| Associated factors (not necessarily causal) | Clinical presentation | Duration of POVL | Workup | Treatment |
Visual loss with pain |
Corneal abrasion[1-5] | - Any type of surgery
- Prolonged surgery
- Exposure of cornea
- Trauma
- Surgery in non-supine position
- Increased age
| - Onset immediate after emergence from anesthesia
- Usually unilateral
- Painful
- Foreign body sensation
- Conjunctival erythema, tearing, photophobia
- Normal pupillary reflexes
- Blurred vision to no visual deficit
| | - History
- Symptoms
- External eye exam
- Pupillary light reflexes
- Fluorescein stain and slit lamp exam
- Topical proparacaine*
| - Prophylactic antibiotic and lubricant eye drops
|
Acute angle closure glaucoma[6-9] | - Any type of surgery
- General anesthesia
- Drugs: adrenergic, anticholinergic, antihistamines, antiparkinsonian, mydriatic, cholinergic, antidepressants
- Genetic/anatomic predisposition
- Female
- Hypermetropia
| - Onset may be delayed >12 hours postop
- Unilateral > bilateral
- Pain: boring quality with ipsilateral headache
- Intermittent blurring of vision with halos
- Nausea, vomiting
- Mid-dilated nonreactive pupil
- Conjunctival erythema
- Corneal epithelial edema
- IOP >21 mmHg
| - Until IOP controlled
- Treatment required within a few hours of onset to prevent permanent vision loss
| - History
- Symptoms
- External eye exam
- IOP >21 mmHg
- Avoid dilated funduscopic exam as it may worsen symptoms
| - Topical and systemic medication to reduce IOP
- Iridotomy for refractory ↑ IOP
- Temporizing maneuvers (ie, anterior chamber paracentesis)
- Avoid eye patch or other Rx that dilates pupils
|
Retrobulbar hematoma[10-14] | - Orbital trauma
- Head and neck procedures
- May occur (rarely) with other surgical procedures when other associated risk factors are present: orbital floor fracture and s/p repair, anticoagulation, uncontrolled hypertension, straining or Valsalva, sneezing, vomiting
| - Most vision loss within 3 to 24 hours, but may be delayed up to seven to nine days
- Unilateral
- Severe, stabbing pain; pressure
- Visual loss from hematoma causing optic nerve ischemia, direct compression, or central retinal artery occlusion
- Nausea, vomiting
- Diplopia, ophthalmoplegia
- Visual flashes
- Relative afferent pupillary defect or absent pupillary reflex
- Eyelid hematoma/ecchymosis
- Subconjunctival hemorrhage
- Proptosis
| - Depends on time to effective treatment
- Treatment required within a few hours of onset to prevent permanent vision loss
| - History
- External eye exam with pupillary light reflexes
- Imaging if necessary, but may delay Rx
| - Surgical emergency if visual loss present
- Lateral canthotomy or inferior cantholysis
- May give topical medications to lower IOP if surgery delayed
|
Pituitary apoplexy[15-17] | - Cardiac surgery; one case report after transurethral prostate surgery
- Reduced blood flow to pituitary: severe hemorrhagic hypotension, head trauma, pituitary irradiation
- Sudden increase in blood flow to the pituitary
- Stimulation of the pituitary
- Anticoagulation
| - Onset immediate to delayed by three months
- Severe headache
- Blurred vision to visual field defect to blindness
- Cranial nerve III commonly involved with dilated, nonreactive pupil
- Ophthalmoplegia
- Altered mental status
- Possible Addisonian crisis
| - Full recovery to permanent blindness (especially for chiasmal injuries)
| - CT/MRI imaging of head
- Lab: electrolytes, glucose, pituitary hormones
| - Surgical decompression for visual changes or altered mental status
- Endocrine replacement as necessary including high-dose corticosteroids
|
Posterior reversible encephalopathy[18-22] | - Preeclampsia, eclampsia
- Not commonly associated with surgery
- Immunosuppressants
- Chemotherapy
- Infection
- Vascular disease
- Renal disease
| - Three postoperative cases: onset immediate after emergence from anesthesia
- May have diffuse headache
- Blurred vision, homonymous hemianopia, blindness
- Nausea, vomiting
- Seizures
- Brainstem symptoms
- Hemiplegia
- Altered mental status
- Normal pupillary light reflexes
- Normal funduscopic exam
- Brisk DTRs
- Positive Babinski
| - Average seven days; range from one day to permanent if progresses to infarction
| - DWI MRI brain showing vasogenic edema posterior circulation, especially subcortical white matter
| - Antihypertensives
- Antiseizure medications for seizures
- Mannitol for cerebral edema
- Magnesium sulfate for preeclampsia/eclampsia
|
Visual loss without pain |
Anterior ischemic optic neuropathy[23-28] | - Cardiac surgery
- Prone spine surgery
- Head and neck surgery
- Older age
- Vascular risk factors
- Anemia
- Vasopressor use
- Hypotension
- Small optic nerve cup-to-disc ratio
- Aberrant physiology or anatomy in the setting of reduced perfusion pressure
| - Onset immediate; may be delayed to POD one to three
- Bilateral > unilateral
- Progresses for a few days before stabilizing
- Altitudinal field cuts, scotoma to complete loss of vision with no light perception
- Relative afferent pupillary defect if asymmetric or amaurotic pupils
- Funduscopic examination: optic disc swelling, attenuated vessels, splinter hemorrhages
| - Usually permanent; may have small degree of recovery
| - History
- Symptoms
- Pupillary light reflexes
- External eye exam
- Dilated funduscopic exam
| - None proven
- Theoretical: optimized hemodynamics, glucocorticoids, mannitol, hyperbaric O2
|
Posterior ischemic optic neuropathy[23-29] | - Prone spinal procedures
- Bilateral head and neck procedures
- Cardiac surgery
- Prolonged duration in position with increased venous pressure in head: prone, Trendelenburg, Wilson frame
- Large blood loss
- Large fluid resuscitation, high crystalloid/colloid ratio
- Wilson frame
- Male sex
- Obesity in prone position
| - Onset usually immediate after emergence from anesthesia, no progression
- Bilateral >> unilateral
- Altitudinal field cuts, scotoma to complete loss of vision with no light perception
- Relative afferent pupillary defect if asymmetric or amaurotic pupils
- Funduscopic exam normal
| - Usually permanent; may have small degree of recovery
| - History
- Symptoms
- Pupillary light reflexes
- External eye exam
- Dilated funduscopic exam
| - None proven
- Theoretical: optimized hemodynamics, glucocorticoids, mannitol, hyperbaric O2
|
Cerebral or cortical visual loss[23,24,27,28] | - Spine fusion
- Cardiac surgery
- Nonfusion orthopedic surgery
- <18 years old
- Charlson risk index >0
- Infarction due to emboli or hypotension
| - Onset immediate after emergence from anesthesia
- Bilateral: total blindness or small area preserved central vision
- Unilateral: contralateral homonymous hemianopia
- Pupillary light reflexes normal
- Funduscopic exam normal
| - Some recovery possible; rarely complete
- Treatment required within a few hours of onset to prevent permanent vision loss
| | - Acute stroke reperfusion therapy. Thrombolysis may be contraindicated in postoperative patients. Mechanical thrombectomy may be possible in some patients.
- Normalization of blood pressure, cardiac output, oxygenation
|
Central retinal artery occlusion[23-25,27,30,31] | - Prone procedures, especially spine
- Cardiac surgery
- Head and neck surgery
- Emboli
- Horseshoe headrest
- Intraocular gas bubbles within two months of GA with nitrous oxide
| - Onset immediate after emergence from anesthesia
- Unilateral
- Complete or nearly complete loss of vision in the affected eye
- Pupillary light reflex sluggish to absent; relative afferent pupillary if caused by globe compression; may have signs of periorbital trauma
- Retinal whitening on funduscopic exam
| - Usually permanent, severe visual loss in affected eye
- If treatment is attempted, it must be performed within a few hours of onset to prevent permanent vision loss
| - External eye exam
- IOP measurement
- Pupillary light reflexes
- Funduscopic exam
| - None proven
- Theoretical: inhaled O2 with 5% CO2, acetazolamide
- Controversial, especially in postoperative setting: thrombolysis
|
Glycine-induced visual loss[32-37] | - Transurethral prostate surgery
- Hysteroscopy
- Long operative time
- Large irrigant absorption
- Increased height of irrigation bag
- High-pressure irrigation
- Head-down position
| - Onset intraoperative if awake; up to several hours postoperatively
- Blurred vision
- Sluggish to fixed and dilated pupils
- Funduscopic exam normal
| - <24 hours; may be longer if severe hyponatremia and other neurological/cardiac dysfunction
| - History
- Lab: serum glycine and ammonia levels
| - Correct volume overload and electrolyte abnormalities
- Supportive
|