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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 591-592

Transient bilateral disc edema with spontaneous resolution following spine surgery: A rare case report


Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, Bhubaneswar, Odisha, India

Date of Submission17-Jan-2021
Date of Acceptance07-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Pradeep K Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar, Odisha - 751 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_145_21

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  Abstract 


A 49-year-old man presented with flashes and transient obscuration of vision in both eyes 1 week after spine surgery for disc prolapse. Best-corrected visual acuity was 20/20 in both eyes. Fundoscopy showed bilateral disc edema. All investigations were normal. There was spontaneous resolution of bilateral disc edema 2 months following presentation.

Keywords: Bilateral, disc edema, spine, transient


How to cite this article:
Panigrahi PK. Transient bilateral disc edema with spontaneous resolution following spine surgery: A rare case report. Indian J Ophthalmol Case Rep 2021;1:591-2

How to cite this URL:
Panigrahi PK. Transient bilateral disc edema with spontaneous resolution following spine surgery: A rare case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:591-2. Available from: https://www.ijoreports.in/text.asp?2021/1/3/591/319981



Peri/post-operative vision loss (POVL) following spine surgery is a rare complication that has been sporadically reported in the literature.[1] As the name suggests, it is usually associated with profound loss of vision.[2] Ischemic optic neuropathy, central retinal artery occlusion, and cortical blindness have been reported as the possible etiologies of POVL following spine surgery.[3] We report a case that presented with bilateral disc edema following spine surgery and underwent spontaneous resolution without any treatment.


  Case Report Top


A 49-year-old nondiabetic, non-hypertensive man presented to us with complaints of transient obscurations of vision and seeing flashes of lights in both eyes of 5 days duration. The patient had undergone a spine surgery for prolapsed disc one week back. The patient had undergone a laminectomy surgery in prone position for prolapsed intervertebral disc at T12-L1 position. The patient did not give any history of prior loss of vision or headache. He was absolutely sure that the symptoms had started following the spine surgery. On examination, best-corrected visual acuity in both eyes was 20/20, N6. Slit-lamp examination of anterior segment was within normal limits. Pupillary reaction was brisk in both eyes. Dilated fundoscopy showed bilateral hyperemic disc edema [Figure 1]a. There were few retinal hemorrhages surrounding the optic disc in left eye [Figure 1]b. Macular area and peripheral retina were normal in both eyes. Intraocular pressure measured using Goldmann's applanation tonometer was 14 and 16 mm of Hg in right and left eye respectively. Ishihara's charting for color vision was normal in both eyes. The patient was able to identify all plates in Isihara's chart bilaterally. A few peripheral edge defects were noted on initial testing of visual fields with Humprey Perimeter (30-2). On repeat testing, visual fields were within normal limits bilaterally.
Figure 1: (a) Colour fundus photograph of right eye showing disc edema. (b) colour fundus photograph of left eye showing disc edema and haemorrhages surrounding the optic disc

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With a provisional diagnosis of papilledema, we immediately referred the patient to a neurosurgeon to rule out any intracranial space-occupying lesion. An MRI was performed which came out negative for space-occupying lesions. MR venography ruled out any cerebral venous thrombosis. Since the patient had complaints of transient blurring of vision, we advised a carotid Doppler study, which also came out normal. Baseline blood investigations were within normal limits. Coagulation profile including prothrombin time, clotting time, activated partial thromboplastin time, protein C and protein S were normal. The patient was advised lumbar puncture for cerebrospinal fluid (CSF) opening pressure study. The patient was very apprehensive as he had undergone recent surgery and refused the procedure. The patient was prescribed neuroprotective agent (Methycobalamine multivitamin tablets). Since the patient was mostly aymptomatic, we opted for close monitoring of the patient without any active treatment for disc edema. The patient was followed 1 and 2 months following presentation. At first-month follow-up, the patient was asymptomatic and the disc edema had started regressing. At 2 months follow-up, best-corrected visual acuity was 20/20, N6 in both eyes. The patient was asymptomatic and the disc edema had resolved in both eyes [Figure 2]. The patient has now been asked to follow-up at regular intervals.
Figure 2: (a and b) Colour fundus photograph of right and left eye showing resolved disc edema 2 months after presentation

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  Discussion Top


Optic disc edema can be associated with various etiologies like raised intracranial pressure, inflammatory, compressive, infiltrative, toxic, nutritional, hereditary, etc., Patients seek medical attention if disc edema is associated with pain, headache or vision loss. In some cases, a diagnosis of disc edema is made on routine fundoscopy in an asymptomatic patient and further investigations lead to a probable etiology. POVL following spine surgery has been well documented in the literature.[1],[2] The most common etiologies associated with POVL have been reported as Ischemic optic neuropathy, central retinal artery occlusion, and cortical blindness.[3] Among ischemic optic neuropathies, the anterior variant is more commonly associated with POVL.[2] All the above-mentioned etiologies are usually associated with gross decrease in vision. Excessive blood loss during the surgery has also been postulated as a possible mechanism leading to POVL.[4]

Our patient is unique because the patient did not have any vision loss during the entire follow-up period. Visual acuity, color vision and pupillary examination were all normal in our case. Bilateral disc edema was noted on fundoscopy. Our patient essentially presented with a papilledema-like picture which differs from the ischemic optic neuropathy like presentation which has been most commonly reported etiology in such cases. We are not totally sure about the cause of disc edema in our case. Sadun et al.[5] have reported transient obscuration of vision in a group of patients with elevated optic disc indistinguishable from papilledema. Transient ischemia with consequent increased pressure and influx of interstitial fluid is the possible mechanism postulated by them. We strongly believe that a similar mechanism was in play in our case. Another possible explanation can be that the prone position maintained during surgery could have somehow led to a change in intracranial CSF pressure leading to disc edema. The drawback in our case was our inability to perform a lumbar puncture for CSF pressure study. Patient's apprehensiveness of having a second procedure so close following the primary procedure prevented us from doing the test.

Pertinent to our case, Jojo and Jakhanwal[6] have reported transient visual obscuration with bilateral disc edema in a 42-year-old woman following spine surgery for thoracolumbar discogenic prolapse. The patient presented with floaters and visual obscurations one month following spine surgery. Similar to our case, the patient had normal vision and bilateral disc edema resolved 6 weeks following presentation.


  Conclusion Top


POVL following spine surgery is a rare complication associated with profound loss of vison. Our case is unique as the patient was asymptomatic and disc edema resolved spontaneously without any active intervention. Further investigations may be warranted to find a possible etiology in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kamming D, Clarke S. Postoperative visual loss following prone spinal surgery. Br J Anaesth 2005;95:257-60.  Back to cited text no. 1
    
2.
Nickels TJ, Manlapaz MR, Farag E. Perioperative visual loss after spine surgery. World J Orthop 2014;5:100-6.  Back to cited text no. 2
    
3.
Li A, Swinney C, Veeravagu A, Bhatti I, Ratliff J. Postoperative visual loss following lumbar spine surgery: A review of risk factors by diagnosis. World Neurosurg 2015;84:2010-21.  Back to cited text no. 3
    
4.
Stang-Veldhouse KN, Yeu E, Rotherberg DM, Mizen TR. Unusual presentation of perioperative ischemic optic neuropathy following major spine surgery. J Clin Anesth 2010;22:52-5.  Back to cited text no. 4
    
5.
Sadun AA, Currie JN, Lessell S. Transient visual obscurations with elevated optic discs. Ann Neurol 1984;16:489-94.  Back to cited text no. 5
    
6.
Jojo V, Jakhanwal SP. Transient symptomatic bilateral optic disc oedema following lumbar spinal surgery— An unusual presentation. Open J Ophthalmol 2017;7:124-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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