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For the past 2 decades, endoscopic sinus surgery (ESS) has proven effective for treating paranasal sinus disease. Orbital complications of varying degrees, from mild orbital hematoma to catastrophic blindness, have been widely reported. However, defects of the visual field resulting from post-ESS ischemic optic neuropathy (ION) has not to our knowledge been reported in the literature. We were presented with a 51-year-old male patient suffering from loss of sight following an otherwise uneventful ESS. ION is a rare condition, characterized by acute or subacute postoperative loss of sight. The major risks for developing ION include intraoperative anemia, hypotension and systemic illnesses such as hypertension, diabetes or renal failure. Otorhinolaryngologists should be aware that this condition may occur following an uncomplicated ESS procedure, and patients should be given prompt opthalmological consultation when loss of sight is diagnosed postoperatively. Early aggressive and rapid correction of blood pressure and blood transfusions may be helpful in the treatment of patients who develop ION after surgery.
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PMID:Ischemic optic neuropathy after endoscopic sinus surgery: a case report. 1272 6

A patient with arteriosclerosis, diabetes mellitus, and giant cell arteritis (GCA) treated continuously with low-dose prednisone developed anterior ischemic optic neuropathy (AION) at 5 and 13 months after clinical diagnosis of GCA. At the time of late recurrent AION, there were no systemic symptoms or elevations in acute phase reactants to signal active arteritis, yet temporal artery biopsy disclosed dramatic inflammation, forcing the presumption that the infarct was arteritic. Recurrent systemic symptoms and elevation of acute phase reactants are not reliable warning signs of reactivated GCA. In patients at high risk for corticosteroid complications, late biopsy may be a reasonable guide to corticosteroid weaning.
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PMID:Late ipsilateral recurrence of ischemic optic neuropathy in giant cell arteritis. 1278 21

Based on histopathology, electron microscopic corrosion cast studies, optic nerve blood flow studies, and clinical data, the pathogenesis of idiopathic nonarteritic ischemic optic neuropathy includes the following features: (1) structurally crowded optic discs are predisposed; (2) laminar and retrolaminar regions are the most common locations for infarction; (3) there is flow impairment in the prelaminar optic disc during the acute phase; (4) lack of consistent choroidal flow impairment and the retrolaminar location of infarcts suggest vasculopathy within or distal to the paraoptic branches of the posterior choroidal arteries; (5) diabetes is the most consistently identified vasculopathic risk factor; (6) impaired autoregulation of the disc circulation by atherosclerosis, with a possible contribution from serotonin and endothelin-mediated vasospasm, may play a role; and (7) progression may be caused by secondary cell death after the initial ischemic insult or compression from cavernous degeneration and mechanical axonal distortion.
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PMID:Pathogenesis of nonarteritic anterior ischemic optic neuropathy. 1278 32

Decreased visual acuity and loss of visual ability are devastating anesthetic and surgical complications. The incidence is greater in patients with preexisting hypertension, diabetes, sickle cell anemia, renal failure, gastrointestinal ulcer, narrow-angle glaucoma, vascular occlusive disease, cardiac disease, arteriosclerosis, polycythemia vera, and collagen vascular disorders. Precipitating factors for ischemic optic neuropathy include prolonged hypotension, anemia, surgery, trauma, gastrointestinal bleeding, hemorrhage, shock, prone position, direct pressure on the globe, and long operative times. Prone and Trendelenburg positions can lead to visual loss related to decreased venous return from the head. Visual impairment may result from increased intracranial pressure, which contributes to undue pressure on the optic nerve. The prone position increases the risk of direct compression injury to the orbit and corneal abrasion. Astute attention to positioning is imperative, especially with the prone position. At-risk patients should receive transfusion once the calculated allowable blood loss has been surpassed. Unacceptable hemoglobin and hematocrit values should be corrected preoperatively and levels monitored during the case to avoid intraoperative anemia in at-risk patients. The blood pressure of patients with predisposing diseases should be kept within normal limits. To avoid this devastating complication, it is imperative that anesthesia providers understand contributing factors and prevention strategies.
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PMID:Visual loss as a complication of nonophthalmologic surgery: a review of the literature. 1563 61

Four patients (age range 54-82, 1F 3M) diagnosed with non-arteritic ischemic optic neuropathy experienced acute worsening of visual function after instillation of phenylephrine for dilated funduscopic examination. They experienced decreased visual function immediately or shortly after administration of topical mydriatic drops given in preparation for funduscopy. In all cases one drop each of 2.5% phenylephrine and 0.5-1% tropicamide was used. Three patients had classical risk factors such as hypertension, diabetes, and had a contralateral "disc-at-risk". The female and youngest patient had ischemic optic neuropathy presumed secondary to lupus erythematosus. The time from acute visual loss to presentation to neuro-ophthalmic care ranged from 1-6 days. The time of onset of the decline in visual function varied from 45 minutes (patient with lupus) to 12 hours after instillation of mydriatic drops. Visual acuity at diagnosis ranged from 20/40-20/400. Phenylephrine is a mydriatic with vasoconstrictive properties, which may be absorbed through the cornea, thus yielding non-negligible intraocular concentrations. Vasoconstriction of the watershed posterior ciliary capillary beds may result in further precipitating infarction of already compromised circulatory territories in edematous optic nerves. Because phenylephrine is a known vasoconstrictor in vivo and in vitro, it is more likely to cause deleterious vasoconstriction and an acute decline in visual function in patients with acute ischemic optic neuropathy than tropicamide. The routine practice of using phenylephrine to prepare patients for funduscopic assessment should be re-examined, particularly in patients with ischemic optic neuropathy.
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PMID:Topical phenylephrine may result in worsening of visual loss when used to dilate pupils in patients with vaso-occlusive disease of the optic nerve. 1551 9

Nonarteritic anterior ischemic optic neuropathy is a common cause of sudden, painless loss of vision present commonly on awakening from sleep. It most commonly affects middle-aged and elderly Caucasian men and women. Involvement of the opposite eye occurs within 3 years in less than 43% of patients. Hypertension, diabetes, and nocturnal hypotension are risk factors. A congenital small cup-to-disk ratio also predisposes to the optic nerve ischemia. There is no effective therapy to treat patients acutely or to prevent recurrence. After 6 months of careful follow-up, 57.3% of patients will have no significant change or worsening of their vision in the involved eye.
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PMID:Nonarteritic anterior ischemic optic neuropathy. 1572 60

Seven patients, aged between 50 and 69 years, had typical features of nonarteritic anterior ischemic optic neuropathy (NAION) within 36 hours after ingestion of sildenafil citrate (Viagra) for erectile dysfunction. Six patients had vision loss within 24 hours after use of the agent. Final visual acuity in the affected eye ranged from 20/20 to light perception. Both eyes were affected in one individual. All affected individuals had pre-existing hypertension, diabetes, elevated cholesterol, or hyperlipidemia. Seven similar cases have been previously reported. Sildenafil may provoke NAION in individuals with an arteriosclerotic risk profile.
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PMID:Nonarteritic ischemic optic neuropathy developing soon after use of sildenafil (viagra): a report of seven new cases. 1651 58

Decreased visual acuity and loss of visual ability are devastating anesthetic and surgical complications. The incidence is greater in patients with preexisting hypertension, diabetes, sickle cell anemia, renal failure, gastrointestinal ulcer, narrow-angle glaucoma, vascular occlusive disease, cardiac disease, arteriosclerosis, polycythemia vera, and collagen vascular disorders. Precipitating factors for ischemic optic neuropathy include prolonged hypotension, anemia, surgery trauma, gastrointestinal bleeding, hemorrhage, shock, prone position, direct pressure on the globe, and long operative times. Prone and Trendelenburg positions can lead to visual loss related to decreased venous return from the head. Visual impairment may result from increased intracranial pressure, which contributes to undue pressure on the optic nerve. The prone position increases the risk of direct compression injury to the orbit and corneal abrasion. Astute attention to positioning is imperative, especially with the prone position. At-risk patients should receive transfusion once the calculated allowable blood loss has been surpassed Unacceptable hemoglobin and hematocrit values should be corrected preoperatively and levels monitored during the case to avoid intraoperative anemia in at-risk patients. The blood pressure of patients with predisposing diseases should be kept within normal limits. To avoid this devastating complication, it is imperative that anesthesia providers understand contributing factors and prevention strategies.
 ...
PMID:Visual loss as a complication of non-ophthalmic surgery: a review of the literature. 1594 13

Ocular involvements of Biermer's anaemia are rarely reported in literature. We present a case of Biermer's anaemia associated with diabetes. Ocular examination showed important conjinctival paleness, diffuse retinal ischemia, Roth's tasks, macular oedema and ischemic optic neuropathy. The patient was treated with vitamin B12 intramusculary. A month later, on examination, we noted a regression of optic neuropathy, the aggravation of ischemic retinopathy and persistence of macular oedema. The patient was treated with laser photocoagulation. The majority of ocular manifestations are reversible if treatment is underlaken early. The combination of diabetes with Biermer's anemia deteriorates the ischemic retinopathy and aggavates its prognosis.
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PMID:[Ocular findings in megaloblastic anemia associated with diabetes. A case report]. 1604 7

Ischemic optic neuropathy is a common cause of visual loss in the older population. This disease is classified into anterior and posterior type according to the location the lesions. The anterior type is due to transient nonperfusion or hypoperfusion of the ciliary circulation in the optic nerve head. The etiology of this disease is multifactorial. The most important risk factors for developing anterior ischemic optic neuropathy (AION) include hypertension, nocturnal hypotension, diabetes mellitus, atherosclerosis and small cup in the optic disc. AION presents with sudden painless loss of vision, pale edema of the optic disc, afferent papillary defect and visual field defects, typically in lower quadrants. Posterior ischemic optic neuropathy (PION) is a rare condition and diagnosis of it usually is made only after other causes of a retrobulbar optic neuropathy have been excluded. There are three distinct subtype of PION: perioperative, arteritic and nonarteritic. They are characterized by acute visual loss, variable visual field defects, relative afferent pupillary defect and normal optic disc.
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PMID:[Ischemic optic neuropathy. Pathogenesis, clinical features, diagnostics and treatment]. 1702 4


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