Anaesthesia, 1981, Volume 36, pages 954-955

CASE REPORT

Temporary blindness following anaesthesia after translumbar aortography

R.C. JOHNSON A N D P.J. MOSS

Summary

A case is reported of temporary blindness following general anaesthesia for translumbar aortography. The possible causes and precipitating factors are discussed.

Key words

Anaesthetic techniques; diagnostic. Complications; cortical blindness.

Case history

A 57-year-old maintenance engineer with a 5-month history of intermittent claudication of the right leg was admitted for translumbar aorto- graphy. He habitually smoked 30 cigarettes per day and had been taking naftidrofuryl oxalate (Praxilene) tablets 100 mg three times daily for one month.

He weighed 72 kg and on examination was found to have an irregular pulse of 52 beats/ minute which an electrocardiogram showed to be due to sinus dysrhythmia. He was normotensive with an arterial pressure of 120/70 mm Hg and except for absent palpable pulses below the femoral artery in the right leg, all other investiga- tions were normal.

He was prernedicated with atropine 0.6 mg and papaveretum 15 mg. The heart rate was 96 beats/minute before induction and the arterial pressure was 160/90 mm Hg.

Anaesthesia was induced with alphaxalone and alphadolone (Althesin) 3.5 ml, followed by suxa-

methonium 100 mg to facilitate tracheal intuba- tion. Muscle relaxation was maintained with alcuronium 15 mg and the patient’s lungs were ventilated with nitrous oxide and oxygen (2: 1) at a rate of 10 breaths/minute and a tidal volume of 600 ml. Anaesthesia was supplemented with pentazocine 60 mg.

The eyes were closed with adhesive tape before he was placed in the prone position with pillows under the thorax and pelvis, the head being turned to the right and supported on a foam wedge.

During anaesthesia the patient’s condition remained stable, the arterial pressure averaged 120/70 mm Hg and the pulse rate averaged 84 beats/minute. No period of hypotension was noted.

Following the procedure, which lasted 30 minutes, reversal of the muscle relaxant was achieved with atropine 1.2 mg together with neostigmine 2.5 mg. As soon as he regained consciousness, the patient complained of com- plete loss of vision. An ophthalamic opinion was

R.C. Johnson, MBBS, FFARCS, Consultant and P.J. Moss, MBBS, FFARCS, Registrar, Department of Anaesthesia, York District Hospital, Wigginton Road, York YO3 7HE.

954 0003-2409/81/1OOO-0954$02.00 0 1981 Blackwell Scientific Publications

Correspondence to: Dr R.C. Johnson.

Temporary blindness after anaesthesia 955

undergoing vertebral angiography suffer tran- sient cortical blindess due to vascular spasm or embolus at the basilar artery bifurcation.

We have been unable to find any case descrip- tions of blindness following translumbar aorto- graphy.

In the case described here we believed that the differential diagnosis lay between visual cortical ischaemia due to basilar artery spasm or embolus at the basilar artery bifurcation, and hysteria.

The fact that vision returned within 20 hours supported the diagnosis of vascular spasm rather then embolus. The injection of radio-opaque contrast medium has been incriminated in caus- ing visual cortical ischaemia following carotid and vertebral angiography? but this seems most unlikely after translumbar aortography.

It is possible that the prone position with the head turned to the right may have compromised the vertebro-basilar circulation, since the second anaesthetic (for the superficial femoral disoblite- ration) in the supine position produced no similar problems.

An ischaemic process in the distribution of the left posterior cerebral artery, as shown on the EEG, may also have been more likely due to this position of the head and neck.

Although we believe that the cause of this patient’s temporary blindness was a combination of factors, the importance of maintenance of arterial pressure and careful positioning, espe- cially of the head and neck, cannot be over- emphasised.

therefore immediately sought. Examination at this stage showed the pupils to be equal and reacting to light. The retinal vessels were patent, carotid pulsation was present and equal on both sides, and the optic discs appeared normal. A diagnosis of cortical blindness due to basilar artery insufficiency resulting from vascular spasm or embolus was made.

The patient was given acetomenaphthone 14 mg and nicotinic acid 50 mg (Pernivit tablets x 2) to promote vasodilatation, and nursed quietly in bed.

Four hours postoperatively he was able to perceive light, and 20 hours postoperatively he stated that his vision had returned to normal.

Visual field perimetry was carried out on the day following anaesthesia, and repeated on two occasions during the following 3 weeks. The findings were consistent with a lesion of the visual cortex. No abnormality of the retina was demon- strated and at 3 weeks the findings were normal.

An electroencephalogram (EEG) was per- formed at the same time. This showed changes consistent with an ischaemic process in the distri- bution of the left posterior cerebral artery and at 26 days this also had returned to normal. X-ray examination of the skull and cervical spine revealed no abnormalities.

The translumbar aortogram showed a local obstruction four inches long in the right super- ficial femoral artery. The patient underwent disobliteration of this obstruction 10 weeks later under general anaesthesia using a technique of ventilation with nitrous oxide and oxygen supple- mented by fentanyl 10 pg/kg. There were no postoperative visual defects following this proce- dure.

Discussion

Loss of vision following general anaesthesia has been reported on a number of occasions. Pressure of the face mask causing retinal artery occlusion has been reported in cases of transient’ and permanent2 postoperative blindness.

Transient cortical blindness lasting up to 7 days has been described following carotid and ver- tebral ang i~graphy~ .~ and coronary angiography5 under local analgesia. In the former series, the authors state that approximately 1% of patients

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2. GIVNER, I, JAFFE NS. Occlusion of central retinal artery following anesthesia. Archives of Ophthalmo-

3 . HORWITZ NH, WENER L. Temporary cortical blind- ness following angiography. Journal of Neurosurgery

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5. FISCHER WILLIAMS M, COTTSCHALK PG, BROWELL JN. Transient cortical blindness-an unusual com- plication of coronary angiography. Neurology 1970; 2 0 353-5.

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