Learning objectives

• Describe the symptoms & risk factors of POVL
• Prevent POVL
• Manage POVL

Definition & mechanisms

• Postoperative visual loss (POVL) is an uncommon complication primarily associated with cardiac, spine, and head and neck surgery that can have a potentially severe impact on quality of life
• Most cases of POVL occur after spinal surgery and while there are many different etiologies, pressure on the eye due to improper head positioning is a common cause of POVL

Etiology

Risk factors

• Male sex
• Obesity
• Diabetes
• Hypertension
• Atherosclerosis
• Hyperlipidaemia
• Smoking
• Sleep apnea
• Hypercoagulability
• Use of vasopressors
• Hemodilution
• Low cup-to-disc ratio
• Use of the Wilson frame
• Longer anesthetic duration
• Prone positioning
• Perioperative anemia & hypotension
• Blood loss
• Type of surgery (highest risk in spinal fusion)

Prevention

• Preoperative evaluation & identification of risk factors
• Preoperative discontinuation of erectile dysfunction medications
• Attention to intraoperative positioning (avoidance of direct ocular pressure)
• Hemodynamic monitoring & management
• Avoid intraoperative hyperventilation
• Postoperative visual evaluation following high-risk procedure
• Monitoring of hemoglobin during long procedures & procedures associated with high blood loss

Management

Suggested reading

• Mac Grory B, Schrag M, Biousse V, et al. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association [published correction appears in Stroke. 2021 Jun;52(6):e309]. Stroke. 2021;52(6):e282-e294.
• Brunk AJ, Ehrhardt KP, Green JB, Mothersele SM, Kaye AD. Postoperative Visual Loss: Anatomy, Pathogenesis, and Anesthesia Considerations. In: Fox IIICJ, Cornett EM, Ghali GE, editors. Catastrophic Perioperative Complications and Management: A Comprehensive Textbook. Cham: Springer International Publishing; 2019. p. 19-29.
• Fleisher, L.A. and Rosenbaum, S.H. (2018) Complications in Anesthesia. Philadelphia, PA: Elsevier. 
• Kitaba A, Martin DP, Gopalakrishnan S, Tobias JD. Perioperative visual loss after nonocular surgery. J Anesth. 2013;27(6):919-926.
• Lee LA. Perioperative visual loss and anesthetic management. Curr Opin Anaesthesiol. 2013;26(3):375-381.
• Frost EA. Visual loss after anesthesia different causes: different solutions–a review. Middle East J Anaesthesiol. 2010;20(5):639-648.
• Roth S. Perioperative visual loss: what do we know, what can we do? British Journal of Anaesthesia. 2009;103:i31-i40.