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Incidence of perioperative ocular injury ranges from 0.002% to 0.2%, highest in cardiac and spine surgery.


Most common ocular injury in nonophthalmologic surgery is corneal abrasion.


Most common cause of permanent perioperative visual loss is ischemic optic neuropathy.

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Most Common Causes of Perioperative Visual Loss
Corneal abrasionRetinal ischemiaIschemic optic neuropathy
SymptomsPainful foreign body sensation, visual acuity may be intact
  • Painless loss of vision
  • Unilateral
  • Periorbital edema
  • Proptosis
  • Chemosis
  • Extraocular muscle injury
  • Ecchymosis
  • Painless loss of vision
  • Bilateral
EtiologyCorneal epithelial defect in anterior segment
  • Central retinal artery occlusion
  • Branch retinal artery occlusion (retinal microemboli or vasospasm)
  • Elevated intraocular pressure
Unknown, perhaps related to optic nerve ischemia, vascular insufficiency, although often no other clinically significant end-organ damage
Risk factors
  • Unprotected, exposed eyes
  • Intraoperative contact lens use
  • Prone positioning
  • Spine surgery
  • Cardiac surgery, bypass
  • External orbital pressure
  • Prone positioning
  • Spine surgery (PION)
  • Cardiac surgery (AION)
  • Prolonged surgery
  • ?Deliberate hypotension
  • ?Hypoxia
  • ?Hemodilution
  • ?Vasoconstrictors
  • ?Anemia
  • ?Elevated venous pressure (e.g., Trendelenburg)
DiagnosisSlit lamp examination with fluorescein
  • Afferent pupillary defect
  • Pale swollen optic disc
  • Cherry red retina
  • Ground glass retina
  • Afferent pupillary defect or nonreactive pupil (CNII)
  • AION: optic disc edema
  • PION: normal optic disc
  • Abnormal visual-evoked potentials
TreatmentAntibiotic drops
  • IV acetazolamide
  • 5% CO2 + O2 inhalation
  • Ocular massage
  • ?Ophthalmic artery fibrinolysis
Attempt to optimize oxygenation and orbital perfusion pressure, although no definitive treatment
  • Good prognosis
  • Expect recovery
  • Poor prognosis
  • Permanent visual loss
  • Poor prognosis
  • Permanent visual loss
  • Tape eyes securely
  • No benefit to lubricant
  • Remove contact lenses
  • Avoid external orbital pressure
  • Frequently examine eyes during prone cases
  • Stage long spine procedures
  • Nadir hematocrit does not differ in patients with ION and those unaffected in noncardiac surgery
  • Massive fluid replacement may be a risk factor for ION (no clear evidence)

PION, posterior ischemic optic neuropathy; AION, anterior ischemic optic neuropathy; CNII, optic nerve; ?, possible, unproven.


Mechanism of nerve injury: stretch, compression, transection, ischemia, metabolic, neoplastic, radiation.


Double crush hypothesis: preexisting neuropathies increase the incidence of subsequent nerve injury.


Prognosis: best with sensory loss, worst with motor weakness and atrophy, poor prognosis with nerve transection.

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Common Neuropathies during General Anesthesia
Ulnar, C8–T1Radial, C5–C8 and T1Brachial plexus, C5–T1Sciatic, L4–S3Femoral, L2–L4Obturator, L2–L4 (ventral rami)
  • Paresthesias of fourth and fifth digits
  • Hypothenar atrophy, weakness of wrist flexion
  • Paresthesias on the dorsum of the hand or posterior arm
  • Wrist drop
  • Limited extension at elbow
Paresthesias, weakness, and atrophy in distribution of specific nerve roots
  • Loss of hip extension, knee flexion
  • Common peroneal: loss of dorsiflexion, eversion, paresthesias in dorsum of foot
  • Tibial: loss of plantar flexion and inversion, paresthesias on plantar aspect of foot
  • Loss of hip flexion, adduction, knee extension
  • Paresthesias in anterior and medial thigh, medial calf
  • ...

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