Intraocular pressure during neurosurgical procedures in context of head position and loss of cerebrospinal fluid

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OBJECTIVE

Perioperative visual loss (POVL) is a rare but serious complication in surgical disciplines, especially in spine surgery. The exact pathophysiology of POVL remains unclear, but elevated intraocular pressure (IOP) is known to be part of it. As POVL is rarely described in patients undergoing intracranial or intradural surgery, the aim of this study was to investigate the course of IOP during neurosurgical procedures with opening of the dura mater and loss of CSF.

METHODS

In this prospective, controlled trial, 64 patients fell into one of 4 groups of 16 patients each. Group A included patients undergoing spine surgery in the prone position, group B patients had intracranial procedures in the prone position, and group C patients were treated for intracranial pathologies in a modified lateral position with the head rotated. In groups A–C, the dura was opened during surgery. Group D patients underwent spine surgeries in the prone position with an intact dura. IOP was measured continuously pre-, peri-, and postoperatively.

RESULTS

In all groups, IOP decreased after induction of anesthesia and increased time dependently after final positioning for the operation. The maximum IOP in group A prior to opening of the dura was 28.6 ± 6.2 mm Hg and decreased to 23.44 ± 4.9 mm Hg directly after dura opening (p < 0.0007). This effect lasted for 30 minutes (23.5 ± 5.6 mm Hg, p = 0.0028); after 60 minutes IOP slowly increased again (24.5 ± 6.3 mm Hg, p = 0.15). In group B, the last measured IOP before CSF loss was 28.1 ± 5.0 mm Hg and decreased to 23.5 ± 6.1 mm Hg (p = 0.0039) after dura opening. A significant IOP decrease in group B lasted at 30 minutes (23.6 ± 6.0 mm Hg, p = 0.0039) and 60 minutes (23.7 ± 6.0 mm Hg, p = 0.0189). In group C, only the lower eye showed a decrease in IOP up to 60 minutes after loss of CSF (opening of dura, p = 0.0007; 30 minutes, p = 0.0477; 60 minutes, p = 0.0243). In group D (control group), IOP remained stable throughout the operation after the patient was prone.

CONCLUSIONS

This study is the first to demonstrate that opening of the dura with loss of CSF during neurosurgical procedures results in a decrease in IOP. This might explain why POVL predominantly occurs in spinal but rarely in intracranial procedures, offers new insight to the pathophysiology of POVL, and provides the basis for further research and treatment of POVL.

German Clinical Trials Register (DRKS) no.: DRKS00007590 (drks.de)

ABBREVIATIONS BP = blood pressure; ION = ischemic optic neuropathy; IOP = intraocular pressure; POVL = perioperative visual loss.

Article Information

Correspondence Patrick Czorlich: University Medical Center Hamburg-Eppendorf, Hamburg, Germany. p.czorlich@uke.de.

INCLUDE WHEN CITING Published online August 24, 2018; DOI: 10.3171/2018.3.JNS173098.

P.C. and T.K. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flowchart of the study protocol. After obtaining written consent for the study, the first ophthalmological examination, including measurement of the IOP, was performed. Perioperative IOP was measured after the beginning of anesthesia, after final prone or lateral positioning, and subsequently every 30 minutes. An additional measurement was performed after opening the dura mater and CSF loss. Final IOP measurements were obtained at the end of the prone/lateral position and in a supine position followed by a second ophthalmological examination before discharge. OR = operating room.

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    Reduction of IOP in groups A, B, and D. Group C is presented in detail, with IOPs demonstrated separately for the upper eye (UE) and lower eye (LE). Distribution of IOPs in each group before surgery, after intubation, after final positioning for surgery, before and after CSF loss, and 30 and 60 minutes after CSF loss. Group D lacks IOP findings for CFS loss as the dura mater was kept intact. ns = not significant. *p < 0.01; **p < 0.001; ***p < 0.0001; ****p < 0.00001.

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    Time and CSF loss related to the development of IOP. Chart distribution of the IOP courses of groups A, B, and D and for the lower and upper eye in group C throughout the entire surgical procedure. a.p. = anteroposterior.

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    BP in relation to IOP. The perioperative course of BP in groups A–C in relation to the IOP, demonstrating no significant difference of the BP course. As in group D, no loss of CSF occurred, and IOP remained stable. No further details of BP are presented.

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