Perioperative Ischemic Optic Neuropathy Research Articles

LONG-TERM FOLLOW-UP ON A RARE CASE OF PERIOPERATIVE POSTERIOR ISCHEMIC OPTIC NEUROPATHY: FINDING HOPE IN THE DARKNESS

Abstract
 Introduction : Perioperative posterior ischemic optic neuropathy (PION) following maxillectomy is a rare and devastating condition that leads to permanent vision loss in most reported cases. This case report offers a different perspective through long-term follow-up, providing valuable insights into the prognosis and potential treatments for PION.
 Case Illustration : Following a left maxillectomy for ameloblastoma, a 28-year-old female experienced sudden vision loss in her left eye. The visual acuity was 5/60, and an altitudinal inferior visual field defect with a superior extension was present. Ishihara's color vision examination revealed 15/38. The patient was diagnosed with perioperative PION and treated with neurotropic and folic acid. After 16 months, optic atrophy was observed. However, there are complete recovery in visual acuity to 5/5 and Ishihara score to 38/38, along with a significant improvement in the visual field defect.
 Discussion : The current management of perioperative PION is focused on prevention, because once vision loss occurs, it is usually severe and irreversible. In our case, the patient exhibited a favorable outcome after a long follow-up period, suggesting that there is still potential for improvement in PION patients. The finding is consistent with previous study, which reported that a small percentage of patients may still experience improved vision during follow-up. The role of neurotropics in improving patient outcomes is further supported by in vitro studies that demonstrate early neurotropic treatment significantly prevents loss of retinal ganglion cells in PION.
 Conclusion : Visual improvement is still possible in perioperative PION and early neurotropic administration may be considered in therapy

Posterior Ischemic Optic Neuropathy after Surgery: A Case Report and Review of Literature

We propose in this work to report a case of perioperative posterior ischemic optic neuropathy, after a cardiac surgery. This is a 45-year-old patient, operated for Coronary Angioplasty and Stenting. 24h after the surgery he noticed a bilateral loss of vision. Examination of the both eyes revealed visual acuity decreased to no light perception, absent pupillary light reflexes and normal fundus. The neurological examinationis normal, macular OCT and cerebral magnetic imaging were normal. Visual evoked potentials were absent confirming the diagnosis of right retrobulbar optic neuropathy. The evolution was marked by no improvement of vision and the development of optic nerve atrophy. Perioperative posterior ischemic optic neuropathy during cataract surgery is an extremely rare incident. Posterior ischemic optic neuropathy is an uncommon complication Its physiopathology is multifactorial and dominated by hypotension and anemia. Its prognosis is bad and visual recovery is generally poor.

A Rare Case of Posterior Ischemic Optic Neuropathy after Appendicectomy

Ischemic optic neuropathy is classified into anterior and posterior ischemic optic neuropathy depending upon the part of optic nerve involved. In anterior optic neuropathy, optic nerve head is involved and in posterior ischemic optic neuropathy(PION) retrobulbar portion is involved. There is sudden loss of vision in both the entities but there are optic disc changes in anterior optic neuropathy while in posterior ischemic optic neuropathy optic disc is normal initially. Etiologically, posterior ischemic optic neuropathy is divided into non arteritic non-surgical, arteritic and perioperative non arteritic posterior ischemic optic neuropathy.

Perioperative ischemic optic neuropathy following subtotal petrosectomy: A rare complication of ear surgery causing vision loss

Perioperative ischemic optic neuropathy following subtotal petrosectomy: A rare complication of ear surgery causing vision loss

Perioperative Ischemic Optic Neuropathy after Cardiac Surgery: Development and Validation of a Preoperative Risk Prediction Model

ObjectivePrevious studies identified risk factors for ischemic optic neuropathy (ION) after cardiac surgery; however, there is no easy-to-use risk calculator for the physician to identify high-risk patients for ION before cardiac surgery. The authors sought to develop and validate a simple-to-use predictive model and calculator to assist with preoperative identification of risk and informed consent for this rare but serious complication. DesignRetrospective case-control study. SettingHospital discharge records. PatientsA total of 5,561,177 discharges in the National Inpatient Sample >18 years of age, with procedure codes for coronary artery bypass grafting, heart valve repair/replacement, or left ventricular assist device insertion. InterventionsAll patients had undergone cardiac surgery. Measurements and Main ResultsKnown preoperative risk factors for ION after cardiac surgery were assessed to develop a risk score and prediction model. This model was validated internally using the split-sample method. There were 771 cases of ION among 5,561,177 patients in the National Inpatient Sample. The risk factors for ION used in the model were carotid artery stenosis, cataract, diabetic retinopathy, macular degeneration, glaucoma, male sex, and prior stroke; whereas uncomplicated diabetes decreased risk. With the internal validation, the predictive model had an area under the receiver operating characteristic curve of 0.66. A risk score cutoff ≥3 had 98.4% specificity. ConclusionsThis predictive model, based on previously identified preoperative factors, predicted risk of perioperative ION with a fair area under the receiver operating characteristic curve. This predictive model could enable screening to provide a more accurate risk assessment for ION, and consent process for cardiac surgery.

Predictive model of ischemic optic neuropathy in spinal fusion surgery using a longitudinal medical claims database

BACKGROUND CONTEXTPerioperative ischemic optic neuropathy (ION) is a devastating complication of spinal fusion surgery. PURPOSETo develop predictive models of this blinding condition using a longitudinal medical administrative claims database, which provides temporal sequence of perioperative ischemic optic neuropathy and potential risk factors. DESIGNNested case control study. PATIENT SAMPLEParticipants in Cliniformatics Data Mart medical claims database (2007–2017) with hospitalization involving lumbar or thoracic spinal fusion surgery and no history of ION. OUTCOME MEASURESPerioperative ION (or not) during hospitalization for lumbar or thoracic spinal fusion surgery. METHODSSixty-five ION cases and 106,871 controls were identified. Matched controls (n=211) were selected based on year of surgery and zip code. Chronic and perioperative variables were assigned based on medical claims codes. Least absolute shrinkage and selection (LASSO) penalized conditional logistic regression with 10-fold cross validation was used to select variables for the optimal predictive model from the subset of variables with p<.15 between cases and matched controls (unadjusted conditional logistic regression). Receiver operating characteristic (ROC) curves were generated for the strata-independent matched and full sample. RESULTSThe predictive model included age 57–65 years, male gender, diabetes with and without complications, chronic anemia, hypertension, heart failure, carotid stenosis, perioperative hemorrhage and perioperative organ damage. Area under ROC curve was 0.75 (95% confidence interval [CI]: 0.68, 0.82) for the matched sample and 0.72 (95% CI: 0.66, 0.78) for the full sample. CONCLUSIONSThis predictive model for ION in spine fusion considering chronic conditions and perioperative conditions is unique to date in its use of longitudinal medical claims data, inclusion of International Classification of Disease-10 codes and study of ophthalmic conditions as risk factors. Similar to other studies of this condition the multivariable model included age, male gender, perioperative organ damage and perioperative hemorrhage. Hypertension, chronic anemia and carotid artery stenosis were new predictive factors identified by this study.

Predicting Risk of Perioperative Ischemic Optic Neuropathy in Spine Fusion Surgery: A Cohort Study Using the National Inpatient Sample.

Ischemic optic neuropathy (ION) is a rare complication of anesthesia and surgery that causes vision loss in spine fusion. We sought to develop a predictive model based on known preoperative risk factors for perioperative ION to guide patient and physician preoperative decision-making. In the National Inpatient Sample (NIS) for 1998-2012, discharges for posterior thoracic, lumbar, and sacral spine fusion were identified and classified by ION status. Variables were selected without weighting via variable clustering using Principal Component Analysis of Mixed Data (PCA-MIX). Hierarchical clustering with 4 clusters was performed, and the variable with largest squared loading in each cluster was chosen. By splitting our sample into a training and testing data set, we developed and internally validated a predictive model. The final model using variables known preoperatively was constructed to allow determination of relative and absolute risk of developing perioperative ION and was tested for calibration and discrimination. The final predictive model based on hierarchical clustering contained 3 preoperative factors, age, male or female sex, and the presence of obstructive sleep apnea (OSA). The predictive model based on these factors had an area under the receiver operating characteristic curve (AUC) of 0.65 and good calibration. A score cutoff of >1 had 100% sensitivity, while score of 3 had 96.5% specificity. The highest estimated absolute risk (844.5/million) and relative risk of ION (46.40) was for a man, age 40-64 years, with OSA. The predictive model could enable screening for patients at higher risk of ION to provide more accurate risk assessment and surgical and anesthetic planning for perioperative ION in spine fusion.

Posterior ischemic optic neuropathy: Perioperative risk factors.

Perioperative posterior ischemic optic neuropathy (PION) is a rare but devastating condition. Visual impairment is commonly bilateral, profound, and irreversible. The most frequently associated triggering events are spine surgeries, other orthopedic surgeries, cardiac bypass surgeries, and radical neck dissection. The etiology is multifactorial. The most commonly reported risk factors are severe and prolonged hypotension, anemia, hemodilution, orbital and periorbital edema, direct orbital compression by prone position, and abnormal autoregulation. This review discusses the current literature on perioperative PION and includes a study conducted by our group to investigate the perioperative risk factors of PION in order to better understand the pathogenesis and help identify high-risk patients. Our results provide further corroborating evidence that PION is associated with spinal, cardiovascular, and abdominal surgeries, longer duration of procedure, and facial edema. Anemia and chronic hypertension are frequent risk factors. Treatment for perioperative PION is uncertain and depends largely on the immediate reversal of hemodynamic alterations. Hence, it is important to identify patients at risk and accordingly take prophylactic measures to prevent its occurrence. Optimizing hemoglobin levels, hemodynamic status, and tissue oxygenation is crucial.

Update on Perioperative Ischemic Optic Neuropathy Associated With Non-ophthalmic Surgery.

Perioperative visual loss (POVL) is a rare, serious complication of non-ophthalmic surgeries. Ischemic optic neuropathy (ION), and retinal arterial occlusion (RAO) are the main causes (1, 2). Less frequent are cortical blindness (3), acute glaucoma (4), and choroidal and vitreous hemorrhage (5). ION is the most common cause for which the neurologist or neuro-ophthalmologist is consulted as it is associated either with a normal ophthalmic exam (posterior ION, PION), or less often, with optic nerve (ON) head swelling (anterior ION, AION). The presumed cause is impaired blood supply to the optic nerve (Figure 1). The most common surgical procedures complicated by ION are cardiac surgery and spinal fusion. Retrospective studies, surveys, and case reports are the basis of most knowledge regarding peri-operative ION (poION), with cohort and case-control studies helping to identify candidate risk factors (6, 7). Animal models have provided insight regarding mechanisms (8). This mini-review is an update on the latest advancements regarding poION in non-ophthalmic surgeries in epidemiological, clinical, and animal studies.

Perioperative Visual Loss in Spine Fusion Surgery

Background:Perioperative ischemic optic neuropathy (ION) causes visual loss in spinal fusion. Previous case–control studies are limited by study size and lack of a random sample. The purpose of this study was to study trends in ION incidence in spinal fusion and risk factors in a large nationwide ad

Perioperative Ischemic Optic Neuropathy (poION) in the United States from 1998-2011 in the Nationwide Inpatient Sample (S48.001)

Perioperative Ischemic Optic Neuropathy (poION) in the United States from 1998-2011 in the Nationwide Inpatient Sample (S48.001)

Sequential Episodes of Perioperative Ischemic Optic Neuropathy After Hip Surgery

Perioperative ischemic optic neuropathy (ION) after nonocular surgery is a rare complication leading to permanent and often severe vision loss. Due in part to the low prevalence of this complication, there remains no reliable way to predict which patients will develop ION. We present a patient with sequential episodes of unilateral perioperative ION, both occurring after otherwise uncomplicated hip operations. Patients and physicians should be aware that perioperative ION after one surgery may increase the risk of ION after subsequent surgeries.

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Unusual presentation of perioperative ischemic optic neuropathy following major spine surgery

Perioperative visual loss following spinal surgery has become of increasing concern among anesthesiologists, surgeons, and patients alike. Perioperative ischemic optic neuropathy often occurs in patients greater than 50 years of age, in association with a number of presumed risk factors, including diabetes, hypertension, small cup-to-disc ratio, preoperative anemia, intraoperative hypotension, prolonged operative time in the prone position, and significant blood loss during surgery. The visual loss is notably devastating, and generally leads to permanent disability. A 44-year-old man whose central visual acuity was completely preserved is presented.

Perioperative Ischemic Optic Neuropathy

Ischemic optic neuropathy is the most common cause of perioperative vision loss. The authors sought to determine its incidence and identify risk factors that may contribute to perioperative ischemic optic neuropathy associated with nonophthalmologic surgical procedures at their institution. Seventeen patients who experienced perioperative ischemic optic neuropathy were included in a retrospective chart review case-control study. The authors matched each patient with two control patients who had a similar surgical procedure but did not lose vision. They analyzed multiple perioperative variables for the case and control groups. From among 126,666 surgical procedures performed during the study period, the authors identified 17 patients with perioperative ischemic optic neuropathy, yielding an overall incidence of 0.013%. There were no hemodynamic variables that differed significantly between the ischemic optic neuropathy patients and the matched control patients. The authors conclude that perioperative ischemic optic neuropathy can occur in the absence of atypical fluctuations in hemodynamic variables during the perioperative period.

Visual Loss after Spinal Surgery

Mayo Clinic, Rochester, Minnesota. warner.mark@mayo.eduIn response to Dr. Larson’s rather dogmatic conclusions on how to avoid perioperative ischemic optic neuropathy, I am pleased that he has never personally experienced this complication in one of his patients. His observation drives home the primary point of the report by Dr. Lee et al. 1and my editorial2: There are too few of these complications at this time to scientifically deduce causative risk factors. Quite simply, it is not logistically or financially possible at this time to prospectively search for causative risk factors of this devastating complication as it occurs in patients undergoing spine surgery while positioned prone.Therefore, it is difficult to understand what data Dr. Larson uses as a basis for his recommendations. There are no data to suggest that limiting crystalloid administration to less than 40 ml/kg regardless of duration of the surgical procedure impacts ischemic optic neuropathy (negatively or positively). The same can be said for his suppositions about hematocrit levels of less than 26 and limiting durations of controlled hypotension to only the dissection period of spine surgery. Data from multiple studies document that many patients who have Dr. Larson’s “risk factors” do not develop ischemic optic neuropathy—and many who develop ischemic optic neuropathy receive crystalloid volumes of less than 40 ml/kg, have hematocrits intraoperatively well above 26, and are provided care without the use of controlled hypotension. In short, there is no scientific reasoning to justify Dr. Larson’s strongly worded, unsupportable recommendations.Dr. Weiskopf raises two points to which I would like to respond. First, he speculates that periodic intraoperative checks of the eyes for absence of direct pressure on patients’ eyes may be useful in preventing central retinal artery thrombosis. His spine team evidently established periodic intraoperative eye checks for all prone-positioned spine surgery patients and found that none of their 3,450 patients developed this complication.3However, as he notes, the frequency of this event is very low. It is, therefore, impossible to draw any conclusion or even inference that his team’s eye checks had anything to do with the outcomes that their patients experienced. Regarding the use of eye checks, it is disappointing to find that 6 of the 10 patients with central retinal artery occlusion in the America Society of Anesthesiologists Visual Loss Registry had at least one eye check during their procedures.1In those 6 patients, eye checks apparently did not prevent this problem from occurring. Therefore, should eye checks be done? Intuitively, yes—they are certainly cheap and easy. However, there are no data showing that they are effective in reducing the frequency or severity of central retinal artery occlusion.Dr. Weiskopf also indirectly suggests that increased inspired oxygen concentrations, resulting in elevated arterial oxygen tension, may be helpful in decreasing the frequency of perioperative vision loss. He cites an excellent study that he and colleagues performed in volunteers who were made acutely anemic, finding that increased inspired oxygen concentrations reversed the negative cognitive effects of the anemia.4Ironically, hyperoxia has an autoregulation-related vasoconstrictive effect on the end-retinal arterioles of the central retinal artery, reducing both the diameter of the arterioles and also their blood flow and velocity.5It is not clear what impact this finding has on blood flow to the various regions of optic nerves, but increasing inspired oxygen concentrations may not be as helpful as he seems to suggest.Mayo Clinic, Rochester, Minnesota. warner.mark@mayo.edu

Ischemic Optic Neuropathy Following Spine Surgery in a 16-Year-Old Patient and a Ten-Year-Old Patient

Peri-operative ischemic optic neuropathy typically occurs in middle-aged or older patients. We report this condition in two patients aged 16 and 10 years. Only six other cases of peri-operative ischemic optic neuropathy have been reported in patients aged less than 30 years, all but one occurring after spinal surgery. Although the visual prognosis appears to be more favorable in younger patients, the pathogenesis of this rare complication of surgery is likely to be the same as that affecting older individuals.

The Incidence of Vision Loss Due to Perioperative Ischemic Optic Neuropathy Associated With Spine Surgery: The Johns Hopkins Hospital Experience

The Incidence of Vision Loss Due to Perioperative Ischemic Optic Neuropathy Associated With Spine Surgery: The Johns Hopkins Hospital Experience

The Incidence of Vision Loss due to Perioperative Ischemic Optic Neuropathy Associated With Spine Surgery

Twenty-year retrospective review of 14,102 spine surgeries. To determine the incidence of perioperative ischemic optic neuropathy (POION) in spine surgery at our institution. In recent years, perioperative vision loss in patients undergoing spine surgery has become an issue of increasing concern to physicians, patients, and medicolegal experts. The incidence of POION in spine surgery has been addressed in two separate studies that found incidences of 0% and 0.12%. We performed a 20-year database search for all patients who underwent spine surgery and had a concurrent ICD-9 discharge diagnosis pertaining to vision loss. Patient charts were reviewed in detail to confirm the diagnosis of POION. Of 14,102 cases of spine surgery during the study time frame, we identified 4 cases of POION, for an incidence of 0.028%. In 3 of the 4 cases, surgery was performed with the patient in the prone position; the fourth patient was placed in the lateral decubitus position. All affected patients had experienced intraoperative anemia, hypotension, or both. The average time of surgery was 420 minutes. POION is a rare but potentially devastating and untreatable complication of spine surgery, particularly that performed with the patient in the prone position. Anemia, hypotension, long duration of surgery, and significant intraoperative hydration may all be risk factors for this condition. All patients undergoing spine surgery should be informed about the low but definite risk of this condition, and every attempt should be made during surgery to maintain stable hemoglobin and mean arterial pressure and to avoid overhydration.