Case Of Central Retinal Artery Occlusion Research Articles

Abstract TP125: Retina and Optic Nerve Diffusion Restriction in Acute Central Retinal Artery Occlusion: A Case-Control Study

Objective: To assess whether diffusion restriction (DR) of the retina and optic nerve (ON) can be accurately and reliably identified on standard stroke protocol brain magnetic resonance diffusion-weighted imaging (DWI-MRI) in patients presenting with acute non-arteritic central retinal artery occlusion (CRAO). Background: Retinal DR (RDR) and ONDR in patients with acute non-arteritic CRAO have been described with various diagnostic accuracies and often identified by experienced neuroradiologists with fair inter-rater agreement. Methods: This retrospective case-control study included patients that presented to our academic center from 2013-2021 with acute non-arteritic CRAO or acute cerebral ischemia (controls, age and gender-matched) and had brain MRI performed within 14 days from symptom onset. Two neuroradiologists, blinded to the site of CRAO and diagnosis, independently reviewed MRI of CRAO cases and controls to assess for the presence of RDR and ONDR. Their inter-rater agreement was calculated (prevalence and bias- adjusted kappa coefficient) and their final consensus was used to perform sensitivity and specificity analyses. Results: We included 128 patients with CRAO (mean age 69 years; 50% males; median time from CRAO to MRI 2 days (IQR 1-5)) and 128 matched controls with acute cerebral ischemia (mean age 68 years; 51% males). After neuroradiologists’ consensus, DR was correctly identified in the retina or ON in 51/128 (39.8%), retina alone 35/128 (27.3%), ON alone 31/128 (24.2%), both retina and ON 15/128 (11.7%), with excellent inter-rater agreement for retina (K=0.91) and ON (K=0.83). There were no cases of RDR or ONDR in the control group. After neuroradiologists’ consensus, sensitivity, specificity, PPV and NPV were 28.1%, 100%, 100%, and 58.2% for RDR and 27.3%, 100%, 100%, and 57.9% for ONDR. Conclusion: Though RDR and ONDR can be identified with excellent interrater reliability, they are infrequent findings and their role in diagnosing acute CRAO is unclear. Observational prospective studies with large cohort of patients, optimization of dedicated and standardized orbit DWI-MRI protocols, and education of neurology and neuroradiology providers are needed to facilitate more accurate identification of RDR and ONDR in hyperacute CRAO.

Incidence of central retinal artery occlusion peaks in winter season.

Stroke incidence exhibits seasonal trends, with the highest occurrences observed during winter. This study investigates the incidence of central retinal artery occlusion (CRAO), a stroke equivalent of the retina, and explores its monthly and seasonal variations, as well as potential associations with weather and ambient air pollutants. A retrospective search of medical records spanning 15 years (January 2008-December 2022) was conducted at the University Eye Hospital Tübingen, Germany, focusing on diagnosed cases of CRAO. Incidences were evaluated on a monthly and seasonal basis (winter, spring, summer, fall). Weather data (temperature, precipitation, atmospheric pressure) and concentrations of ambient air pollutants [fine particulate matter (PM2.5), coarse particulate matter (PM10), nitrogen dioxide (NO2), and ozone (O3)], were analyzed for a potential association with CRAO incidence. Out of 432 patients diagnosed with CRAO between 2008 and 2022, significantly varying incidences were observed monthly (p = 0.025) and seasonally (p = 0.008). The highest rates were recorded in February and winter, with the lowest rates in June and summer. Concentrations of NO2, PM2.5 and lower ambient air temperature (average, minimum, maximum) showed significant correlations with CRAO incidence. This comprehensive 15-year analysis reveals a pronounced winter peak in CRAO incidence, with the lowest occurrences in summer. Potential associations between CRAO incidence and ambient air pollutants and temperature underscore the importance of considering seasonal trends and call for further investigations to elucidate contributing factors, potentially leading to targeted preventive strategies and public health interventions.

Abnormal retinal vessel filling in central retinal artery occlusion

ABSTRACT Clinical relevance Central retinal artery occlusion (CRAO) is an ophthalmic emergency with a poor prognosis. Several initial CRAO presentation factors can influence the final visual outcome. Fluorescein angiography filling of retinal vessels in CRAO has not been studied in great detail. Background The aim of this paper is to study the aberrant filling of the retinal vessels on fluorescein angiography in patients with CRAO and understand its clinical relevance. Methods Cases of CRAO diagnosed between June 2017 and May 2022 and who had undergone a fundus fluorescein angiography were included. Comparisons were made between the cases with and without aberrant filling of the retinal vessel. Results Twenty-two eyes of 22 patients (14 males and 8 females) with CRAO underwent fluorescein angiography. Ages of the patients ranged from 18 to 73 years, while time interval between development of acute onset vision problems and presentation to the retinal clinic ranged from a minimum of 1 day to a maximum of 30 days. Snellen visual acuity at presentation ranged from perception of light (PL +) to 6/6. On fluorescein angiography, aberrant flow of the fluorescein dye into the retinal vein was observed in four of the 22 (18%) eyes with CRAO. All these cases showed a patient's temporal cilioretinal artery. The cases with aberrant filling of the retinal vessels showed a better presenting visual acuity (6/6–6/60), lesser severity of inner retinal damage and a better final visual acuity (6/6–6/60) compared to CRAO cases without aberrant filling. Conclusion Aberrant filling of the retinal vein can be seen on fluorescein angiography in eyes with CRAO and a patent temporal cilioretinal artery. Such eyes with aberrant retinal vessel filling have a better visual prognosis.

Retinal OCT findings in acute central retinal artery occlusion of varying severity at different disease stages – a retrospective, observational study

PurposeTo study the optical coherence tomography (OCT) changes in eyes with acute central retinal artery occlusion (CRAO) of different severity and at different disease stages.MethodsThe study included acute CRAO cases of < 7 days duration, imaged on OCT at various time points. Based on the OCT findings at presentation, cases were classified into three severity groups: mild, moderate, and severe. OCT scans were evaluated and classified into four-time intervals based on symptom duration.ResultsThere were 39 eyes from 38 patients with acute CRAO who underwent 96 OCT scans. At presentation, the study had 11, 16, and 12 cases of mild, moderate, and severe CRAO, respectively. Middle retinal layer opacification was more common in mild CRAO cases, which caused inner retinal layer thinning over time. Moderate CRAO cases had total inner retinal layer opacification, which resulted in retinal thinning over time. Prominent middle limiting membrane (p-MLM) sign was seen in mild and moderate CRAO eyes while were not visualised in severe CRAO. This sign gradually faded out over time. Other OCT findings in higher grades of CRAO included inner retinal fluid, neurosensory detachment, internal limiting membrane detachment, hyperreflective foci, and posterior vitreous opacities. Regardless of the CRAO grade, the final end-point seen was inner retinal layer thinning over time.ConclusionOCT in CRAO is a useful for determining the severity of retinal ischemia, disease stage, tissue damage mechanism, and final visual outcome. More prospective studies analysing a larger number of cases at fixed time points will be required in the future.Trial RegistrationTrial Registration Number: Not applicable.

Central retinal artery occlusion: a retrospective study of disease presentation, treatment, and outcomes

ObjectifL'occlusion de l'artère centrale de la rétine (OACR) constitue en fait une forme d'accident vasculaire cérébral (AVC) oculaire au pronostic visuel médiocre. Si la physiopathologie de l'OACR est semblable à celle de l'AVC ischémique, l'OACR s'accompagne de défis uniques en matière de diagnostic et de prise en charge, ce qui donne lieu à une grande variabilité en pratique clinique. Notre étude a pour objectif d’évaluer les résultats de l'examen initial, le traitement et le bilan de l'OACR dans un centre de soins tertiaires du Canada sur une période de 2 ans, et de proposer des axes d'amélioration potentielle de la prise en charge de ces patients. MéthodesRevue rétrospective réalisée dans un établissement unique qui regroupait 27 patients chez lesquels on a établi un diagnostic d'OACR entre mars 2018 et mars 2020 à Edmonton, en Alberta. RésultatsLa plupart des patients qui ont subi une OACR ont d'abord consulté un spécialiste des soins oculaires (14 sur 27); d'autres se sont rendus au service des urgences (10 sur 27) ou ont consulté leur médecin de famille (2 sur 27). Trois patients (11,1 %) ont consulté dans les 4,5 heures suivant l'apparition des symptômes. Lors de l'examen initial, l'acuité visuelle de 81 % des patients était de 20/400 ou pire dans l’œil atteint. Aucun patient n'a fait l'objet d'une thrombolyse. La majorité des cas d'OACR était d'origine non artéritique (92,6 %). Tous les patients présentaient déjà au moins un facteur de risque vasculaire, et 48 % des patients ont fait l'objet d'une intensification du traitement médicamenteux. Une sténose de la carotide homolatérale a été diagnostiquée chez 5 patients (18,5 %); d'ailleurs, 3 patients ont dû subir une endartériectomie de la carotide. On a noté la présence d'une fibrillation auriculaire chez 2 patients. Enfin, il s'est produit une ischémie cérébrale symptomatique chez 2 patients dans les 6 semaines suivant l'OACR. ConclusionsLa majorité des patients qui ont subi une OACR ont consulté un spécialiste des soins oculaires, mais très peu l'ont fait à l'intérieur de la fenêtre pendant laquelle une thrombolyse peut être réalisée, soit dans les 4,5 heures suivant l’épisode. Voilà qui met en lumière l'importance des stratégies de sensibilisation du public. Notre étude fait également ressortir le taux significatif de comorbidité générale présente chez ce type de patients.

Contribution of Orbital Ultrasound to the Diagnosis of Central Retinal Artery Occlusion.

We aimed to evaluate the diagnostic value of orbital ultrasound in the etiologic diagnosis of central retinal artery occlusion (CRAO). For this purpose, patients with CRAO evaluated at our center between 2011 and 2021 were reviewed. Demographic variables, vascular risk factors and ultrasound findings were collected. An orbital duplex was performed in all cases and complemented with other diagnostic explorations. We attended 36 cases of CRAO. In all patients, orbital ultrasound confirmed the diagnosis of CRAO: in 75% emboli material (spot sign) was observed in CRA and in 25% flow alteration in CRA without visible embolus. The positive spot sign (PSS) group differed from patients with negative spot sign (NSS) in terms of etiology: 8 PSS cases (29.6%) had a major cardioembolic cause, 4 (14.8%) a large vessel atheromatous disease, 15 (55.6%) an undetermined cause. Some 21 (77.8%) PSS patients had some minor cardioembolic cause, mainly calcifications of the left valves. In the NSS group, 2 (22%) were diagnosed with giant cell arteritis (GCA). In CRAO, the ultrasound spot sign could be a guide for the detection of embolic sources. Its absence makes it necessary to consider more strongly the possibility of arteritis. Furthermore, our findings suggest a key role of calcium embolism in PSS patients.

In Reply: Thrombotic Neurovascular Disease in COVID-19 Patients.

To the Editor: We read with interest the Letter entitled “Letter: Thrombotic Neurovascular Disease in COVID-19 Patients”1; it is a case series on stroke presentation over COVID-19 patients. We are particularly interested in patient 8, the one and only central retinal artery occlusion (CRAO) case due to internal carotid artery (ICA) occlusion, who was also highlighted by the authors. CRAO and ophthalmic artery occlusion (OAO) are both blinding ocular emergencies presenting with acute visual loss, and examinations would find end organ ischemia, ie, whitening of the retina on ophthalmoscopy. Their difference lies barely on the site of occlusion, and they are the ocular equivalent and harbinger of ischemic cerebrovascular stroke.2 From our basic understanding of the neuroanatomy and vascular supply, ICA supplies the ophthalmic artery, which then branches out the central retinal artery. Patient 8 described by Sweid et al1 had ICA occlusion, and the ophthalmic artery should be underperfused. Based on the vascular anatomy, the retina ischemia should be caused by a more proximal obstruction, and OAO should likely be the diagnosis instead of CRAO. Ocular manifestation of COVID-19 has recently been a hot debate and research topic with evolving case reports published on both arterial (CRAO,3-5 OAO6) and venous (central retinal vein occlusion)7-9 retinal vascular diseases induced by COVID-19 hypercoagulability, thromboembolic pathology, and vasculitis tendency. As ophthalmologists operating a hyperbaric oxygen therapy (HBOT) center to treat acute CRAO,10 we are interested to know more on the correlation of COVID-19 and CRAO. For background knowledge, HBOT is useful only for CRAO but not OAO, because OAO compromised the posterior ciliary arteries, which supply the eye's choroidal circulation.11 Without intact choroidal circulation, HBOT could not help reperfusing the ischemic neurosensory retina.12,13 Global literature on the incidence and correlation of CRAO with COVID-19 is limited. There were only 3 case reports for COVID-19 related CRAO,3-5 and 1 case of COVID-19 related OAO,6 after a comprehensive search over PubMed, Medline, EMBASE, Cochrane library, and Google Scholar with the terms [“central retinal artery occlusion” OR “CRAO”] and [“COVID” OR “coronavirus”] as on January 16, 2021. Clarification of this special case within the COVID-19 stroke series would help concrete the evidence available between CRAO and COVID-19, and guide ophthalmologists’ treatment plan. HBOT is indicated for CRAO during the COVID-19 pandemic to salvage vision as supported by the position statement from European Committee for Hyperbaric Medicine.14 Our tertiary CRAO referral center serving >7 million population has treated 15 acute CRAO cases with HBOT under the COVID-19 local outbreak, but there were no cases tested positive for SARS-CoV-2 before or after their CRAO episodes, mean follow up period was 5.0 mo. In practice, clarification of the difference between CRAO and OAO is essential for treatment implication as mentioned above. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Capturing the Occult Central Retinal Artery Occlusion Using Optical Coherence Tomography

ABSTRACT Aims: To report spectral-domain optical coherence tomography (OCT) findings in cases of impending or occult central retinal artery occlusion (CRAO) in which a diagnosis other than CRAO was made on initial presentation. Methods: Retrospective, observational case series of patients diagnosed with CRAO for whom on initial presentation fundal examination and OCT findings were deemed unremarkable and/or a diagnosis other than CRAO was made. OCT images from the initial presentation were then reviewed for evidence of inner retinal ischaemia. Results: In total, 214 cases of CRAO were identified. Eleven patients (5.14%) had been given an alternative initial diagnosis at their first presentation in casualty and were included. The age range was 20–84 years and 81% (9/11) were male. On review of initial OCT imaging performed in casualty, all cases had evidence of inner retinal ischaemia. Conclusions: CRAO is an ophthalmic emergency which leads to vision loss which is often irreversible. Examination of the fundus may be normal early in the course of the disease and therefore a timely diagnosis may be missed. This case series reports the OCT findings of inner retinal ischaemia in patients with occult or impending CRAO which may aid in the early diagnosis and referral to stroke services.

Assessment of Trends in the Incidence Rates of Central Retinal Artery Occlusion in Korea From 2002 to 2015

Central retinal artery occlusion (CRAO) is associated with and shares common risk factors with cardiovascular diseases. Over the past several decades, the incidence rates of stroke and ischemic heart disease have substantially decreased in high-income industrialized countries. However, little is known regarding current trends in CRAO incidence rates. To estimate trends in the incidence rates of CRAO in Korea. This nationwide population-based cohort study was designed on September 7, 2017, and used data from the Korean National Health Insurance Service from January 1, 2002, to December 31, 2015. Individuals with incident CRAO between 2002 and 2015 were identified using the CRAO diagnostic code (H34.1) from the International Classification of Diseases, Tenth Revision. Unadjusted CRAO incidence rates were calculated using the number of CRAO cases identified and the corresponding midyear population, which was obtained from resident registration data. Standardized incidence rates were calculated based on the 2015 census population, and weighted mean annual incidence rates with 95% CIs were computed based on the Poisson distribution. To identify trends in incidence rates, joinpoint regression analysis was performed using standardized incidence rates, and annual percentage changes (APCs) were calculated across the 12-year study period. Data were analyzed from May 1, 2019, to April 30, 2020. Temporal trends in CRAO incidence rates (measured as cases per 100 000 person-years) and age-standardized APCs in CRAO incidence rates using joinpoint and birth cohort analyses. Among 50 million residents of Korea, 9892 individuals (5884 men [59.5%]) with incident CRAO between 2002 and 2015 were identified. The mean age of Korean individuals diagnosed with CRAO was 62.4 years (range, 0-97 years); among men and women, the mean age was 61.5 years (range, 0-96 years) and 63.6 years (range, 0-97 years), respectively. The mean standardized incidence rate of CRAO was 2.00 cases per 100 000 person-years (95% CI, 1.97-2.04 cases per 100 000 person-years) among the entire population, 2.43 cases per 100 000 person-years (95% CI, 2.37-2.49 cases per 100 000 person-years) among men, and 1.61 cases per 100 000 person-years (95% CI, 1.57-1.66 cases per 100 000 person-years) among women. The highest incidence rate (9.85 cases per 100 000 person-years; 95% CI, 9.10-10.60 cases per 100 000 person-years) was observed among those aged 80 to 84 years (13.74 cases per 100 000 person-years [95% CI, 12.16-15.32 cases per 100 000 person-years] for men and 8.04 cases per 100 000 person-years [95% CI, 7.21-8.86 cases per 100 000 person-years] for women). The incidence rate in the overall study population decreased over time (APC, -3.46%; 95% CI, -4.3% to -2.6%), and this decreasing trend was more evident in women (APC, -4.56%; 95% CI, -5.7% to -3.4%) than in men (APC, -2.90%; 95% CI, -3.9% to -1.9%). The decrease in the incidence rate was more evident among participants younger than 65 years (APC, -6.80%; 95% CI, -8.3% to -5.2%) than among those 65 years and older (APC, -0.57%; 95% CI, -1.5% to -0.4%). Among participants born after 1930, a decrease in the CRAO incidence rate over time was observed in every age group, while the same decreasing trend was not present among those born before 1930. This study found that the CRAO incidence rate has been decreasing among residents of Korea, especially among women, individuals younger than 65 years, and individuals born after 1930. This observed decrease may be associated with the development of a national health care system and the general improvement in chronic disease management.

Prevalence of SARS-CoV-2 among central retinal artery occlusion patients: A case series-HORA study report No. 3

Introduction: COVID-19 patients are susceptible to hypercoagulability, thromboembolic, and vasculitis state; central retinal artery occlusion (CRAO) could be caused by hyperviscosity syndrome, thromboembolic accidents, and vasculitis. Evolving case reports are correlating CRAO with COVID-19 patients. Our case series aims to reveal the prevalence of SARS-CoV-2 among CRAO patients under the COVID-19 pandemic.Methods: Medical records of all CRAO patients who attended our tertiary referral hospital, during COVID-19 local outbreak (March to November 2020), were reviewed. Respiratory tract samples were tested for SARS-CoV-2 by the validated Xpert Xpress SARS-CoV-2 assay. If patients were able to cooperate, oropharyngeal saliva samples were obtained. Otherwise, nasopharyngeal and deep throat swabs were taken by registered nurses.Results: A total of 15 CRAO patients (7 males, 8 females) were identified during the 9-month study period. The mean age was 72.1-years (range 45-88 year). None of the patients were infected by SARS-CoV-2 before their CRAO disease episodes. Three patients had a history of CRAO over the contralateral eye. No patient was diagnosed with COVID-19 up to their last follow-up (mean 255.4 days, range 152-341 days). Without any COVID-19 positive case, correlation statistical tests on SARS-CoV-2 infection and CRAO were not established.Conclusions: Some of the presumed COVID-19 related CRAO cases may be just coincident with at-risk patients, as COVID-19 is prevalent across the world. More in-depth research, with adjustment to known confounding risk factors, is needed to establish a genuine correlation.

Central retinal artery occlusion with aphasia, secondary to internal carotid artery dissection in a young man

Abstract Introduction: Central retinal artery occlusion (CRAO) is an ophthalmic emergency, requiring immediate diagnosis and treatment. CRAO usually causes severe loss of vision. We report a case of CRAO, secondary to an internal carotid artery dissection, in which there was a good prognosis owing to early intervention. Patient concern: A healthy 41-year-old man experienced sudden monocular loss of vision and transient aphasia. The light reflex was absent and fundus examination revealed an intra-arterial thrombus in his left eye. Diagnosis: CRAO and transient ischemic attack owing to internal carotid artery dissection. Intervention: The patient was treated with Anterior chamber paracentesis to decrease intraocular pressure and antithrombotic therapy for CRAO. Anticoagulation therapy was started after diagnosing internal carotid artery dissection. Outcome: The light reflex recovered and the patient's vision improved from no light perception to 20/20 after the anterior chamber paracentesis and antithrombotic therapy. Conservative treatment improved blood flow of the internal carotid artery, without recurrence of ischemic symptoms. Conclusion: CRAO requires urgent diagnosis and treatment to achieve a good visual outcome. It is also important to simultaneously test for systemic diseases and initiate appropriate treatment.

Current treatment of central retinal artery occlusion: a national survey.

Central retinal artery occlusion (CRAO) is an ophthalmological emergency, the retinal analog of a stroke. To date there is no consensus or national guidelines on how this disorder should be managed. As academic neurologists and ophthalmologists treat CRAO frequently, we set out to understand how these clinicians approach patients with CRAO with a national survey. We identified university-associated teaching hospitals offering vascular neurology, neuro-ophthalmology and/or retina fellowships in the US and asked the directors of the programs to respond to questions in an open response format to profile the acute management of CRAO at their institution. We found remarkable heterogeneity in the approach to acute treatment of patients with CRAO among the 45 institutions that responded to the survey. Only 20% had a formal policy, guideline or white paper to standardize the approach to treatment. The primary treating physician was an ophthalmologist, neurologist, or neuro-ophthalmologist 44, 27, and 4% of the time, respectively; 24% were co-managed acutely by neurology and ophthalmology. Intravenous fibrinolysis was offered to selected patients in 53% of institutions, and was the preferred initial treatment in 36%. When the acute treatment team involved a vascular neurologist, fibrinolysis was more likely to be considered a first-line treatment (p<0.05). Anterior chamber paracentesis, ocular massage and hyperbaric oxygen therapy were offered 42, 66 and 7% of the time, respectively, while 9% of institutions offered no treatment. Anterior chamber paracentesis was more likely to be offered at programs where neurologists were not involved in treating CRAOs (p<0.001). At 35% of institutions, patients with acute CRAO were not routinely referred to a general emergency room for initial evaluation and treatment. Carotid imaging was routinely obtained by 89% of programs, magnetic resonance imaging of the brain by 69%, echocardiogram by 62%, laboratory screening for an inflammatory state by 27% and retinal angiography by 30%. The thoroughness of vascular risk factors' screening was greater in programs that routinely referred acute CRAO cases to the emergency department. This survey shows that there is significant variability in treatment practices for acute CRAO in the US. Because of the high cerebrovascular and cardiovascular risk reported in this population of patients, it is notable that the approach to risk factor screening is also highly variable and many programs do not routinely refer patients to an emergency department for urgent evaluation. Finally, there appears to be equipoise among treatment teams regarding the efficacy of systemic fibrinolysis, as 53% of programs report a willingness to treat at least some patients with this modality.

Quantitative analysis of retinal layers' optical intensities on 3D optical coherence tomography for central retinal artery occlusion.

Optical coherence tomography (OCT) provides not only morphological information but also information about layer-specific optical intensities, which may represent the underlying tissue properties. The purpose of this study is to quantitatively investigate the optical intensity of each retinal layers in central retinal artery occlusion (CRAO). Twenty-nine CRAO cases at acute phase and 33 normal controls were included. Macula-centered 3D OCT images were segmented with a fully-automated Iowa Reference Algorithm into 10 layers. Layer-specific mean intensities were determined and compared between the patient and control groups using multiple regression analysis while adjusting for age and optical intensity of the entire region. The optical intensities were higher in CRAO than in controls in layers spanning from the retinal ganglion cell layer to outer plexiform layer (standardized beta = 0.657 to 0.777, all p < 0.001), possibly due to ischemia. Optical intensities were lower at the photoreceptor, retinal pigment epithelium (RPE), and choroid layers (standardized beta = −0.412 to −0.611, all p < 0.01), possibly due to shadowing effects. Among the intraretinal layers, the inner nuclear layer was identified as the best indicator of CRAO. Our study provides in vivo information of the optical intensity changes in each retinal layer in CRAO patients.

Interest of local intra-arterial fibrinolysis in acute central retinal artery occlusion: Clinical experience in 16 patients

Central retinal artery occlusion (CRAO) is a rare disease with poor visual prognosis. We evaluated clinical effectiveness of in situ fibrinolysis with original angiographic scores describing the aspect of carotid siphon, proximal ophthalmic artery, and choroid blush. Retrospective study of 16 consecutive cases of CRAO between 2007 and 2013. Fourteen underwent in situ fibrinolysis, two were excluded due to pre-occlusive internal carotid stenosis on pre-procedural diagnostic angio-CT. Fibrinolysis was performed with rt-PA (average injected dose: 35 mg), with an average onset delay of 8hours (4-17h). We reported angiographic scores pre- and post-fibrinolysis, visual acuity (VA) before and after treatment, and VA improvement evaluated by ophthalmologist 6 to 12 months after thrombolysis. Six patients (43%) recovered post-fibrinolysis VA significally improved, superior or equal to 1/10 (1/10 to 8/10). An irregular carotid siphon (2 cases) appeared as a predictive factor of failure. Fibrinolysis procedure led to a significant improvement of angiographic permeability of proximal ophthalmic artery (P=0.0498), but this result was not accompanied by any VA improvement. The aspect of choroid blush showed no correlation with the management of thrombolysis. In situ fibrinolysis was more effective than medical treatments or natural evolution of CRAO (VA improvement was respectively 40% and 20%). However, the benefit/risk ratio must be discussed, and an angio-CT of supra-aortic trunks could be systematically performed before thrombolysis, to assess the potential VA recovery compared with complications such as ischemic stroke.

Treatment of Acute Central Retinal Artery Occlusion with Ocular Ischemic Syndrome

Purpose: We report a case of treatment of acute central retinal artery occlusion (CRAO) with ocular ischemic syndrome (OIS). Case summary: A 72-year-old man presented with acute loss of vision in the right eye on that day. At initial examination, visual acuity tested positive for light sensitivity in the right eye. Fundus examination demonstrated a visible embolus at the central retinal artery overlying the optic disc head and a cherry-red spot in the fovea. Fluorescein angiography revealed that filling of the choroidal circulation was delayed, and the arteriovenous transit time was even further delayed. Carotid angiography showed marked stenosis within the right internal carotid artery. Laboratory tests included blood tests for hypercoagulability evaluation, for which the results were non-specific. To treat acute CRAO with OIS in the right eye, transluminal Nd:YAG laser embolectomy (TYE) was performed twice, and carotid angioplasty with stenting was conducted within the stenosed internal carotid artery. One month after the TYE procedure and carotid stenting, the patient’s visual acuity improved to 0.06 and the arteriovenous transit time was within normal limits on fluorescein angiography. Conclusions: The visual prognosis in eyes with CRAO plus an associated choroidal circulatory disturbance is extremely poor. However, we experienced and reported a case of CRAO with OIS treated successfully through a prompt TYE procedure and carotid angioplasty with stenting. J Korean Ophthalmol Soc 2014;55(8):1242-1247

Nationwide Incidence of Clinically Diagnosed Central Retinal Artery Occlusion in Korea, 2008 to 2011

To define the incidence and demographics of clinically diagnosed central retinal artery occlusion (CRAO) in Korea. Nationwide population-based retrospective study using data entered into the Korean national health claims database from 2007 to 2011. Data of the entire Korean population (N = 47,990,761, based on the 2010 census) were analyzed. We used the national health claims database to identify patients diagnosed with CRAO. Incident cases were those with no claims related to CRAO in 2007 and were included once on the earliest claims related to CRAO in the years 2008 to 2011. Incident cases had a disease-free period before diagnosis of at least 1 to 4 years. The average incidence rate of CRAO was estimated according to the entire Korean population. The person-time incidence rates of clinically diagnosed CRAO in Korea, including the age- and sex-specific incidence rates, were estimated. A total of 3464 CRAO cases (59.1% men) were identified. The incidence rate of clinically diagnosed CRAO during the study period was 1.80 per 100,000 person-years (95% confidence interval [CI], 1.74-1.86). The incidence rate among men and women was 2.15 (95% CI, 2.05-2.24) and 1.47 (95% CI, 1.39-1.54) per 100,000 person-years (male-to-female ratio, 1.47), respectively. The age-specific male-to-female ratios were constant between the ages of 30 and 89 years (range, 1.51-2.10 years). The highest incidence of 10.08 (95% CI, 8.80-11.35) per 100,000 person-years was observed in those aged 80 to 84 years (14.65 [95% CI, 11.90-17.40] and 8.00 [95% CI, 6.63-9.37] per 100,000 person-years for men and women aged 80-84 years, respectively). The incidence rate of CRAO increased exponentially with age until the 9th decade of life. To our knowledge, this is the first nationwide epidemiologic study of CRAO in individuals of all ages. The incidence rate of CRAO in Korea increased exponentially with increasing age and was highest among those aged 80 to 84 years. Moreover, the incidence rate in men was 1.47 times higher than that in women.

Sudden Unilateral Visual Loss and Ptosis after Autologous Fat Injection and Simultaneous Bont/A Treatment

Central retinal artery occlusion (CRAO) following cosmetic surgery seems to be rare and disastrous disease inducing sudden visual loss. Even if tough treatment is prescribed initially, the prognosis of visual recovery is more regretable. In this paper, we report one case of CRAO combined with ptosis resulting from simultaneous autologous fat injection and BoNT/A treatment in theglabellar area for cosmetic problems. We confirmed CRAO by fluorescein angiography. There are many possible causes of visual loss following cosmetic surgery; however, the commonest form is autologous fat injection up to now. To our knowledge, there have been little reports of CRAO combined with ptosis in autologous fat injection procedures. These facts must be kept in mind by all cosmetic plastic surgeons and ophthalmologists of the importance of careful measures and immediate treatment of iatrogenically induced ocular complications.

Aspects évolutifs de la rétine en coupe OCT spectral domain lors des oblitérations artérielles rétiniennes

Retinal artery occlusions are a straightforward, essentially clinical diagnosis. The role of spectral domain ocular coherence tomography (SD-OCT) in this condition is not well described. Anoxic retinal edema develops in the acute phase of retinal artery occlusion (RAO) followed by a regressive phase giving way to retinal atrophy. The purpose of the study was to determine dynamics of theses retinal changes in central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO) using spectral domain optical coherence tomography (SD-OCT). A prospective study of patients hospitalized at Hôpital Edouard-Herriot de Lyon between June and September 2009 was performed after patient education and informed consent. Retinal thickness of patients with central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or cilio-retinal artery occlusion was measured centered on the macula or on the site of occlusion with spectral domain optical coherence tomography (SD-OCT) using Cirrus(®) (Carl Zeiss Meditec, Germany) upon admission, throughout hospitalization, at 1 month and at 3 months. Thickness and reflectivity of the various retinal layers were compared with the fellow eye. Fourteen patients were included (seven CRAO, six BRAO and one cilio-retinal artery occlusion). SD-OCT in the acute phase showed retinal thickening and increased reflectivity confined to the inner retinal layers supplied by the retinal circulation with decreased reflectivity from the photoreceptor and retinal pigment epithelial layers secondary to a shadowing effect in the affected area. These changes subsequently resolved at 1 month and gave way to a marked thinning of the inner retinal layers by 3 months. In one case of CRAO associated with an ophthalmic artery occlusion and consequent occlusion of the ciliary circulation as well, initial OCT revealed complete retinal thickening involving both the inner and outer layers. This study demonstrates that the anoxic intracellular edema resulting from retinal artery occlusions (RAO) observed histologically appears on OCT as a thickening of the inner retinal layers in the acute stage of the condition, giving way to atrophic areas starting at approximately 1 month ("pseudonormalization") and becoming clearly atrophic at 3 months. SD-OCT is useful in the diagnosis of RAO, especially if the patient is seen later in the disease process, when the ischemic retinal whitening is no longer present on fundus exam.

Acute Central Retinal Artery Occlusion Treated with Intravenous Recombinant Tissue Plasminogen Activator

Central retinal artery occlusion (CRAO) causes ischemic stroke of the eye. We report a case of CRAO that was successfully treated with intravenous recombinant tissue plasminogen activator (rt-PA) and review the current literature. A 64-year-old right-handed man presented to the emergency department with acute left eye amaurosis. An ophthalmologic assessment revealed a left afferent pupillary defect, minimal visual acuity, macular edema with a cherry red spot, and multiple emboli in the inferotemporal arcade of the left eye. A neurologic examination was otherwise nonfocal; neuroimaging was normal. Acute CRAO was diagnosed, and rt-PA was administered intravenously 185 minutes after symptom onset. A repeat examination 4.5 hours after treatment found improved vision, reduced macular edema, and no emboli. An ophthalmologic evaluation 10 days later found a visual acuity of 20/200 in the left eye and bilateral arterial sclerosis without evidence of retinal emboli or macular edema. This case illustrates that intravenous rt-PA may be an effective therapeutic option for CRAO in select patients. Given the current literature and the recommended established safety window for thrombolytics in acute ischemic cerebral stroke, it is reasonable to administer intravenous treatment for CRAO within 4.5 hours after symptom onset. Nevertheless, it is critical that a prospective clinical trial confirm the efficacy, safety, and time window for treatment.

Thrombophilia and retinal vascular occlusion

PurposeThe purpose of this research was to assess associations of thrombophilia with central retinal vein occlusion (CRVO), central retinal artery occlusion (CRAO), and amaurosis fugax (AF); to evaluate outcomes of normalizing high homocysteine; and to study CRVO, CRAO, and AF developing in estrogens/estrogen agonists in women subsequently shown to have thrombophilia.MethodsMeasures of thrombophilia–hypofibrinolysis were obtained in 132 CRVO cases, 15 CRAO cases, and 17 AF cases. Cases were compared to 105 healthy control subjects who did not differ by race or sex and were free of any ophthalmologic disorders. All cardiovascular disease (CVD) risk factors were compared to healthy general populations.Main outcome measuresThe main outcome measure of this study was thrombophilia.ResultsCRVO cases were more likely than controls to have high homocysteine (odds ratio [OR] 8.64, 95% confidence intervals [CI]: 1.96–38), high anticardiolipin immunoglobulin M (IgM; OR 6.26, 95% CI: 1.4–28.2), and high Factor VIII (OR 2.47, 95% CI: 1.31–7.9). CRAO-AF cases were more likely than controls to have high homocysteine (OR 14, 95% CI: 2.7–71.6) or the lupus anticoagulant (OR 4.1, 95% CI: 1.3–13.2). In four of 77 women with CRVO (two found to have high homocysteine, two with inherited high Factor XI), CRVO occurred after starting estrogen–progestins, estrogen–testosterone, or estrogen agonists. In one of eight women with CRAO found to have high anticardiolipin antibody IgG, CRAO occurred after starting conjugated estrogens, and AF occurred after starting conjugated estrogens in one of eleven women with AF (inherited protein S deficiency). Therapy for medians of 21 months (CRVO) and 6 months (CRAO-AF) was 5 mg folic acid, 100 mg B6, and 2000 mcg/day B12 normalized homocysteine in 13 of 16 (81%) CRVO cases and all five CRAO-AF cases with pretreatment hyperhomocysteinemia. The CRVO cases had an excess of hypertension; CRAO-AF cases had an excess of type 2 diabetes and hypertension.ConclusionTreatable thrombophilia, hyperhomocysteinemia in particular, is more common in RVO cases than in normal controls. RVO occurs after estrogens or estrogen agonists were administered in women subsequently shown to have thrombophilia.