Anterior ischemic optic neuropathy due to abdominal hemorrhage after laparotomy for uterine myoma

This retrospective observational case report describes a very rare but dreadful ocular complication due to severe blood loss in association with a major surgical procedure. It is the first time that this complication is reported in gynecological surgery.

A previously healthy 41-year-old woman underwent hysterectomy because of large uterine myomas. Postoperatively, she was found to be severely anemic (hemoglobin 7.2 g/dl), but refused blood transfusion. Thirty-six hours after the first operation, relaparotomy was performed with extraction of a 1.5 l blood clot from the abdominal cavity. When she woke up from general anesthesia, the woman complained of visual loss in her left eye. At the time of visual loss, the hemoglobin level was 5.2 g/dl and the patient agreed to infusion of packed red blood cells. Ophthalmic examination revealed in the left eye an anterior ischemic optic neuropathy (AION). The optic disk was small, swollen and hyperemic (visual acuity at 8/10 with a superior altitudinal visual field defect). The right eye also had a small optic disk with a small cup (disk at risk), but no functional impairment. Despite blood transfusion, the left eye did not show any recovery and the optic disk had a pale appearance when examined after 3 years.

Development of AION in this case was due to severe blood loss accompanied by head-down surgery in an eye with so-called "disk at risk". Meticulous management of perioperative systemic hypotension and early correction of anemia may reduce the risk of perioperative visual loss.