Perioperative risk factors for posterior ischemic optic neuropathy

Infarction of the optic nerve posterior to the lamina cribrosa, called posterior ischemic optic neuropathy (PION), is a condition that can result in profound bilateral blindness. Cases of PION treated at this institution and those described in the literature were analyzed to identify clinical features that profile those individuals at risk of PION in an attempt to identify major contributing factors that could be addressed prophylactically to enable effective prevention.

Salient clinical features in seven cases of PION diagnosed at the Doheny Eye Institute between 1989 and 1998 are compared with 46 cases of PION reported in the literature.

In the Doheny series there were six men and one woman aged 12 to 66 years (mean, 47 years). Five patients were status-post spine surgery, one was status-post knee surgery, and one had a bleeding stomach ulcer. Vision loss was simultaneously bilateral in six of seven patients (85.7%) and was apparent immediately after surgery. There were no abnormal retinal or choroidal findings including diabetic retinopathy, in any of the patients. Notable contributing factors were blood loss in all seven patients, ranging from 2,000 to 16,000 mL, with a drop in hematocrit of 9.5% to 19% (mean, 14%), and intraoperative systemic hypotension in all patients. Facial edema was a factor in three of six spine surgery patients (50%). Patients reported in the literature had a mean age of 50 years and were also predominantly men (34 of 46, 74%) who underwent spine surgery (30 of 46, 65.2%).

Middle-aged men undergoing spine surgery with prolonged intraoperative hypotension and postoperative anemia and facial swelling are at risk of developing PION from hypovolemic hypotension. Avoiding or immediately correcting these contributory factors can reduce the incidence of PION.