Central Retinal Artery Obstruction Research Articles

Retinal vessel analysis in vascular occlusions of the eye

Aims/Purpose: This cohort study investigates how the static and dynamic vessel parameters differ in patients with vascular occlusions and if there are any variations between the different types of vessel occlusion.Methods: Patients with the diagnosis of branch retinal artery obstruction BRAO, central retinal artery obstruction CRAO, branch retinal vein obstruction BRVO, central retinal vein obstruction CRVO, anterior ischaemic optic neuropathy AION and any combination of these Combo were included in our study. During their inpatient stay for cardiovascular diagnostics all patients were examined via static and dynamic vessel analysis (IMEDOS Health GmbH, Jena) to obtain the arteriovenous ratio (AVR), the central retinal artery equivalent (CRAE), the central retinal vein equivalent (CRVE) and the flicker light induced dilation of the retinal arteries (FLA) and veins (FLV). The vessel density was determined via OCT angiography (Heidelberg Engineering GmbH, Heidelberg).Results: 34 patients (70% male; 30% female; mean age 69.6 ± 11.3 years) with 9 (26.5%) CRVO, 8 (23.5%) AION, 5 (14.7%) BRAO and 4 (11.8%) CRAO, BRVO and Combo each have been included. The best visual acuity (BCVA) of the diseased eye differed significantly between the groups (AION 0.41 ± 0.61, CRAO 2.40 ± 0.20, BRAO 0.16 ± 0.05, CRVO 0.81 ± 0.86, BRVO 0.18 ± 0.10, Combo 1.53 ± 0.68; p < 0.001) whereas the BCVA of the healthy eyes were comparable. The CRVE showed a significant difference between the groups CRAO – CRVO (p = 0.008), CRAO – Combo (p < 0.001) and BRAO–Combo (p = 0.026). The FLV of the diseased eye was significantly higher in patients with AION than in the CRAO group (p = 0.049). The parameters of the static vessel analysis of the healthy eyes were comparable.Conclusions: Preliminary analysis shows significant differences of individual parameters of the retinal vessel analysis between different types of vascular occlusion. The diagnostic and research benefit for the individual patient remains to be further evaluated.

Current status and development direction of hyperbaric medicine in Korea

Background: The indications of hyperbaric oxygen therapy (HBOT) covered by the health insurance in Korea increased to 16 in 2019, which includes acute central retinal artery obstruction within 24 hours of vision loss; anemia due to excessive bleeding, since blood transfusion is impractical; chronic refractory osteomyelitis (Wagner grade ≥3); and intracranial abscess.Current Concepts: HBOT affects the treatment in the primary and secondary mechanisms. According to the Boyle’s law, the primary mechanism is important in treating decompression sickness and intravascular air embolism by decreasing the volume of air bubbles when pressure increases, whereas the secondary mechanism involves hyperoxygenation of the primary mechanism and various effects, such as vasoconstriction, angiogenesis, immune function enhancement, reperfusion injury prevention, antimicrobial action, and gas washout effect, occur. In the past 5 years, domestic HBOT has made significant progress. However, there are many non-therapeutic lowpressure HBOT facilities that are limited by insurance coverage issues, quality equipment management, and medical personnel in HBOT facilities.Discussion and Conclusion: To solve the problem, the introduction of the definition of therapeutic hyperbaric pressure and certification system of HBOT facilities must be initiated. Moreover, the system should be improved so that insurance can be applied for a more indication of HBOT.

Combined Central Retinal Vein Occlusion and Central Retinal Arterial Obstruction with Cilioretinal Artery Sparing

Combined Central Retinal Vein Occlusion and Central Retinal Arterial Obstruction with Cilioretinal Artery Sparing

Hyperbaric Oxygen Therapy to Avoid Blindness From Filler Injection.

The most serious complication of filler or fat injection is blindness. According to a recent systematic review of 98 patients of blindness provoked by filler or fat injection, only 2 patients had the outcome of a complete recovery of vision.In the literature, only 2 papers were found in which hyperbaric oxygen therapy (HBOT) was used in ophthalmic artery obstruction. However, no improvement of vision was obtained in either patient. Recently, the authors treated a patient who had central retinal vein occlusion and cilioretinal artery occlusion with HBOT (daily 2-hour sessions at 253 kPa for 14 days), and his visual acuity returned to normal.In central retinal artery obstruction, if the cilioretinal artery is present, it will maintain the thickness of the retina to a variable extent. Though the size of the cilioretinal artery and the area it supplies varies, 36.2% (32.1-40.2%) of people have a cilioretinal artery.Thereafter, HBOT might be applied to patients with central retinal artery occlusion following filler injection.

English

Central retinal artery occlusion following blunt trauma a 19-year-old patient presented with complaints of severe loss of vision in the right eye following a high pressure compressor gas injury of 1 day duration. External ocular examination revealed ecchymosis in the right eye and relative afferent pupillary defect. Fundus examination showed whiteout retina and a cherry red spot at the macula in the right. A clinical diagnosis of right central retinal arterial obstruction (CRAO) was made. CRAO in young is a rare disease usually found in patients with cardiac embolic diseases, coagulopathies or systemic vascular inflammations and rarely following trauma. Despite active intervention the visual loss persisted. Hence the case report. INTRODUCTION: A 19 year old male presented with history of trauma to the right eye at his work place with a high pressure gas compressor at his work place of 1 day duration. He complained of sudden loss of vision in the right eye. He also complained of redness, watering and pain on eye movements. He did not complain of flashes of light or floaters in the affected eye. There was no history of headache, vomiting, loss of consciousness or nasal bleed. On examination the visual acuity in the right eye was perception of light. Projection of rays was absent in the superior and inferior quadrants and visual acuity in the left eye was 6/6. Examination of the right eye showed ecchymosis in the lids, sub conjunctival hemorrhage, congestion. (Fig. 1) There was a conjunctival laceration from 9-1 clock hours (Fig. 2) with a relative afferent pupillary defect (Grade 3). Fundus examination of the right eye – Media was clear. Disc appeared hyperemic; margins were well defined with a flame shaped hemorrhage at the disc. There was arteriolar attenuation and venous dilatation. Pale whitish edematous retinal area noted in all quadrants with significant edema concentrated over posterior pole. Small area of normal retina noted in nasal and temporal aspect of disc. Vascularity around the macula was obscured and a cherry red spot was seen at the macula (Fig. 3). The intraocular pressure by applanation tonometry was 24mmHg in the right eye and 14 nn Hg in the left eye. The examination of the anterior and posterior segments of the left eye was within normal limits. A diagnosis of traumatic central retinal occlusion was made. Routine blood investigations and coagulation profile was done which was normal. CT orbit showed extensive areas of air pockets in extraconal and intraconal area along with extension into the optic canal and suprasellar areas. (Fig. 4) (Fig. 5). Treatment was initiated with ocular massaging, paracentesis, vasodilators-nitrates, topical antibiotic-NSAID combination, topical timolol malleate BD and oral acetazolamide 500mg BD. Oral steroids were started 1mg/Kg per body weight. Vision improved to hand movements on the first day after treatment. 4 weeks later the vision improved to counting fingers close to face and 4/60 in the temporal quadrant. Rapd remained in the right eye, the fundus showed a paler disc with retinal whitening and a cherry red spot at the macula. DOI: 10.14260/jemds/2014/3954

Proposed Mechanism for Central Retinal Artery Occlusion Following Neurointervention Other Than Thromboembolism: Iodine Contrast

Objective: Nonionic contrast media to lower osmolality are widely used in most cerebral angiography. But, there is no ideal contrast media near to blood which has similar viscosity and osmolality. The authors proposed mechanism by contrast media itself as the possible cause of rare central retinal artery occlusion. Material and Methods: The first case is the 47-year-old female complained decreased visual acuity immediately after transfemoral cerebral angiography (TFCA). Diffusion magnetic resonance (MR) showed no evidence of intracranial lesion. Some branches of central retinal artery (CRA) were obstructed and retinal edema was found on fluorescence fundus photography. The second case is about the 67-year-old male who developed the central retinal artery obstruction (CRAO) 1hour after coil embolization on unruptured cerebral aneurysm. Results: The current available nonionic contrast media have various range of osmolality, in those the iopamidiol has the lowest osmolality but it is far from that of human blood. The mechanisms of CRAO the authors suggest are as follows: (1) periarterial edema from hyperosmolality and induced inflammation, (2) thrombogenic effect from higher viscosity, and (3) decreased blood flow and barrier aggravating ischemia. Conclusion: The authors suggest that angiography operating setting (e.g., tube voltage selection) should be optimized in circumstances with lower osmolar and viscous contrast media.

A Complication as a Toxic Retinopathy in a Case After Scleral-Fixed Intraocular Lens Implantation

To report a complication similar a toxic retinopathy. The eye is aphakia due to trauma. The patient is a 70-year-old man. The anesthesia was applied as topically, with subtenon enjection. Two percent sodium hyaluronate (Protectalon 2%) was used as viscoelastic and for endophthalmitis prophylaxis sefuroksim aksetil 1 mg/ 0.1 cc was given at the end of operation. The patient complained blindness. Central retinal artery obstruction, central retinal vein occlusion, peripapiller and macular hemorrhage and optic atrophy were observed in fundus examination. After 6 months, corneal haze, especially at the upper side, occurred. It is clear that, this complication is a toxic retinopathy and a result of sequence of events. After all, a case which has resulted to such a complication due a surgery has never been reported previously. J Med Cases. 2013;4(3):153-155 doi: https://doi.org/10.4021/jmc971w

A Complication as a Toxic Retinopathy in a Case After Scleral-Fixed Intraocular Lens Implantation

To report a complication similar a toxic retinopathy. The eye is aphakia due to trauma. The patient is a 70-year-old man. The anesthesia was applied as topically, with subtenon enjection. Two percent sodium hyaluronate (Protectalon 2%) was used as viscoelastic and for endophthalmitis prophylaxis sefuroksim aksetil 1 mg/ 0.1 cc was given at the end of operation. The patient complained blindness. Central retinal artery obstruction, central retinal vein occlusion, peripapiller and macular hemorrhage and optic atrophy were observed in fundus examination. After 6 months, corneal haze, especially at the upper side, occurred. It is clear that, this complication is a toxic retinopathy and a result of sequence of events. After all, a case which has resulted to such a complication due a surgery has never been reported previously. doi: http://dx.doi.org/10.4021/jmc971w

Fluorescein Angiographic Findings after Intra-arterial Chemotherapy for Retinoblastoma

To evaluate fluorescein angiography (FA) findings after intra-arterial chemotherapy (IAC) for retinoblastoma. Retrospective case series. Twenty-four eyes of 24 patients. Fifty-five IAC procedures for delivery of melphalan 5 mg and possible carboplatin 30 mg. Vascular flow of iris, retina, and choroid after IAC. All patients received melphalan 5 mg, whereas the first 6 patients also were treated with additional carboplatin 30 mg. The IAC was performed as primary treatment in 17 eyes and as secondary treatment (after systemic chemotherapy) in 7 eyes. Two patients also received external-beam radiotherapy before IAC. At presentation, FA revealed neovascularization of the iris (NVI) in 8 eyes, and after IAC, complete NVI regression was noted in 5 eyes (63%). After a mean follow-up of 13 months after IAC, FA depicted the main tumor with decreased fluorescence in 22 eyes (92%). After 55 ophthalmic artery catheterizations, retinal vascular abnormalities by FA were detected in 7 eyes (13%) and choroidal vascular abnormalities were detected in 6 eyes (11%). The retinal abnormalities included ophthalmic artery obstruction (n = 1), transient ophthalmic artery spasm (n = 1), central retinal artery obstruction (n = 1), branch retinal artery obstruction (n = 2), and peripheral retinal ischemia (n = 2). Additional retinal neovascularization was found in 1 patient. The choroidal abnormalities included sector (n = 5) or diffuse (n = 1) choroidal nonperfusion. New-onset iris neovascularization was found in 2 patients. Retinal vascular abnormalities were diagnosed after median of 1 month after the first IAC, whereas choroidal vascular abnormalities were found after median of 5 months after the first IAC. Fluorescein angiography suggests that vascular perfusion to the retina and the choroid can be compromised after IAC for retinoblastoma. The most common vascular abnormality was choroidal sector or diffuse nonperfusion.

Early Hyperbaric Oxygen Treatment for Nonarteritic Central Retinal Artery Obstruction

To compare hyperbaric oxygen treatment combined with hemodilution with hemodilution only in central retinal artery obstruction. Retrospective, nonrandomized case series. We reviewed records of all our patients diagnosed with central retinal artery obstruction between 1997 and 2010. In these patients, hyperbaric oxygen and hemodilution therapy had been administered routinely (oxygen group). Where hyperbaric oxygenation could not be performed, patients were underwent hemodilution only (control group). Patients with presenting visual acuity (VA) of up to 20/200 within 12 hours of onset were included in our analysis. Exclusion criteria included cilioretinal vessels or arteritic occlusion. The oxygen group comprised 51 patients, and the control group comprised 29 patients. Mean baseline VA was counting fingers (oxygen group) and 20/1000 (control group; P = .1). Most other potential confounders, including duration of symptoms, also did not differ significantly at baseline. In the oxygen group, mean VA improvement was 3 lines (P < .0001). This was sustained over a follow-up of 3 months (P = .01). In the control group, mean improvement was 1 line (P = .23 at discharge, P = .17 at follow-up). Differences between both groups were not significant (P = .07 at discharge, P = .26 at follow-up). The number of patients gaining 3 lines or more was 38.0% versus 17.9% at discharge (P = .06) and 35.7% versus 30.8% at follow-up (P = .76). We saw significant VA improvement after the combined treatment, but not when using hemodilution only. Confirming superiority of the combination treatment requires a randomized, prospective trial. A high number of nonresponders highlights the need to improve our understanding and treatment of hypoxia-related metabolic insults after central retinal artery obstruction.

Bilateral central retinal arterial obstruction following head trauma: A very rare case report

A 30-year-old patient presented at our outpatient department with complaints of severe loss of vision in both eyes following a head injury six days back. He also had a fracture at left side of the mandible and a few bruises over the left cheek. External ocular examination revealed subconjuctival hemorrhage in the left eye and bilateral sluggishly reacting pupils. Fundus examination showed white- out retina and a cherry red spot at the macula in both eyes. A clinical diagnosis of bilateral central retinal arterial obstruction (CRAO) was made which was later confirmed by fundus fluorescence angiography. Bilateral CRAO is a rare disease usually found in patients with cardiac embolic diseases, giant cell arteritis or systemic vascular inflammations. Our case is the second reported case in English literature of bilateral CRAO following head trauma.

Giant cell arteritis with eye involvement - color doppler imaging (cdi) of retrobulbar vessels findings

Background. Giant cell arteritis is a primary vasculitis, that affects medium-sized arteries, especially branches of the ECA. Purpose. The main objective was to assess the role of CDI of retrobulbar vessels in the study of two patients with Horton’s disease with eye involvement. Methods. We have used a sonographer with 8-15 MHz linear probe for CDI of orbital vessels. Results. Both patients presented malaise, temporal headache, tender temporal arteries and laboratory signs of inflammation. The first patient had a left central retinal artery obstruction, and the second one had a left ischaemic optic neuropathy. They presented a painless, severe loss of vision of the left eye. Temporal artery histology was positive in both cases. Ultrasound investigation was performed before corticosteroid treatment. CDI of retrobulbar vessels detected low blood velocities, especially end-diastolic velocities and high resistance index in all retrobulbar vessels, in both orbits, for both patients (especially on the affected side). Typical sonographic features in temporal arteritis were ”dark halo sign” (vessel wall thickening), associated with stenoses or occlusions of branches of ECA. Interestingly, in both cases, the CCA and the ICA were, also, affected. Conclusions. Ultrasound technique is a valuable diagnostic tool to investigate giant cell arteritis.

Central Retinal Artery Obstruction in Protein S Deficiency

Purpose: To report a case of central retinal artery obstruction (CRAO) caused by protein S deficiency. Case summary: A 36-year-old man presented with acutely reduced visual acuity in the right eye. The patient had no other diseases such as diabetes mellitus or hypertension. The visual acuity was 20/20 in the right eye and light perception in the left eye. Afferent pupillary defect was observed in theleft eye. Fundus examination showed diffuse retinal opacification and a cherry-red spot at the macula. Thus the patient was diagnosed with CRAO in the left eye. There were no abnormal findings on routine hematologic tests including blood coagulation test. Protein C activity, antithrombin III activation, anticardiolipin antibody were within normal limits but protein S activity was decreased. Thus, the patient was diagnosed with CRAO with protein S deficiency. Conclusions: Coagulation factors such as protein S need to be measuredin cases of CRAO in young patients without medical problems.

The association between dominant macular drusen and central retinal artery occlusion in young females with cardiac valve disease

To describe uncommon association between central retinal artery obstruction and dominant macular drusen in two young female patients. First patient, a 22-year-old female was presented with right central artery obstruction associated with bilateral dominant macular drusen. Systemic evaluation disclosed the presence of mitral valve regurge. Second patient, a 34-year-old female with a previous history of right central retinal artery obstruction diagnosed elsewhere. Fundus exam showed bilateral dominant macular drusen and her systemic evaluation revealed severe rheumatic valve stenosis, moderate aortic regurge with moderate to severe tricuspid regurge and she underwent mitral valve replacement. To the best of our knowledge, the association between central retinal artery obstruction and dominant macular drusen was not previously reported.

Ocular ischemic syndrome, central retinal artery obstruction, and branch retinal artery obstruction 1,2

Ocular ischemic syndrome is a condition characterized by visual loss described mainly in males 50 years and older secondary to carotid artery stenosis or occlusion. Loss of vision results from chronic ischemic changes to the anterior and posterior segments of the eye. Pain around the eye has been reported in up to 40% of the patients. Also, these patients may report difficulty adjusting to a darker environment after light exposure. Neovascularization of the iris and retina is common. Associated systemic conditions include arterial hypertension, coronary artery disease, diabetes mellitus, cerebrovascular disease and tobacco use. Digital subtraction angiography can demonstrate carotid artery obstruction in the majority of patients, however less invasive procedures such as contrast enhanced MR angiography in combination with duplex ultrasound correlates with the degree of carotid stenosis. Carotid endarterectomy in addition to management of neovascularization of iris or retina is the treatment of choice, however, the prognosis for visual recovery is still limited. Acute retinal arterial obstruction is a dramatic and usually irreversible painless loss of vision that can involve the central retinal artery or an arterial branch, most commonly secondary to cerebrovascular and cardiovascular disease. Other associated conditions include various hematological, infectious and metabolic abnormalities. In central retinal artery occlusion a common finding includes a cherry red spot in the macula. A careful evaluation of all potential sources of emboli is essential in this condition since there is a strong association with fatal outcome due to cardiovascular disease and stroke. Other etiologies such as coagulopathies, collagen vascular diseases and viral infections have been identified in patients with retinal arterial obstructions. Despite aggressive intervention the visual prognosis of central retinal artery occlusion remains poor.

Combined central retinal arterial and venous obstruction: emergency ophthalmic arterial fibrinolysis.

To investigate the role of urokinase selectively perfused into the ophthalmic artery as an emergency treatment for combined central retinal arterial obstruction (CRAO) and central retinal venous obstruction (CRVO). Over a 6-year period, 11 consecutive patients presented with recent combined CRAO and CRVO (< or =72 hours). Urokinase (300,000 IU) was selectively perfused via the femoral artery into the ophthalmic artery for 40 minutes. Evaluation criteria were Snellen visual acuity with best correction, funduscopic results, and retinal arteriovenous transit time assessed over a mean 3.5-year follow-up. Mean vision and retinal perfusion were tested by means of repeated-measures analysis of variance. The correlation between visual improvement and retinal perfusion improvement was evaluated by means of Spearman rank correlation. Substantial improvement in vision and retinal perfusion was noted in seven of the 11 patients treated. Mean vision improvement was significant (P =.009) within 24-48 hours after fibrinolysis, increased until 1 month after (P =.006), then remained stable throughout the follow-up (P >.10). Visual improvement correlated with retinal perfusion improvement during the period from before fibrinolysis to 24-48 hours after (P =.028). In all patients with improved results, retinal hemorrhages transiently increased. One patient had intravitreal hemorrhage shortly after fibrinolysis. For this uncommon clinical entity, which typically has a poor visual outcome, these results suggest that ophthalmic arterial fibrinolysis may restore retinal perfusion, which leads to rapid substantial visual improvement in many cases of combined CRAO and CRVO, without systemic complications, but it may be responsible for intravitreal hemorrhage.

RETINAL ARTERY OCCLUSIONS

In 1859, von Graefe 90 described an embolic central retinal artery obstruction in a patient with endocarditis and multiple systemic emboli. Knapp, 54 however, mentions that several years earlier Virchow had suggested that an embolus might be seen directly in a retinal artery with the ophthalmoscope. Within 5 years after von Graefe's report, Sweiger described the histopathologic correlate of central retinal artery obstruction. 30 In 1868 Mauthner suggested that spasmodic contractions could lead to retinal arterial obstruction, and in 1874 Loring implicated focal obstructive disease within the retinal vessels as a cause. 30 By the turn of the 20th century, more than two dozen reports of retinal arterial obstruction had appeared in the ophthalmic literature.

Postoperative Ischemic Optic Neuropathy

Postoperative Ischemic Optic Neuropathy

Combined central retinal artery-central vein obstruction

The cases of 23 patients with unilateral combined central retinal artery-central retinal vein obstruction are described. Criteria for the abnormality included: a history of relatively sudden visual loss; superficial retinal whitening in the posterior pole in combination with a cherry spot; and intraretinal blood, generally associated with dilated and/or tortuous retinal veins. In five instances (22%) the obstructions developed after retrobulbar injection. Among the 21 patients with followup for at least 6 months, or until the onset of neovascularization of the iris, 17 (81%) developed rubeosis iridis. Late histopathology was obtained in two eyes. Hemorrhagic necrosis of the retina was observed in some areas of the posterior pole and attenuation of the inner retinal layers, similar to that seen with late central retinal artery obstruction, was noted elsewhere. Periphlebitis of the central retinal vein within the optic nerve was found in each case.

A Prospective Study of Acute Central Retinal Artery Obstruction

We conducted a prospective study to determine the incidence of ocular neo-vascularization following acute central retinal artery obstruction. Only patients initially evaluated within 7 days of visual loss were eligible. Any patient with pre-existing ocular neovascularization or clinical evidence of the ocular ischemic syndrome noted at the initial evaluation was excluded. During the 18-month study, 33 consecutive patients were enrolled. Six patients subsequently developed neovascularization of the iris, an incidence of 18.2%. In these six patients, neovascularization of the iris appeared as early as 12 days to as late as 15 weeks following the artery obstructions. Five of the six patients (15.2% of the total) later developed neovascular glaucoma. Another patient in this series developed neovascularization of the optic disc without neovascularization of the iris, an incidence of 3.0%. Only two of the seven patients with ocular neovascularization had ipsilateral hemodynamically significant carotid artery disease as determined by noninvasive carotid artery testing. This study confirms results of previous retrospective studies that the incidence of ocular neovascularization after central retinal artery obstruction is higher than commonly thought. It also shows that, in the majority of cases, carotid artery disease is not responsible for the neovascularization seen after central retinal artery obstruction.