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Ischemic Optic Neuropathy as a Rare but Potentially Devastating Complication of Liposuction

Agostini, Tommaso M.D.; Lazzeri, Stefano M.D.; Figus, Michele M.D.; Nardi, Marco M.D.; Pantaloni, Marcello M.D.; Lazzeri, Davide M.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1735-1738
doi: 10.1097/PRS.0b013e31820a657e

Department of Plastic and Reconstructive Surgery; University of Florence; Florence, Italy (Agostini)

Ophthalmology Unit; Hospital of Pisa; Pisa, Italy (S. Lazzeri, Figus, Nardi)

Plastic and Reconstructive Surgery Unit; Hospital of Pisa; Pisa, Italy (Pantaloni, D. Lazzeri)

Correspondence to Dr. Davide Lazzeri, Plastic and Reconstructive Surgery Unit, Hospital of Pisa, Via Paradisa 2, Cisanello 56100, Pisa, Italy,

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It was with interest that we read the extremely didactic CME article by Iverson and Pao on liposuction published in your Journal.1 Recently reviewing all cases of nonarteritic anterior ischemic optic neuropathy following any type of plastic, reconstructive, and aesthetic surgery procedures,2 we found six cases3–8 following liposuction procedures. We would like to take the opportunity to discuss some key points in the diagnosis and management of ischemic optic neuropathy as a severe though rare complication occurring after liposuction.

Perioperative anterior or posterior ischemic optic neuropathy is a rare entity occurring as consequence of laminar or retrolaminar optic nerve infarction determined by several injuries other than giant cell arteritis that produces ischemic damage to ganglion cell axons leading to axonal and visual field loss and decreased visual acuity.9–11 Of six cases described (mean age, 39 years; range, 30 to 49 years) following liposuction, three were bilateral anterior ischemic optic neuropathy,4,5,7 two were unilateral anterior ischemic optic neuropathy,6,8 and one was unilateral posterior ischemic optic neuropathy3 (Table 1). The average volume of aspirated fat was 7400 ml (range, 2800 to 22,000 ml). Minagar and colleagues8 reported the case of a 47-year-old woman with no atherosclerotic risk factors who complained of postoperative hypotension and anemia after liposuction of the abdomen, thighs, and arms. Visual loss developed in her right eye 2 days after the procedure, and a pallid optic disc edema was detected by means of ophthalmoscopy. The left optic disc was not crowded, and had a normally sized cup. Because results of magnetic resonance imaging and magnetic resonance angiography of the brain were negative, the authors8 stated that the patient had had a postoperative anterior ischemic optic neuropathy precipitated by acute blood loss and hypotension. Interestingly, Sigbatullah et al.6 presented a very similar patient with left anterior ischemic optic neuropathy, suffering an inferior altitudinal field defect on the second postoperative day after liposuction, caused by hemodilution (the hematocrit value was only 23.5 percent). A possible anterior ischemic optic neuropathy also in the right eye was presumed but not confirmed because of the visual field depression and normal ophthalmoscopy. Foroozan and Varon7 described a case of bilateral anterior ischemic optic neuropathy after a high-volume liposuction procedure. The 30-year-old patient also developed pulmonary embolism and dural venous sinus thrombosis with thrombocytopenia and anemia. Bilateral pallid optic disc edema and hemorrhages were observed during the examination. Although transverse sinus thrombosis was disclosed on magnetic resonance imaging, the intracranial pressure values were not reported. Postoperative severe anemia (hemoglobin of 7.0 g/dl and a hematocrit of 21.6 percent) was reported. Ribeiro Monteiro et al.5 discussed a case in which visual loss was produced by bilateral anterior ischemic optic neuropathy in the setting of chronic papilledema in idiopathic intracranial hypertension. Infarction of the optic disc already crowded and submitted to an increased pressure of the cerebrospinal fluid was the result of hypotension caused by large-volume liposuction. The authors concluded that visual loss may have developed because of red blood cell loss, transient hemodilution, and hypotension. Moura et al.4 managed a case of bilateral anterior ischemic optic neuropathy that arose 4 days after surgery. Cerebrospinal fluid examination, lumbar pressure measurements, and magnetic resonance imaging of the brain were all normal. An inferior altitudinal field defect and optic disc edema in both eyes with a peripapillary hemorrhage in the left eye did not improve with corticosteroid therapy. Rath et al.3 reported a right posterior ischemic optic neuropathy in an otherwise uneventful liposuction procedure combined with breast augmentation. Their 43-year-old patient presented 2 days after surgery with a best-corrected visual acuity of 20/200 in the right eye, afferent pupillary defect, and red color desaturation in the right eye. No neurologic disorders were disclosed, whereas a homozygotic asset of prothrombin II variant was noted, suggesting a microembolism-related posterior ischemic optic neuropathy. Visual acuity of 20/80 and cecocentral scotoma of the right eye persisted after 6 months.

Table 1

Table 1

Table 1

Table 1

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.

Department of Plastic and Reconstructive Surgery

University of Florence

Florence, Italy

Stefano Lazzeri, M.D.

Michele Figus, M.D.

Marco Nardi, M.D.

Ophthalmology Unit

Hospital of Pisa

Pisa, Italy

Marcello Pantaloni, M.D.

Davide Lazzeri, M.D.

Plastic and Reconstructive Surgery Unit

Hospital of Pisa

Pisa, Italy

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There are no financial conflicts or interests to report in association with the content of this communication.

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1. Iverson RE, Pao VS. MOC-PS(SM) CME article: Liposuction. Plast Reconstr Surg. 2008;121:1–11.
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. (in press).
3. Rath EZ, Falick Y, Rumelt S. Posterior ischemic optic neuropathy following breast augmentation and abdominal liposuction. Can J Ophthalmol. 2009;44:346–347.
4. Moura FC, Cunha LP, Monteiro ML. Bilateral visual loss after liposuction: Case report and review of the literature. Clinics (Sao Paulo) 2006;61:489–491.
5. Ribeiro Monteiro ML, Moura FC, Cunha LP. Bilateral visual loss complicating liposuction in a patient with idiopathic intracranial hypertension. J Neuroophthalmol. 2006;26:34–37.
6. Sigbatullah M, Kupersmith MJ, Zerykier A, Volpe S. Ischemic optic neuropathy after liposuction: Case report and review. J Neuroophthalmol. 2005;29:91–93.
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. 2000;181:132–136.
9. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res. 2009;28:34–62.
10. Murthy TVSP, Bathia P, Prabhakar T, Gogna RL. Postoperative visual loss. J Anaesth Clin Pharmacol. 2006;22:3–8.
11. Newman NJ. Perioperative visual loss after nonocular surgeries. Am J Ophthalmol. 2008;145:604–610.
12. Hunt K, Bajekal R, Calder I, Meacher R, Eliahoo J, Acheson JF. Changes in intraocular pressure in anaesthetized prone patients. J Neurosurg Anesthesiol. 2004;16:287–290.
13. Buono LM, Foroozan R. Perioperative posterior ischemic optic neuropathy: Review of the literature. Surv Ophthalmol. 2005;50:15–26.

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