Background: A variety of factors have been linked to perioperative visual loss during or directly after nonocular\nand ocular surgeries. Prolonged immobilization, biochemical factors and hemodynamic instability have been discussed\nas factors in the pathogenesis of this devastating complication. Perioperative visual loss in four consecutive patients, all\nfeaturing Flammer syndrome, is reported herein. To our knowledge, we present the first case series, which associates\nperioperative visual loss with Flammer syndrome. We assume that a low perfusion pressure, disturbed autoregulation\nof the ocular blood flow and altered drug sensitivity in such subjects, play significant role in the pathogenesis of this\ndreaded complication.\nCases presentation: We analysed the medical records of four consecutive patients with permanent perioperative\nvisual loss and complemented our findings with additional history taking and clinical examinations. A variety of tests\nwas performed, including colour Doppler ultra sonography of the re troocular vessels, static and dynamic retinal vessel\nanalysis. The visual loss was unilateral in three patients and bilateral in one. An extensive review of published\nperioperative vision loss cases was conducted.\nAll four patients were male Caucasians, and exhibited prominent signs and symptoms of Flammer syndrome.\nThe visual loss originated from a propensity for unstable ocular blood flow, combined with hyperreactivity\ntoward pharmacological stimuli, leading together to disturbed autoregulation of the blood supply, and subsequently - to\nocular hypoxia. An identified intrinsic hypoperfusion diathesis was a crucial pathophysiologic link in all of the patients.\nOther, yet unknown systemic or local factors may also be involved in this process.\nConclusions: A review of numerous publications of perioperative visual loss and our data, support our hypothesis for\na novel pathophy siologic model and incorporate Flammer syndrome as a distinct risk factor for paradoxical visual loss,\nduring nonocular and ocular surgeries, or invasive procedures. To prevent the complications produced by\ndisturbed blood flow auto regulation in such patients, guidelines for screening and tailored preoperative\napproach are given.
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