Irreversible bilateral ischemic optic neuropathy in the post-operative myocardial revascularization setting: case report
Year: 2024
Type: conference-paper
Study design: Case Report
Abstract: Case presentation: Male, 71 years old, white, hypertensive, overweight, with severe coronary insufficiency, heart failure (HF), sleep apnea, dyslipidemia, post-myocardial revascularization surgery (without complications) with extracorporeal circulation (ecc). In the immediate postoperative period (PO), he was sent to the intensive care unit (ICU) due to spikes in arterial hypotension, desaturation (requiring norepinephrine) and anemia. On the 4th PO, in the ward, he developed decreased visual acuity and subsequent loss of complete vision (5th PO), without reaction to light. brain tomography ruled out a stroke, while magnetic resonance imaging (MRI) revealed hypoglycemic encephalopathy, cause of cortical blindness due to amaurosis; by retinography, peridiscal micro-hemorrhages were evident, with a bilateral atrophic area. He was discharged on the 10th PO, with the diagnostic hypothesis of hypoglycemic encephalopathy. However, without showing any improvement in the condition, on the 11th day after vision loss, an eye fundus examination and fluorescein angiography revealed: edema, pallor of the papilla, signs of hypo fluorescence and candle flame hemorrhage, considering hypothesis of anterior ischemic optic neuropathy (AION). On the 17th day after amaurosis, skull MRI showed nonspecific changes in optic nerves, corroborating NAION. Inflammatory tests were conducted, with results within normal limits. Pulses with methylprednisolone (3x/day) were then performed, however, without improvement. On the 50th day after visual loss, a new fundus examination revealed: pallor and reduction in papillary edema; optic nerve atrophy; confirming bilateral non-arteritic AION (NAION). After one year of PO, the patient developed a diagnosis of total blindness, remaining in bilateral amaurosis and without perception of light. Discussion: Perioperative visual loss is a rare and feared complication in the postoperative period of non-ophthalmic surgeries, which can result in serious and irreversible damage. The patient, here in the PO of cardiac surgery, had preoperative risk factors (comorbidities), which in addition to postoperative risk factors (hemodynamic decompensation and use of vasoactive drugs) contributed to NAION. This condition is related to optic nerve infarction, resulting in hypoperfusion and ischemia. It has been shown that NAION is a diagnosis of exclusion, which makes its diagnosis difficult. Treatments do not have good evidence of effectiveness so far, so the prognosis tends to be darker, considering the prevention of risk factors essential. Final comments: Recognizing the previous clinical history, immediate anatomical and etiological diagnosis is essential to guide the diagnosis, management, and prognosis of NAION. Case reports like this tend to contribute to the recognition of rare complications, decentralizing health information, as well as its applicability.
Source: Arquivos de Neuro-Psiquiatria
DOI: 10.5327/cbn240980
Language: English
Topic: Retinal and Optic Conditions
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $200
OpenAlex ID: W4416865645