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A Devastating Case of Bilateral Permanent Vision Loss After Microsurgical Reconstruction of the Lower Extremity

Keith, Jerrod N MD Stofman, Guy M MD
University of Pittsburgh
2012-02-11

Presenter: Jerrod Keith, MD

Affidavit:
The above work was all done by Jerrod Keith, MD.

Director Name: Joseph Losee MD

Author Category: Chief Resident Plastic Surgery
Presentation Category: Clinical
Abstract Category: General Reconstruction

How does this presentation meet the established conference educational objectives?
This paper discusses a common scenario in reconstructive plastic surgery; lower extremity reconstruction. In addition it highlights a rare but extreme morbidity of vision loss. Although this complication is rare, it does occur in plastic surgery patients (both reconstructive and aesthetic), and it's therefore important for practitioners to be educated in the disease process and how to lower this risk.

How will your presentation be used by practicing physicians in the audience?
This presentation highlights the severe complication of postoperative ischemic optic neuropathy. Physicians will be informed about this disease process, but more importantly we will also discuss methods to reduce the risk of occurrence and minimize known risk factors.

Purpose: We intend to share our experience about a devastating complication encountered during lower extremity microsurgical reconstruction, resulting in bilateral permanent blindness.

Methods: This case highlights a 60yo caucasion male with multiple medical comorbidities. He presented with a deep calcaneal abscess, eventually leaving exposure of the achilles tendon and calcaneous. Free flap reconstruction was performed using a saphenous vein graft and latissimus dorsi muscle with the patient placed in the prone position. The reconstruction was successful, notwithstanding transient intraoperative anemia and moderate hypotension.

Results: Postoperatively, the patient was found to have bilateral vision loss. After an extensive neurologic and ophthalmologic workup, he was diagnosed with bilateral postoperative ischemic optic neuropathy (ION); a permanent diagnosis. Postoperative ION is a tragic complication, rarely seen in plastic surgery. It is most common after spinal surgery, but bilateral involvement is even more unusual. The pathogenesis, clinical features, and management are controversial. Considering the known risk factors, our patient provided the "perfect storm" for such a complication. Predisposing risk factors include all aspects of systemic cardiovascular and small vessel ocular disease. Known precipitating factors read like this patient's operative report: prolonged surgery, prone position, anemia, hypotension, facial edema, and hemorrhage. Unfortunately, once the damage has occurred, little exists to improve vision.

Conclusions: Bilateral postoperative ischemic optic neuropathy is a rare and catastrophic event, especially after unsuspecting surgery involving one's lower extremity. In high risk medical patients undergoing complex and lengthy operations, knowledge of this unfortunate complication is important to make every effort to minimize known risk factors.

Author Contact Information:
Jerrod Keith
3550 Terrace St
664 Scaife Hall
Pittsburgh, PA
15261

412-383-8082
412-576-4451 (cell)
412-383-8986 (fax)

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