This issue of the APSF Newsletter opens with a personal and tragic account of postoperative visual loss (POVL) in an anesthesiologist and follows with an update on POVL, a comprehensive review of informed consent, and a spine surgeon's perspective. We hope that these timely articles will increase awareness of POVL and encourage appropriate preoperative informed consent.
I'm a retired anesthesiologist. I was asked by Dr. Lorri Lee to write a brief article from the patient's perspective about posterior ischemic optic neuropathy (PION). I should know about it. It happened to me. I've been slow to write this. It's a rather painful subject.
Following my fifth back operation in September 2006 (a prone, redo 3-level lumbar fusion), I had so much swelling I was unable to open my eyes at all until about noon the next day. I at first thought I had Lacri-lube in my right upper eye, but soon became aware of the pulsating colors of scintillating scotomata in the upper 80% of the field of my right eye. (It was interesting in that, at least in the lower portion of the affected area, I could see through the flashing colors.) Having given a lecture on PION, I was pretty sure what the problem was. I called the surgeon's office and somehow impressed upon them that I needed to see an ophthalmologist right away. Fundoscopic exam was normal. Over the next 3 to 4 days, the scintillations diminished and were gradually replaced by gray with some improvement of the field cut to about 70%. I've been followed by a neuro-ophthalmologist with minimal improvement. Pallor in the infero-medial right optic disc was first noted on day 20, confirming the diagnosis of PION and ruling out anterior ischemic optic neuropathy (AION). I can still read normally, albeit a little bit slower, and my binocular vision is intact so I can drive; this doesn't affect daily life too much. I'm told my left eye is not quite normal, but I can't tell that because I have nothing to compare it to.
I practiced anesthesiology for 28 years, both in academic and private practice. I have not returned because I don't think someone with a significant visual field defect should be routinely responsible for intubating patients. I don't want to hurt somebody. I think I could probably intubate someone right now without difficulty, but the day that I didn't everyone in that room who knew of my problem or should have known would get to write a check. No one should want to be my partner.
I have no grudge against my surgeon or anesthesiologist (my former partner). They did a good job. My surgery lasted 7-1/2 hours with blood loss around 700 ml, less than the average of 9.8 hours and 2010 ml for PION cases. All of the recorded PION cases had either an anesthetic time >5 hours or a blood loss >1000 ml, so I was at risk on the basis of time. But this was not a problem to be expected. In fact, it is a complication for which there is currently no way to monitor, no way to prevent, and no way to treat. I'm really quite fortunate, because 68% of the 83 cases (recorded at the time) woke up completely bilaterally blind and improved very little. Very probably, with another 20 or 30 minutes of surgery, I would have been in that 68%.
I knew about this complication. I had been to lectures about it, and I had lectured about it. I had discussed it at great length with my anesthesiologist. I will say that it was never mentioned by my surgeon, and when it happened, he tried to blame it on the anesthesiologist. Later, he told me he had seen one case as a fellow but thought it was a fluke. His office still reassures me this never happens. That's comforting. I'm sure it occurs far less often in private practice because procedures there tend to go much faster than they do in teaching hospitals. But it does happen.
If this had occurred without my knowing of the possibility, I would feel far differently about it.
I'm very fortunate in that when I first entered private practice I had an older partner who pulled me aside and told me that since I had 4 kids I needed to get disability insurance that specified my occupation as anesthesiology. He told me it would be expensive and that I should never complain and always pay the premiums. Without that advice, my family would be in big trouble. The amount I receive is far less than what I was making and I still have 2 kids in college, so things are a bit tough around here. The Texas Medical Association, of which I had been a member for many years, refused me for medical insurance and that has become an ongoing problem.
I was at the top of my game when this occurred. The back problem now seems to have been solved, but what else do you do when you're a fully trained clinical anesthesiologist and can't practice anesthesiology at age 58? Pain medicine is an obvious option but that frequently involves a lot of bending over and the lifting and turning of patients. I really don't want to do another residency. There are general medicine things out there and I had hoped some administrative positions. But potential employers and even some of your former colleagues look at you like you are some sort of malingerer when you tell them this story! So far, the only thing I've found is a small job examining military recruits.
This complication is a devastating one for patients and their families, even when it does not result in complete blindness. Disclosure on every case needs to be done not only by the anesthesia team, but also by the surgeon. An issue of this magnitude has to be presented well ahead of time in order to be properly understood, and the surgeon is the only one who has that opportunity. In addition, this is the only way it will be understood as a complication of positioning rather than an anesthetic complication.
Dr. Anthony D. Lehner, MD, was a practicing anesthesiologist in Dallas, TX.