1. Blindness After Surgery- Can You See the Answer? COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2014 55 year old man is admitted for lumbar-sacral spine surgery  Cigarette smoker, hypertension, obesity  Unremarkable preoperative evaluation Surgery associated with blood loss 1250 cc, treated with 2 units PRBC Duration of surgery 7 hours, hemodynamically stable Remains intubated and sedated overnight Case

4. Copyright © 2014 Devices for Spine Surgery Wilson Table Jackson Table Mayfield Pins

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6. Copyright © 2014 Case Extubation in morning (pod 1) approximately 12 hours post op He is awake, alert, and oriented but has bilateral blindness  Exam: BP 110/70 (same as preop), hr 66  No ocular trauma  Pupillary light reflexes absent  No other neurologic findings  Fundoscopic exam normal  Head CT: normal What is the cause and prognosis of his blindness ?

7. Copyright © 2014 What is causing his blindness? Ocular trauma Embolic stroke Central retinal artery occlusion Cortical blindness

8. Copyright © 2014 What is causing his blindness? Ocular trauma  No trauma on exam Embolic stroke Central retinal artery occlusion Cortical blindness

9. Copyright © 2014 What is causing his blindness? Ocular trauma  No trauma on exam Embolic stroke  Not with this surgery. More common following valve surgery, CABG, CABG + valve, carotid surgery Central retinal artery occlusion Cortical blindness

10. Copyright © 2014 What is causing his blindness? Ocular trauma  No trauma on exam Embolic stroke  Not with this surgery. More common following valve surgery, CABG, CABG + valve, carotid surgery Central retinal artery occlusion  Unilateral  In spine surgery due to head malpositioning with subsequent eye compression – trauma Cortical blindness

11. Copyright © 2014 What is causing his blindness? Ocular trauma  No trauma on exam Embolic stroke  Not with this surgery. More common following valve surgery, CABG, CABG + valve, carotid surgery Central retinal artery occlusion  Unilateral  In spine surgery due to head malpositioning with subsequent eye compression – trauma Cortical blindness  Embolic posterior cerebral infarction  Emboli uncommon in this procedure  Normal pupillary response

12. Copyright © 2014 What is causing his blindness? Ocular trauma  No trauma on exam Embolic stroke  Not with this surgery. More common following valve surgery, CABG, CABG + valve, carotid surgery Central retinal artery occlusion  Unilateral  In spine surgery due to head malpositioning with subsequent eye compression – trauma Cortical blindness  Embolic posterior cerebral infarction  Emboli uncommon in this procedure  Normal pupillary response

13. Copyright © 2014 Marcus from Southern California: Ischemic Optic Neuropathy (ION)  Anterior ischemic optic neuropathy  Disk edema  Posterior Ischemic Optic Neuropathy  Normal fundus

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15. Spine surgery ASA Practice Advisory for Spine surgery (June 2006) EBL > 1000cc Anesthesia > 6 hours Bilateral visual loss Relatively healthy patients No evidence of vascular injury to other organs Hypotension not the cause, anemia not the cause Multifactorial Anterior vs. posterior by fundoscopic exam Normal MRI, CT Vision rarely improves

16. Copyright © 2014 Risk Factors with Odds Ratios for Ischemic Optic Neuropathy 1.Male Sex2.53 2.Obesity2.83 3.Wilson Frame Use4.30 4.Longer Anesthesia Duration1.39/hr 5.Estimated Blood Loss1.34 6.Colloid as % of Non-Blood Replacement0.67

17. Copyright © 2014 Ischemic Optic Neuropathy (ION)  Etiology unknown  Risks in our case  Back surgery  Wilson frame use  Blood loss  Male  Long duration of surgery

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