J Korean Ophthalmol Soc.  2019 Jul;60(7):712-717. 10.3341/jkos.2019.60.7.712.

Visual Loss with Ophthalmoplegia after Prone Position Spinal Surgery

• Park MH
• Kim JH
• Yoo JM

• KMID: 2453025
• DOI: http://doi.org/10.3341/jkos.2019.60.7.712

Abstract

PURPOSE
We report a case of acute visual loss with ophthalmoplegia after prone position spinal surgery who had blood supply dependence on collateral circulation due to occlusion of the Internal carotid artery.
CASE SUMMARY
A 74-year-old man was referred to the department of ophthalmology for acute visual loss and ophthalmoplegia after lumbar spine surgery performed in prone position. On the initial visit, his right visual acuity was 0.8 and the left visual acuity was negative light perception. Intraocular pressure was normal. There was a relative afferent pupillary defect and ophthalmoplegia of all directions in the left eye. Because of the ptosis of the upper eyelid in the left eye, it was impossible to tune the eye voluntarily. The cherry red spot and pale retina were observed on the fundus examination. On brain magnetic resonance imaging angiography, we found complete obstruction of the left internal carotid artery. He had intravenous injection of 1 g methylprednisolone for 3 days, and discharged with per oral medicine. After 1 month of treatment, the ophthalmoplegia was slightly improved, but visual acuity was not recovered.
CONCLUSIONS
In this case, unlike previous reports, acute visual loss and ophthalmoplegia occurred after spinal surgery the patient who had collateral circulation for ocular blood supply because of complete obstruction of the left internal carotid artery. This report highlights the importance of being aware of the anatomical variant in possible complications of external ocular compression after non-ocular surgery.

Keyword

Internal carotid artery occlusion; Ophthalmoplegia; Retinal artery occlusion; Visual loss

MeSH Terms

Aged
Angiography
Brain
Carotid Artery, Internal
Collateral Circulation
Eyelids
Humans
Injections, Intravenous
Intraocular Pressure
Magnetic Resonance Imaging
Methylprednisolone
Ophthalmology
Ophthalmoplegia*
Oral Medicine
Prone Position*
Pupil Disorders
Retina
Retinal Artery Occlusion
Spine
Visual Acuity
Methylprednisolone

Figure

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  Figure 1 Photographs in the nine cardinal directions. (A) At his initial visit after spinal surgery, limitation of abduction, supraduction and infraduction are shown in the left eye. Because of the ptosis of the upper eyelid, it is impossible to tune the eye voluntarily. The left eye pupil is dilated at 4.5 mm. (B) After 1 month, the external ophthalmoplegia was improved.

• 

  Figure 2 Posterior segment of the left eye. (A) Fundus photographs of patient on initial visit, (B) and last follow up at 7 months later. The cherry red spot on fovea with pale retina was showed, it developed chorioretinal atrophy several months later. (C) The reflectivity and thickness of inner retina was increased on optical coherence tomography, (D) arm to retinal time and arterio-venous transit time delay with delayed filling (28 seconds after injection) was detected on fluorescein angiography.

• 

  Figure 3 Brain magnetic resonance Image images of the patient. (A) On a fluid attenuated inversion recovery image, left optic nerve exhibits marked enhancement (arrow), (B) extraocular muscles show diffuse swelling (arrows). (C) Reconstructed magnetic resonance angiography image reveals complete occlusion in the left internal carotid artery (ICA) (red arrowheads) from the bifurcation site of left common carotid artery (short arrow), while intact right ICA (arrowheads). The left vertebral artery (long arrow) is enlarged, directly originated from left subclavian artery. (D) Complete occlusion in the left ICA (arrowhead) is visible on the axial view, by contrast to well visible right ICA (arrow).

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