Skip to Main Content

Chapter 62. Postoperative Complications

Teresa A. Mulaikal, MD; Sansan S. Lo, MD

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.

|Download (.pdf)|Print
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
Prognosis
  • Good prognosis
  • Expect recovery
  • Poor prognosis
  • Permanent visual loss
  • Poor prognosis
  • Permanent visual loss
Prevention
  • 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.

|Download (.pdf)|Print
Common Neuropathies during General Anesthesia
Ulnar, C8–T1Radial, C5–C8 and T1Brachial plexus, C5–T1Sciatic, L4–S3Femoral, L2–L4Obturator, L2–L4 (ventral rami)
Symptoms
  • 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
  • Lateral femoral cutaneous nerve: ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close