Incidence, Risk Factors, and Management of Blindness after Orbital Surgery

Abstract

Purpose: Severe vision loss is a risk of orbital surgery which physicians should counsel patients about, but the overall risk rate is unknown. This research was conducted to determine the risk of severe vision loss related to orbital surgery. Design: Retrospective review. Participants: Patients who underwent orbital surgery at either of 2 academic medical centers between January 1994 and December 2014. Methods: A billing database search was conducted to identify all patients who had orbital surgery during the study period, cross-checked against diagnostic codes related to vision loss. Charts were screened to determine baseline demographic and medical history, surgical procedure, intraoperative and perioperative management, and visual acuity. Patients with preoperative visual acuity >= 20/200 that worsened <= 20/400 after orbital surgery were included for detailed review. Statistical analysis was conducted to identify factors posing particular risk or benefit to visual outcome in these patients. Main Outcome Measures: Visual acuity after orbital surgery. Results: A total of 1665 patients underwent orbital surgery during the inclusion period, with 14 patients sustaining severe vision loss ranging from counting fingers at 1 foot to no light perception (overall risk, 0.84%). The causes of vision loss included retrobulbar hemorrhage, malpositioned implant, optic nerve ischemia, or direct optic nerve insult. When stratified by surgical approach, the risk of a blinding surgical complication was significantly higher for patients undergoing orbital floor repair in the setting of multiple facial fractures (subgroup risk, 6.45%), bony decompression of the optic canal (subgroup risk, 15.6%), or intracranial approach to the orbital roof (subgroup risk, 18.2%). Seven of 8 patients with a potentially reversible cause of postoperative vision loss underwent urgent repeat surgery, and 2 regained substantial vision (20/20 and 20/25). Administration of intravenous corticosteroids had no significant effect on visual acuity outcome. Conclusions: The overall risk of severe vision loss after orbital surgery is 0.84%. The subgroup risk is higher in patients undergoing facial polytrauma repair, optic canal decompression, or orbital apex surgery from an intracranial approach. Close postoperative monitoring and urgent assessment and management of acute vision loss may improve visual outcome in some patients. (C) 2018 by the American Academy of Ophthalmology