- Department of Neurosurgery, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
Nancy E. Epstein
Department of Neurosurgery, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
DOI:10.4103/2152-7806.182543Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Epstein NE. How to avoid perioperative visual loss following prone spinal surgery. Surg Neurol Int 17-May-2016;7:
How to cite this URL: Epstein NE. How to avoid perioperative visual loss following prone spinal surgery. Surg Neurol Int 17-May-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/how-to-avoid-perioperative-visual-loss-following-prone-spinal-surgery/
Background:In a prior article, “Perioperative visual loss (POVL) following prone spinal surgery: A review,” Epstein documented that postoperative visual loss (POVL) occurs in from 0.013% to 0.2% of spine procedures performed in the prone position. POVL is largely attributed to ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), cortical blindness (CB), direct compression (prone pillows/horseshoe, eye protectors), and rarely, acute angle closure glaucoma.
Methods:Risk factors for ION include prolonged surgery, extensive fusions, anemia, hypotension, hypovolemia, diabetes, obesity, use of the Wilson frame, male sex, and microvascular pathology. CRAO may result from improper prone positioning (e.g., eye compression or rotation contributing to jugular/venous or carotid compression), while CB more typically results from both direct compression and obesity.
Results:Several preventive/prophylactic measures should limit the risk of POVL. The routine use of an arterial line and continuous intraoperative monitoring document intraoperative hypotension/hypovolemia/anemia that can be immediately corrected with appropriate resuscitative measures. Application of a 3-pin head holder completely eliminates direct eye compression and maintains the neck in a neutral posture, thus avoiding rotation that can contribute to jugular/venous obstruction and/or inadvertent carotid compression. In addition, elevating the head 10° from the horizontal directly reduces intraocular pressure.
Conclusions:The best way to avoid POVL following prone spine surgery is to prevent it. Routine use of an arterial line, intraoperative monitoring, a 3-pin head holder, and elevation of the head 10° from the horizontal should limit the risk of encountering POVL after spinal procedures performed in the prone position.
Keywords: Blindness, central retinal artery occlusion, cortical blindness, glaucoma, ischemic optic neuropathy, postoperative visual loss, prone position, spinal surgery
In an analysis of forty articles by Epstein, entitled perioperative visual loss (POVL) following prone spinal surgery: A review, the frequency of POVL ranged from 0.013% to up to 1%, with most studies citing a frequency of 0.2%.[
In 2014, The American Society of Anesthesiologists postoperative visual loss registry database determined that posterior ischemic optic neuropathy (PION) was responsible for 89% of cases of POVL.[
For 21 single case studies, POVL was attributed to acute angle closure glaucoma (AACG) (three patients), ION (three patients), CB (three patients), CRAO (four patients), ischemic orbital compartment syndrome/compression (one patient), central retinal artery branch occlusion CRA (one patient), or general POVL (six patients).[
POVL is a rare but devastating complication of prone spine surgery that can be largely averted utilizing four major and several minor prophylactic measures. Routine use of an arterial line and continuous intraoperative monitoring (somatosensory and/or motor evoked potentials) signal the acute onset of hypotension/hypovolemia/anemia, directly or indirectly, allowing for their immediate correction with appropriate resuscitative measures. Application of a 3-pin head holder avoids direct eye compression and maintains the neck in a neutral posture, avoiding rotation that may contribute to jugular (venous congestion) and/or carotid compression (embolization). Finally, as pointed out by Emery et al. in 2015, elective elevation of the head 10° from the horizontal directly reduces intraocular pressure (IOP) during prone spine surgery.[
It is critical to understand the risks, etiologies, and measures readily available to avoid POVL following prone spinal surgery. The first line of defense is to choose your patients carefully, analyzing the import of their comorbid risk factors. If they are about to undergo a prone spinal procedure, does it really have to be that extensive? Is an instrumented fusion really necessary? Furthermore, are there substantial risk factors for POVL that can be addressed prior to surgery (e.g., ophthalmological evaluation of the glaucoma patient, correction of anemia, better control of diabetes)? Most importantly, routine prophylactic measures should be carefully considered and should include placing an arterial line, utilization of intraoperative monitoring, applying the 3-pin head holder, and elevating the head 10°.
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1. Berg KT, Harrison AR, Lee MS. Perioperative visual loss in ocular and nonocular surgery. Clin Ophthalmol. 2010. 4: 531-46
2. Emery SE, Daffner SD, France JC, Ellison M, Grose BW, Hobbs GR. Effect of head position on intraocular pressure during lumbar spine fusion: A randomized, prospective study. J Bone Joint Surg Am. 2015. 97: 1817-23
3. Epstein NE. Perioperative visual loss following prone spinal surgery: A review. Surg Neurol Int. 2016. 7: 365-78
4. Kamming D, Clarke S. Postoperative visual loss following prone spinal surgery. Br J Anaesth. 2005. 95: 257-60
5. Nandyala SV, Marquez-Lara A, Fineberg SJ, Singh R, Singh K. Incidence and risk factors for perioperative visual loss after spinal fusion. Spine J. 2014. 14: 1866-72
6. Nickels TJ, Manlapaz MR, Farag E. Perioperative visual loss after spine surgery. World J Orthop. 2014. 5: 100-6
7. 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. 109: 1534-45
8. Zimmerer S, Koehler M, Turtschi S, Palmowski-Wolfe A, Girard T. Amaurosis after spine surgery: Survey of the literature and discussion of one case. Eur Spine J. 2011. 20: 171-6