Suspected Orbital Compartment Syndrome Leading to Visual Loss After Pterional Craniotomy

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. 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. 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.