The americal society of anesthesiologists postoperative visual loss registry
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The Americal Society of Anesthesiologists Postoperative Visual Loss Registry. Analysis of 93 spine surgery cases with postoperative visual loss Anesthesiology 2006; 105:652-9 R2 김용일. Postoperative visual loss (POVL). Relatively uncommon but devastating complication

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The Americal Society of Anesthesiologists Postoperative Visual Loss Registry

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The Americal Society of Anesthesiologists Postoperative Visual Loss Registry

Analysis of 93 spine surgery cases with postoperative visual loss

Anesthesiology 2006; 105:652-9

R2 김용일


Postoperative visual loss (POVL)

  • Relatively uncommon but devastating complication

    • 0.2-4.5% in spine & cardiac surgery

  • Ophthalmologic lesions

    • Ischemic optic neuropathy (ION)

    • Not consistent with an etiology of globe compression

    • associated atherosclerotic risk factors

    • Adverse effects of antihypertensive medications

      • Sildenafil

  • Multi-institutional database

    • Very low number of POVL case

    • ASA POVL Registry

      • Established in 1999


Materials and Methods


Study populations

  • POVL occurring within 7 days after nonocular surgery

    • 93 cases associated with spine surgery


Patient and perioperative characteristics

  • Information collected

    • Patient demographics

    • Medical Hx : riskfactors for vascular disease, current medications, surgical history

      • Obesity, HTN, coronary artery disease, MI, CVA, DM, hypercholesterolemia, tobacco Hx

    • Intraoperative information

      • Procedure description, number of levels, type of headrest & surgical frame, position, frequency of eye checks

      • Duration of anesthetic, surgery, prone positioning

      • Type of anesthetic, drugs, fluids, estimated blood loss, type of blood products, preoperative & lowest Hb/Hct, urine output

      • Use of deliberate hypotension, specific hypotensive agents

      • Intraoperative blood pressure

      • Presence of hypothermia (<35℃)

      • Intraoperative events

        • Cardiiogenic shock, cardiac arrest, seizures, direct trauma to the eye


Ophthalmologic examination characteristics and diagnostic criteria

  • Ophthalmologic examination

    • Type of visual deficit, time when visual symptoms were first noted, funduscopic examination, ophthalmologic diagnosis

  • Classification of specific lesion

    • Central retinal artery occlusion (CRAO)

      • Pale ischemic retina with pathognomonic cherry-red spot at macula

        • And relative afferent pupillary defect or reduced pupillary light reflex

    • Anterior ischemic optic neuropathy (AION)

      • Edematous disc with or without peripapillary flame-shaped hemorrhages

        • And relative afferent pupillary defect or reduced pupillary light reflex

    • Posterior ischemic optic neuropathy (PION)

      • Normal early funduscopic examination

        • With relative afferent pupillary defect or absent pupillary light reflex

  • Any treatment and prognosis for recovery of vision was noted

  • Inclusion criteria

    • Any POVL case associated with spine surgery from ASA POVL Registry

    • Diagnosis of CRAO, AION, PION, or unspecified ION


Results

93 cases of POVL associated with spine surgery As of June 2005


  • No statistically significant differences between AION and PION

    • Demographics, coexisting diseases, surgical characteristics, anesthetic management

    • Uncertainty whether AION and PION are different disease states with separate etiologies

       all AION, PION, and unspecified ION were combined under ION


Demographics and coexisting diseases

No patient had a preoperative history of glaucoma


Description of operations and positioning


Description of operations and positioning (2)

All were positioned prone for a portion of procedure

Except two anterior spine procedure

Eye checks were documented by anesthesiologist in 51%


Anesthetic management

Mean anesthetic duration

9.8 ± 3.1 h

  • General anesthesia

    • Combination of volatile and narcotic (89%)

      • Isoflurane (59%), sevoflurane (14%), desflurane (22%), nitrous oxide (29%)

    • TIVA with propofol and narcotic (2%)

    • Unknown general anesthetic agents (8%)

Median EBL

2.0 L


Anesthetic management (2)

Colloid (hydroxydthyl starch or albumin) used in 30%

Nadir Hct of 30% or greater

in 17% of cases

Urine output was less than 0.5ml/kg/h

In 24% of cases


Anesthetic management (3)

Labetalol or esmolol (n=10)

Volatile agents (n=5)

Phenylephrine administered in 27%

Hypothermia in 10%


Ophthalmologic findings

Complete blindness with loss of light perception

64 of 138 affected eyes (47 Pts)

Median onset time of reporting

Postoperatively 15 h


Spine surgery cases with CRAO

Not significantly different

Horseshoe headrests in 3 cases

Foam pads in 2 cases

Miscellaneous headrests in 5 cases

Not significantly different

Eye checks in 6 cases


Discussion


Limitation of this study

  • POVL is low-incidence complication

     prospective data collection was impractical

    • Incidence of any POVL cannot be ascertained

  • Reporting bias, error from retrospective data collection

  • Increase in POVL in spine surgery may be related to

    • Increased awareness of the problem

    • Increased rates of spinal fusion operations


Etiology of ION

  • Etiology of ION remains unknown

  • Male patients is 72%

    • 48% male : 52% female in spinal fusion procedures

      • National inpatient sample data for 1999

    • Influence of sex on ulnar nerve injuries : 70% male

    • Previous study of ulnar neuropathy

      • Anatomical differences & hormonal differences

    • Protective effect of estrogen on cerebral ischemia

      • Experimental animal models


Etiology of ION (2)

  • Age

    • Older patients may be more vulnerable

      • Young age did not immune to this complication

    • “Normal” anatomical or physiologic variation in optic nerve blood supply

       may place more at risk than others

    • Preoperative identification of high risk group

       not currently possible


Etiology of ION (3)

  • Mayfield pins used in 16 pts

    • With eyes free of pressure

       ION occurs in absence of pressure on globe

    • Lack of retinal ischemia in ION

    • ION in both eyes in the majority

       more consistent with a systemic etiology

      • 10 Pts of CRAO (result from globe compression)

         all had unilateral disease

         usually with ipsilateral periocular trauma


Etiology of ION (4)

  • Blood pressure management varied widely

    • Autoregulation of cerebral blood flow has been well demonstrated

    • Not clear whether optic nerve also has autoregulation

    • No difference in lowest BP between visual loss and no visual loss

      • Case-control study by Myers et al.

  • Anemia

    • Cannot be discerned by this study

    • ION occurs in the absence of anemia


Etiology of ION (5)

  • Estimated blood loss (EBL) and anesthetic duration

    EBL of 1,000ml or greater in 82%

    Anesthetic duration of 6 h or longer in 94%

    • Not yet enough information to confirm a relation


Etiology of ION (6)

  • Prone position in 72%

    • Hypothesis

      • Venous pressure within optic nerve may increased during prone

         Perhaps due to venous engorgement

      • Intraocular pressure increased in prone position

      • Artery on posterior optic nerve are small end-vessel from surrounding pia

      •  blood flow in posterior optic nerve may be susceptible to increased venous pressure

      • Case reports of ION after radical neck operation with bilateralinternal jugular vein ligation

        • Increased venous and intracranial pressure

    • Hypothesis “compartment syndrome of the optic nerve”

      • Increased venous pressure and interstitial fluid accumulation

      • Within relatively nondistensible space

        • Semirigid lamina cribrosa at optic nerve head

        • Bony optic canal

           recommended head-up position and colloid-based fluid resuscitation

        • Its role in prevention of ION remains undetermined


Etiology of ION (7)

  • ION almost always occurred

    • Without any accompanying evidence of vascular injury in other critical organs

      • Such as heart or brain

    • Optic nerve vasculature may be uniquely vulnerable tohemodynamic perturbations in prone position in some patients


Summary

  • More than two thirds of ASA POVL Registry

    • Related to spine surgery in prone position

  • 89% : ION

    • Relatively healthy Pts

    • Wide range of nadir Hct & BP management

       multifactorial etiology

    • EBL > 1,000ml or anesthetic duration > 6 hr

       96%

  • For lengthy spine surgery in prone position

     risk of visual loss should be considered


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