Extreme care must be used in positioning patients for surgery in a prone position. A padded Mayfield headrest may not be appropriate for all patients undergoing spinal surgery, as exophthalmus or a flattened nasal bridge may allow transmission of pressure to the globe. Our current approach is to use supplementary foam rubber support, with repeated, meticulous attention to keeping the eyes free from all pressure. Finally, unexplained intraoperative occurrence of a bradyarrhythmia or conduction disturbance may signal increased intraorbital pressure during general anesthesia.