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World Neurosurg. 2018 Feb;110:309-314. doi: 10.1016/j.wneu.2017.11.111. Epub 2017 Nov 27.

The Enigma of Orbital Compartment Syndrome After Lumbar Spine Surgery in the Prone Position: Case Report and Literature Review.

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Division of Neurosurgery, Galeão Air Force Hospital, Rio de Janeiro, Brazil; Postgraduate Program in Neurology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil. Electronic address:
Postgraduate Program in Neurology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil; Division of Neurosurgery, Fluminense Federal University, Rio de Janeiro, Brazil.



Perioperative visual loss after spinal surgery is a devastating complication for the patient and the surgical team. Two known major causes are ischemic optic neuropathy and central retinal artery occlusion (CRAO). Traditional understanding of CRAO has been consistently related to occurrence of periocular trauma and signs of increased intraorbital pressure in addition to visual loss. However, such orbital signs are not a feature of any common perioperative visual loss syndrome.


A 55-year-old woman underwent prolonged lumbar decompression and fusion for spinal stenosis under general anesthesia in the prone position. At the end of surgery, periocular hyperemia, corneal edema, and a tense orbit on the right side were noted. Complete internal and external ophthalmoplegia was observed on examination. Orbital computed tomography confirmed the clinical diagnosis of orbital compartment syndrome. Bony decompression was performed, but the treated eye remained blind. Resolution of the complete ophthalmoplegia was observed during late follow-up.


In retrospect, patients diagnosed with often misunderstood CRAO and ischemic optic neuropathy with orbital signs after spinal surgery most likely had orbital compartment syndrome. The inclusion of orbital signs in the clinical picture of ischemic optic neuropathy and CRAO is not only incorrect but also gives the impression of therapeutic futility, thereby preventing successful orbital decompression in a timely fashion.


Central retinal artery occlusion; Ischemic optic neuropathy; Orbital compartment syndrome; Perioperative visual loss; Prone position; Spine surgery

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