Korean J Ophthalmol.  2013 Oct;27(5):372-375. 10.3341/kjo.2013.27.5.372.

Acute Bilateral Visual Loss Related to Orthostatic Hypotension

• Kim JY
• Kim KN
• Kim WJ
• Lee YH

• KMID: 1707292
• DOI: http://doi.org/10.3341/kjo.2013.27.5.372

Abstract

A 50-year-old man had undergone lumbar vertebral surgery and was confined to bed in the supine position for three months. When he sat up from the prolonged supine position, he showed clinical signs of orthostatic hypotension and reported decreased vision in both eyes. He also had underlying anemia. Ophthalmologic findings suggested bilateral anterior ischemic optic neuropathy (ION) as the cause of the visual loss. Although there are numerous reports of ION in the setting of hemodynamic compromise, such as systemic hypotension, cases of ION-associated orthostatic hypotension are very rare.

Keyword

Ischemic optic neuropathy; Optic disc edema; Orthostatic hypotension; Visual loss

MeSH Terms

Acute Disease
Blindness/diagnosis/*etiology/physiopathology
Fluorescein Angiography
Fundus Oculi
Humans
Hypotension, Orthostatic/*complications/physiopathology
Male
Middle Aged
Visual Acuity

Figure

• 

  Fig. 1 Fundus photograph indicating features of optic disc edema in both eyes (A,B) and peripapillary flame-shaped hemorrhage in the left eye (B).

• 

  Fig. 2 Fluorescein angiography on the day of initial visit (A,C) and two weeks later (B,D). (A) Venous phase demonstrating definite delayed dye filling on the right optic disc. (B) Arterio-venous phase two weeks later showing improved filling on the right optic disc. (C) Venous phase showing delayed dye filling on the left optic disc. (D) Venous phase two weeks later showing improved filling on the left optic disc.

• 

  Fig. 3 (A) Optic nerve disc edema in both eyes and peripapillary flame-shaped hemorrhage in the left eye were resolved. Both optic discs showed temporal pallor after six months of decreased vision. (B) Optical coherence tomography demonstrating prominent thinning in the retinal nerve fiber layer in both eyes six months after the initial event. TEMP = temporal; SUP = superior; NAS = nasal; INF = inferior.

Reference

1. Hayreh SS. Anterior ischemic optic neuropathy. VIII. Clinical features and pathogenesis of post-hemorrhagic amaurosis. Ophthalmology. 1987; 94:1488–1502.

2. Johnson MW, Kincaid MC, Trobe JD. Bilateral retrobulbar optic nerve infarctions after blood loss and hypotension: a clinicopathologic case study. Ophthalmology. 1987; 94:1577–1584.

3. Katz DM, Trobe JD, Cornblath WT, Kline LB. Ischemic optic neuropathy after lumbar spine surgery. Arch Ophthalmol. 1994; 112:925–931.

4. Miller NR, Newman NJ, Biousse V, Kerrison JB. Walsh and Hoyt's clinical neuro-ophthalmology. 6th ed. Philadelphia: Lippincott Williams & Wilkins;2005. p. 371–374.

5. Haider S, Astbury NJ, Hamilton DV. Optic neuropathy in uraemic patients on dialysis. Eye (Lond). 1993; 7(Pt 1):148–151.

6. Knox DL, Hanneken AM, Hollows FC, et al. Uremic optic neuropathy. Arch Ophthalmol. 1988; 106:50–54.

7. Chobanian AV, Lille RD, Tercyak A, Blevins P. The metabolic and hemodynamic effects of prolonged bed rest in normal subjects. Circulation. 1974; 49:551–559.

8. Servilla KS, Groggel GC. Anterior ischemic optic neuropathy as a complication of hemodialysis. Am J Kidney Dis. 1986; 8:61–63.

9. Jackson TL, Farmer CK, Kingswood C, Vickers S. Hypotensive ischemic optic neuropathy and peritoneal dialysis. Am J Ophthalmol. 1999; 128:109–111.

10. Michaelson C, Behrens M, Odel J. Bilateral anterior ischaemic optic neuropathy associated with optic disc drusen and systemic hypotension. Br J Ophthalmol. 1989; 73:762–764.

11. Basile C, Addabbo G, Montanaro A. Anterior ischemic optic neuropathy and dialysis: role of hypotension and anemia. J Nephrol. 2001; 14:420–423.

12. Cove DH, Seddon M, Fletcher RF, Dukes DC. Blindness after treatment for malignant hypertension. Br Med J. 1979; 2:245–246.

13. Pryor JS, Davies PD, Hamilton DV. Blindness and malignant hypertension. Lancet. 1979; 2:803.

14. Taylor D, Ramsay J, Day S, Dillon M. Infarction of the optic nerve head in children with accelerated hypertension. Br J Ophthalmol. 1981; 65:153–160.

15. Chisholm IA. Optic neuropathy of recurrent blood loss. Br J Ophthalmol. 1969; 53:289–295.

16. Klewin KM, Appen RE, Kaufman PL. Amaurosis and blood loss. Am J Ophthalmol. 1978; 86:669–672.

17. Connolly SE, Gordon KB, Horton JC. Salvage of vision after hypotension-induced ischemic optic neuropathy. Am J Ophthalmol. 1994; 117:235–242.

18. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res. 2009; 28:34–62.

19. Arnold AC, Badr MA, Hepler RS. Fluorescein angiography in nonischemic optic disc edema. Arch Ophthalmol. 1996; 114:293–298.

20. Saini JS, Jain IS, Dhar S, Mohan K. Uremic optic neuropathy. J Clin Neuroophthalmol. 1989; 9:131–133.

21. Nieminen T, Kööbi T, Tammela TL, Kähönen M. Hypotensive potential of sildenafil and tamsulosin during orthostasis. Clin Drug Investig. 2006; 26:667–671.