Perioperative visual loss (POVL) is an uncommon, but devastating complication that remains primarily associated with spine and cardiac surgery. The incidence and mechanisms of visual loss after surgery remain difficult to determine. According to the American Society of Anesthesiologists Postoperative Visual Loss Registry, the most common causes of POVL in spine procedures are the two different forms of ischemic optic neuropathy: anterior ischemic optic neuropathy and posterior ischemic optic neuropathy, accounting for 89% of the cases. Retinal ischemia, cortical blindness, and posterior reversible encephalopathy are also observed, but in a small minority of cases. A recent multicenter case control study has identified risk factors associated with ischemic optic neuropathy for patients undergoing prone spinal fusion surgery. These include obesity, male sex, Wilson frame use, longer anesthetic duration, greater estimated blood loss, and decreased percent colloid administration. These risk factors are thought to contribute to the elevation of venous pressure and interstitial edema, resulting in damage to the optic nerve by compression of the vessels that feed the optic nerve, venous infarction or direct mechanical compression. This review will expand on these findings as well as the recently updated American Society of Anesthesiologists practice advisory on POVL. There are no effective treatment options for POVL and the diagnosis is often irreversible, so efforts must focus on prevention and risk factor modification. The role of crystalloids versus colloids and the use of α-2 agonists to decrease intraocular pressure during prone spine surgery will also be discussed as a potential preventative strategy. Core tip: Perioperative visual loss (POVL) is an uncommon, but devastating complication that remains primarily associated with spine and cardiac surgery. The incidence and mechanisms of visual loss after surgery remain difficult to determine. Ischemic optic neuropathy accounts for the vast majority of these cases, with retinal ischemia, cortical blindness, and posterior reversible encephalopathy observed with low incidence. Recently identified risk factors include obesity, male sex, Wilson frame use, longer anesthetic duration, greater estimated blood loss, and decreased percent colloid administration. POVL is often permanent and untreatable, so prevention is key to limiting its impact. Nickels TJ, Manlapaz MR, Farag E. Perioperative visual loss after spine surgery. World J Orthop 2014; 5(2): 100-106 Available from:

1. Application of the nitric oxide (NO) donor, sodium nitrite and the NO synthase substrate l-arginine had no effect on nerve-evoked transmitter release in the rat isolated phrenic nerve/hemidiaphragm preparation; however, when adenosine A(1) receptors were blocked with the adenosine A(1) receptor antagonist 1,3-dipropyl-8-cyclopentylxanthine (DPCPX) prior to application of sodium nitrate or l-arginine, a significant increase in transmitter release was observed. In addition, the NO donor s-nitroso-N-acetylpenicillamine (SNAP) significantly increased transmitter release in the presence of DPCPX. In the present study, we have made the assumption that these NO donors elevate the level of NO in the tissue. Future studies should test other NO-donating compounds and also monitor the NO concentrations in the tissue to ensure that these effects are, in fact, NO induced. 2. Elevation of cGMP in this preparation with the guanylyl cyclase activator 3-(5'-hydroxymethyl-2'-furyl)-1-benzyl indazole (YC-1) significantly enhanced transmitter release. In the presence of DPCPX and the selective guanylyl cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ), which blocks the production of cGMP, the excitatory effects of sodium nitrite and l-arginine were abolished. 3. These results suggest that NO serves to enhance transmitter release at the rat neuromuscular junction (NMJ) via a cGMP pathway and this facilitation of transmitter release can be blocked with adenosine. Previously, we demonstrated that adenosine inhibits N-type calcium channels. Because NO only affects transmitter release when adenosine A(1) receptors are blocked, we suggest that NO enhances transmitter release by enhancing calcium influx via N-type calcium channels. Further studies are needed to confirm that NO alters transmitter release via cGMP and that this action involves the N-type calcium channel. 4. The results of the present study are consistent with a model of NO neuromodulation that has been proposed for the mammalian vagal-atrial junction. This model suggests that NO acts on NO-sensitive guanylyl cyclase to increase the intracellular levels of cGMP. In turn, cGMP inhibits phosphodiesterase-3, increasing levels of cAMP, which then acts on the N-type calcium channels to enhance calcium influx, leading to an increase in transmitter release. Our only modification to this model for the NMJ is that adenosine serves to block the modulation of transmitter release by NO.

1. Theophylline and aminophylline have been widely used as inhibitors of phosphodiesterase when examining the role of cAMP in regulating cell function. In reality, however, these phosphodiesterase inhibitors may have additional sites of action that could complicate the interpretation of the results. These additional sites of action could include antagonism of inhibitory adenosine autoreceptors and release of intracellular calcium. The purpose of the present study was to determine which of the above three is the primary mechanism by which theophylline and aminophylline affect transmitter release at the mammalian neuromuscular junction. 2. Quantal release measurements were made using intracellular recording techniques. A variety of drugs were used to elucidate this pathway. Isoproterenol, an adenylate cyclase activator, was first used to establish the effect of enhanced levels of cAMP. Theophylline application on its own or in the presence of a drug combination that blocked the adenosine receptor and phosphodiesterase pathways caused significant release depression, opposite to what is expected if it was functioning to enhance cAMP levels. However, when applied in the presence of a drug combination that blocked the adenosine receptor, phosphodiesterase and intracellular ryanodine calcium pathways, theophylline was unable to depress release. Therefore, it was concluded that the major mechanism of action of theophylline is depression of transmitter release by causing the release of intracellular calcium. 3. Aminophylline application alone resulted in a significant enhancement of release. However, when coupled with an adenosine receptor blocker, the ability of aminophylline to enhance transmitter release was blocked, suggesting that its dominant mechanism of action is adenosine receptor inhibition. 4. Taken together, these results indicate that the use of theophylline and aminophylline is inappropriate when examining the role of cAMP at the mammalian neuromuscular junction.