Perioperative Visual Loss in Spine Surgery
Summary
Perioperative visual loss (POVL) is a rare but devastating complication of spine surgery, most commonly manifesting as ischaemic optic neuropathy or retinal arterial occlusion. The condition arises predominantly in lengthy procedures performed in the prone position, where factors such as prolonged hypotension, substantial blood loss and elevated intraocular pressure converge to impair perfusion of the optic nerve or retina. Risk is heightened by patient-specific factors including advanced age, diabetes, hypertension and vascular dysregulation. Intraoperative anaesthetic management, fluid balance and patient positioning play pivotal roles in prevention. Despite its low incidence—estimated at fewer than 0.1% of major spine operations—POVL commands significant clinical attention because of its often irreversible nature. Current strategies focus on meticulous control of haemodynamics, minimising head-down angles, optimising fluid administration and elevating awareness among surgical and anaesthesia teams. Early recognition of visual changes remains challenging, underscoring the need for perioperative protocols that integrate ocular monitoring and standardise preventive measures to reduce the global burden of this sight-threatening event.
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Perioperative Visual Loss in Spine Surgery publication trend
The graph below shows the total number of articles in perioperative visual loss in spine surgery across all publications each year (not limited to Nature Index journals).
Technical terms
Perioperative visual loss (POVL): Sudden loss of vision occurring during or immediately after non-ocular surgery.
Ischaemic optic neuropathy (ION): Injury to the optic nerve due to inadequate blood supply, subdivided into anterior and posterior forms.
Intraocular pressure (IOP): The fluid pressure inside the eye, elevated levels of which can compromise optic nerve perfusion.
Optic nerve sheath diameter (ONSD): An ultrasonographic measure of the optic nerve’s surrounding cerebrospinal fluid space, indicative of intracranial or orbital pressures.
Prone positioning: Lying face down during surgery, a configuration that can increase venous pressure in the head and affect ocular hemodynamics.
References
- Update on Perioperative Ischemic Optic Neuropathy Associated With Non-ophthalmic Surgery. Frontiers in Neurology (2018).
- The effect of restrictive vs. liberal fluid protocols on ocular parameters in patients undergoing prone spine surgery: a randomized controlled trial. Perioperative Medicine (2023).
- Effect of different surgical positions on intraocular pressure: a cross-sectional study. BMC Ophthalmology (2022).
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