Anesth Pain Med. 2014 May; 4(2): e7291.
DOI: 10.5812/aapm.7291
Case Report
Published online 2014 April 6.
Human Erythropoietin Effect in Postoperative Visual Loss Following Spine
Surgery: A Case Report
1,2
2
3
Valiollah Hassani ; Mohammad Mohsen Homaei ; Ali Shahbazi ; Mohammad Mahdi
2
2,*
2
4
Zamani ; Saeid Safari ; Shermila Nadi ; Abolfazl Rahimizadeh ; Mohammad Hossein
5
3
Lashkari ; Siamak Alizadeh Zendehrood
1Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
2Department of Anesthesiology, Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, Iran
3Physiology Research Center (PRC), Iran University of Medical Sciences, Tehran, Iran
4Department of Neurosurgery, Pars General Hospital, Tehran, Iran
5Department of Ophthalmology, Iran University of Medical Sciences, Tehran, Iran
*Corresponding author: Saeid Safari, Department of Anesthesiology, Rasoul Akram Medical Center, Iran University of Medical Sciences, Niayesh Av., Tehran, Iran. Tel: +98-2166509059,
Fax: +98-2166515758, E-mail: drsafari.s@gmail.com
Received: July 17, 2012; Revised: October 15, 2013; Accepted: November 3, 2013
Introduction: Postoperative visual loss (POVL) has become the focus of attention for anesthesiologists as a hallmark of perioperative
management in spine surgery. A number of Intraoperative and postoperative factors has been documented but the exact etiology
is still unclear. Nowadays, perioperative management and also complete curing of POLV is a big question of ophthalmologists and
anesthesiologists. The purpose of this case report is to present a unique experience of complete curing the POLV.
Case Presentation: Our patient was a 61-year-old man, with 75 kg weight and 180 cm height. The patient had no history of visual
impairment except mild cataract in his right eye. The patient had a history of diffuse idiopathic skeletal hyperostosis (DISH). The
patient had undergone lumbar surgery in prone position. The operation time was about 6 hours. About 30 minutes after transferring to
postanesthesia care unit (PACU), patient was awake and complained of losing his eyesight. There was no vision and light perception in his
right eye on primary examination. Urgent ophthalmologist consultation was requested. In ophthalmology examinations, the pupil reflex
to light was absent in the right eye. After obtaining patients and his family informed consent, four hours after the operation, 40000 I.U.
of recombinant human erythropoietin (rhEPO) was administered for patient in PACU (IV infusion, in 30 min). An ophthalmologist visited
him every 6 hours after administration of rhEPO. The patient was transferred to intensive care unit (ICU) one hour later with total visual
loss in the right eye. Ophthalmologic examination after the second dose of rhEPO, 30 hours after the operation, reported pupil reflex
enhancement and light perception in his right eye. Finally the third dose of rhEPO (40000 I.U., IV infusion) was administered on the third
day. Ophthalmologic examination after the third dose of rhEPO, 60 hours after the operation, reported normal pupillary light reflex of the
right eye and visual acuity improvement to 20/20. The patient was discharged from hospital after six days, with normal visual acuity and
without any new complications except surgical site pain.
Conclusions: Our case report showed the therapeutic effect of rhEPO in complete curing of POVL. Regarding the side effects of EPO such
as thrombogenic effects or mild hemodynamic changes like transient sinus tachycardia during infusion, it seems that beneficial effects of
EPO is more than its disadvantages and expenses, for patients with POVL.
Keywords: Complications; Optic Neuropathy, Ischemic; Postoperative Period; Postoperative; Spinal Cord Ischemia; Vision Disorders
1. Introduction
Postoperative visual loss (POVL) is a rare but important
complication in non-ocular surgeries (1, 2). This complication has been reported following several kinds of surgeries, including, spinal, cardiac, vascular, brain, sinus
and even prostatectomy surgeries (3, 4). Many studies
have reported POVL in spinal surgeries, in prone positioning (5, 6). Due to malpositioning or head movements
in prone position, external pressure to eyes increases in
spinal surgery and results in POVL (7). In addition to positioning, some preoperational conditions were reported
as probable etiologies of POVL, such as previous history
of endothelial vascular disturbances (hypertension, diabetes mellitus, smoking, atherosclerosis), anemia and
closed angle glaucoma; and some operational risk factors were reported also, including severe hemorrhage,
and hypotension during the operation (4).
Implication for health policy/practice/research/medical education:
This case report showed the beneficial effect of rhEPO in complete curing of POVL.
Copyright © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar Corp. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
Hassani V et al.
It has been documented that central retinal artery occlusion (CRAO) and ischemic optic neuropathy (ION)
are the common mechanisms of POVL (8). Symptoms of
POVL, differ in patients, depending on the location and
extent of the lesion; but loss of visual acuity in entire or
in a part, lack of light perception, and absence of pupillary light reflex are the common symptoms (9). In POVL,
normal fundoscopy with impaired ocular movement due
to extra-ocular muscle oedema may be seen (10). Abnormal fundoscopic findings are more probable in anterior
ischemic optic neuropathy (AION) and CRAO comparing
posterior ischemic optic neuropathy (PION) (7).
Although some perioperative consideration such as correction of anemia, regulating blood pressure, lowering
the ocular or optic nerve pressure, and administration of
acetazolamide and mannitol have been suggested, there
is no reliable therapeutic option nowadays, and some of
the patients would lose their vision for lifetime (4, 9, 11).
The exact pathophysiological mechanism of ION is not
known. Some animal studies have been developed to clarify the pathophysiologic mechanisms of ION and effects
of potential therapeutic agents (9, 12). Recently, some
studies have shown the role of erythropoietin and its
receptors in the pathophysiology of ION (13); and some
animal studies demonstrated that recombinant human
erythropoietin (rhEPO) can reverse the histopathological
process of ION and causes functional recovery following
ION (14, 15). Here we present a case of POVL following the
PSF surgery, treated successfully with rhEPO.
2. Case Presentation
The authors obtained patient and his family’s consent
and consulted the institutional ethics review board (IRB)
for approval (not deemed necessary by the IRB) for publishing in this journal. The patient was a 61 years old man,
75 kg weight and 180 cm height. He was admitted to Pars
General Hospital, Tehran, Iran, for posterior spinal fusion
(PSF) of C7-T1. He had a history of neck trauma about one
year before. In past medical history, there was no history
of hypertension, diabetes mellitus or, ischemic heart disease. He had no history of visual impairment, except mild
cataract in his right eye. He had a history of diffuse idiopathic skeletal hyperostosis (DISH). Before the operation,
hemoglobin was 13.15 g/dL; platelet count was 235×10 3/
µL, and clotting time (CT) and bleeding time (BT) were in
the normal range. Biochemistry tests did not show any
pathologic states. Preoperative consultation of anesthesiologist, revealed no risk factor for general anesthesia.
The electrocardiogram (ECG) had normal findings with
normal sinus rhythm without any ST segment or T wave
changes. He was transferred to the operating room to undergo PSF with general anesthesia.
Anesthesia pre-medications were 2 mg midazolam, 30
μg sufentanil and 100 mg lidocaine. Anesthesia was induced by 300 mg Thiopental-Na and 40 mg atracurium.
Patient was intubated with a number eight endotracheal
2
tube and positioned in prone position. Patient head positioned on a horseshoe head rest. Anesthesia was maintained during the operation by using propofol infusion
(75-100 μg/kg/min), in conjunction with a remifentanil
infusion (0.1-0.2 μg/kg/min), atracurium (0.2 mg/kg/every 30 min) and a mixture of nitrous oxide (3 L/min) and
oxygen (3 L/min). The ventilation protocol consisted of an
inspired oxygen fraction of 1.0, inspiratory to expiratory
ratio of 1:2, and a respiratory rate adjusted to normocapnia (end-tidal carbon dioxide partial pressure between 30
and 40 mmHg). Mechanical ventilation was performed
with a tidal volume of 10 mL/kg ideal body weight (IBW)
and ZEEP (zero-positive end expiratory pressure).
The operation time was about 6 hours. Standard monitoring included continuous ECG, pulseoximetry, capnography and urine output during anesthesia. Noninvasive
BP measurements were performed at 5-min intervals.
Urine output was 800 mL during the operation and there
was no significant change in blood pressure. Blood loss
was 2500 mL during the operation, which was replaced
by 900 mL packed red blood cell, 200 mL fresh frozen
plasma and 3000 mL of crystalloids. The patient was extubated after reversing with 3mg neostigmine and 1.5 mg
atropine sulfate.
About thirty minutes after transferring to postanesthesia care unit (PACU), patient was awaked and complained
ofvisual impairment in his right eye. There was no vision
and light perception in his right eyeinprimary examinations. Urgent ophthalmologist consultation was requested. In ophthalmology examinations, left eye had normal
visual acuity, normal pupil reflex and normal fundoscopy. In the right eye, the pupil reflex to light was absent
and there was no light perception, and positive Marcus
Gunn sign, and mild cataract was identified. Right eye
fundoscopy showed normal appearance of retina and optic disk with no abnormality in retinal vessels. PION was
proposed as diagnosis. Postoperative hemoglobin was
10 mg/dL, while other laboratory tests including arterial
blood gases had normal findings. Postoperative ECG and
chest X-ray did not have any pathologic changes.
Finally, four hours after the operation, 40000 I.U. of rhEPO (PD poein®, Pooyesh Darou, Tehran, Iran) was administered (IV infusion, 30 min) to patient in postanesthesia
care unit (PACU). An ophthalmologist visited the patient
every 6 hours until complete curing of visual loss. The
patient was transferred to intensive care unit (ICU) one
hour later with total visual loss in his right eye. Patient
received three doses of methylprednisolone (500 mg, IV,
every 8 hours) and one dose of enoxaparin (60 mg, S.C.) in
ICU. Thirty hours after the operation, the second dose of
rhEPO (40000 I.U., IV infusion) was administered. Sixth
ophthalmologic examination was performed after the
second dose of rhEPO and after 30 hours from the end
of operation, which revealed pupil reflex enhancement
and light perception in the right eye, for the first time.
In eighth ophthalmologist examination, after the second
dose of rhEPO visual acuity was improved to 10/20, eighth
Anesth Pain Med. 2014;4(2):e7291
Hassani V et al.
ophthalmologist examination was performed after 42
hours after the operation.
Finally, the third dose of rhEPO (40000 I.U., IV infusion)
was administered on the third day (52 hours after the
operation). In 11th ophthalmologist visit, after the third
dose of rhEPO, pupillary reflex of the right eye had normal findings, and visual acuity gradually progressed to
20/20. Eleventh ophthalmologist visit was performed after 8 hours of the third dose of rhEPO and 60 hours after
the operation. The patient was discharged from hospital
after six days, with normal visual acuity and without any
new complications except surgical site pain. No adverse
effects were seen after rhEPO infusion, except transient
sinus tachycardia during infusion. After six months of
follow up, his bilateral visual acuity was performed, and
his visual acuity remained 20/20 after 6 months of the
operation.
3. Discussion
This case report introduced a patient with POVL in one
eye, after spinal surgery in prone positioning. Previous
reports have shown that this complication is more frequent after spinal surgery compared to other surgeries
such as cardiac and vascular surgeries (16, 17). Based on
the American Society of Anesthesiology postoperative
visual loss registry report, 83 cases from all 93 cases of
POVL were occurred following spinal surgery, and most
of these patients had prone positioning during the operation. POVL can also occur without external pressure to
eyes in prone positioning (18). Duration of surgery equal
or more than six hoursis reported as another risk factor
predisposing POVL (18). Duration of surgery in this case
was 6 hours approximately, which may have contributed
to visual loss in this patient. Another predisposing factor in this patient was considerable hemorrhage (about
2500 mL). Most of POVL cases had massive hemorrhage
during the operation (18). Although the hemoglobin
concentration in this patient was 10 mg/dL at the end of
operation, but it seems that this index is not reliable especially after fluid replacement therapy. Hemodilution
was also reported to have a role in developing POVL (9);
However, senile atherosclerotic changes was not present
in our patients as another known risk factors of POVL.
CRAO and anterior or posterior ION are the main mechanisms of POVL (8, 9). Diagnosis is based on fundoscopic
and pupillary light reflex examinations. Abnormal findings in fundoscopy such as pale ischemic retina with
cherry-red spot or edematous disc with or without prepapillary flame-shaped hemorrhages have been seen in
CARO and AION cases, respectively, while PION cases had
normal fundoscopic examination (7). Total visual and
light perception loss, lack of pupillary light reflex and
positive Marcus Gunn pupil in the presence of normal
fundoscopy, implemented the diagnosis of PION in this
case. However, reports of the American Society of Anes-
Anesth Pain Med. 2014;4(2):e7291
thesiologists (ASA) indicated that POVL due to PION is
more likely to involve both eyes (7).
There is not a reliable therapeutic option for POVL patients at present, and considerable number of patients
would lose their visual acuity for entire lifetime (11, 12).
Based on the findings of animal models showing the beneficial effects of rhEPO on ION, we decided to treat this
case with rhEPO (13-15). It was seen that rhEPO (40,000
I.U., in three consecutive days) completely reversed the
POVL in our patient.
It has been shown that erythropoietin (EPO) can protect neural cells from injuries induced by hypoxia, infections and neurotoxicity (19-21). EPO released during
hypoxia can inhibit neural cell death by its antiapoptotic
mechanisms (22) and also can promote neurogenesis in
the central nervous system (23). EPO receptors are normally expressed in retinal ganglion cells and may have
physiological roles in the retina (24, 25). EPO can prevent apoptosis in animal studies, via activation of some
protein kinases pathways and recruitment of antiapoptotic molecules like NF-Ƙβ and bcl2 in the retina (14, 15,
21). The important finding of this study was that rhEPO
reversed total visual loss, completely after 60 hours. The
rhEPO possibly via its antiapoptotic mechanisms cured
our patients with monocular POVL. Of course, in a recent
study by Quraishi et al. a single patient following spinal
surgery,was presented with transient bilateral POVL.
This patient’s visual loss improved within 48 hours (26).
POLV was monocular in our patients and was improved
30 hours from the operation and 24 hours after the first
dose of rhEPO. According to Quraishi report, our result
might not be interfered by rhEPO therapy,nonetheless
the first time of improvement occurred sooner than other reports, may support the beneficial effects of rhEPO.
On the other hand, our case of monocular POVL, reversed
completely, exact 8 hours after the third dosage of rhEPO
and 60 hours after the operation. Evidently, we have not
continuous ophthalmologist visit, but in 8th visit of ophthalmologist, 14 hours after the second dose of rhEPO, visual acuity was 10/20, and 8 hours after the third dose of
rhEPO, visual acuity reversed completely to 20/20.
In conclusion, this case report showed the beneficial effect of rhEPO in complete curing of POVL. Regarding a
few side effects of EPO such as thrombogenic effects or
mild hemodynamic changes like transient sinus tachycardia during infusion, it seems that beneficial effects of
EPO is more than its disadvantages and expenses, for patients with POVL. However, further investigations need to
consider rhEPO as a therapeutic option in patients with
postoperative visual loss to confirm its beneficial effects.
This finding is promisingin the absence of specific therapeutic option for POVL.
Acknowledgements
The authors have nothing to declare.
3
Hassani V et al.
Authors’ Contribution
Conception and design, critical revision of the manuscript: VH; MMH; Literature search, Clinical analysis,
scientifically revision of the manuscript and data interpretation and writing the manuscript: SS; ASH and MMZ.
Data collection, critical revision of the manuscript: SHN;
SAZ; AR; MHL.
11.
12.
13.
14.
Financial Disclosure
The authors declared no financial disclosure.
Funding/Support
This article was not supported by any funding organization.
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