Perioperative Visual Loss Associated with Spine Surgery

Publication Date: January 1, 2019

Summary of Advisory Statements

Preoperative Patient Evaluation and Preparation

Review a patient’s preoperative history and perform an appropriate examination to identify patients with conditions such as preoperative anemia, vascular risk factors (e.g., hypertension, diabetes, peripheral vascular disease, coronary artery disease, previous stroke, carotid artery stenosis, tobacco use), and obesity.
Inform patients that certain preoperative conditions may increase their risk of perioperative visual loss in spine surgery. These include, but are not limited to, those who are male, obese, or have vascular disease risk factors such as hypertension, and peripheral vascular disease.
Inform patients in whom prolonged procedures, substantial blood loss, or both are anticipated that there may be an increased risk of perioperative visual loss.
  • Determine on a case-by-case basis whether or not to inform patients who are not anticipated to be “high-risk” for visual loss.

Intraoperative Management

Blood Pressure Management

Assess the patient’s baseline blood pressure. Continually monitor systemic blood pressure in high-risk patients. Determine on a case-by case basis whether deliberate hypotension should be used in high-risk patients.
  • Check for the presence of preoperative hypertension, its degree of control, the preoperative use of antihypertensive drugs, and the patient’s risk of end-organ damage before using deliberate hypotension in a high-risk patient.

    • Discuss with the surgeon whether deliberate hypotension is necessary.

  • Maintain arterial pressure at higher levels in hypertensive patients to prevent risks to end organs.

  • Use deliberate hypotension in high-risk patients only when the anesthesiologist and surgeon agree that its use is essential.
    • Treat prolonged significant decreases in blood pressure.


Management of Blood Loss and Administration of Fluids

Periodically monitor hemoglobin or hematocrit values during surgery in high-risk patients who experience substantial blood loss.
  • Use transfusions of blood as deemed appropriate.
  • Crystalloids or colloids alone or in combination may be used to maintain adequate replacement of intravascular volume.

Use of Vasopressors

Adrenergic agonists may be used on a case-by-case basis when it is necessary to correct for hypotension.

Patient and Head Positioning Devices

Position the high-risk patient so that the head is level with or higher than the rest of the body when possible.
  • Maintain the high-risk patient’s head in a neutral forward position (e.g., without significant neck flexion, extension, lateral flexion, or rotation) when possible.
Avoid direct pressure on the eye to prevent retinal artery occlusion.
  • A head holder may be applied by the spine surgeon in patients in whom head positioning is challenging.
Check the position of the eyes periodically during surgery to ensure the head has not moved and there is no eye compression.

Staging of Surgical Procedures

Staged spine procedures may be used on a case-by-case basis for high-risk patients.

Postoperative Management

Assess the vision of a high-risk patient when the patient becomes alert (e.g., in the recovery room, intensive care unit, or nursing floor).
  • If there is concern regarding potential visual loss, obtain an urgent ophthalmologic consultation to determine its cause.
  • Computerized tomography or magnetic resonance imaging may be used on a case-by-case basis to rule out intracranial causes of visual loss as well as to visualize an abnormal optic nerve.
  • Additional management may include optimizing hemoglobin or hematocrit values, hemodynamic status, and arterial oxygenation.

Recommendation Grading




Perioperative Visual Loss Associated with Spine Surgery

Authoring Organization

Publication Month/Year

January 1, 2019

Document Type


External Publication Status


Country of Publication


Document Objectives

The purpose of this Advisory is to enhance awareness and reduce the frequency of perioperative visual loss during and after spine surgery.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse anesthetist, nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D018917 - Optic Neuropathy, Ischemic, D015356 - Retinal Artery Occlusion


anesthesia, perioperative, perioperative visual loss, Visual loss

Source Citation

Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery 2019: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss, the North American Neuro-Ophthalmology Society, and the Society for Neuroscience in Anesthesiology and Critical Care*. Anesthesiology 2019;130(1):12-30.