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Post-Operative Visual Loss Prone — FRCA Final MCQ

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HardGeneral AnaesthesiaPost-Operative Visual Loss ProneFRCA Final

A 60-year-old man (ASA III) has a lumbar laminectomy in the prone position on a Montreal mattress. Post-operatively he develops bilateral visual loss. Examination shows no light perception bilaterally with normal pupillary responses. What is the most likely diagnosis?

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Correct answer: D — Cortical blindness from posterior circulation stroke

Post-operative visual loss (POVL) after prone spine surgery is a rare but devastating complication. The most common cause is ischaemic optic neuropathy (ION) – either anterior (AION) or posterior (PION). Risk factors include: prolonged prone surgery (>6 hours), significant blood loss, hypotension, anaemia, male sex, and obesity. PION is more common than AION after spine surgery. Bilateral involvement with preserved pupillary responses (retrobulbar pathology) is typical of PION. If pupils are unreactive, cortical blindness or retinal artery occlusion should be considered. There is no proven treatment for ION.

Reference: ASA – 2019 – Practice advisory for perioperative visual loss; RCOA – 2023 – Spinal surgery positioning