New Methods of Diagnosis and Treatment of Ophthalmic Artery Stenosis in Patients with Ischemic Central Retinal Vein Occlusions

Abstract

Introduction: The purpose of this report was to examine if correlations exist in patients with Ischemic Central Retinal Vein Occlusion syndromes and significant narrowing’s of the ophthalmic arteries. Further, we wanted to see if a minimally invasive technique could accurately indicate low orbital arterial perfusion and predict which patients may benefit from cerebral angiography. By identifying proximal ophthalmic artery lesions which may contribute to retinal hypo perfusion and severe visual loss, ophthalmic artery revascularization may be a reasonable recommendation in selected cases. One patient who underwent revascularization experienced dramatic improvement in visual function and retinal morphology. If ophthalmic artery disease proves to be a relatively consistent finding in Ischemic Central Retinal Vein occlusive disease, techniques for intervention could be offered. Methods: In nine patients with ischemic central vein occlusion who had sudden or rapidly progressive visual loss, studies of choroidal perfusion and cerebral angiography were obtained. Binocular Fundus Reflectometry was used in all patients to evaluate choroidal perfusion. OPG and ODM were also evaluated in each patient. Cerebral angiography was used with special attention to orbital filling details with use of subtraction and magnification views. In all patients other metabolic factors, lesions causing mass effect producing lesions, and cardiac factors were ruled out unusual causes of ischemic central vein occlusion syndromes. Additionally, each patient had evaluation for present or past history of ocular infections. In one of the patients who suffered from rapid progressive visual loss with a diagnosis of ischemic central retinal vein occlusion and had an identifiable focal proximal ophthalmic artery narrowing, a microsurgical bypass of the ophthalmic artery was performed to reverse hypo perfusion. Results: All patients had a negative workup for other cardiac, metabolic and radiologic factors that could cause a picture of ischemic central retinal vein occlusion No patient had evidence of ocular infection or a past history of ocular infection. All patients had abnormalities of perfusion indicated by abnormal reflectograms on the affected side. Three of the nine patients had contralateral abnormalities of ocular perfusion according to BFR. In each of these cases arteriography indicated abnormalities of the ophthalmic artery on the opposite side that would account for the abnormal perfusion indicated by BFR. In six of the nine cases a definite focal abnormality in the proximal orbital portion of the ophthalmic artery could be identified. In the other three cases where no definite proximal obstructing lesion could be seen, clear evidence of distal diffuse arterial disease was seen. These abnormalities include abrupt narrowing of filling in the main trunk of the ophthalmic artery, slow or absent filling of the choroid blush, and nonvisualization of the ciliary or distal branches of the ophthalmic artery such as the lacrimal and supra orbital arteries. In the patient who underwent the bypass of the ophthalmic artery, dramatic and sustained improvement in visual acuity and visual fields were seen as well as resolution on ophthalmoscopy of the retinal hemorrhages and congestion. Conclusions: Syndromes of ischemic central retinal vein occlusion that presents as sudden and severe visual loss may have significant narrowing’s of the orbital ophthalmic artery which can be detected by minimally invasive technology. Binocular fundus reflectometry appears to be a sensitive indicator of low ocular perfusion and valuable to select patients for arteriography. These stenotic lesions may account significantly for decreased perfusion and may go unappreciated unless systematically searched for. Some of these lesions may be treatable by microsurgical revascularization which may result in visual improvement. Identification of a consistent in Ischemic Central Retinal Vein Occlusion syndrome would greatly expand our ability to manage this disorder. It may become helpful to correlate ocular perfusion and ophthalmic artery anatomy when assessing and classifying Ischemic Central Retinal Vein Occlusion.