Acute postoperative visual loss

A 50-year-old healthy woman underwent an uncomplicated elective clipping of a right middle cerebral artery aneurysm via pterional craniotomy. Ophthalmology was consulted urgently in the recovery roombecause of complaints of vision loss andophthalmoplegia in the right eye. On examination, visual acuity was no light perception (NLP) OD and 20/20 OS. Pupils were equal and round, with a 3+ relative afferentpupillarydefect in the right eye. Intraocular pressure was within normal limits in both eyes. There was completeophthalmoplegia in the righteyewithnosigns of restriction on forced ductions and normalmotility in the left eye. Visual field was full to confrontation in the left eye. The right eye also demonstratedmild fullness of theorbit, right cheek skin erythema, traceproptosis, and trace conjunctival chemosis. Posterior examinationwas significant for diffuse retinalwhiteningwith a cherry-red spot in themacula in the right eye (Figure 1A). Therewere noother neurologic deficits identified on examination. Acomputed tomographyscanwithout contrastdidnot showanacute intracranial hemorrhage and demonstrated diffuse enlargement of the right extraocular muscles. Magnetic resonance imaging of the brain and orbits with contrast again showed enlargement and abnormal signal of the extraocular muscles on the right (Figure 1B); there was no evidence of cavernous sinus pathology. Quiz at jamaophthalmology.com A B