Perioperative central retinal artery occlusion after prone posterior cervical spine surgery treated with delayed hyperbaric oxygen therapy: a case report and targeted literature review

BACKGROUND: Perioperative central retinal artery occlusion (CRAO) is a rare but potentially devastating cause of visual loss after non-ocular surgery. Prone spinal and posterior cervical procedures may increase ocular risk through local orbital compression, impaired venous drainage and reduced ocular perfusion. Management is particularly difficult after surgery, when diagnosis may be delayed, conventional reperfusion strategies may be impractical or relatively contraindicated, and the role of delayed hyperbaric oxygen therapy (HBOT) remains uncertain. CASE PRESENTATION: A 53-year-old man with atlantoaxial subluxation underwent posterior atlantoaxial reduction and internal fixation under general anaesthesia in the prone position. Intra-operative haemodynamics remained stable; however, after the patient was returned to the supine position, a transient pressure mark and erythema were noted over the right orbit. After extubation, the patient reported blurred vision in the right eye and had a reduced right pupillary light reflex. Ophthalmological assessment showed hand-motion visual acuity, posterior pole retinal oedema and a cherry-red spot at the macula. Multimodal imaging showed findings consistent with CRAO, with fundus fluorescein angiography providing additional supportive evidence. Thrombolysis was considered relatively contraindicated in the early postoperative setting, and endovascular intervention was judged unlikely to provide meaningful benefit. As visual function remained severely impaired after initial conservative measures, HBOT was started approximately 52 h after the first postoperative visual complaint and delivered once daily at 2.0 ATA for 14 sessions. Best-corrected visual acuity later improved to 20/25 in the affected eye, with interval structural improvement on retinal imaging, although severe visual field loss persisted with only slight improvement. CONCLUSIONS: This case highlights perioperative CRAO as a rare but serious complication of prone posterior cervical spine surgery. Early recognition and prevention of ocular compression remain essential. In selected postoperative cases where standard reperfusion options are limited, delayed HBOT may still be worth considering, although its therapeutic role requires further investigation.