Janik, Daniel, MD Post-Operative Visual Loss POSTOPERATIVEVISUALLOSS APreventableComplication? DISCLOSURE DanielJ.Janik,MD AssociateProfessor UniversityofColoradoDenver Ihavenocommercialorother conflictsofinterest EyeInjuryAssociatedwith Overview Anesthesia MoosDD,LindDM.JournalofPerianesthesiaNursing2006;21(5):332341 • Generalincidenceofeyeinjuries GildWM,PosnerKL,etal.Anesthesiology1992;76:2048 • Visualloss– incidence • Eyeinjuryaccountsfor38%ofanesthesiarelated • Typesofvisualloss malpracticeclaims • Riskfactors • Generalanesthesia83% • Strategiesforprevention • Monitoredanesthesiacare11% • Conductionblockade7% • ASArecommendations • Incidenceofcornealabrasion: Roth1996– 0.034%(nonophthalmicsurgery) Cucchiara1988– 0.17%(neurosurgical,mostlyprone) EyeInjuryAssociatedwith PostoperativeVisualLoss Anesthesia RothSetal,Anesthesiology1996;85:10207 GildWM,PosnerKL,etal.Anesthesiology1992;76:2048 LeeLA,PosnerKL,etal.RegAnesthPainMed2008;33:416422 • 60,965anestheticsfrom19881992 • 30%ofclaimswereforeyeinjuryassociatedwith movementduringeyesurgery • Nonocularsurgery Blindnesswasoutcomeinallcases • 34 Pa tien ts (0. 056%)w itheye in jury, 2 Medianpaymenthigh($90,000) patients(0.003%)withvisualloss • Ifyoudoeyeblocks: • Only21%ofallcaseshaddiscerniblecause Youwillhaveasignificantlyalteredriskprofilerelatedto permanenteyedamagefromeyeblockneedlesthanifyou onlyprovideMAC(48vs.3inclaimsstudy) CRASH 2013 Janik, Daniel, MD Post-Operative Visual Loss PostoperativeVisualLoss PostoperativeVisualLoss RothSetal,Anesthesiology1996;85:10207 WarnerME,Anesthesia&Analgesia2001;93:141721 • IndependentRiskFactors: Lengthofsurgery • 501,342anestheticsfrom19861998 Lateralpositioning • 405casesofvisualloss Operationsonheadorneck • 216rega ine df u llvi s ionwithi n30 d ays Generalanesthesia • 189lostvision>30days SurgeryonMonday 185underwentophthalmologic/neurosurgical procedurewithtissuedamageorloss 4withouttissuedamage/loss=0.0008% PostoperativeVisualLoss PostoperativeVisualLoss WarnerME,Anesthesia&Analgesia2001;93:141721 WarnerME,Anesthesia&Analgesia2001;93:141721 • Possiblefactors: • Noneof26,212neuraxialblockadepatients Anemia hadvisualloss Hypotension • Noneof11,942spinalsurgerypatientshad loss>30days(8hadloss<30days) SurgicalDuration • Datacontrastswith0.06%lossaftercardiac Combination surgery(Nuttall,2001) PostoperativeVisualLoss PostoperativeVisualLoss NuttallGAetal,AnesthesiaandAnalgesia2001;93:14106 PatilCG,LadEM,etal.Spine2008;33(13):14916 •Studyof27,915patientsundergoingCPB • RetrospectivestudyusingNational •17hadION;0.06%(12AION,5PION) InpatientSampledatafrom1993to2003 •Bivariateriskfactors: undergoingspine surgery: LowHgbconc(<8.5g/dL) 4,728,815patientstotal Atheroscleroticvasculardisease 4134(0.087%)hadpostoperativevisualsxs Preoperativeangiogram 271(0.006%)haddiagnosisofION •Univariateriskfactors 47(0.001%)haddiagnosisofCRAO RBCtransfusions(OR1.3) AnynonRBCproduct(OR4.4) Overallincidencewas0.094% CRASH 2013 Janik, Daniel, MD Post-Operative Visual Loss PostoperativeVisualLoss PostoperativeVisualLoss PatilCG,LadEM,etal.Spine2008;33(13):14916 PatilCG,LadEM,etal.Spine2008;33(13):14916 • Highestincidence: • RiskfactorsforION: Surgeryforscoliosis– 0.28% Hypotension:OR10.1 Posterioronlyapproach– 0.29% Peripheral vascular disease:OR 6 .3 Anterioronlyapproach– 0.17% • RiskfactorsfornonION,nonCRAOloss: Anemia:OR5.9 Age<18years:OR5.8 Age>84years:OR3.2 • Note– thisstudydidnotdefinehypotension Peripheralvasculardisease:OR2.0 oranemia Preexistinghypertension:OR1.3 Bloodtransfusion:OR2.2 Postoperative VisualLoss PostoperativeVisualLoss ShenYandRothS,Anesthesiology2008;109:A1013 ShenYandRothS,Anesthesiology2008;109:A1013 • RetrospectivestudyusingNational • Spinalfusionwithvisualloss: InpatientSamplefrom1996to2005 83%posteriorapproach • Ratesofvisualloss: VisualLossRate Malevs.femalesimilar 0.035 Younger SiSpina lflfus ion– 1: 3364(0 .029%) 0.03 0.025 Similarcomorbiditiestopatientswithoutloss 0.02 Laminectomy– 1:11,453(0.0087%) Percent 0.015 0.01 Appendectomy– 1:78705(0.0012%) 0.005 TotalPatients=139 0 Appendectomy Laminectomy SpinalFusion • Spinalfusionwithvisualloss: 140 120 100 80 57%lumbar/lumbosacral NumberofPatients 60 40 35%thoracic/thoracolumbar 20 0 8%cervical PosteriorApproach AnteriorApproach PostoperativeVisualLoss PostoperativeVisualLoss HolySEetal,Anesthesiology2009;110:24653 SummaryofStudiesReportingIncidence • 126,666operationsfrom19982004 • Retrospectivechartreviewandcasecontrolstudy Year Population Incidence • NonRocular surgery;ION only Roth, Thistead, et al 1996 General Surgical 0.003% • 17cases(0.013%overallincidence) Warner, Warner, et al 2001 General Surgical 0.001% Nuttall, Garrity, et al 2001 Cardiac 0.060% CABG– 0.33% Kalyani,Miller, et al 2004 Cardiac 0.113% Spine– 0.36% Stevens, Kelley, et al 1997 Spine 0.200% Other– 0.003% Chang, Miller 2005 Spine 0.028% 16/17wereMALE(moreonthatlater) • Patil, Lad, et al 2008 Spine 0.094% Shen, et al 2009 Spine 0.01% CRASH 2013 Janik, Daniel, MD Post-Operative Visual Loss MostCommonCauses AnatomicClassificationofVisualLoss WilliamsELetal;AnesthAnalg1995;80:101829 • IschemicOpticNeuropathy(ION) • CentralRetinalArteryOcclusion(CRAO) • CorticalBlindness • CentralRetinalVeinOcclusion AION:Anteriorischemicopticneuropathy PION:Posteriorischemicopticneuropathy CorticalBlindness CorticalBlindness • Causedbydamagetotheopticradiationor • Physicalfindings: occipitalcortex(resultingininfarction) Normalopticdisk from: Retentionofpupillaryreflex Embolism(particulateorair) AbnormalCTorMRI • Prognosis: Sustainedhypotension Good Cardiacarrest • Treatment: • Presentation: MaintainHgbandnormalcerebralperfusionpressure Painlesslossofvision,patterndependson toavoidextendingdamage areaaffected HyperbaricO2 ifairembolismissuspected CentralRetinalArteryOcclusion • Usuallycausedbycompressionoftheeye leadingtoincreasedintraocularpressurewith resultantdecrease or cessation of flow inthe centralretinalartery • Endresultisretinalischemiaduetolackof oxygendelivery Nonhemorrhagicinfarctinleftoccipitallobe From StamboughJL,DolanD,etal,JAmAcadOrthopSurg2007;15:156 165 CRASH 2013 Janik, Daniel, MD Post-Operative Visual Loss CentralRetinalArteryOcclusion CentralRetinalArteryOcclusion RothS.ASARefresherCourseLectures2008 • Prognosis: • Presentation: Usuallyirreversible Symptomonsetwithin24hours • Treatment: Unilateral visualloss Noconsistentlfflyeffectivetreatment Nolightperception Acetazolamideandinhalationof5%CO2? • Physicalfindings: • Etiology: Afferentpupildefect Emboli Periorbitaledemaorothertrauma Improperpositioning Cherryredspotonfundoscopicexam Externalcompression(headandnecksurgery) VascularSupplyofAnteriorOpticNerve IschemicOpticNeuropathy WilliamsELetal;AnesthAnalg1995;80:101829 • Anteriorischemicopticneuropathy(AION) RNonarteritic (morecommon perioperativetype) RAiiArteritic • Posteriorischemicopticneuropathy(PION) AnteriorIschemicOpticNeuropathy AnteriorIschemicOpticNeuropathy • Causedbytransientdecreaseinperfusion • Presentation: pressureofthenutrientvesselsofthe anterioropticnervebelowautoregulatory Painlessvisualloss range UllUsually ifit24infirst24R48 hoursa ftersurgery Afferentpupildefectorunreactivepupils Decreasedmeanarterialpressure Usuallynoteduponawakening Increasedintraocularpressure Both Visualfielddeficits(inferior)orcompleteloss bilateral • Injurydependsonseverityanddurationof Commonly ,butmaybeunilateral transientischemia CRASH 2013 Janik, Daniel, MD Post-Operative Visual Loss AnteriorIschemicOpticNeuropathy AnteriorIschemicOpticNeuropathy– Etiology WilliamsEL.AnesthesiologyClinNAm2002;20:367384 • PhysicalFindings: • Predisposing • Precipitating factors Factors Earlyopticdiskedema optic disk hemorrhages Variablebloodsupply Acute systemic (posteriorciliaryarteries) hypotension* Diskedemareplacedbypallorin23months Smallopticdisksize Venousobstruction* • Prognosis: Aging Raisedintraocular Hypertension pressure PoorR <30%showsomeimprovement Smoking Loweredhematocrit* • Treatment: Diabetesmellitus Increasedbloodviscosity Vasculardisease (sicklecell;polycythemia) None IschemicOpticNeuropathy– Visual PosteriorIschemicOpticNeuropathy FieldDeficit • Causedbydecreasedoxygendeliverytoposterior portionofopticnerve(betweenopticforamenand wherecentralretinalarteryentersnerve) • Nerveonly fed by pial vessels which aresensitive to compression • Notusuallyassociatedwithocclusivevascular disease • MorelikelytobeassociatedwithembolithanAION AmericanSocietyofAnesthesiologists,PostoperativeVisualLossRegistry VascularSupplyoftheEye PosteriorIschemicOpticNeuropathy Baig2007 • Presentation: SimilartoAION,butmayalsodevelopslower • Physicalfindings: Opticdiskappearsnormalearly Milddiskedemadayslater OrbitalCTmayshowenlargedintraorbitaloptic nerve CRASH 2013 Janik, Daniel, MD Post-Operative Visual Loss PosteriorIschemicOpticNeuropathy– PosteriorIschemicOpticNeuropathy Etiology WilliamsEL.AnesthesiologyClinNAm2002;20:367384 • Prognosis: • Multifactorial: Poor– likeAION,usuallyfixeddeficit Hypotension* • Treatment: LowHemoglobin* None Increasedintraorbitalvenouspressure Infection Venousobstruction* Congenitalabsenceofcentralretinalartery Internalcarotidarterydissection PosteriorIschemicOpticNeuropathy Fundoscopy – RiskFactors DunkerS,HsuHY,etal.JAmCollSurg2002;194:705710 Normal Papilledema • 7Institutionalcasesplusliteraturesearch • Male • M50ldMeanage50yearsold • Spinesurgery Atrophied Disc Cherry Red Spot • Intraoperativehypotension • Largebloodloss(200016,000ml) • Dropinhematocritof9.519%(mean14%) • Facialswelling PostoperativeVisualLoss ASAPOVLRegistry AnatomicConsiderations • EstablishedbyASAinJune1999 • Bloodsupplytoopticnerveisvulnerable