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Título

Bilateral Simultaneous Non-Arteritic Anterior Ischemic Optic Neuropathy in a elderly after spine surgery: a case report

RESUMO

Case report: A 78 years-old woman, caucasian, a retiree, residing in Belo Horizonte, Minas Gerais State, Brazil. Patient with systemic arterial hypertension and right peripheral facial nerve palsy. Prior cataract surgery. Due to spinal stenosis, she was submitted to a thoracic lumbar spinal decompression procedure on March 31th, 2022. Performed for nine hours in a prone position without intercurrences. After eight hours, she awoke from anesthesia with psychomotor agitation and complaining of severe pain at the surgical site and reduced bilateral visual acuity. Progressed to loss of color vision and ultimately bilateral amaurosis. She denied other focal symptoms or headaches. No reports of mental confusion by assistant staff. Without a history of visual impairment. The patient presented to the neurological examination with a regular general condition, good spatial orientation, alertness, Glasgow Coma Scale 15, right corectopia, normal extrinsic ocular motricity, hand movement perception half a yard away, right peripheral facial nerve palsy, without meningeal irritation signs. Ophthalmoscopy revealed bilateral papilledema more evident on the left and retinal pigment epithelium atrophy, without signs of vasculitis. Magnetic Resonance Angiography of the skull revealed moderate stenosis of the left anterior cerebral artery, hypoplasia of the left vertebral artery, and moderate stenosis of the supraclinoid segment internal carotid artery, but with the good distal flow. Magnetic Resonance Imaging of skull without restriction on diffusion-weighted imaging or hyperintense signal on T2-weighted FLAIR. There was a gradual spontaneous improvement of the visual deficit. On April 04th, she reported a return to baseline visual acuity. She had uncorrected visual acuity in both eyes: 20/70 vision. Discussion: Postoperative visual loss following prone spine surgery occurs in from 0.013% to 1% of cases, and the most frequently quoted risk is 0.2%. It is attributed mainly to ischemic optic neuropathy. The multiple factors contributing to POVL may include; prolonged operative times, long-segment spinal instrumentation, anemia, intraoperative hypotension, greater estimated blood loss (EBL), microvascular pathology, and decreased percent colloid administration. Final Comments: Laboratory tests revealed no hematimetric abnormalities and no excessive bleeding or hemodynamic instability was reported during surgery, however, the operative time was prolonged.

Palavras Chave

Optic Neuropathy . Spine . Time Length of Surgery