VOLUME 30, ISSUE 1

Incidence of Post-Operative Vision Loss in the Pediatric Population:
A Nationwide Population-Based Analysis

Rabail Chaudhry MD, Erin Williams MD, Ranu Jain MD, Cameron Bruner MSI, Greesha Pednekar MD, Muaz Aijazi MD, Maria Matuszczak MD, George W. Williams MD

** summary of an abstract presented at the American Society of Anesthesiologists Annual Meeting, Boston, MA Oct 21-25, 2017

Postoperative vision loss (POVL) is a very rare complication that can occur during both ocular and non-ocular surgery. Due to the extremely high value placed on vision, this complication is particularly devastating, despite its rare occurrence. Among non-ocular surgeries, POVL has been documented with the highest frequency in cardiac and spinal fusion surgeries, comprising 0.0864% and 0.0309% of cases respectively (1). Other estimates have placed the occurrence of POVL during spinal surgeries between 0.0008 and 0.2% (2,3). Anesthesiologists in Houston at Memorial Hermann Hospital/McGovern Medical School as well as Texas Children’s Hospital/Baylor College of Medicine examined POVL in the pediatric population.

While the rate of occurrence of POVL varies between studies and types of surgeries, the causative factors of this condition do not. The pathogenesis of POVL has been attributed to a number of factors including, but not limited to, ischemia of the optic nerve (ION), occlusion of the central artery of the retina, cortical ischemia, and corneal abrasion (4). Of these, ischemic optic neuropathy has been shown to be the most prevalent, comprising up to 89% of all POVL cases (5,6).

Until now, however, there have been few studies conducted on the occurrence of POVL in the pediatric population. In a nationwide review of POVL between the years of 1996 and 2005, Shen and colleagues found that POVL was much more likely to occur in pediatric patients than adult patients (1). They discovered the rate of POVL in pediatric patients to be 0.0437%, while the rate among those ages 18-49 was a mere 0.0092%, and those over 50 was 0.0246-0.0287%. It was proposed that the higher percentage of pediatric patients experiencing POVL was due to a greater susceptibility to cortical ischemia (1). Another recent study of 42,339 pediatric patients undergoing corrective scoliosis surgery found that 0.16% of patients experienced POVL. Of those 0.16% cases all were attributed to cortical ischemia (7).

In 2016, Rubin and colleagues stated that the incidence of POVL has declined significantly over the past decade (8). While this may be true, the greater percentage of pediatric patients experiencing POVL remains a cause for alarm. Therefore, because of the relative lack of literature regarding this catastrophic condition in the pediatric population, we set out to elucidate the prevalence of POVL among pediatric patients undergoing commonly performed surgical procedures and the potential risk factors that may contribute to the development of this severe complication.

Utilizing the Kid’s Inpatient Database (KID) from 2012, they identified patients who underwent a surgical procedure of interest based on the presence of International Classification of Diseases, 9th version (ICD-9-CM) procedure codes.

The KID is the largest all-payer pediatric inpatient care database in the United States and contains data from approximately 3 million pediatric discharges each year (9). It was developed for the Healthcare Cost and Utilization Project (HCUP).

Among 3,038,451 unweighted discharges, 157,331 discharges were associated with surgeries of interest. Of these discharges, the incidence of POVL was 0.10%. However, the incidence of POVL was significantly different amongst the various age groups (p <0.001) with the highest incidence noted in the 1-5 yr. group (0.218%), followed by 6-10 yr. group (0.138%), and was least in the 11-17 yr. (0.06%).

The highest rates of POVL were observed in neurosurgery (0.48%; OR 4.14; p <0.001), followed by transplant surgery (0.25%) and spinal surgery (0.25%). The majority of the cases seen in neurosurgery were due to cortical blindness (0.45%), while a few were attributed to Retinal Vascular Occlusion (RVO) (0.02%). Surprisingly, the incidence of ION was extremely rare in the pediatric population.

We analyzed the odds of developing POVL for each patient demographic and type of surgery. The odds of developing POVL were not statistically significantly different among different age groups. No differences in gender were observed. Patients undergoing elective procedure had significantly higher odds of developing POVL (OR 3.36, p value <0.01).

Among the risk factors, patients with anemia were almost 3 times more likely to develop POVL (OR 2.94, p value <0.001). Patients who required blood transfusion (OR 2.18, p value 0.002) or experienced hypotension (OR 2.77, p value 0.009) were also at a significantly greater risk of developing vision loss.

In conclusion, differences were noted in the most common causes of POVL between adults and children. Unlike adults, where POVL is most often a result of ION, the incidence of POVL in the pediatric age group was found to be 0.10% and was most often a result of cortical blindness. The highest incidences of POVL were found in neurosurgery and patients with preexisting anemia. Intraoperative hypotension and those requiring blood transfusion were noted to be at a greater risk of developing vision loss. Although rare, POVL is a devastating complication which may frequently be preventable. Although the causes of POVL have not been completely elucidated, physicians can take certain preventive measures, such as thorough preoperative evaluation to detect and optimize modifiable risk factors such as anemia, in hopes of lowering the risk of POVL. Since the main cause of POVL in children is related to cortical blindness, proper positioning of patients during surgery and maintaining normotension using vasopressors and intravenous fluids judiciously might also reduce the risk of developing post-operative blindness.

References:

  1. Shen Y, Drum M, Roth S. 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. Anesth Analg 2009; 109(5): 1535-1545
  2. Warner ME, Warner MA, Garrity JA, MacKenzie RA, Warner DO. The frequency of perioperative vision loss. Anesth Analg 2001; 93: 1417–21.
  3. Stevens W, Glazer PA, Kelley SD, Lietman TM, Bradford DS. Ophthalmic complications after spinal surgery. Spine 22: 1319–1324, 1997.
  4. Newman NJ. Perioperative Visual Loss After Nonocular Surgeries. Am J Ophth. 2008;145(4):604-610.
  5. Grover V, Jangra K. Perioperative vision loss: A complication to watch out. JAnaesth, Clin Pharm. 2012;28(1):11-16.
  6. Epstein NE. Perioperative visual loss following prone spinal surgery: A review. Surgical Neurology International. 2016;7(Suppl 13):S347-S360.
  7. Garza R, Samdani AF, Sponseller PD, Ain MC, Miller NR, Shaffrey CI, Sciubba DM. Visual loss after corrective surgery for pediatric scoliosis: incidence and risk factors from a nationwide database. Spine J. 2016 Apr; 16(4): 516-522.
  8. Rubin, DS, Parakati, I, Lee, LA, Moss, HE, Joslin, CE, Roth, S Perioperative visual loss in spine fusion surgery: Ischemic optic neuropathy in the United States from 1998 to 2012 in the Nationwide Inpatient Sample. Anesthesiology. 2016;125(3):457-464.
  9. HCUP Kids’ Inpatient Database (KID). Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/kidoverview.jsp. Accessed 03 Dec 2016.

Next