Post-op vision problems?

Specialties CRNA

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35 yr old ESRD, HTN and Diabetic pt. Post Lap-Choly with uneventful case. Gave 10mg metoclopramide, 50mg zantac during due to pre-op N&V. Paralysis reversed with Neo and Robinul with smooth emergence and extubation while deep. Pt awakened and pain free. While taking pt to recovery, she complained of not being able to see. Since this was my first real case to be involved with from start to finish as an SRNA, i stuck around for a few minutes to see outcome of vision problems (no apparent changes while i was there). Pt. looked to have poor vision prior to surgery - signature on consents was all over the place as she signed them right in front of me. I know that anticholinesterases can cause miosis and some blurred vision but we gave her the corresponding dose of robinul, which hopefully would offset muscarinic effects. Has anyone ever had a pt. like this complain of vision problems in recovery. Could she have had sluggish response to Robinul due to ESRD OR an accentuated response to Neostigmine? Since I did not stick around for F/U (it was end of shift), I don't know if her vision got better. I can only hope that it was a short-lived drug rxn because eyes were protected appropriately during the case and no reason to think that high O2 or BP issues could have caused retinal issues. Any thoughts?

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Ragin,

Two Points:

There could be multiple causes, from as simple as blurry vision from the ointment to retinal artery ischemia. Here is a legal website with some good information. /http://www.thedoctors.com/risk/specialty/anesthesiology/J4213.asp

Second Point. I am appalled that you left the patient because it was the end of the shift. It is time to get out of the nurse mentality of shift work and in to the professional mode of being a CRNA. I would never consider leaving a patient who had such a major complication, would stay around to talk with the consultant ophthalmologist or whoever. Show your concern, be part of the solution, or you will take 100% of the blame.

I know it is early for you in this profession, but remember it is a profession, and these are some of the reasons why we get paid the big bucks.

yoga CRNA

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-- pt had hx of hypertension - it is likely the BP didn't drop too low for you to be concerned - but it may have been too low for this particular patient... if their retinal artery is used to a map of 110 and you run em at 64 - it risks damage....

hope all turns out well...yoga - correct me if i am wrong - but this usually turns out to be transient doesn't it???

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Thanks everyone for the responses. I might not have put enough info into my topic. Yoga, this was my very first day in the OR as a student and I did not run the case. I had to share my time and questioning with 2 fellow students. The CRNA preceptor did not seem very concerned with the vision problems and performed a f/u assessment on her as well as sending over the MDA to assess the situation after we had left the PACU area. I had a genuine concern for the situation, but what am I to say at this stage in the game? I mean, I definitely would have stood my ground regarding appropriate f/u and tx if I felt my preceptor was blowing things off. My fellow students and I discussed it with the preceptor and felt like this would probably be a short-lived complication. As for her BP, I kept an eye on her MAP closely and she really did not stray too far from her baseline during the entire case. I thought about this all weekend and tried to look some things up in my textbooks with minimal success. One last thing, as far as the ointment in her eyes, I did get a washcloth when we got to the PACU and wiped her eyes out thoroughly, especially after her first c/o vision problems. That is one thing that I always did for any of my patients in the unit. How uncomfortable it must be to wake up with blurred vision from that goop in your eyes. Again, thanks for the responses and I'm sure i'll be back for some Q & A sessions. Starting Regional next week and looking forward to a busy summer.

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Ragin,

I didn't mean to be too hard on you--didn't realize it was your first day in the OR. We tend to agonize over complications and unexpected events and I am pleased that you posted so we could offer some opinions. Hopefully, you will have time to do both a medline and google search on the topic. I did, and found some interesting information.

Please do a follow-up on her and let us know how she is doing.

On a personal note, I recently had cataract surgery and two days postop had acute corneal edema and inability to see anything out of that eye. It happened while I was doing anesthesia. There is nothing more frightening. It is ok now, but the eyes are very important.

yoga

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Specializes in Anesthesia.
.......as far as the ointment in her eyes, I did get a washcloth when we got to the PACU and wiped her eyes out thoroughly, especially after her first c/o vision problems......How uncomfortable it must be to wake up with blurred vision from that goop in your eyes. ......

So then your patient simply had blurred vision, I guess, rather than she woke up and said, I can't see, I'm blind.

That's my horror story on this subject.

Healthy OB patient gets three surgeries within 24 hours: C-Section, then an attempt to control postop bleeding, then a splash'n'slash emergency hyster to stop DIC. Hypotensive? You betcha! Threw everything at her I had -- vasopressors, blood & fluids, etc. MAP no doubt dipped below 50 briefly. Can't say what it was before I got hold of her in OR. Then she wakes up in ICU and says, first words, I'm blind.

Consult internal med doc comes looking for me with daggers in her eyes.

Two very long hours later (!!!) the vision loss clears spontaneously, completely and permanently. OK, now exhale.......

Neurologist later assures me that transient vision loss is not an uncommon phenomenon following profound shock, hypoperfusion of the occipital cortex.

Be careful out there, folks!

deepz

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Specializes in I know stuff ;).

wow

now thats scary. good story deepz.

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http://www.webmm.ahrq.gov/case.aspx?caseID=100

Found this while I was doing some preliminary research for a POVL study.

Note the scary part - the patient's blurry vision immediately after the case was attributed to the eye lube ointment!

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http://www.webmm.ahrq.gov/case.aspx?caseID=100

Found this while I was doing some preliminary research for a POVL study.

Note the scary part - the patient's blurry vision immediately after the case was attributed to the eye lube ointment!

Thank you. This helps to explain why my former eye doctor would ask at each exam whether I had ever undergone general anesthesia (he was not interested when I mentioned conscious sedation).

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