Posterior Ischemic Optic Neuropathy

[wilmington]

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I have just completed a surgery resulting in a patient with PION following lengthy prone position spine surgery resulting in total bilateral vision loss. Am interested in discussion with anyone with similar experience or comments. Thanks.Wilmington

 

[UTSouthwestern]

A very unfortunate situation.

I have not had a direct experience with this phenomenon, but I have heard of situations such as yours primarily with undetected direct pressure on the globe. Profound hypotension, volume overloaded patients in the prone position, and patients with severe atherosclerotic disease with probable optic emboli are the other situations I heard of.

For all of my prone cases, I use the optipads or a face pillow with a large enough of an opening to ensure that both eyes are free of pressure and I constantly check the patient to ensure that aggressive operating or table motion has not changed the position of the head.

Likewise, I use controlled, but not ridiculous hypotension to ensure that perfusion pressures are adequate and lastly, I keep the patient in a minimum 30 degree reverse T berg position to allow for adequate venous drainage from the head.

 

[Planktonmd]

I have just completed a surgery resulting in a patient with PION following lengthy prone position spine surgery resulting in total bilateral vision loss. Am interested in discussion with anyone with similar experience or comments. Thanks.Wilmington

Not much to discuss, it happens, there are certain things that could be risk factors: Long surgery, prone position, Low hemoglobin, Hypotension, and possibly use of pressors.
It's a horrible outcome and usually irreversible.

 

[jwk]

I'd be interested in hearing more details about what was or wasn't done. Padding, hypotension or not, length of case, a-line, CVP, etc.

There is a PeriOperative Vision Loss registry through the ASA - they're trying to come up with good solid reasons why this happens, although it appears it's multifactorial and no single cause or group of causes appears to hold true in all cases.

We no longer offer deliberate controlled hypotension in our hospitals for virtually any procedures. Too many risks, not enough benefits. Our orthopedic surgeons have quickly dropped their insistence on controlled hypotension for shoulder cases after the horror stories in the APSF Newsletter.

http://www.apsf.org/resource_center/newsletter/2007/summer/01_beach_chair.htm

 

[osufan]

A good review about current theories/recommendations regarding PION.


http://thejns.org/doi/pdf/10.3171/foc.2007.23.5.16

hope it helps

 

[InductionAgent]

I wonder how many of these patients may have had some degree of pre-existing elevated IOP. Screening for glaucoma (and treatment as indicated)should be considered as part of the preoperative evaluation for elective spinal surgeries.

(Edited with hedging language to cut my losses)

 

[jwk]

I wonder how many of these patients may have had some degree of pre-existing elevated IOP. Screening for glaucoma (and treatment as indicated)should become a routine part of the preoperative evaluation for all elective spinal surgeries.

I don't know that I've seen that suggestion anywhere in the literature. Many spine patients are young and otherwise healthy - lots of them in their late 20's or early 30's.

Elevated IOP is not usually the issue. Extrinsic pressure perhaps. Hypoperfusion of the optic nerve, whether from hypotension, over-aggressive fluid resuscitation, low hematocrit, or other reasons seem to be a more likely cause.

Here's the link to the ASA Closed Claim section on POVL. Lots of info, but unfortunately, also lots of variables to consider.

http://depts.washington.edu/asaccp/eye/index.shtml

 

[InductionAgent]

I don't know that I've seen that suggestion anywhere in the literature. Many spine patients are young and otherwise healthy - lots of them in their late 20's or early 30's.

Elevated IOP is not usually the issue.
]

Yeah, on further reading it's periorbital edema, not intraocular fluid that's the main issue. Nonetheless, I wouldn't be excited about spine surgery in a patient with uncontrolled glaucoma or baseline elevated IOP.

 

[gasnewby]

I have just completed a surgery resulting in a patient with PION following lengthy prone position spine surgery resulting in total bilateral vision loss. Am interested in discussion with anyone with similar experience or comments. Thanks.Wilmington

guy's probably a med mal attorney. writes like a layperson

 

[numbmd]

We had a case like that in our institution. Usually it is a combination of periorbital edema combined with gravity. Add in a really long case and it could be a problem.

Not that it makes any difference in outcome, but on all long spinal cases I now ask the surgeon to put the head in pins, just to take the issue of malpositioning out of the equation. Probably just protecting my own a$$ and not really that much at that.

Once it happens, nothing you can do but buy sunglasses and a dog.....

 

[wilmington]

Will post more details when I have a moment. As you can imagine, this is a catastrophic occurance, and has shattered my sleep for many a night.
Wilmington.

 

[wilmington]

Patient 59yo WF, no prior history of diabetes, hypertension; long history of Adenoid Cystic Carcinoma originating in right salivary gland, mets to spine at C7, T1, and T5 and numerous to both lungs. Procedure involved debulking tumors, and spine stabilization, prone position with pins, 12 hours. Pt blood pressure 140/70; BP at start of surgery after sedation 119. Induced hypotension, minimum of 100. Blood loss 3500ml. Significant perioperative facial edema. Subsequent PION diagnosis total bilateral vision loss.

 

[KungPOWChicken]

there was a recent study of this subject that found two main correlates with blindness. The first was prone position for greater than six hours and the second was intraoperative blood loss of over a liter. My guess is that your patient met both of these. Interestingly hypotension and position are not factors for this type of blindness. The cause is related to edema.

 

[dhb]

long history of Adenoid Cystic Carcinoma originating in right salivary gland, mets to spine at C7, T1, and T5 and numerous to both lungs.

sucks, better outcome would have been death...

 

[2ndyear]

That's a lot of blood loss. Something that will come up when this gets reviewed is why the operation was not staged. We do a fair amount of spinal tumor surgery, and many of the extensive ones are staged. Do cervical one day, recover, come back for thoracic or lumbar, or some variant of this.

Patient 59yo WF, no prior history of diabetes, hypertension; long history of Adenoid Cystic Carcinoma originating in right salivary gland, mets to spine at C7, T1, and T5 and numerous to both lungs. Procedure involved debulking tumors, and spine stabilization, prone position with pins, 12 hours. Pt blood pressure 140/70; BP at start of surgery after sedation 119. Induced hypotension, minimum of 100. Blood loss 3500ml. Significant perioperative facial edema. Subsequent PION diagnosis total bilateral vision loss.

 

[zippy2u]

Mets to spine and lungs and pt is gettin' spine surgery---what's wrong with that picture. Now the mofo is blind, will have back pain until he dies and ya just cut perhaps several months off his life ---can ya phuck this dude up any more? What ya should have done is give the guy a bag of morphine pills and told him to enjoy what life he has left. Regards, -----Zip