Anterior ischemic optic neuropathy: A complication after systemic inflammatory response syndrome

Background: Patients are surviving previously fatal injuries, Unique morbid ities are occurring in these survivors. Anterior ischemic optic neuropathy represents a previously unrecognized cause of blindness in the trauma victi m. We hypothesize that this phenomenon is caused by unique characteristics of optic edema/ pressure or decreased blood flow associated with massive re suscitation. Methods: Between November of 1991 and August of 1998, there were 18,199 adm issions to our trauma center. Of this group, 350 patients required massive volume resuscitation (> 20 liters infused over first 24 hours). Patients ha ving closed head injuries, facial fractures or direct orbital trauma were e xcluded from study. The following variables were studied: demographics, inj ury severity (Injury Severity; Score, highest lactate, worst base deficit, and lowest pH) crystalloid and transfusion requirements, ventilator require ments (PEEP) Results: Of the 350 patients with massive resuscitation, 9 patients were di agnosed with anterior ischemic optic neuropathy (2.6%). Of these, seven pat ients required celiotomy (78%). Six of the seven celiotomy patients had dam age control celiotomies and abdominal compartment syndrome (86%). One patie nt had a repair of a subclavian artery; one had a complex acetabular repair . Blindness was unilateral in five patients and bilateral in four. All nine patients had evidence of global hypoperfusion, systemic inflammatory respo nse, massive resuscitation, and high ventilatory support; one patient requi red cardiopulmonary resuscitation. Conclusion: Prone positioning is known to be associated with an increased i ntraocular pressure. We postulate that the combination of massive resuscita tion and prone positioning will increase the incidence of anterior ischemic optic neuropathy. As such,,ve recommend that prone positioning for adult r espiratory, distress syndrome be reserved for only those patients at risk o f death.