Transcript Periop Vision Lossx

Perioperative Visual Loss
Kevin Driscoll
Matt Mitchell
Carolyn Srinivasan
Objectives
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Epidemiology
Anatomy
Physiology
Pathophysiology
Treatment
Prevention
Considerations
Vision Loss: Epidemiology &
Anatomy
Vision Loss
• Incidence of perioperative visual loss (POVL)
after non-ocular surgery
– 0.002% of all surgeries (Newman, 2008)
– 0.2% of cardiac and spine surgeries (Newman, 2008)
• Any portion of the visual pathway may be
involved
– Cornea to the occipital lobe
– Optic nerve
• Most common site of permanent injury
• Presumed mechanism is ischemia
• Anterior ischemic optic neuropathy (AION)
– Cardiac surgery patients
• Posterior ischemic optic neuropathy (PION)
– Spine and neck procedures.
• Age 5 to 81 years
Vision Loss: Review of Literature
Roth S, et al. Eye injuries after nonocular surgery: a study of 60,965
anesthetics from 1988 to 1992. Anesthesiology 1996;85:1020 –1027.
– University of Chicago (1988-1992)
– 60,965 patients undergoing non-ocular surgery
– 1 patient (0.002%) suffered non-corneal POVL
Warner ME, et al. The frequency of perioperative vision loss. Anesth Analg
2001;93:1417–1421.
– Mayo Clinic, retrospective study, excluded cardiac surgeries
– 501,342 non-cardiac surgeries
– 4 patients (0.0008%) developed POVL for longer than 30 days
Nuttall GA, et al. Risk factors for ischemic optic neuropathy after
cardiopulmonary bypass: a matched case/control study. Anesth Analg
2001;93:1410–1416.
– Mayo Clinic, retrospective study
– 27,915 cardiopulmonary bypass (CABG) procedures
– 17 (0.06%) patients were identified with peri-operative ION
Vision Loss: Review of Literature
Stevens WR, et al. Ophthalmic complications after spinal surgery.
Spine1997;22:1319 –1324.
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3 centers (1985-1994)
3,450 spine surgeries
7 cases (0.2%) with visual loss (2 patients with occipital infarctions, 4 patients with ION,
and 1 patient with a central retinal vein occlusion)
Roth S, et al. Postoperative visual loss: still no answers– yet. Anesthesiology
2001;95:575–577.
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15 year study of nearly 225,000 surgeries
3 of 3,351 patients (0.09%) developed POVL after spinal surgery
50-fold higher rate compared with all other non-ocular procedures
Chang SH, et al. The incidence of vision loss due to perioperative ischemic
optic neuropathy associated with Spine surgery: the Johns Hopkins
Hospital Experience. Spine 2005;30:1299 –1302.
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20 year retrospective review at Johns Hopkins Hospital
14,102 spine surgeries
ION was identified in four cases (0.028%)
ASA POVL Registry
• In 1999, the ASA POVL Registry was established in
response to concerns that POVL seemed to be
increasing
• Purpose:
– Meaningful analysis
– Identify risk factors
– Develop preventive measures
• The database consists of:
– Voluntary, anonymously reported cases
– Visual loss within seven days of non-ocular surgery
– Standardized form that includes:
• detailed demographic, historical, examination, and intraoperative
information
• www.asaclosedclaims.org
ASA POVL Registry
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June 2005 - 131 cases of POVL reported
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95 spine cases
12 cardiac cases
6 major vascular cases
5 orthopedic cases
13 miscellaneous cases
2006 ASA Interim Report – in-depth analysis of 93 cases of POVL
associated with spine surgery
– 83 cases of ION
• 67% were PION
• 23% AION
• 10% unspecified ION
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– 10 cases of central retinal artery occlusion
73% of all cases in the setting of spine surgery
Age range: 5 to 81 years
MALES predominated among the spine cases
82% had one pre-existing vascular risk factor
64% had an ASA physical status I or II (healthy)
Vision Loss: Anterior Segment
• The cornea is the
most commonly
reported location of
ocular injury during
anesthesia
• Corneal abrasions
and or exposure
• Usually NOT a
cause of permanent
visual loss
Vision Loss: Retina
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Most common retinal cause of visual
loss is central retinal artery
occlusion (CRAO)
Due to systemic or local arterial
embolism
Cardiac and other vascular surgeries
Prone position spine surgeries
– external compression of the globe
due to malposition of head
ASA POVL Registry
– 93 spine surgery cases with
postoperative visual loss
• 10 patients had CRAO
• all unilateral
• 7 (of the 10) had additional
evidence of peri-ocular trauma,
(ipsilateral decreased
supraorbital sensation, ptosis,
erythema, corneal abrasion,
and ophthalmoplegia)
Vision Loss: Optic Nerve
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Most common site of permanent
injury to the visual pathways in the
setting of general anesthesia for nonocular surgery is the optic nerves
Most often presumed mechanism of injury
in this location is ischemia
Pupillary reactions are abnormal
ION is the most frequent condition
associated with permanent POVL
The most common surgical setting is
spine surgery in the prone position
Anterior ION
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Posterior ION
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Acute disk edema
Cardiac Surgery
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Acute fundoscopic appearance: normal
Spinal (Prone) and Radical Neck Surgeries
Incidence increasing
Vision Loss: Retrochiasmal
Visual Pathways
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Homonymous hemianopsia (unilateral)
versus cortical visual impairment
(bilateral)
Pupillary reactions are normal
Usually ischemic in origin - embolic
cerebral infarction (posterior cerebral
arteries)
– Other mechanisms - neck trauma
during intubation
Risk of stroke after general, noncardiac
procedures is 0.08% to 0.7%
Resection of head and neck tumors and
cardiac and vascular surgeries are
associated with higher risks
Most peri-operative strokes are infarctions
and are embolic in origin
Incidence of visual loss from retrochiasmal infarction in the peri-operative
period is unknown
Physiology and Pathophysiology
Review
•We don’t see with our eyes but the interpreted visual signal to the
cortex (occipital lobe).
•Information is transmitted to the brain via the optic nerve.
•Each of the optic nerves receives blood supply from branches of the
ophthalmic artery within each eye socket. The optic disc has a unique
blood supply (the posterior ciliary arteries).
A Closer look at the blood supply
•Blood supply to the chorid is thru the opthalmic artery (1)
• one branches becomes the central retinal artery(2).
•2 branches which become the posterior ciliary arteries (3).
•These are the main arteries indicated for peri-operative visual loss
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Perioperative Vision loss
• Corneal Damage
• Central Retinal Artery Occlusion
(CRAO)
• Ischemic Optic Neuropathy (ION)
• Defined by where the lesion
occurs on the optic nerve:
• Anterior ION
• Posterior ION
Direct Corneal Damage
•Most Common preventable reason for Unilateral Vision Loss
www.surgical-pathology.com/retinal_artery.htm
Central Retinal Artery Occlusion (CRAO)
•The neurons of the retina, like those in the
rest of the nervous system, are extremely
susceptible to hypoxia.
•Central retinal artery occlusions may
follow thrombosis of the retinal artery, as in
atherosclerosis or giant cell arteritis, or
emboli of various types. Intracellular edema,
manifested by retinal pallor, is prominent,
especially in the macula where the ganglion
cells are most numerous.
The vacularized choroid beneath the center
of the macula (foveola) stands out in sharp
contrast as a prominent “cherry red spot”.
Central Retinal Artery Occlusion (CRAO)
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Usually caused by external pressure on the globe (positioning)
Common findings are unilateral vision loss with signs of external
periorbital swelling or ecchymosis.
Prone position causes increase in intraocular pressure. Coupled
with malposition this insult may lead susceptible patient
populations to vision loss.
Direct Compression has been implicate. Mimics an accelerated
glaucoma. pressure from malposition or direct pressure on the
globe is translated from the Optic disk to the Central Retinal
Artery.
Ischemic Optic Neuropathy (ION)
• Etiology is still unclear. But there is a decreased
delivery of O2 to the optic nerve.
• Procedural dependent factors associated with ION
elicited from the ASA closed claims:
• Anemia
• Prolonged procedures (>6.5hrs)
• Sustained blood loss (44.7% of EBV)
• Combination of the above
• ION is further defined by where the lesion occurs and
findings on retinal exam.
Ischemic Optic Neuropathy (ION)
Anterior ION:
•Occurs in watershed area of Posterior Ciliary Artery (2 branches)
•Anterior Optic Nerve supplied by multiple sources
•Located in or near optic disk visible on retinal exam as edema.
Ischemic Optic Neuropathy (ION)
Posterior ION:
•Pial branches from Internal Carotid supply mid-orbital optic nerve
•Pial branches are found with variable density and in an unusual T-shaped
perpendicular fashion.
•This arrangement is characteristic of a low pressure system
•Lumbar operations high incidence (LION)
Contributing factors to ION
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Hypotension
Hypovolemia
Hypoxemia
Hemodilution
Facial edema
Use of Vasopressors
Prone
Head down
Increase in venous pressure
Treatment & Prevention
Prevention is a good thing
• Prevention starts with:
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Understanding of etiology
Understanding of Pathophysiology
Understanding of Risk Factors
Understanding the modalities to truly prevent POVL
UTILIZING the modalities to treat POVL
How to appropriately prevent POVL
• Understanding the risk factors
– Procedure dependent risk factors
– CABG, prone cases, neck, nose and sinus surgery,
• Intra-operative events- large EBL, systemic
Hypotension, long duration of procedure (>5 hrs), and
anemia
How to appropriately prevent POVL
• Understanding the risk
factors
– Patient dependent risk
factors
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Hypertension
Atherosclerosis
Tobacco use
Diabetes Mellitus
Morbid obesity
How to appropriately prevent POVL
• Understanding the risk factors
– Procedural issues related to decrease oxygen
delivery to the optic nerve
• large EBL, prolonged Hypotension(52%), anemia,
(9.9hrs)
OR
• ASA POVL registry as of 2000 had 23 incidents of
POVL
– Prone spine cases most common position (57%)
– CABG (22%)
• Ischemic optic neuropathy was the chief diagnosis in 20/23
reported cases
ASA POVL Registry
• Patient dependent related risk factors
Variable
All Cases (n=23)
Median Age (range)
58 (24-73) years
Obesity (percent cases) 13 (56 percent)
Hypertension
11 (48 percent)
Diabetes Mellitus
5 (22 percent)
Smoking History
12 (52 percent)
Atherosclerosis
12 (52 percent)
Lee, LA: Postoperative visual loss data gathered and analyzed. ASA Newsletter 64(9): 25-27, 2000.
ASA POVL Registry 2006
Variables
Mean age
Obesity
Hypertension
Diabetes Mellitus
Smoking History
Atherosclerosis
(CAD)
Cerebrovascular disease
Increased Cholesterol/Lipids
1 Coexesting diseases
n (% of 83 cases)
50 +/- 14yrs
44 (53%)
34 (41%)
13 (16%)
38 (46%)
8 (10%)
3 ( 4%)
11 (13%)
68 (82%)
Lee, L. et al. (2006). The American society of anesthesiologist postoperative visual loss registry. Anesthesiology. 105, 652-9. Lee, L. et al. (2006). The
American society of anesthesiologist postoperative visual loss registry. Anesthesiology. 105, 652-9.
Considerations
Current recommendations from ASA
Task Force on Peri-operative Blindness
Current recommendations for major spine surgery
1. Consider risk explanation in consenting process
2. Use arterial catheters to monitor BP, consider CVP
monitoring with CVC
3. Use colloids along with Crystalloids for replacement of
volume
4. Position Head of Bed so that it is EQUAL or ABOVE the
level of the HEART.
5. Consider staging surgeries. (decrease anesthesia time)
Lee, L. (2008). Solutions to POVL mystery requires research. The Official Journal of the Anesthesia Patient Safety Foundation. 23(1), P.3
Prone position Related Devices
Anesthesia Related Prone Position
Devices
Summary
• Remember the Etiology of POVL
• Remember the Case/Anesthetic specific
considerations of POVL
• Remember the Patient specific
considerations
• APSF recommendations based on current
literature to reduce the incidence of POVL
References
• Baig M, Lubow M, Immesoete P, et al. Vision loss after spine surgery:
review of the literature and recommendations. Neurosurgery Focus.
2007; 23 1-9.
• Chang SH, Miller NR. The incidence of vision loss due to perioperative
ischemic optic neuropathy associated with Spine surgery: the Johns
Hopkins Hospital Experience. Spine 2005;30:1299 –1302.
• Hayreh, SS. Posterior ischemic optic neuropathy: clinical features,
pathogenesis, and management. Eye. 2004; 18:1188-1206.
• Lee, LA: Postoperative visual loss data gathered and analyzed. ASA
Newsletter. 2000;64:25-27.
• Lee, L. Solutions to POVL mystery requires research. The Official
Journal of the Anesthesia Patient Safety Foundation. 2008;23:p.3.
• Newman, NJ. Perioperative Visual Loss After Nonocular Surgeries.
Am J Opthalmol 2008;145:4:604-610.
• Nuttall GA, Garrity JA, Dearani JA, et al. Risk factors for ischemic
optic neuropathy after cardiopulmonary bypass: a matched
case/control study. Anesth Analg 2001;93:1410–1416.
References
• Roth S, Barach P. Postoperative visual loss: still no answers– yet.
Anesthesiology 2001;95:575–577.
• Roth S, Thisted RA, Erickson JP, Black S, Schreider BD. Eye injuries
after nonocular surgery: a study of 60,965 anesthetics from 1988 to
1992. Anesthesiology 1996;85:1020 –1027.
• Stevens WR, Glazer PA, Kelley SD, Lietman TM, Bradford DS.
Ophthalmic complications after spinal surgery. Spine1997;22:1319 –
1324.
• Warner ME, Warner MA, Garrity JA, et al. The frequency of
perioperative vision loss. Anesth Analg 2001;93:1417–1421.