Suspected Orbital Compartment Syndrome Leading to Visual Loss After Pterional Craniotomy

Background: Perioperative visual loss is a potentially devastating surgical complication. Its occurrence is exceedingly rare after nonocular surgery, but recent literature has explored several etiologies contributing to its development.

Case presentation: We document a case of perioperative visual loss after a pterional craniotomy for the excision of a temporal meningioma in a 47-year-old woman with no significant medical history. The intraoperative course was uneventful, with a myocutaneous flap reflected anteriorly across the orbit. Postoperatively, the patient demonstrated a third cranial nerve palsy and an afferent pupillary defect, with visual loss that persisted > 3 months postsurgery. A diagnosis of central retinal artery occlusion secondary to intraoperative orbital compartment syndrome was considered the likely etiology. However, several alternate diagnoses could not be excluded.

Conclusions: Orbital compartment syndrome should be considered in neurosurgical patients presenting with postoperative ophthalmoplegia and central retinal artery occlusion. We recommend a multidisciplinary perioperative approach to reduce the incidence of perioperative visual loss and orbital compartment syndrome in patients undergoing pterional craniotomy.