Visual loss and ophthalmoplegia are very infrequent complications after spinal surgery.^1,2 Visual loss may be caused by ischaemic optic neuropathy, central retinal artery or vein occlusion, or occipital stroke.^2,3 Previous reports have attributed this complication to patient positioning, intraoperative blood loss, and controlled hypotension or shock.^2–5 Associated risk factors include anaemia, prolonged surgical time, bradyarrhythmia, hypertension, diabetes, smoking, vascular disease, and increased blood viscosity.^2,6 Ophthalmoplegia after spinal surgery is even more unusual than visual loss, and only few reports exist in the literature.^6–8 Moreover, magnetic resonance image (MRI) studies to differentiate between cavernous sinus thrombosis and direct compression of orbital contents have not been previously described. We therefore report two patients who developed this unusual combination of ophthalmoplegia and central retinal artery occlusion (CRAO) after spinal surgery.

Case 1

A 62 year old male ex-smoker underwent a L2–L3 posterior spinal decompression and segmental instrumentation for lumbar stenosis and scoliosis, in prone position with ocular protection (gauze swab and tape). The surgery lasted 2 hours and 45 minutes. Before the procedure blood pressure was 140/60 mm Hg and during operation it was maintained at 90/60 mm Hg. Just after surgery he complained of visual loss and left ocular and nasal pain. Examination revealed left palpebral oedema, local erythema, blindness, and total ophthalmoplegia of the left eye. Left pupil was dilated and …