Ischemic optic neuropathy (ION) resulting in perioperative vision loss (POVL) is a rare occurrence following nonocular procedures. Bilateral simultaneous anterior ION (AION) is even rarer, and no cases have been reported after central neuraxial block. We report a case of bilateral simultaneous AION, confirmed by multimodal imaging, in a 66-year-old male patient who underwent total knee arthroplasty under epidural anesthesia in which episodes of hypotension-one intraoperatively and one late postoperatively-had occurred. Hypotension is the most common adverse effect to epidural block, and counseling about POVL should extend beyond general anesthesia to include those undergoing procedures with central neuraxial block.