POVL Postoperative Visual LossPOVL Postoperative Visual Loss
Caleb A. Rogovin, CRNA, MS, CCRN, CENTemple University Hospital
Philadelphia, PA
NJANA FALL MEETING
Sunday October 11, 2009
POVLPOVL
• A rare but devastating complication
• May involve one or both eyes with partial or complete visual loss
• May result in temporary, partial or complete permanent blindness
• 0.0008%-1% depending on surgical procedure (Non-ocular in nature)
Anatomy of the EyeAnatomy of the Eye
• The cornea and lens focus light on the retina
• Iris controls amount of light reaching the retina by altering size of pupil
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Ocular AnatomyOcular Anatomy
• Eye has 3 chambers• Anterior
• Posterior
• Vitreous
• Ciliary Body produces aqueous humor
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Ocular AnatomyOcular Anatomy
• Aqueous humor flows through posterior chamber by way of pupil to anterior chamber and drains through Canal of Schlemm
http://www.mydr.com.au/content/images/categories/eyes/anatomy_of_eye.gif
Ocular AnatomyOcular Anatomy
• RETINA • Sensory portion of eye
• Optic Nerve• Axons are derived
from retinal ganglion cells
Ocular Blood SupplyOcular Blood Supply
• Blood supply to most of the eye is supplied by the Ophthalmic Artery• First intracranial branch of internal carotid
artery
• Increased Intraocular Pressure (IOP) decreases retinal blood flow
• IOP = (rate of aqueous humor production/facility of outflow) + EVP (episcleral venous pressure)
• Changes in HCT may alter ocular blood flow…anemia is bad!
Associated with…Associated with…
• Spine Surgery• Prone Position
• Neck Surgery• Cardiac Surgery• Nasal/Sinus Surgery
• Direct damage to the vascular system of the eye may cause spasm or thrombosis in arteries
• Compression of retinal artery by formation of a hematoma
• Intra-arterial injection of local anesthesia with epinepherine
POSTERIOR SPINE SURGERYPOSTERIOR SPINE SURGERY
• This is the major focus
• Majority of cases are related to this surgery
• ASA Postoperative Visual Loss Registry• Analysis of 93 spine cases with POVL• Anesthesiology 2006; 105:652-9 Lee et al.
• Majority of POVL (80%) was associated with Ischemic Optic Neuropathy (ION)
Spine SurgerySpine Surgery
• Associated Clinical Information
• Length of Surgery• >6 hours
• EBL• >1000 mL
• Deliberate Hypotension*• NOT a factor in POVL
• Prone Position
• Head Fixation*• NOT a factor
Deliberate HypotensionDeliberate Hypotension
• Autoregulation of blood flow in the cerebral vasculature is well documented and understood (???Well, maybe but not by me!)
• It is not clear whether the human optic nerve also has the ability to autoregulate in both the anterior and posterior regions
Central Venous Pressure (CVP)Central Venous Pressure (CVP)
• CVP is increased • Head down position• Head turned to one side• Direct abdominal pressure
Prone PositionProne Position
• Prone position itself, significantly increases intraocular pressure
• 10% Reverse Trendelenberg position reverses the increase
ION Ischemic Optic NeuropathyION Ischemic Optic Neuropathy
• Ischemic Optic Neuropathy• An ischemic insult to the optic nerve• Divided into ANTERIOR and POSTERIOR • Diagnosis depends on which part of the nerve is
affected…ANTERIOR and POSTERIOR sections have different blood supplies
IONION
• ANTERIOR • POSTERIOR• Main vascular supply
is Pial vessels derived from branches of the OA
• Farthest from an arterial supply
• Most commonly implicated with hemorrhagic hypotension
IONION
• Anterior Ischemia• Optic disc edema
• Occasional vision improvement
• Posterior Ischemia• Delayed edema
• Seldom vision improvement
IONION
• Posterior portion of optic nerve is farthest from arterial supply
• Main vascular supply from Pial vessels from branches of opthalmic artery
• NO autoregulatory control• Posterior portion is vulnerable to fall in
perfusion pressure and anemia
IONION
• Diagnosis of exclusion• No definitive opthalmoscopic findings
• Does not suggest that there was extrinsic pressure on the eye• Direct pressure yields
• Retinal Artery Thrombosis which exhibits retinal pallor and “cherry red spot”
Central Retinal Artery Occlusion CRAO
Central Retinal Artery Occlusion CRAO
• Unilateral visual loss
• Most commonly associated with an embolus
• Cherry red spot with retinal edema
• Vision occasionally improves
• Prolonged pressure on the globe
Additional AssociationsAdditional Associations
• Acute Glaucoma
• TURP• Glycine Toxicity
TreatmentTreatment
• There is no real treatment!
• Acetazolamide• Decreases IOP
• Diuretics (Mannitol, Furosemide)• Decrease swelling
• Corticosteroids• Decrease axonal swelling
DevicesDevices
• No specific product has been shown to be more effective
Mayfield Pins…Tell San Francisco Story
IONION
• ASA Visual Loss Registry• ION was associated with 83 of 93 spine cases• Mean Anesthetic Duration: 9.8 +/- 3.1 hours• Mean Age: 50 +/- 14 years• Mayfield Pins: 16/83 cases• EBL: 2.0L (range: 0.1-25L)• ION was most common cause of visual loss after
spine surgery
Case ReportsCase Reports
• ION after spinal surgery• Canadian Journal of Anesthesia 1998
• Cortical blindness secondary to cyclosporine after orthotopic heart transplantation: a case report and review of the literature• J Heart Lung Transplant 1996
• CRAO after scoliosis surgery with a horseshoe headrest • Spine 1993
• Amaurosis secondary to massive blood loss after lumbar spine surgery• Spine 1994
CASE REPORTSCASE REPORTS
• Transient postoperative blindness as a possible effect of glycine toxicity• Arthroscopy 1990
• Anterior ischemic optic neuropathy: a complication after extracorpreal circulation• Ann Thorac Cardiovasc 1998
• Blindness after intranasal ethmoidectomy• Rhinology 1993
• Unilateral blindness after prone spine surgery• Anesthesiology 2001
The Effects of Steep Trendelenburg Positioning on Intraocular Pressure During Robotic Radical Prostatectomy
The Effects of Steep Trendelenburg Positioning on Intraocular Pressure During Robotic Radical Prostatectomy
• Awad, H., Santilli, S., Ohr, M., Roth, A., Yan, W., Fernandez, S., Roth, A., Patel. International Anesthesia Research Society, 109 (2), August 2009.
• IOP increases significantly in anesthetized patients undergoing robotic prostatectomy in steep t-burg position
• Quantified changes in IOP throughout the procedure
The Effects of Steep Trendelenburg Positioning on Intraocular Pressure During Robotic Radical Prostatectomy
The Effects of Steep Trendelenburg Positioning on Intraocular Pressure During Robotic Radical Prostatectomy
• This increase in IOP may be related to the occurrence of Ischemic Optic Neuropathy
• Peak Airway Pressure
• MAP
• EtCO2
• Surgical duration• PREDICTORS OF IOP INCREASE IN T-BURG
OK…OK…
• So what do we know?• POVL is a rare but tragic complication• Majority of cases are related to ION• Factors:
• Length of surgical procedure• EBL• Direct compression on eye• Prone Position• Pre-existing Medical Conditions• Hemorrhagic Anemia
OK…OK…
• Deliberate Hypotensive Techniques• NOT associated with >
incidence of POVL
• No specific transfusion threshold to eliminate risk
• Colloids should be used along with crystalloids to maintain intravascular homeostasis in patients with large blood loss
Anesthetic PlanningAnesthetic Planning
• Head should be level with or higher than the heart when possible (10% Reverse T-Berg)
• Head should be maintained in a neutral position
• Consider staging procedure• For those very long (>6 hr) procedures when
feasible
• Discuss POVL with anesthesia risks and complications
POVLPOVL
• A rare, unexpected, devastating complication
• Anesthetic vigilance!• Awareness of associated factors• Proper positioning• Anemia• Crystalloids and Colloids• Blood Pressure
NEW INFORMATIONNEW INFORMATION
• APSF Newsletter• Volume 23, No. 1, 1-20 Spring 2008
• If my spine surgery went fine, why can’t I see?• Postoperative Visual Loss and Informed Consent
• Anthony Lehner, MD
New InformationNew Information
• Current Reviews for Nurse Anesthetists• Lesson 5 Volume 31 7/17/2008• C. Phillip Larson Jr., M.D.C.M.
• A Rational Approach for Preventing Blindness During Posterior Spinal Surgery
What do “I” do?What do “I” do?
• Careful pre-op assessment and anesthesia risks and complications
• Consider Arterial Line and Central Line
• Limit surgical time to <6 hours• Stage Procedures
• Monitor HCT• <26% consider transfusion
What do “I” do?What do “I” do?
• Keep head in neutral position or slightly higher than heart
• Limit Crystalloids to 5cc/kg/hr• Current Reviews
• BE VIGILANT!
REFERENCESREFERENCES
• A report by the American Society of Anesthesiologists Task Force on Perioperative Blindness. Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery. Anesthesiology 2006; 104:1319-28.
• Lee, L., Roth, S., Posner, K., et al. The american society of anesthesiologists postoperative visual loss registry. Anesthesiology 2006; 105:652-9.
REFERENCESREFERENCES
• Warner, M. Postoperative visual loss experts, data and practice. Anesthesiology 2006;105:641-2.
• Chaudhry, T., Chamberlain, M., Vila, H. Unusual cause of postoperative blindness. Anesthesiology 2007; 106:869-79.
• Roth, S., Barach, P. Postoperative visual loss: still no answers-yet. Anesthesiology 2001; 95:575-77.
REFERENCESREFERENCES
• Ochroch, E., Fleisher, L. Retrospective analysis: looking backward to point the way forward. Anesthesiology 2006; 105:643-44.
• Katz, D., Karlin, L. Visual field defect after posterior spine fusion. Spine 2005; 30:E83-85.
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