VISUAL LOSS A F T E R CARDIOPULMONARY BYPASS P H I L I P J. TAUGHER,
M.D.
Milwaukee, Wisconsin
From Jan. 1 through Dec. 31, 1974, 808 surgical procedures with cardiopulmonary bypass were performed here and ten pa tients had visual loss. Although neurologic complications among patients undergoing cardiopulmonary bypass are well known,1'2 the particular problem of visual loss has not been emphasized. CASE REPORTS
Case 1—This 51-year-old man underwent a four-vessel coronary artery graft procedure on Feb. 27, 1974. The aortic line was taken apart and put together again three times to clear it of bubbles. There were no other problems and the patient tolerated the procedure well. Total anes thetic time was nine hours ; the time on cardio pulmonary bypass was two hours and SO minutes; the average perfusion rate was 66 ml/kg/minute; and the average mean arterial pressure was 77 mm Hg. The procedure was done under hypo thermia. The lowest hematocrit value was 15% and it remained below 25% for three hours. The pa tient was blind when he awoke from the anesthetic. His left arm was paralized and his left leg and the left side of his face were paretic. He was alert and oriented. His eyes were deviated conjugately to the right but on command he could move them to the midline. Babinski reflexes were more active on the left side. Some light perception was present in each eye but it was more reliable when pro jected from the right than from the left homonymous visual fields. The pupils were the same size and they reacted to direct and consensual light stimulation. The media were clear in each eye and there were no ophthalmoscopically visible ab normalities. A brain scan done on March 7 (Fig. 1) showed abnormal uptake bilaterally in the occipital area but chiefly on the right. The paresis of his left leg and the left side of his face had largely disappeared by the time of his discharge on March 13. The paralysis of his left hand per sisted. One week later visual acuity began to im prove. He had a rapid and progressive improve ment of visual acuity for about three weeks. When last seen on June 24, best corrected visual acuity was 20/200 in each eye. Visual fields done at that time showed generalized depression (Fig. 2). There were right homonymous inferior paracentral scotomata that caused him serious trouble when From the Section of Ophthalmology, St. Luke's Hospital, Milwaukee, Wisconsin. Reprint requests to Philip J. Taugher, M.D., 6080 S. 108 St., Hales Corners, WI 53130.
he tried to read. The patient's wife suggested he had developed defects in his judgment that were not present before surgery. His right hand im proved to the point where he picked up light objects. Case 2—This 63-year-old woman underwent a two-vessel coronary artery bypass graft procedure on March 25, 1974. Hypothermia was not used. Total anesthetic time was three hours and 20 minutes; the time on cardiopulmonary bypass was 53 minutes ; the average perfusion rate was 54 ml/ kg/minute; and the average mean arterial pressure was 88 mm Hg. The lowest hematocrit count was 16% and it remained below 25% for 35 minutes. This patient had a history of chronic anxiety and depression. Because of this, evaluation of her condition after surgery was difficult. She appeared to be blind but she was so combative and irrational that accurate assessment was not possible. She appeared to recognize the surgeon in the re covery room and she called him by name but several days later she denied all light perception. Except for the defect in her vision and the irrationality there were no other abnormal neuro logical signs. Ophthalmologic and ophthalmoscopic examinations were normal including pupillary re actions. A brain scan done on April 2 showed abnormal uptake in the occipital area bilaterally but to a greater degree on the right (Fig. 3). Her general physical condition gradually improved al though she remained depressed. At the time of her discharge on May 1, central visual acuity was 20/30 in each eye but she had a dense right homonymous hemianopia that persisted (Fig. 4). Case 3—This 50-year-old man underwent a four-vessel coronary artery bypass graft pro cedure under hypothermia on May 1, 1974. The total anesthetic time was 6% hours; the time on cardiopulmonary bypass was two hours; the aver-
Fig. 1 (Taugher). Case 1. Brain scan demon strates abnormal uptake in the occipital area bilaterally (arrows). 280
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Fig. 2 (Taugher). Case 1. Restriction of peripheral isopters and bilateral paracentral scotomata in a 51-year-old man. age perfusion rate was 55 ml/kg/minute ; and the average mean arterial pressure was 72 mm Hg. The lowest hematocrit reading was 18% and it remained below 25% for two hours. This patient first complained of blurry vision several days after surgery but had noticed the trouble on recovery from the anesthetic. No ocular abnormality was observed when he was examined by an ophthal mologist on May 9. Visual fields were not done at that time. Visual impairment seemed slight at the time and he was discharged without further examination. He continued to experience poor vision, however, and consulted an ophthalmologist in his home town. On examination visual acuity was 20/20 in each eye but visual field testing re vealed the presence of bilateral right inferior para central scotomata (Fig. 5). This defect inter fered considerably with his ability to read, but +4-00 diopter bifocal additions were prescribed which gave him considerable relief. Case 4—This 58-year-old woman underwent a five-vessel coronary artery bypass graft procedure under hypothermia on May 9, 1974. The total anes thetic time was seven hours; the time on cardiopulmonary bypass was four hours; the average perfusion rate was 77 mlAg/miniite ; and the average mean arterial pressure was 64 mm Hg. The lowest hematocrit count was 14% and it re mained below 25% for three hours. The patient recovered from the anesthetic with a flaccid paralysis of the right arm and leg. She had a depressed sensorium and was almost unresponsive. She showed no sign of vision but in the begin ning this was difficult to evaluate because of her unresponsiveness. Babinski reflexes were pres ent bilaterally and deep tendon reflexes were in
creased throughout but were greater on the left than on the right. Ophthalmologic and ophthalmoscopic examinations were normal including normal pupillary reactions. A brain scan done on May 5 revealed multiple areas of abnormal uptake in the posterior cortex (Fig. 6). She recovered the total use of her arm and leg and she speaks without defect or evidence of intellectual impairment but she remains blind. Case 5—This 46-year-old man underwent a six-vessel coronary artery graft procedure under hypothermia on May 17, 1974. The total anesthetic
Fig. 3 (Taugher). Case 2. Brain scan demon strates abnormal uptake in the occipital area bi laterally (arrows).
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Fig. 4 (Taugher). Case 2. Right homonymous hemianopia in a 63-year-old woman. time was six hours; the time on cardiopulmonary bypass was two hours; the average perfusion rate was 64 ml/kg/minute; and the average mean arterial pressure was 79 mm Hg. The lowest hematocrit count was 19% and the hematocrit stayed below 25% for one hour. The patient re covered from the anesthetic totally blind and with paresis of his left arm and leg. He kept his eyes deviated conjugately to the right when unstimu-
lated but he could move them to the left on com mand. He was otherwise alert and cooperative. On May 21, light perception was present in the right eye but not in the left. Pupillary reactions were normal as were the results of the ophthalmoscopic examination. A brain scan done on May 29 showed abnormal uptake in the posterior cortex on both sides of the brain (Fig. 7). Since that time the paresis of his left leg has improved to the point
Fig. S (Taugher). Case 3. Bilateral paracentral scotomata in a 50-year-old man.
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Fig. 7 (Taugher). Case 5. Brain scan demon strates abnormal uptake in the occipital area (arrows).
Fig. 6 (Taugher). Case 4. Brain scan demon strates multiple areas of abnormal uptake through out the brain. where he can now walk without assistance. The paresis of his left arm remains unchanged. Visual acuity in both eyes improved to 10/400. Case 6—This 58-year-old man had undergone
a five-vessel coronary artery bypass graft pro cedure under hypothermia elsewhere on Sept. 9, 1974. The total anesthetic time was seven hours; the time on cardiopulmonary bypass was 3}4 hours ; the average perfusion rate was 51 ml/kg/minute; and the average mean arterial pressure was 73 mm Hg. The patient tolerated the procedure well but he awoke from the anesthetic with markedly reduced vision. Ophthalmologic examination dis closed only the defect in visual acuity, with normal pupillary reactions and a normal ophthalmoscopic examination. Visual fields done on Sept. 20 re vealed bilateral central scotomata with the defect RIGHT 30
Fig. 8 (Taugher). Case 6. Bilateral central scotomata and a partial right superior quadrantonopia in a 58-year-old woman.
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Fig. 9 (Taugher). Case 6. Brain scan demonstrates abnormal uptake in the occipital area (arrow). on the right being larger than the one on the left (Fig. 8). A brain scan done on Sept. 23 revealed an abnormal amount of uptake in both occipital lobes (Fig. 9). Best corrected visual acuity was R.E.: S/400, and L.E.: 20/400. Case 7—This 62-year-old man underwent a fivevessel coronary artery bypass graft under hypo
thermia on Sept. 26, 1974. During the year before surgery he experienced episodes of angina and blurry vision. The surgery was performed with out complications. Total anesthetic time was 13 hours; the time on cardiopulmonary bypass was 4}4 hours ; average perfusion rate was 69 ml/kg/ minute; and the average mean arterial pressure
Fig. 10 (Taugher). Case 7. Left homonymous hemianopia with partial involvement of the right visual field in a 62-year-old man.
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Fig. 11 (Taugher). Case 8. Left homonymous hemianopia in a 53-year-old man. was 67 mm Hg. The patient was unresponsive after surgery and could not move his left arm or leg. He gradually improved and was fully respon sive several weeks later. He was alert and able to converse but tended to lose his train of thought and he occasionally gave inappropriate answers to questions. This man was not examined by an ophthalmologist until three weeks after surgery when best corrected acuity was 20/30 in each eye and he had a left homonymous hemianopia (Fig. 10). His eyes were normal including pupillary reactions and ophthalmoscopic examination. At that time he moved his left arm and left leg but he was unable to walk or to grasp objects with his left hand. He has since been lost to follow-up. Case 8—This 53-year-old man underwent an emergency two-vessel coronary artery bypass graft procedure without hypothermia on Nov. 2, 1974. He had had an inferior wall myocardial infarction in August and later experienced chest pain on mini mal exertion. The average perfusion rate was 60 ml/kg/minute ; the average mean arterial pres sure was 50 mm Hg; the total anesthetic time was three hours and 15 minutes; and the time on cardiopulmonary bypass was one hour. The lowest hematocrit count was 19% and it remained below 25% for one hour and 35 minutes. The patient reported later that he was aware of a defect in his vision as soon as he recovered from the anesthetic. Ophthalmologic examination three days after sur gery showed a left homonymous hemianopia. This was revealed by confrontation testing. The defect was still present when visual fields were plotted on Dec. 7 (Fig. 11). Best corrected acuity at that time was R.E.: 20/30, and L.E.: 20/50. A brain scan study revealed abnormal uptake in the right occipital cortex (Fig. 12). This patient has since
been lost to follow-up. Case 9—This 49-year-old man underwent a three-vessel coronary artery bypass graft pro cedure on Nov. 15, 1974. The procedure was done without hypothermia. Total anesthetic time was five hours and 14 minutes; the time on cardio pulmonary bypass was one hour and 16 minutes; the average perfusion rate was 68 ml/kg/minute; and the average mean arterial pressure was 57 mm
Fig. 12 (Taugher). Case 8. Brain scan demon strates abnormal uptake in occipital area (arrow).
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Fig. 13 (Taugher). Case 10. Bilateral paracentral scotomata in a 46-year-old man. Hg. The lowest hematocrit count was 14% and it remained below 25% for two hours and 15 min utes. The patient enjoyed an uneventful recovery until Nov. 18, when he began to experience inter mittently blurred vision. Occasionally, parts of his left visual field were missing or he had bilateral central blind spots that were edged with an illumi nated frill. This recurrent symptom persisted only until Nov. 21. Visual fields were not done during an episode of blurry vision and when they were done on Nov. 22, no abnormality was found. Ophthalmologic examination on that date was nor mal. Case 10—This 46-year-old man underwent a two-vessel coronary artery bypass graft procedure under hypothermia on Nov. 15, 1974. The total anesthetic time was seven hours ; the time on cardiopulmonary bypass was 2γϊ hours ; average perfusion rate was 68 ml/kg/minute; and the average mean arterial pressure was 78 mm Hg. The lowest hematocrit count was 21% and it re mained below 25% for 55 minutes. The patient noticed that things looked blurry in the recovery room but he did not mention this to anyone be cause he thought it was to be expected. Several days later he noticed that he could not read. Visual fields on Nov. 19 revealed bilateral paracentral scotomata (Fig. 13). Ophthalmologic examination was otherwise normal. Best corrected visual acuity was 20/20 in each eye; +4.00 diopter bifocals made reading less difficult. DISCUSSION
The visual loss experienced by these pa tients ranged from total permanent blind
ness (Case 4) to a brief period of transi ent ischémie attacks (Case 9). Symptoms were limited to visual loss in most patients, but in Cases 1, 5, and 7 there was associated motor impairment as well (Table). In the cases documented by brain scan the symp toms were due to occipital cortical infarction but the exact mechanism by which this took place is unknown. Reports of loss of visual acuity after cardiopulmonary bypass have been infre quent. Alfano, Fabritus, and Garland3 re ported three cases in 1957 after commissurotomy for mitral stenosis. In 1965, Gilman4 reported two cases as part of a group of other neurologic complications. Total visual loss due to occipital in farction is uncommon. In 1957, Symonds and Mackenzie5 reported a series of 58 such cases, none of which were associated with surgery of any kind. It was their opinion that most if not all of their cases were due to embolie rather than thrombotic phenomena. To support this contention they referred to the work of Beevor6 and Collier7 who demonstrated by means of injection of colored materials into the cerebral circu lation that collateral circulation from the
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TABLE SUMMARY OF CASE REPORTS
Case No., Anesthetic Sex. Age, Time yrs
Bypass Time
2 hrs. 50 min
1,M,51
9 hrs
2, F, 63
4. F, 58
3 hrs. 20 min 6 hrs, 30 min 7 hrs
5.M.46
6 hrs
2 hrs
6, M. 58
7 hrs
7, M. 62
13 hrs
8.M.53
3 hrs, 15 min 5 hrs, 14 min 7 hrs
3 hrs, 30 min 4 hrs, 30 min 1 hr
3.M.50
9.M.48 10, M, 46
S3 min 2 hrs 4 hrs
Ihr, 16 min 2 hrs, 30 min
Average Hypo- Flow Rate, . ^ i e ä " . thermia ml/kg/min Arterial Pressure, mm Hg
+ — + + — + +. — — +
66
77
54
88
55
72
77
64
64
79
51
73
69
67
60
50
68
57
68
77
middle cerebral arteries was enough to fill the bed usually supplied by the posterior cerebral arteries even when the supply from these vessels was totally cut off. This suggests that even total occlusion of both posterior cerebral arteries by clot would be insufficient to cause total blindness. Symonds and Mackenzie5 also cited the work of Kubic and Adams 8 who reported 17 cases of pathologically confirmed basilar artery occlusion. Of these 17 cases bilateral occipital lobe infarction occurred in only one. In seven cases the clot extended into both posterior cerebral arteries. Of these seven cases one had the bilateral occipital infarction, four had unilateral involvement, and two had no occipital damage. The possibility that the visual loss experi enced by our patients was due to cerebral entrapment of multiple emboli must be con sidered. The brain scans show multiple areas of damage suggestive of embolie injury. Embolization has also occurred during sur gery with carrliopulmonary bypass.9'10 How ever, in all of these patients, symptoms have been confined to the visual system and oc casionally have included the motor system in
Blind
Visual Acuity Less Than 20/200
— — — + — — — — — —
+ — — + + + — — — —
Visual Para- Central Acuity Hemiacentral Scoto- HemiBetter nopia Scotomata paresis Than mata 20/30
— + + — — — + + + +
— + — — — — + + — —
+ — + — — — — — — +
— — — — + + — — — —
+ — — + + — + — — —
the form of hemiparesis. One would expect emboli to produce a more random pattern of damage. Another possible explanation is the oc currence of selective laminar necrosis due to generalized cerebral anoxia.11'12 The visual and motor regions of the cortex are particularly susceptible to anoxia9 and these cases may simply demonstrate the vulner ability of these areas. If selective laminar cortical necrosis does occur despite appar ently adequate pressures and flow rates, then the cerebral hemodynamics during cardiopulmonary bypass are not fully under stood. The total and permanent visual loss ex perienced by one patient (Case 4) is evi dently an unusual occurrence but we sus pect that the comparatively milder forms of visual loss experienced by the other patients are not as uncommon. When patients are recovering from cardiac surgery their com plaints of blurry or peculiar vision can easily be overlooked. The milder manifestations of this problem can go unnoticed unless ophthalmologic consultation is requested and visual fields are examined.
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AMERICAN JOURNAL OF OPHTHALMOLOGY SUMMARY
Ten cases of visual loss ranging from total blindness to a brief period of transient ischémie attacks occurred after cardiopulmonary bypass. Brain scan studies indicated occipital cortical infarction as the cause. Thrombosis, embolization, and selective laminar cortical necrosis due to cerebral anoxia were possible mechanisms. REFERENCES
1. Branthwaite, M.: Neurological damage related to open heart surgery. A clinical survey. Thorax 27:748, 1972. 2. Javid, H., Tufo, H , Najfi, H., Dye, W., Hunter, J., and Julian, O. : Neurological abnormali ties following open heart surgery. J. Thorac. Cardiovasc. Surg. 58:502, 1969. 3. Alfano, J., Fabritus, R., and Garland, M.: Visual loss following commissurotomy for mitral stenosis. Am. J. Ophthalmol. 44:213, 1957. 4. Gilman, S.: Cerebral disorders after open heart operations. N. Engl. J. Med. 272:489, 1965.
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5. Symonds, C, and Mackenzie, I. : Bilateral loss of vision from cerebral infarction. Brain 80:415, 1957. 6. Beevor, C. : On the distribution of the different arteries supplying the human brain. Philos. Trans. R. Soc. Lond. 200:1, 1908. 7. Beevor, G, and Collier, J. : Contribution to the study of the cortical localization of vision. A case of quadrantic hemianopia. Brain 27:153, 1904. 8. Kubic, C, and Adams, R. : Occlusion of the basilar artery ; clinical and pathological study. Brain 69:73, 1946. 9. Reed, C, Romagnoli, A., Taylor, D., and Clark, D.: Particulate matter in bubble oxygenators. J. Thorac. Cardiovasc. Surg. 68:971, 1974. 10. Helmsworth, J., Gall, E., Perrin, E., Braley, S., Flege, J., Koplan, S., and Keirle, A.: Occurrence of emboli during perfusion with an oxygenator pump. Surgery 53:177, 1963. 11. Courville, C. : Etiology and pathogenisis of laminar cortical necrosis. Arch. Neurol. Psych. 79:7, 1958. 12. Stockard, J., Bickford, R., Chir, B., and Schäuble, J.: Pressure-dependent cerebral ischemia during cardiopulmonary bypass. Neurology 23:521, 1957.
MINIATURE
"Cure your eyes, is it ?" Said T o m m y W a r n e . " W h y , to be sure I can. W h y didn't you ax me afore? I thought you LIKED squintin." " I don't then ; I hate it." " V e r y well ; you shall see straight this very night if you do what I tell you. Go home and tell your.wife to make your bed on the roof of the four-poster; and she must make it widdershins, turnin' lied-tie and all against the sun, and puttin' the pillow where the feet come as a rule. That's all." "Fancy my never thinkin' of anything so simple as that !" said Joby. A r t h u r Quiller-Couch Widdershins, in Shorter Stories J . M . Dent & Sons, 1944
M.D.
Milwaukee, Wisconsin
From Jan. 1 through Dec. 31, 1974, 808 surgical procedures with cardiopulmonary bypass were performed here and ten pa tients had visual loss. Although neurologic complications among patients undergoing cardiopulmonary bypass are well known,1'2 the particular problem of visual loss has not been emphasized. CASE REPORTS
Case 1—This 51-year-old man underwent a four-vessel coronary artery graft procedure on Feb. 27, 1974. The aortic line was taken apart and put together again three times to clear it of bubbles. There were no other problems and the patient tolerated the procedure well. Total anes thetic time was nine hours ; the time on cardio pulmonary bypass was two hours and SO minutes; the average perfusion rate was 66 ml/kg/minute; and the average mean arterial pressure was 77 mm Hg. The procedure was done under hypo thermia. The lowest hematocrit value was 15% and it remained below 25% for three hours. The pa tient was blind when he awoke from the anesthetic. His left arm was paralized and his left leg and the left side of his face were paretic. He was alert and oriented. His eyes were deviated conjugately to the right but on command he could move them to the midline. Babinski reflexes were more active on the left side. Some light perception was present in each eye but it was more reliable when pro jected from the right than from the left homonymous visual fields. The pupils were the same size and they reacted to direct and consensual light stimulation. The media were clear in each eye and there were no ophthalmoscopically visible ab normalities. A brain scan done on March 7 (Fig. 1) showed abnormal uptake bilaterally in the occipital area but chiefly on the right. The paresis of his left leg and the left side of his face had largely disappeared by the time of his discharge on March 13. The paralysis of his left hand per sisted. One week later visual acuity began to im prove. He had a rapid and progressive improve ment of visual acuity for about three weeks. When last seen on June 24, best corrected visual acuity was 20/200 in each eye. Visual fields done at that time showed generalized depression (Fig. 2). There were right homonymous inferior paracentral scotomata that caused him serious trouble when From the Section of Ophthalmology, St. Luke's Hospital, Milwaukee, Wisconsin. Reprint requests to Philip J. Taugher, M.D., 6080 S. 108 St., Hales Corners, WI 53130.
he tried to read. The patient's wife suggested he had developed defects in his judgment that were not present before surgery. His right hand im proved to the point where he picked up light objects. Case 2—This 63-year-old woman underwent a two-vessel coronary artery bypass graft procedure on March 25, 1974. Hypothermia was not used. Total anesthetic time was three hours and 20 minutes; the time on cardiopulmonary bypass was 53 minutes ; the average perfusion rate was 54 ml/ kg/minute; and the average mean arterial pressure was 88 mm Hg. The lowest hematocrit count was 16% and it remained below 25% for 35 minutes. This patient had a history of chronic anxiety and depression. Because of this, evaluation of her condition after surgery was difficult. She appeared to be blind but she was so combative and irrational that accurate assessment was not possible. She appeared to recognize the surgeon in the re covery room and she called him by name but several days later she denied all light perception. Except for the defect in her vision and the irrationality there were no other abnormal neuro logical signs. Ophthalmologic and ophthalmoscopic examinations were normal including pupillary re actions. A brain scan done on April 2 showed abnormal uptake in the occipital area bilaterally but to a greater degree on the right (Fig. 3). Her general physical condition gradually improved al though she remained depressed. At the time of her discharge on May 1, central visual acuity was 20/30 in each eye but she had a dense right homonymous hemianopia that persisted (Fig. 4). Case 3—This 50-year-old man underwent a four-vessel coronary artery bypass graft pro cedure under hypothermia on May 1, 1974. The total anesthetic time was 6% hours; the time on cardiopulmonary bypass was two hours; the aver-
Fig. 1 (Taugher). Case 1. Brain scan demon strates abnormal uptake in the occipital area bilaterally (arrows). 280
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Fig. 2 (Taugher). Case 1. Restriction of peripheral isopters and bilateral paracentral scotomata in a 51-year-old man. age perfusion rate was 55 ml/kg/minute ; and the average mean arterial pressure was 72 mm Hg. The lowest hematocrit reading was 18% and it remained below 25% for two hours. This patient first complained of blurry vision several days after surgery but had noticed the trouble on recovery from the anesthetic. No ocular abnormality was observed when he was examined by an ophthal mologist on May 9. Visual fields were not done at that time. Visual impairment seemed slight at the time and he was discharged without further examination. He continued to experience poor vision, however, and consulted an ophthalmologist in his home town. On examination visual acuity was 20/20 in each eye but visual field testing re vealed the presence of bilateral right inferior para central scotomata (Fig. 5). This defect inter fered considerably with his ability to read, but +4-00 diopter bifocal additions were prescribed which gave him considerable relief. Case 4—This 58-year-old woman underwent a five-vessel coronary artery bypass graft procedure under hypothermia on May 9, 1974. The total anes thetic time was seven hours; the time on cardiopulmonary bypass was four hours; the average perfusion rate was 77 mlAg/miniite ; and the average mean arterial pressure was 64 mm Hg. The lowest hematocrit count was 14% and it re mained below 25% for three hours. The patient recovered from the anesthetic with a flaccid paralysis of the right arm and leg. She had a depressed sensorium and was almost unresponsive. She showed no sign of vision but in the begin ning this was difficult to evaluate because of her unresponsiveness. Babinski reflexes were pres ent bilaterally and deep tendon reflexes were in
creased throughout but were greater on the left than on the right. Ophthalmologic and ophthalmoscopic examinations were normal including normal pupillary reactions. A brain scan done on May 5 revealed multiple areas of abnormal uptake in the posterior cortex (Fig. 6). She recovered the total use of her arm and leg and she speaks without defect or evidence of intellectual impairment but she remains blind. Case 5—This 46-year-old man underwent a six-vessel coronary artery graft procedure under hypothermia on May 17, 1974. The total anesthetic
Fig. 3 (Taugher). Case 2. Brain scan demon strates abnormal uptake in the occipital area bi laterally (arrows).
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Fig. 4 (Taugher). Case 2. Right homonymous hemianopia in a 63-year-old woman. time was six hours; the time on cardiopulmonary bypass was two hours; the average perfusion rate was 64 ml/kg/minute; and the average mean arterial pressure was 79 mm Hg. The lowest hematocrit count was 19% and the hematocrit stayed below 25% for one hour. The patient re covered from the anesthetic totally blind and with paresis of his left arm and leg. He kept his eyes deviated conjugately to the right when unstimu-
lated but he could move them to the left on com mand. He was otherwise alert and cooperative. On May 21, light perception was present in the right eye but not in the left. Pupillary reactions were normal as were the results of the ophthalmoscopic examination. A brain scan done on May 29 showed abnormal uptake in the posterior cortex on both sides of the brain (Fig. 7). Since that time the paresis of his left leg has improved to the point
Fig. S (Taugher). Case 3. Bilateral paracentral scotomata in a 50-year-old man.
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Fig. 7 (Taugher). Case 5. Brain scan demon strates abnormal uptake in the occipital area (arrows).
Fig. 6 (Taugher). Case 4. Brain scan demon strates multiple areas of abnormal uptake through out the brain. where he can now walk without assistance. The paresis of his left arm remains unchanged. Visual acuity in both eyes improved to 10/400. Case 6—This 58-year-old man had undergone
a five-vessel coronary artery bypass graft pro cedure under hypothermia elsewhere on Sept. 9, 1974. The total anesthetic time was seven hours; the time on cardiopulmonary bypass was 3}4 hours ; the average perfusion rate was 51 ml/kg/minute; and the average mean arterial pressure was 73 mm Hg. The patient tolerated the procedure well but he awoke from the anesthetic with markedly reduced vision. Ophthalmologic examination dis closed only the defect in visual acuity, with normal pupillary reactions and a normal ophthalmoscopic examination. Visual fields done on Sept. 20 re vealed bilateral central scotomata with the defect RIGHT 30
Fig. 8 (Taugher). Case 6. Bilateral central scotomata and a partial right superior quadrantonopia in a 58-year-old woman.
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Fig. 9 (Taugher). Case 6. Brain scan demonstrates abnormal uptake in the occipital area (arrow). on the right being larger than the one on the left (Fig. 8). A brain scan done on Sept. 23 revealed an abnormal amount of uptake in both occipital lobes (Fig. 9). Best corrected visual acuity was R.E.: S/400, and L.E.: 20/400. Case 7—This 62-year-old man underwent a fivevessel coronary artery bypass graft under hypo
thermia on Sept. 26, 1974. During the year before surgery he experienced episodes of angina and blurry vision. The surgery was performed with out complications. Total anesthetic time was 13 hours; the time on cardiopulmonary bypass was 4}4 hours ; average perfusion rate was 69 ml/kg/ minute; and the average mean arterial pressure
Fig. 10 (Taugher). Case 7. Left homonymous hemianopia with partial involvement of the right visual field in a 62-year-old man.
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Fig. 11 (Taugher). Case 8. Left homonymous hemianopia in a 53-year-old man. was 67 mm Hg. The patient was unresponsive after surgery and could not move his left arm or leg. He gradually improved and was fully respon sive several weeks later. He was alert and able to converse but tended to lose his train of thought and he occasionally gave inappropriate answers to questions. This man was not examined by an ophthalmologist until three weeks after surgery when best corrected acuity was 20/30 in each eye and he had a left homonymous hemianopia (Fig. 10). His eyes were normal including pupillary reactions and ophthalmoscopic examination. At that time he moved his left arm and left leg but he was unable to walk or to grasp objects with his left hand. He has since been lost to follow-up. Case 8—This 53-year-old man underwent an emergency two-vessel coronary artery bypass graft procedure without hypothermia on Nov. 2, 1974. He had had an inferior wall myocardial infarction in August and later experienced chest pain on mini mal exertion. The average perfusion rate was 60 ml/kg/minute ; the average mean arterial pres sure was 50 mm Hg; the total anesthetic time was three hours and 15 minutes; and the time on cardiopulmonary bypass was one hour. The lowest hematocrit count was 19% and it remained below 25% for one hour and 35 minutes. The patient reported later that he was aware of a defect in his vision as soon as he recovered from the anesthetic. Ophthalmologic examination three days after sur gery showed a left homonymous hemianopia. This was revealed by confrontation testing. The defect was still present when visual fields were plotted on Dec. 7 (Fig. 11). Best corrected acuity at that time was R.E.: 20/30, and L.E.: 20/50. A brain scan study revealed abnormal uptake in the right occipital cortex (Fig. 12). This patient has since
been lost to follow-up. Case 9—This 49-year-old man underwent a three-vessel coronary artery bypass graft pro cedure on Nov. 15, 1974. The procedure was done without hypothermia. Total anesthetic time was five hours and 14 minutes; the time on cardio pulmonary bypass was one hour and 16 minutes; the average perfusion rate was 68 ml/kg/minute; and the average mean arterial pressure was 57 mm
Fig. 12 (Taugher). Case 8. Brain scan demon strates abnormal uptake in occipital area (arrow).
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Fig. 13 (Taugher). Case 10. Bilateral paracentral scotomata in a 46-year-old man. Hg. The lowest hematocrit count was 14% and it remained below 25% for two hours and 15 min utes. The patient enjoyed an uneventful recovery until Nov. 18, when he began to experience inter mittently blurred vision. Occasionally, parts of his left visual field were missing or he had bilateral central blind spots that were edged with an illumi nated frill. This recurrent symptom persisted only until Nov. 21. Visual fields were not done during an episode of blurry vision and when they were done on Nov. 22, no abnormality was found. Ophthalmologic examination on that date was nor mal. Case 10—This 46-year-old man underwent a two-vessel coronary artery bypass graft procedure under hypothermia on Nov. 15, 1974. The total anesthetic time was seven hours ; the time on cardiopulmonary bypass was 2γϊ hours ; average perfusion rate was 68 ml/kg/minute; and the average mean arterial pressure was 78 mm Hg. The lowest hematocrit count was 21% and it re mained below 25% for 55 minutes. The patient noticed that things looked blurry in the recovery room but he did not mention this to anyone be cause he thought it was to be expected. Several days later he noticed that he could not read. Visual fields on Nov. 19 revealed bilateral paracentral scotomata (Fig. 13). Ophthalmologic examination was otherwise normal. Best corrected visual acuity was 20/20 in each eye; +4.00 diopter bifocals made reading less difficult. DISCUSSION
The visual loss experienced by these pa tients ranged from total permanent blind
ness (Case 4) to a brief period of transi ent ischémie attacks (Case 9). Symptoms were limited to visual loss in most patients, but in Cases 1, 5, and 7 there was associated motor impairment as well (Table). In the cases documented by brain scan the symp toms were due to occipital cortical infarction but the exact mechanism by which this took place is unknown. Reports of loss of visual acuity after cardiopulmonary bypass have been infre quent. Alfano, Fabritus, and Garland3 re ported three cases in 1957 after commissurotomy for mitral stenosis. In 1965, Gilman4 reported two cases as part of a group of other neurologic complications. Total visual loss due to occipital in farction is uncommon. In 1957, Symonds and Mackenzie5 reported a series of 58 such cases, none of which were associated with surgery of any kind. It was their opinion that most if not all of their cases were due to embolie rather than thrombotic phenomena. To support this contention they referred to the work of Beevor6 and Collier7 who demonstrated by means of injection of colored materials into the cerebral circu lation that collateral circulation from the
VOL. 81, NO. 3
VISUAL LOSS
287
TABLE SUMMARY OF CASE REPORTS
Case No., Anesthetic Sex. Age, Time yrs
Bypass Time
2 hrs. 50 min
1,M,51
9 hrs
2, F, 63
4. F, 58
3 hrs. 20 min 6 hrs, 30 min 7 hrs
5.M.46
6 hrs
2 hrs
6, M. 58
7 hrs
7, M. 62
13 hrs
8.M.53
3 hrs, 15 min 5 hrs, 14 min 7 hrs
3 hrs, 30 min 4 hrs, 30 min 1 hr
3.M.50
9.M.48 10, M, 46
S3 min 2 hrs 4 hrs
Ihr, 16 min 2 hrs, 30 min
Average Hypo- Flow Rate, . ^ i e ä " . thermia ml/kg/min Arterial Pressure, mm Hg
+ — + + — + +. — — +
66
77
54
88
55
72
77
64
64
79
51
73
69
67
60
50
68
57
68
77
middle cerebral arteries was enough to fill the bed usually supplied by the posterior cerebral arteries even when the supply from these vessels was totally cut off. This suggests that even total occlusion of both posterior cerebral arteries by clot would be insufficient to cause total blindness. Symonds and Mackenzie5 also cited the work of Kubic and Adams 8 who reported 17 cases of pathologically confirmed basilar artery occlusion. Of these 17 cases bilateral occipital lobe infarction occurred in only one. In seven cases the clot extended into both posterior cerebral arteries. Of these seven cases one had the bilateral occipital infarction, four had unilateral involvement, and two had no occipital damage. The possibility that the visual loss experi enced by our patients was due to cerebral entrapment of multiple emboli must be con sidered. The brain scans show multiple areas of damage suggestive of embolie injury. Embolization has also occurred during sur gery with carrliopulmonary bypass.9'10 How ever, in all of these patients, symptoms have been confined to the visual system and oc casionally have included the motor system in
Blind
Visual Acuity Less Than 20/200
— — — + — — — — — —
+ — — + + + — — — —
Visual Para- Central Acuity Hemiacentral Scoto- HemiBetter nopia Scotomata paresis Than mata 20/30
— + + — — — + + + +
— + — — — — + + — —
+ — + — — — — — — +
— — — — + + — — — —
+ — — + + — + — — —
the form of hemiparesis. One would expect emboli to produce a more random pattern of damage. Another possible explanation is the oc currence of selective laminar necrosis due to generalized cerebral anoxia.11'12 The visual and motor regions of the cortex are particularly susceptible to anoxia9 and these cases may simply demonstrate the vulner ability of these areas. If selective laminar cortical necrosis does occur despite appar ently adequate pressures and flow rates, then the cerebral hemodynamics during cardiopulmonary bypass are not fully under stood. The total and permanent visual loss ex perienced by one patient (Case 4) is evi dently an unusual occurrence but we sus pect that the comparatively milder forms of visual loss experienced by the other patients are not as uncommon. When patients are recovering from cardiac surgery their com plaints of blurry or peculiar vision can easily be overlooked. The milder manifestations of this problem can go unnoticed unless ophthalmologic consultation is requested and visual fields are examined.
288
AMERICAN JOURNAL OF OPHTHALMOLOGY SUMMARY
Ten cases of visual loss ranging from total blindness to a brief period of transient ischémie attacks occurred after cardiopulmonary bypass. Brain scan studies indicated occipital cortical infarction as the cause. Thrombosis, embolization, and selective laminar cortical necrosis due to cerebral anoxia were possible mechanisms. REFERENCES
1. Branthwaite, M.: Neurological damage related to open heart surgery. A clinical survey. Thorax 27:748, 1972. 2. Javid, H., Tufo, H , Najfi, H., Dye, W., Hunter, J., and Julian, O. : Neurological abnormali ties following open heart surgery. J. Thorac. Cardiovasc. Surg. 58:502, 1969. 3. Alfano, J., Fabritus, R., and Garland, M.: Visual loss following commissurotomy for mitral stenosis. Am. J. Ophthalmol. 44:213, 1957. 4. Gilman, S.: Cerebral disorders after open heart operations. N. Engl. J. Med. 272:489, 1965.
OPHTHALMIC
MARCH, 1976
5. Symonds, C, and Mackenzie, I. : Bilateral loss of vision from cerebral infarction. Brain 80:415, 1957. 6. Beevor, C. : On the distribution of the different arteries supplying the human brain. Philos. Trans. R. Soc. Lond. 200:1, 1908. 7. Beevor, G, and Collier, J. : Contribution to the study of the cortical localization of vision. A case of quadrantic hemianopia. Brain 27:153, 1904. 8. Kubic, C, and Adams, R. : Occlusion of the basilar artery ; clinical and pathological study. Brain 69:73, 1946. 9. Reed, C, Romagnoli, A., Taylor, D., and Clark, D.: Particulate matter in bubble oxygenators. J. Thorac. Cardiovasc. Surg. 68:971, 1974. 10. Helmsworth, J., Gall, E., Perrin, E., Braley, S., Flege, J., Koplan, S., and Keirle, A.: Occurrence of emboli during perfusion with an oxygenator pump. Surgery 53:177, 1963. 11. Courville, C. : Etiology and pathogenisis of laminar cortical necrosis. Arch. Neurol. Psych. 79:7, 1958. 12. Stockard, J., Bickford, R., Chir, B., and Schäuble, J.: Pressure-dependent cerebral ischemia during cardiopulmonary bypass. Neurology 23:521, 1957.
MINIATURE
"Cure your eyes, is it ?" Said T o m m y W a r n e . " W h y , to be sure I can. W h y didn't you ax me afore? I thought you LIKED squintin." " I don't then ; I hate it." " V e r y well ; you shall see straight this very night if you do what I tell you. Go home and tell your.wife to make your bed on the roof of the four-poster; and she must make it widdershins, turnin' lied-tie and all against the sun, and puttin' the pillow where the feet come as a rule. That's all." "Fancy my never thinkin' of anything so simple as that !" said Joby. A r t h u r Quiller-Couch Widdershins, in Shorter Stories J . M . Dent & Sons, 1944
