Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2015.03.005
Brazilian Journal of Anesthesiology
Clinical Information

Postoperative visual loss due to conversion disorder after spine surgery: a case report

Perda visual conversiva em pós-operatório de cirurgia de coluna: relato de caso

Dailson Mamede Bezerra; Eglantine Mamede Bezerra; Antonio Jorge Silva Junior; Marco Aurélio Soares Amorim; Denismar Borges de Miranda

http://dx.doi.org/10.1016/j.bjane.2015.03.005 Braz J Anesthesiol, vol.68, n1, p.91-95, 2018
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Abstract

Abstract Background and objective Patients undergoing spinal surgeries may develop postoperative visual loss. We present a case of total bilateral visual loss in a patient who, despite having clinical and surgical risk factors for organic lesion, evolved with visual disturbance due to conversion disorder. Case report A male patient, 39 years old, 71 kg, 1.72 m, ASA I, admitted to undergo fusion and discectomy at L4-L5 and L5-S1. Venoclysis, cardioscopy, oximetry, NIBP; induction with remifentanil, propofol and rocuronium; intubation with ETT (8.0 mm) followed by capnography and urinary catheterization for diuresis. Maintenance with full target-controlled intravenous anesthesia. During fixation and laminectomy, the patient developed severe bleeding and hypovolemic shock. After 30 min, hemostasis and hemodynamic stability was achieved with infusion of norepinephrine, volume expansion, and blood products. In the ICU, the patient developed mental confusion, weakness in the limbs, and bilateral visual loss. It was not possible to identify clinical, laboratory or image findings of organic lesion. He evolved with episodes of anxiety, emotional lability, and language impairment; the hypothesis of conversion syndrome with visual component was raised after psychiatric evaluation. The patient had complete resolution of symptoms after visual education and introduction of low doses of antipsychotic, antidepressant, and benzodiazepine. Other symptoms also regressed, and the patient was discharged 12 days after surgery. After 60 days, the patient had no more symptoms. Conclusions Conversion disorders may have different signs and symptoms of non-organic origin,including visual component. It is noteworthy that the occurrence of this type of visual dysfunc-tion in the postoperative period of spinal surgery is a rare event and should be remembered asa differential diagnosis.

Keywords

General anesthesia, Blindness, Conversion disorder, Laminectomy, Decubitus ventral

Resumo

Resumo Justificativa e objetivo Pacientes submetidos a procedimentos cirúrgicos espinhais podem evoluir com perda visual pós-operatória. Apresentamos quadro de perda visual bilateral total em paciente que, apesar de apresentar fatores de risco clínicos e cirúrgicos para lesão orgânica, evoluiu com distúrbio visual conversivo. Relato de caso Masculino, 39 anos; 71 kg; 1,72 m; ASA I, admitido para realização de artrodese e discectomia em L4-L5 e L5-S1. Venóclise, cardioscopia, oximetria, PANI; indução com remifentanil, propofol e rocurônio; intubação com TOT 8,0 mm seguida por capnografia e diurese por sondagem vesical. Manutenção em anestesia venosa total alvo-controlada. Durante fixação e laminectomia, evoluiu com importante sangramento e choque hipovolêmico. Após 30 minutos obteve-se hemostasia e estabilidade hemodinâmica com infusão de noradrenalina, expansão volêmica e hemoderivados. Na UTI, evoluiu com confusão mental, fraqueza em membros e perda visual bilateral. Não foi possível identificar achados clínicos, laboratoriais ou de imagem para lesão orgânica. Evoluiu com episódios de ansiedade, labilidade emocional e distúrbio de linguagem; foi aventada hipótese de síndrome conversiva com componente visual após avaliação psiquiátrica. Apresentou melhoria total de sintomas visuais após educação e introdução de baixas doses de antipsicótico, antidepressivo e benzodiazepínico. Houve regressão dos demais sintomas com alta no décimo segundo dia pós-operatório. Encontrava-se assintomático após 60 dias. Conclusões Distúrbios conversivos podem apresentar diversos sinais e sintomas de origem nãoorgânica, incluindo componente visual. Destaca-se que a ocorrência desse tipo de disfunçãovisual no pós-operatório de cirurgias espinhais é evento raro e deve ser lembrado como diag-nóstico diferencial.

Palavras-chave

Anestesia geral, Cegueira, Transtorno conversivo, Laminectomia, Decúbito ventral

References

Katz DA, Karlin LI. Visual field defect after posterior spine fusion. Spine. 2005;30:E83-5.

Blauth CI, Arnold JV, Schulenberg WE. Cerebral microembolism during cardiopulmonary bypass: retinal microvascular studies in vivo with fluorescein angiography. J Thorac Cardiovasc Surg. 1988;95:668-76.

Ozcan MS, Praetel C, Bhatti T. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg. 2004;99:1152-8.

Johnson LJ, Arnold AC. Incidence of nonarteritic and arteritic anterior ischemic optic neuropathy: a population-based study in the state of Missouri and Los Angeles County, California. J Clin Neuroophthalmol. 1994;14:38-44.

Schobel GA, Schmidbauer M, Millesi W. Posterior ischemic optic neuropathy following bilateral radical neck dissection. Int J Oral Maxillofac Surg. 1995;24:283-7.

Newman MF, Mathew JP, Grocott HP. Central nervous system injury associated with cardiac surgery. Lancet. 2006;368:694-703.

Bruce BB, Newman NJ. Functional visual loss. Neurol Clin. 2010;28:789-802.

Berg KT, Harrison AR, Lee MS. Perioperative visual loss in ocular and nonocular surgery. Clin Ophthalmol. 2010;4:531-46.

Roth S, Thisted RA, Erickson JP. Eye injuries after non ocular surgery; a study of 60,965 anesthetics from 1988 to 1992. Anesthesiology. 1996;85:1020-7.

Shmygalev S, Heller AR. Perioperative visual loss after nonocular surgery. Anaesthesist. 2011;60:683-94.

Kawaguchi M, Hayashi H, Kurita N. Postoperative visual disturbances after nonophthalmic surgery. Masui. 2009;58:952-61.

Grover V, Jangra K. Perioperative vision loss: a complication to watch out. J Anaesthesiol Clin Pharmacol. 2012;28:11-6.

Lee L, Roth S, Todd M. Risk factor associated with ischemic optic neuropathy after spinal fusion surgery. Anesthesiology. 2012;116:15-24.

Apfelbaum JL, Roth S, Connis RT. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Anesthesiology. 2012;116:274-85.

Toth C. Pregabalin: latest safety evidence and clinical implications for the management of neuropathic pain. Ther Adv Drug Saf. 2014;5:38-56.

Diagnostic and statistical manual of mental disorders (DSM-5®). 2013.

Carson A, Stone J, Hibberd C. Disability, distress, and unemployment in neurology outpatients with symptoms "unexplained by organic disease". J Neurol Neurosurg Psychiatry. 2011;82:810-3.

Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76:i2-i12.

Sharpe M, Walker J, Williams C. Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology. 2011;77:564-72.

Maddock H, Carley S, McCluskey A. An unusual case of hysterical postoperative coma. Anesthesia. 1999;54:717-8.

Judge A, Spielman F. Postoperative conversion disorder in a pediatric patient. Paediatr Anaesth. 2010;20:1052-4.

Chen CS, Lee AW, Karagiannis A. Practical clinical approaches to functional visual loss. J Clin Neurosci. 2007;14:1-7.

Aybek S, Hubschmid M, Mossinger C. Early intervention for conversion disorder: neurologists and psychiatrists working together. Acta Neuropsychiatr. 2013;25:52-6.

Goldstein LH, Chalder T, Chigwedere C. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;74:1986-94.

Czarnecki K, Thompson JM, Seime R. Functional movement disorders: successful treatment with a physical therapy rehabilitation protocol. Parkinsonism Relat Disord. 2012;18:247-51.

Voon V, Lang AE. Antidepressant treatment outcomes of psychogenic movement disorder. J Clin Psychiatry. 2005;66:1529-34.

Oulis P, Kokras N, Papadimitriou GN. Adjunctive low-dose amisulpride in motor conversion disorder. Clin Neuropharmacol. 2009;32:342-3.

Messina A, Fogliani AM. Valproate in conversion disorder: a case report. Case Rep Med. 2010;2010:1-3.

Stone J, Hoeritzauer I, Brown K. Therapeutic sedation for functional (psychogenic) neurological symptoms. J Psychosom Res. 2014;76:165-8.

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