Loss of vision after anaesthesia for nonophthalmic surgery: a persistent problem

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Editor,Postoperative loss of vision is a devastating complication. It may be due to central retinal artery occlusion or to postoperative ischaemic optic neuropathy. We report here four cases of loss of vision.Case 1A 74-year-old female patient underwent a total knee arthroplasty second revision. Her medical history included arterial hypertension controlled by diuretic treatment. Routine analysis was normal. General anaesthesia was induced with fentanyl, midazolam, thiopental and atracurium and maintained with isoflurane in O2 and N2O. Surgery lasted 3 h. Fluid loading was 1 l of Hartman's solution and 1 l of hetastarch. A blood salvage device allowed treatment of 3.7 l and restitution of 1 l. Intraoperative systolic blood pressure (BP) was maintained between 80 and 120 mmHg. Wound blood drainage amounted to 0.8 l during the first 24 h, and 0.5 l of hetastarch was administered. From the evening of day 1, the patient complained of blurred vision that reached complete blindness at day 3. Haemoglobin level was 6.6 g dl−1. Four units of packed red cells were transfused. The ophthalmologist noted absence of light perception. Fundal examination showed disc swelling with thin, fine and rigid arteries. Fluorescein retinal angiography confirmed bilateral anterior ischaemic optic neuropathy (ION) in an atheromatous patient. No recovery occurred.Case 2A 49-year-old female patient with an unremarkable medical history underwent an arthroscopic meniscectomy. Spinal anaesthesia was performed with 40 mg hyperbaric lidocaine. An ephedrine infusion was simultaneously initiated (60 mg in 500 ml) with BP stable (120/70 mmHg). Fifteen minutes after tourniquet inflation and skin incision, the patient complained of sickness and anxiety. Systolic BP was 80 mmHg. The ephedrine infusion was accelerated and systolic BP increased to 180 mmHg. The hypotension had lasted less than 10 min. The day after, the patient complained of blurred vision. Fundal examination showed bilateral macular oedema. Fluorescein retinal angiography demonstrated transient retinal ischaemia, secondarily aggravated by ephedrine-induced vasospasm. Four years later, the patient still has a bilateral central scotoma with a visual acuity of 9/10 and 10/10 and a restriction on driving a car.Case 3A 65-year-old black male patient underwent L2–L3 laminectomy and L2–L5 rearthrodesis. His medical history included hypertension treated by verapamil, hypercholesterolaemia, hyperuricaemia and renal insufficiency (blood creatinine 123 mmol l−1). General anaesthesia was induced with thiopental, midazolam, sufentanil and pancuronium. The patient was installed in the prone position with his head on a horseshoe headrest. Deliberate hypotension was achieved with isoflurane and isosorbide dinitrate (systolic BP 80–70 mmHg). Surgery lasted 6 h with 2.1 l blood loss. Two autologous packed red cell and fresh frozen plasma units were given. The intraoperative haematocrit was above 33%. The patient was extubated 12 h after surgery and immediately complained of complete blindness. Fundoscopy and retinal angiography were normal. Haemoglobin electrophoresis demonstrated heterozygous sickle cell trait and alpha-thalassaemia minor. A later fundoscopy showed normal papilla with a cherry red macula. The final diagnosis was a possible anterior ION, secondarily complicated by bilateral central retinal artery occlusion (CRAO).Case 4A 54-year-old male patient was scheduled for subtotal glossectomy. His medical history included chronic abuse of alcohol and tobacco, diabetes mellitus requiring insulin, hypertension and one episode of acute pancreatitis and chemotherapy with cisplatyl and 5-fluorouracil. Anaesthesia was induced with propofol, midazolam and succinylcholine and maintained with remifentanil and desflurane in air. Surgery lasted 9 h and included bilateral radical neck dissection with right internal jugular vein section. Total fluid loading was 6 l of isotonic saline, 1 l of gelatin and 0.5 l of Hartman's solution. Intraoperative haemoglobin was 12.3–10.

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