Perioperative Visual Loss After Spine Surgery: A Case-Based Review of Posterior Ischemic Optic Neuropathy

Perioperative visual loss (POVL) is an uncommon but life-altering complication that has been reported most often after prolonged spine procedures performed in the prone position. Among the recognized causes, posterior ischemic optic neuropathy (PION) accounts for the majority of cases in this setting and is believed to result from impaired perfusion of the retrobulbar optic nerve. Clinical and registry data consistently associate PION with intraoperative anemia, sustained or relative hypotension, substantial blood loss, large-volume fluid administration with hemodilution, and preexisting vascular disease that limits autoregulatory reserve. Advanced age and systemic atherosclerotic burden further increase susceptibility by reducing the optic nerve's tolerance to ischemic stress. This case-based educational review describes an elderly patient with significant systemic diseases, including vasculopathy, who developed acute, painless visual loss after lumbar spinal surgery. Using this clinical scenario, we examine the interplay between patient-specific risk factors and intraoperative physiology, review the underlying vascular anatomy and pathophysiology of PION, and outline an approach to early recognition and differential diagnosis of postoperative visual deficits. Management principles are discussed with an emphasis on hemodynamic optimization, prompt specialist consultation, and realistic counseling regarding prognosis. The goal of this structured discussion is to provide anesthesiology trainees and perioperative clinicians with a practical framework to recognize high-risk situations, implement preventive strategies, and respond appropriately should this rare but catastrophic complication occur.