Anterior ischemic optic neuropathy after hemorrhagic shock

Waking Up Blind in the ICU: A Case Report of Ischemic Optic Neuropathy in a Burn Patient

The objective of this report is to analyze and summarize the current literature of ischemic optic neuropathy (ION), a rare complication in severe burn and trauma victims, while presenting an urban burn center's experience with the condition. This is an unfortunate condition and this report will raise awareness to a potential complication in the burn patient population as well as in critically ill patients in other settings.

We present the case of a 27-year-old healthy male patient admitted to our Burn Center with 85% total body surface area (TBSA) full-thickness burns sustained in a house fire. The patient had a complicated hospital course but improved over time and was weaned off of prolonged ventilation and sedation. Subsequently, he complained of bilateral blindness. A fundoscopic examination demonstrated bilateral pale optic nerves with sparing of the remaining peripheral retina consistent with ION. The patient suffered complete bilateral vision loss. He had multiple factors that could have instigated the development of ION, including several episodes of septicemia, hypovolemic shock and severe adult respiratory distress syndrome (ARDS) with refractory hypoxemia requiring a prolong ventilation support and vasopressor therapy. 

Due to the advancement of the treatment of acute burns, the survival rate of patients that once would have succumbed to their burn injury, is increasing. With these new achievements, we are facing new challenges and complications. ION has a significant impact on the quality of the patient’s life. The early diagnosis will not necessarily translate into a benefit for these patients as no treatment has been proven successful. Extensive retrospective and prospective studies are necessary to identify and treat this patient population.

A case series: bilateral ischemic optic neuropathy secondary to large volume fluid resuscitation in critically ill burn patients

Ischemic optic neuropathy (ION) in the trauma setting is a rare and devastating condition associated with systemic hypotension, massive volume resuscitation, and sepsis. The objective of this case series is to highlight a potential correlation between severe burn and ischemic optic neuropathy. We present three patients with total body surface area (TBSA) thermal injury burns ranging from 57 to 68% treated at the North Carolina Jaycee Burn Center that developed bilateral ischemic optic neuropathy during their hospital stay. Each patient required greater than 25 L of crystalloid fluid within 24 h after admission, suffered multiple bouts of sepsis, and required extended pressor support. We postulate that ischemic optic neuropathy develops as a result of the interplay between the patient's systemic pathophysiology, i.e. shock, sepsis and the continued need for large volume fluid resuscitation. Current treatments of ION have not proven to be effective, except for possibly limiting fluid resuscitation. In the few cases of refractory burn shock, the incidence of this condition is unlikely to be readily improved. However, it is important for clinicians to be aware of this devastating complication and consider early ophthalmology involvement in the care of severely burned patients.

Blindness after Blunt Facial Trauma: Are There Any Clinical Clues to Early Recognition?

BACKGROUND

Vision-threatening injury is a relatively rare but devastating complication of maxillofacial trauma. Identification is not always straightforward. The purpose of this study was to look at our experience of blindness after blunt facial injuries to see whether any useful patterns or risk factors were identified to assist in early recognition.

METHODS

This was a retrospective, qualitative study undertaken at the University Hospital of North Staffordshire. All case notes, plain radiographs, and computed tomographic scans were reviewed and the relevant data collated.

RESULTS

Over a 10-year period, 17 patients were identified in which loss of vision occurred secondary to blunt injury to the face.

CONCLUSION

It is important to maintain a high index of suspicion when dealing with maxillofacial trauma, particularly if the patient is not cooperative. We provide a list of salient features to look for in the examination and history to aid the clinician.

Anterior ischemic optic neuropathy in children: case reports and review of the literature

Anterior ischemic optic neuropathy, infarction of the optic nerve head owing to inadequate perfusion through the posterior ciliary arteries, is a common cause of visual loss in adults but is rarely reported in children, in part because the diagnosis is overlooked. We report two cases of young children undergoing chronic peritoneal dialysis, who suffered bilateral visual loss from anterior ischemic optic neuropathy. Predisposing local anatomic and multiple systemic factors included a small optic nerve head with little cupping, possible intraocular hypertension, and systemic hypotension, hypovolemia, and anemia. The literature on anterior ischemic optic neuropathy is reviewed.

Anterior ischemic optic neuropathy: a complication after systemic inflammatory response syndrome

BACKGROUND

Patients are surviving previously fatal injuries. Unique morbidities are occurring in these survivors. Anterior ischemic optic neuropathy represents a previously unrecognized cause of blindness in the trauma victim. We hypothesize that this phenomenon is caused by unique characteristics of optic edema/ pressure or decreased blood flow associated with massive resuscitation.

METHODS

Between November of 1991 and August of 1998, there were 18,199 admissions to our trauma center. Of this group, 350 patients required massive volume resuscitation (>20 liters infused over first 24 hours). Patients having closed head injuries, facial fractures or direct orbital trauma were excluded from study. The following variables were studied: demographics, injury severity (Injury Severity Score, highest lactate, worst base deficit, and lowest pH) crystalloid and transfusion requirements, ventilator requirements (PEEP) RESULTS: Of the 350 patients with massive resuscitation, 9 patients were diagnosed with anterior ischemic optic neuropathy (2.6%). Of these, seven patients required celiotomy (78%). Six of the seven celiotomy patients had damage control celiotomies and abdominal compartment syndrome (86%). One patient had a repair of a subclavian artery; one had a complex acetabular repair. Blindness was unilateral in five patients and bilateral in four. All nine patients had evidence of global hypoperfusion, systemic inflammatory response, massive resuscitation, and high ventilatory support; one patient required cardiopulmonary resuscitation.

CONCLUSION

Prone positioning is known to be associated with an increased intraocular pressure. We postulate that the combination of massive resuscitation and prone positioning will increase the incidence of anterior ischemic optic neuropathy. As such, we recommend that prone positioning for adult respiratory distress syndrome be reserved for only those patients at risk of death.