Perioperative vision loss after sequential lower extremity fracture surgery: a case report

Abstract

Perioperative vision loss (POVL) is a rare but serious complication, most frequently reported after cardiac and prone spinal surgeries. POVL following lower extremity surgery is uncommon. We herein report a case of POVL in a man in his mid-thirties after a third surgery to repair a lower extremity fracture. The patient developed vision loss 3 hours postoperatively following sequential surgeries for a lower extremity fracture. Before the third surgery, he was in a hypercoagulable state, and tranexamic acid was administered to reduce intraoperative blood loss. After POVL occurred, anticoagulant and antithrombotic agents, as well as high-dose steroid pulse therapy, were promptly administered. The patient’s vision recovered 3 days later, with no abnormalities found during follow-up visits over the next 6 months. For patients at high risk of thrombosis, POVL warrants careful attention. The coagulation system should be kept as stable as possible, and medications that may promote thrombosis, such as tranexamic acid, should be used cautiously.

Introduction

Perioperative vision loss (POVL) is a rare but serious complication most commonly reported following cardiac and prone spinal surgeries, with an overall incidence ranging from 0.09% to 0.36%. ¹ POVL occurring after lower extremity surgery is even more uncommon, with very few cases reported to date. Although exceedingly rare, POVL can profoundly and negatively impact a patient’s quality of life. This makes such cases noteworthy and valuable to report.

We herein describe a patient in his mid-thirties who developed POVL 3 hours after undergoing a third corrective surgery following a car accident. The patient was in a hypercoagulable state and thus received tranexamic acid prior to the surgery. After the onset of POVL, anticoagulant and antithrombotic agents, as well as high-dose steroid pulse therapy, were promptly administered. The patient’s vision completely recovered within 3 days.

Case report

A man in his mid-thirties underwent open reduction and internal fixation of an acetabular fracture, skin avulsion repair, and reverse skin grafting of the left calf under spinal anesthesia combined with a suprainguinal fascia iliaca block. Three hours postoperatively, he experienced vision loss.

The patient had no history of underlying disease before hospital admission following multiple injuries sustained in a car accident. POVL occurred after the patient’s third surgery. Two weeks prior, he had undergone emergency surgery for these injuries, including open reduction and internal fixation with external fixation for a left tibial fracture, popliteal artery thrombectomy, and arteriovenous ligation of the left leg. After this surgery, he was admitted to the intensive care unit for observation. Papaverine (30 mg every 8 hours), alprostadil (10 µg once daily), 20% mannitol (250 mL injection every 12 hours), and rivaroxaban (10 mg once daily) were administered to maintain vessel patency, and his vital signs remained stable postoperatively. Six days later, he underwent debridement and vacuum-assisted closure of the surgical wound. A routine blood examination before the third surgery revealed a low hemoglobin level (110 × 10⁹/L) and a high platelet count (566 × 10⁹/L), with coagulation testing showing elevated fibrinogen (6.19 g/L) and D-dimer levels (2.45 µg/mL). Other laboratory test results were within normal ranges.

The patient underwent routine monitoring upon entering the operating room, and radial artery catheterization was performed to monitor the arterial blood pressure. A suprainguinal fascia iliaca block with 40 mL of 0.35% ropivacaine and a subarachnoid space block with 20 mg of 0.5% ropivacaine were then administered. Tranexamic acid (TXA) (0.25 g) and vancomycin (500 mg) were given intravenously 30 minutes before surgery. The patient received a continuous infusion of dexmedetomidine for sedation, with his eyelids closed throughout. The surgery, performed with the patient in the lateral decubitus position, lasted 4 hours. His vital signs remained stable during the procedure, and vasoactive agents were not required. Intraoperative infusions included 1000 mL of crystalloid solution, 1500 mL of colloid solution, and 400 mL of autologous blood conserved by isovolumic hemodilution. The intraoperative blood loss was 400 mL, and his hemoglobin level was 99 g/L at the end of surgery. Afterward, the patient was transferred to the post-anesthesia care unit and returned to the ward after 30 minutes of observation without complications.

Three hours postoperatively, the patient reported vision loss in both eyes. A physical examination showed that both pupils were 3 cm in size and equal, with intact light reflexes, including direct and indirect reactions; however, he had no light perception in either eye. Computed tomography and computed tomography angiography of the head were performed immediately but revealed no abnormalities, and a neurological examination showed no issues. Fundus examinations of the conjunctiva, cornea, pupils, crystalline lens, optic nerve head, retina, and macula also revealed no abnormalities, with normal direct and indirect light reflexes. Thus, the diagnosis remained unclear. An ophthalmologist considered the vision loss to be associated with ischemia of the retinal or cranial nerves. Based on the examination results, the patient received intravenous methylprednisolone (500 mg) and Xueshuantong injection (250 mg) once daily.

On day 2, the patient reported improved light perception. A flash-evoked potential examination was performed, but the results showed a loss of flash-evoked potentials in both eyes. Given the patient’s reported improvement, we increased the methylprednisolone dose to 1 g and continued the 250 mg Xueshuantong injection once daily. On day 3, the patient reported further recovery of light perception, with the ability to count fingers, distinguish colors, identify distant objects clearly, and distinguish nearby objects with diplopia. Considering these improvements, we continued administering 1 g of methylprednisolone and 250 mg of Xueshuantong once daily. Clopidogrel (75 mg once daily), alprostadil (10 µg once daily), and aspirin (100 mg once daily) were also administered for antiembolism and vasodilation therapy. By day 4, the patient reported complete recovery of vision. During the 6-month follow-up, his visual acuity was not significantly abnormal. All treatments were performed with the patient’s consent, and his recovery was satisfactory.

Written informed consent for publication, including permission for identification of information and images in an online open-access publication, was obtained from the patient. This case report did not require ethical review because all relevant patient information was de-identified, ensuring that the patient cannot be identified through this publication. The reporting of this study conforms to the CARE guidelines. ²

Discussion

POVL is a rare yet serious complication, with an estimated incidence of 0.0008% to 0.0020%. However, once it occurs, it can severely impact a patient’s quality of life. ³ Although the pathological mechanism of POVL is not fully understood, vascular ischemia along the visual pathway appears to be a primary cause.^1,4 Therefore, predisposing risk factors for ischemia in the visual pathway may contribute to POVL. These risk factors include preoperative patient-related factors, such as hypertension, diabetes, peripheral vascular disease, cardiovascular and cerebrovascular diseases, obesity, obstructive sleep apnea, smoking, coagulopathy, and anemia. Perioperative risk factors include hypotension, significant blood loss, blood transfusion, prolonged surgery, prone positioning, the use of a Wilson frame, multiple operative levels, and perioperative organ damage. ⁵ The main diagnoses associated with POVL are ischemic optic neuropathy, central retinal artery occlusion, and cortical blindness. ³

Our patient was in a hypercoagulable state and experienced binocular vision loss after undergoing sequential traumatic orthopedic surgeries. We suspect that the cause of POVL in this case was multifactorial. First, sequential traumatic orthopedic surgery itself could have contributed to POVL. Although POVL occurs primarily after spinal or cardiac surgeries, sporadic cases have been reported following hip surgery. ⁶ In our case, the patient underwent open reduction and internal fixation of an acetabular fracture during his third surgery; reports of POVL after this type of surgery are rare. Second, anemia and hypercoagulability may be risk factors for POVL because they can lead to vascular obstruction in the visual pathways. Third, TXA could be a contributing factor. TXA, an antifibrinolytic drug widely used to reduce bleeding during orthopedic surgery, ⁷ has been associated with sporadic reports of thrombosis. For example, Xie et al. ⁸ reported a case of circulatory collapse caused by intracardiac thrombosis associated with TXA in 2016. Therefore, the use of TXA remains controversial.^9,10 Although reports of vision loss following TXA use are rare, Wijetilleka et al. ¹¹ documented a case of central retinal vein occlusion associated with TXA in 2017. The drug label information for TXA also mentions retinal degeneration observed in animal studies (cats and dogs) after oral or intravenous administration. Therefore, special attention should be paid to patients at high risk of thrombosis when using TXA. Although brain computed tomography angiography revealed no pathology in this patient, our antithrombotic and anticoagulant treatments were effective, supporting our hypothesis of ischemia along the visual pathways. The intraoperative blood loss and duration of the third surgery were within routine limits, with no obvious factors identified that might have led to thrombosis.

Conclusions

Greater attention should be given to the risk of POVL in patients with a high risk of thrombosis. For these patients, maintaining stability in the coagulation system is essential, and medications that may increase the risk of thrombosis, such as TXA, should be used with caution.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605241300048 - Supplemental material for Perioperative vision loss after sequential lower extremity fracture surgery: a case report

Supplemental material, sj-pdf-1-imr-10.1177_03000605241300048 for Perioperative vision loss after sequential lower extremity fracture surgery: a case report by Ruimin Luo, Liji Lu and Yuyuan You in Journal of International Medical Research