients.

Ophthalmologists at the Mayo Foundation conducted a prospective study to delve deeper into perioperative vision problems, focusing on changes in visual accommodation and acuity in adult patients undergoing various elective surgical procedures. Among 671 patients, 28 reported a new onset of blurred vision lasting at least 3 days post-surgery. Seven of these 28 patients required new corrective lenses or adjustments to their eyeglass or contact prescriptions due to persistent blurry vision. The majority of the remaining patients noted the resolution of blurry vision within 1 to 2 months. The study did not identify any significant risk factors for this issue.

Perioperative vision problems occur more frequently in high-risk surgeries, such as cardiac and spine surgeries. Shen and colleagues recently investigated the prevalence of perioperative visual loss in the US Nationwide Inpatient Sample (NIS) across the eight most common surgical procedures. They found the highest frequencies in spine surgery (3.09 per 10,000) and cardiac surgery (8.64 per 10,000). The primary causes of visual loss following non-ocular surgery are ischemic optic neuropathy and retinal vascular occlusion. Perioperative ischemic optic neuropathy is rare, with an estimated occurrence of approximately 1 in 60,000 to 1 in 125,000 anesthetics. In cases of ischemic optic neuropathy, visual loss typically occurs within the first 24 to 48 hours after surgery, often upon the patient’s awakening. This type of visual loss is typically painless and may present with an afferent pupil defect or non-reactive pupil, no light perception, or visual field deficit. Patients may also experience decreased or absent color vision. Possible risk factors for perioperative visual loss include prone positioning, lengthy spinal fusion surgery, decreased arterial pressure, blood loss, abnormal autoregulation of optic nerve blood flow, low cup-to-disc ratio, use of vasopressors, hypercoagulability, and systemic risk factors such as hypertension, diabetes, atherosclerosis, hyperlipidemia, smoking, and sleep apnea syndrome.

Central retinal artery occlusion (CRAO), another cause of perioperative vision problems, reduces blood flow to the entire retina, resulting in visual impairment. In the perioperative period, the most common causes are improper patient positioning and external compression of the eye. Internal pressure within the orbit can also increase due to retrobulbar hemorrhage, which is associated with vascular injuries during sinus or nasal surgery. Retinal microemboli, often seen during open-heart surgery, can also lead to retinal ischemia and perioperative vision loss. The correct use of modern head-positioning devices, such as square or circular foam headrests with cutouts for the eyes and a mirror for visual inspection (e.g., Prone View), is recommended to prevent compression and reduce the risk of retinal ischemic events.

References

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Warner ME, Fronapfel PJ, Hebl JR, Herman DC, Warner DO, Decker P, Warner MA. Perioperative visual changes. Anesthesiology. 2002 Apr;96(4):855-9. doi: 10.1097/00000542-200204000-00012. PMID: 11964592.

Ho VT, Newman NJ, Song S, Ksiazek S, Roth S. Ischemic optic neuropathy following spine surgery. J Neurosurg Anesthesiol. 2005 Jan;17(1):38-44. PMID: 15632541. PMCID: PMC2699455.

Brown RH, Schauble JF, Miller NR. Anemia and hypotension as contributors to perioperative loss of vision. Anesthesiology. 1994 Jan;80(1):222-6. doi: 10.1097/00000542-199401000-00033. PMID: 8291715.

Shen Y, Drum M, Roth S. The prevalence of perioperative visual loss in the United States: a 10-year study from 1996 to 2005 of spinal, orthopedic, cardiac, and general surgery. Anesth Analg. 2009 Nov;109(5):1534-45. doi: 10.1213/ane.0b013e3181b0500b. Epub 2009 Aug 27. PMID: 19713263.

Roth S. Perioperative visual loss: what do we know, what can we do? Br J Anaesth. 2009 Dec;103 Suppl 1(Suppl 1):i31-40. doi: 10.1093/bja/aep295. PMID: 20007988. PMCID: PMC2791856.

Alexandrakis G, Lam BL. Bilateral posterior ischemic optic neuropathy after spinal surgery. Am J Ophthalmol. 1999 Mar;127(3):354-5. doi: 10.1016/s0002-9394(98)00343-2. PMID: 10088754.

Awad H, Santilli S, Ohr M, Roth A, Yan W, Fernandez S, Roth S, Patel V. The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy. Anesth Analg. 2009 Aug;109(2):473-8. doi: 10.1213/ane.0b013e3181a9098f. PMID: 19608821.