Postoperative Vision Loss Following Prone Position Spinal Surgery: A Review of Published Cases
DOI:
https://doi.org/10.5281/zenodo.22279629Keywords:
Postoperative vision loss, Ischemic optic neuropathy, Prone position, Spinal surgery, Central retinal artery occlusionAbstract
Background: Postoperative visual loss (POVL) is a rare but devastating complication of prone-position spinal surgery, most often
caused by ischemic optic neuropathy (ION). Objective: To synthesize published epidemiology, pathophysiology, and case-level evidence on POVL after prone spinal surgery. Methods: Narrative review of case reports, case series, registries, administrative-database studies, case-control analyses, and practice advisories. Findings: Incidence ranges roughly from 1 to 6 per 10,000 spinal fusions, declining over 1998-2012 (1.63 to 0.60 per 10,000). Independent risk factors include male sex, obesity, Wilson frame use, longer anesthetic duration, greater blood loss, and lower colloid proportion. Published cases document posterior ION, central retinal artery occlusion, and cortical blindness, frequently bilateral and often permanent. Conclusions: No treatment reliably reverses established POVL; management centers on risk stratification, staged surgery, hemodynamic and hematocrit optimization, and positioning vigilance.
References
Stevens, W.R., Glazer, P.A., Kelley, S.D., Lietman, T.M., Bradford, D.S. (1997) Ophthalmic complications after spinal surgery. Spine, 22(12): 1319-1324.
Myers, M.A., Hamilton, S.R., Bogosian, A.J., Smith, C.H., Wagner, T.A. (1997) Visual loss as a complication of spine surgery: a review of 37 cases. Spine, 22(12): 1325-1329.
Lee, L.A., Roth, S., Posner, K.L., Cheney, F.W., Caplan, R.A., Newman, N.J., et al. (2006) The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology, 105(4): 652-659.
Roth, S., Moss, H.E. (2018) Update on perioperative ischemic optic neuropathy associated with non-ophthalmic surgery. Frontiers in Neurology, 9: 557.
American Society of Anesthesiologists Task Force on Perioperative Visual Loss, North American Neuro-Ophthalmology Society and Society for Neuroscience in Anesthesiology and Critical Care (2019) Practice advisory for perioperative visual loss associated with spine surgery 2019: an updated report. Anesthesiology, 130(1): 12-30.
The Postoperative Visual Loss Study Group (2012) Risk factors associated with ischemic optic neuropathy after spinal fusion surgery. Anesthesiology, 116(1): 15-24.
Shah, S.H., Chen, Y.F., Moss, H.E., Rubin, D.S., Joslin, C.E., Roth, S. (2020) Predicting risk of perioperative ischemic optic neuropathy in spine fusion surgery: a cohort study using the National Inpatient Sample. Anesthesia & Analgesia, 130(4): 967-974.
Goyal, A., Elminawy, M., Alvi, M.A., Long, T.R., Chen, J.J., Bradley, E., et al. (2019) Ischemic optic neuropathy following spine surgery: case control analysis and systematic review of the literature. Spine, 44(15): 1087-1096.
American Society of Anesthesiologists Task Force on Perioperative Visual Loss (2012) Practice advisory for perioperative visual loss associated with spine surgery: an updated report. Anesthesiology, 116(2): 274-285.
Rubin, D.S., Parakati, I., Lee, L.A., Moss, H.E., Joslin, C.E., Roth, S. (2016) Perioperative visual loss in spine fusion surgery: ischemic optic neuropathy in the United States from 1998 to 2012 in the Nationwide Inpatient Sample. Anesthesiology, 125(3): 457-464.
Moss, H.E., Xiao, L., Shah, S.H., Chen, Y.F., Joslin, C., Roth, S. (2020) Perioperative ischemic optic neuropathy in spinal fusion surgery: validating a predictive scoring system. The Spine Journal, 20(10): 1527-1528.
Shen, Y., Drum, M., Roth, S. (2009) The prevalence of perioperative visual loss in the United States: a 10-year study from 1996 to 2005 of spinal, orthopedic, cardiac, and general surgery. Anesthesia & Analgesia, 109(5): 1534-1545.
Holy, S.E., Tsai, J.H., McAllister, R.K., Smith, K.H. (2009) Perioperative ischemic optic neuropathy: a case control analysis of 126,666 surgical procedures at a single institution. Anesthesiology, 110(2): 246-253.
Rubin, D.S., Matsumoto, M.M., Moss, H.E., Joslin, C.E., Tung, A., Roth, S. (2017) Ischemic optic neuropathy in cardiac surgery: incidence and risk factors in the United States from the National Inpatient Sample 1998 to 2013. Anesthesiology, 126(5): 810-821.
Epstein, N.E. (2016) Perioperative visual loss following prone spinal surgery: a review. Surgical Neurology International, 7(14): 347.
Epstein, N.E. (2016) How to avoid perioperative visual loss following prone spinal surgery. Surgical Neurology International, 7(14): 328.
Sperber, J., Owolo, E., Zachem, T.J., Bishop, B., Johnson, E., Lad, E.M., et al. (2024) Perioperative blindness in spine surgery: a scoping literature review. Journal of Clinical Medicine, 13(4): 1051.
Buono, L.M., Foroozan, R. (2005) Perioperative posterior ischemic optic neuropathy: review of the literature. Survey of Ophthalmology, 50(1): 15-26.
Cheng, M.A., Todorov, A., Tempelhoff, R., McHugh, T., Crowder, C.M., Lauryssen, C. (2001) The effect of prone positioning on intraocular pressure in anesthetized patients. Anesthesiology, 95(6): 1351-1355.
Bae, K.Y., Kim, K.H., Joo, J.C. (1996) Central retinal artery occlusion after cervical spine surgery in prone position under general anesthesia: a case report. Korean Journal of Anesthesiology, 31(1): 114-117.
Sys, J., Michielsen, J., Mertens, E., Verstreken, J., Tassignon, M.J. (1996) Central retinal artery occlusion after spinal surgery. European Spine Journal, 5(1): 74-75.
Tang, X., Hao, Y., Yu, Y., Lin, K., Kang, X. (2026) Perioperative central retinal artery occlusion after prone posterior cervical spine surgery treated with delayed hyperbaric oxygen therapy: a case report and targeted literature review. BMC Anesthesiology, advance online publication.
Goni, V., Tripathy, S.K., Goyal, T., Tamuk, T., Panda, B.B., BK, S. (2012) Cortical blindness following spinal surgery: very rare cause of perioperative vision loss. Asian Spine Journal, 6(4): 287-290.
Huber, J.F., Grob, D. (1998) Bilateral cortical blindness after lumbar spine surgery: a case report. Spine, 23(16): 1807-1809.
Nguyen, A., Hasoon, J., Li, T., Robinson, C.L., Nguyen, V. (2026) Perioperative visual loss after spine surgery: a case-based review of posterior ischemic optic neuropathy. Orthopedic Reviews, 18: article 163036.
Bhandari, S., Pokharel, K., Sah, B.P. (2019) Postoperative visual loss following spine surgery: a case report. Journal of the Nepal Medical Association, 57(218).
Ramakrishnan, A., Singh, S., Puri, S.K. (2024) A case report on acute visual loss with ophthalmoplegia following spine surgery. Cureus, 16(9): e68453.
Lee, L.A., Lam, A.M. (2001) Unilateral blindness after prone lumbar spine surgery. Anesthesiology, 95(3): 793-795.
