The possible cause and pathophysiology are currently unknown, although it seems more likely a transient hypoperfusion of the optic nerve circulation rather than embolic lesions.12 Nevertheless, the development of ischemic optic neuropathy seems to be linked to perioperative hypotension and blood loss during the procedure, anemia, significant intraoperative dehydration, surgical trauma, shock, and lengthy time of surgical procedure.2 Risk factors cause axonal edema that is supposed to be the trigger of a compartment syndrome in a structurally crowded optic disc with the result of producing axonal degeneration and loss of retinal ganglion cells by means of apoptosis.9 However, although anemia and hypotension have been reported in most cases of postoperative visual loss, fortunately, patients do not display ocular damage so often, shifting the interest of the research onto other presumed risk factors.2,9,10 It is likely that head-down or prone position (that itself significantly increases intraocular pressure12) rather than jugular vein ligation as presumed by some authors is another risk factor leading to an increased orbital pressure that reduces arterial perfusion pressure. This may justify why this complication frequently follows neck dissection (even when jugular veins are spared)2 and spinal surgery.2,13 Alternatively, it has been shown that patient-specific susceptibility such as optic disc morphology and a faulty autoregulation of the optic nerve circulation and defective autonomic variations in blood supply play a key role in the development of this disease,2,9–11 confirming the vulnerability of the optic nerve blood supply to hemodynamic alterations.10
Management of ischemic optic neuropathy is predicated on early detection, with early ophthalmic assessment and referral. To prevent ischemic optic neuropathy, some important preventive measures should be taken, including intraoperative head-up position, adequate hemoglobin concentration, and maintenance of a low intraocular pressure. The administration of acetazolamide and retinal diuretics such as mannitol and furosemide in combination with systemic corticosteroids and antiplatelet agents is aimed at reducing optic nerve edema,2 and it seems to be effective, especially in the acute phase.2 Recommendations should be to remove and restore both predisposing and precipitating factors to reduce the risk of anterior ischemic optic neuropathy and, when already present, to avoid its development in the contralateral eye and further episodes in the same eye.
Ischemic optic neuropathy is a rare but potentially devastating complication of liposuction. Because the number of procedures of liposuction has increased dramatically, physicians should be aware that anemia, hypotension, long duration of surgery, and significant intraoperative hydration may all be risk factors for this condition. Surgeons should inform all patients undergoing liposuction about the risk of this possible though rare condition. During the procedure, every effort should be made to maintain stable hemoglobin and mean arterial pressure and to avoid overhydration. Inquiring about transient visual obscuration and screening for papilledema before proceeding with liposuction on such patients should be considered preoperatively by physicians.
Tommaso Agostini, M.D.
Stefano Lazzeri, M.D.
Michele Figus, M.D.
Marco Nardi, M.D.
Marcello Pantaloni, M.D.
Davide Lazzeri, M.D.
There are no financial conflicts or interests to report in association with the content of this communication.
1. Iverson RE, Pao VS. MOC-PS(SM) CME article: Liposuction. Plast Reconstr Surg
2. Agostini T, Lazzeri D, Agostini V, Mani R, Shokrollahi K. Ischemic optic neuropathy and implication for plastic surgeons: Report of a new case and review of the literature. Ann Plast Surg.
3. Rath EZ, Falick Y, Rumelt S. Posterior ischemic optic neuropathy following breast augmentation and abdominal liposuction. Can J Ophthalmol
4. Moura FC, Cunha LP, Monteiro ML. Bilateral visual loss after liposuction: Case report and review of the literature. Clinics (Sao Paulo)
5. Ribeiro Monteiro ML, Moura FC, Cunha LP. Bilateral visual loss complicating liposuction in a patient with idiopathic intracranial hypertension. J Neuroophthalmol
6. Sigbatullah M, Kupersmith MJ, Zerykier A, Volpe S. Ischemic optic neuropathy after liposuction: Case report and review. J Neuroophthalmol
7. Foroozan R, Varon J. Bilateral anterior ischemic optic neuropathy after liposuction. J Neuroophthalmol
. 2004;24: 211–213.
8. Minagar A, Schatz NJ, Glaser JS. Liposuction and ischemic optic neuropathy: Case report and review of literature. J Neurol Sci
9. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res
10. Murthy TVSP, Bathia P, Prabhakar T, Gogna RL. Postoperative visual loss. J Anaesth Clin Pharmacol
11. Newman NJ. Perioperative visual loss after nonocular surgeries. Am J Ophthalmol
12. Hunt K, Bajekal R, Calder I, Meacher R, Eliahoo J, Acheson JF. Changes in intraocular pressure in anaesthetized prone patients. J Neurosurg Anesthesiol
13. Buono LM, Foroozan R. Perioperative posterior ischemic optic neuropathy: Review of the literature. Surv Ophthalmol
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