Central retinal artery occlusion and central retinal vein occlusion in contralateral eye / Oclusão da artéria central da retina com oclusão da veia central em olho contralateral

ABSTRACT The case of a 55-year-old male who presented central retinal vein occlusion with marked macular ischemia in left eye is reported. Despite the intervention with sustained-release dexamethasone polymer injection and other clinical measures, the visual acuity was severely reduced in left eye. After 8 months, he returned to the emergency with acute visual loss of 2 hours of progression in right eye due to a central retinal artery occlusion, sparing only the territory of the cilioretinal artery. Patient underwent clinical maneuvers with anterior chamber paracentesis and intravenous injection of tissue plasminogen activator. Fluorescein angiography immediately after the procedures showed recanalization, but despite arterial vasodilation, no complete recanalization was observed after 24 hours. The patient developed retinal atrophy.

RESUMO Apresenta-se o caso de um paciente do sexo masculino, de 55 anos, com oclusão de veia central retiniana com acentuada isquemia macular em olho esquerdo. Apesar da intervenção com injeção de polímero de liberação lenta de dexametasona e outras medidas clínicas tomadas, ele evoluiu com severa baixa da acuidade visual em olho esquerdo. Após 8 meses, retornou à emergência com perda visual aguda de 2 horas de evolução em olho direito devido à oclusão de artéria central retiniana, poupando apenas o território da artéria ciliorretiniana. O paciente foi submetido a manobras clínicas, com paracentese de câmara anterior e injeção endovenosa de ativador do plasminogênio tecidual. A angiografia fluoresceínica imediatamente após as manobras mostrou recanalização, porém, a despeito do vasodilatador arterial, não foi observada completa recanalização com 24 horas. O paciente evoluiu com atrofia retiniana.

Trombolisis intrarterial en la oclusión de la arteria central de la retina / Intra-arterial thrombolysis in central retinal artery occlusion

La oclusión de la arteria central de la retina es considerada una urgencia oftalmológica con mal pronóstico visual, a pesar de los métodos convencionales de tratamiento. Los recientes avances en neurorradiología permiten realizar un cateterismo selectivo en la arteria oftálmica e inyectar un agente fibrinolítico cerca del lugar de la obstrucción. Esta intervención podría ser efectiva en ciertos tipos de oclusiones y se han obtenido resultados prometedores en pacientes con oclusiones de la arteria central de la retina. Se realizaron búsquedas en diferentes publicaciones relacionadas con la especialidad en los últimos 10 años en bases de datos de revistas líderes de Oftalmología, con el objetivo de mostrar la trombolisis intrarterial como opción de tratamiento para la oclusión de la arteria central de la retina. La baja incidencia de esta enfermedad, además de que los pacientes acuden a consulta con frecuencia fuera del periodo de ventana, son justificantes por las que no se recogen respuestas definitivas, lo que se suma a la heterogenicidad de tratamiento coadyuvante empleado en los diferentes centros y al uso de fibrinolíticos y de dosis variados. Se requieren ensayos clínicos aleatorizados que permitan determinar su superioridad frente a las medidas convencionales, el grado de beneficio en contraposición al riesgo de eventos adversos y el tipo de pacientes que son candidatos a esta medida terapéutica que se avecina de manera prometedora para mejorar el pronóstico visual de estos pacientes(AU)

The occlusion of the retina central artery is considered an ophthalmological emergency with poor visual prognosis, despite conventional treatment methods. Recent advances in neuroradiology allow a selective catheterization in the ophthalmic artery and inject a fibrinolytic agent near the site of the obstruction. This intervention could be effective in certain types of occlusions and promising results have been obtained in patients with Central Retina Artery occlusions. We searched different publications related to the specialty, using the database of leading journals of ophthalmology, in the last 10 years; with the objective of showing intra-arterial thrombolysis as an option of treatment for the Retinal Central Artery Occlusion. The low incidence of this disease, together with the fact that patients frequently visit outside the window period, are justifying why no definitive answers are collected, which adds to the heterogeneity of coadjutant treatment used in the different centers, controversial window period and use of fibrinolytics and varied doses. Randomized clinical trials are required to determine its superiority to conventional measures, the degree of benefit as opposed to the risk of adverse events and the type of patients that are candidates for this therapeutic approach that is promising to improve the visual prognosis of these patients(AU)

Tratamiento con Trombolisis Selectiva de la Arteria Oftálmica en un caso de oclusión de la arteria central de la retina (OACR). Reporte de un caso / Selective Thrombolysis Treatment of Ophthalmic Artery in a central retinal artery occlusion case. Case report

Objetivo: Presentar a través de un caso la utilidad de la trombolisis intraarterial local usada dentro de las primeras horas del evento en un paciente que ha presentado oclusión de la arteria central de la retina (OACR). Método: Reporte de caso en el manejo de un paciente con OACR. Resultados: Se reporta el manejo con trombolisis selectiva de la arteria oftálmica en un paciente con OACR de 16 horas de evolución en el OD. Se presentó a urgencias con disminución de la agudeza visual de 20/CD en el OD; se realizaron exámenes clínicos y paraclínicos incluyendo angiografía retinal y exámenes neurológicos. 16 horas después del evento se realizó el procedimiento y se realiza una nueva angiografía a las 48 horas que muestra una resolución completa de la oclusión y una mejoría de la AV a 20/50. Conclusiones: La trombolisis intraarterial local puede ser una alternativa exitosa para reperfundir la circulación retinal en casos de OACR. No existe hasta ahora un protocolo definido para este procedimiento, pero debe ser tenido como una alternativa terapéutica.

Objective: To describe the usefulness of local intraarterial thrombolysis used within the first hours of the event in a patient who presented with central retinal artery occlusion (CRAO). Method: Case report. Results: Therapy with selective thrombolysis of the ophthalmic artery in a patient with CRAO and 16 hours of evolution in the OD is reported. The patient was seen in the emergency room with decreased visual acuity of 20 / CD in the OD; clinical and laboratory examinations were performed including retinal angiography and neurological examinations. 16 hours after the event, the procedure was performed and a new angiography 48 hours later showed complete resolution of the arterial occlusion and improvement in the VA to 20/50. Conclusions: Selective intraarterial thrombolysis can be a successful procedure in cases of CRAO. A protocol should be defined for this procedure, which must be considered as a therapeutic alternative.

Oclusión de la arteria central de la retina posterior a embolización de malformación arterio - venosa facial. Reporte de caso / Central retinal artery occlusion after embolization of arteriovenous malformation. Case report

Objetivo: Describir el caso clínico de una paciente con oclusión de la arteria central de la retina (OACR) bilateral posterior a la embolización de una malformación arterio ­ venosa facial congénita y revisar la literatura sobre el tema. Diseño del estudio: Reporte de caso. Metodología: Se reportó el caso de una paciente con oclusión de arteria central de la retina bilateral que consulta a la clínica Unidad Láser del Atlántico, Barranquilla ­ Colombia en agosto de 2013, se hizo revisión detallada de la historia clínica y se tomaron fotos a color y angiografía fluoresceïnica de la retina. Resultados: La paciente consulta por presentar pérdida de la visión en ambos ojos posterior a una terapia endovascular con embolesferas realizada como tratamiento para una malformación arterio - venosa localizada en la punta de la nariz desde la infancia. La angiografía fluoresceinica de la retina evidencia: 1. Oclusión de la arteria central de la retina bilateral. 2 Persistencia de perfusión en rama superior de bifurcación de arteria temporal inferior ojo derecho 3. Variante anatómica de arteria cilioretiniana ojo izquierdo. Conclusión: La mayoría de las obstrucciones de las arterias centrales de la retina resultan en pérdida severa y permanente de la visión, es por tal motivo que teniendo en cuenta las potenciales complicaciones de origen embólico de los procedimientos intervencionistas, los pacientes necesitan ser conscientes del riesgo que este tratamiento puede implicar. Oftalmólogos, radiólogos y demás personal a cargo de este tipo de procedimientos deben tener un alto índice de sospecha diagnóstica de una OACR ante una disminución repentina de la visión durante o inmediatamente después de este tipo de procedimientos intervencionistas. De igual manera se resalta la necesidad de la evaluación cuidadosa de angiografías para la detección de cualquier vaso colateral anormal antes de la embolización.

Objective: To describe the clinical case of a female patient with central retinal artery occlusion (CRAO) after an embolization procedure as a primary treatment for a congenital nasal vascular lesion, its evolutions and sequela and review the current literature about this subject. Study Design: Case report. Methods: We reported the case of a patient with central retinal artery occlusion, who presented at Clinica Unidad Laser del Atlantico on august 2013. Her medical record was reviewed and analyzed. Posterior segment photographs and fluorescein angiography were taken. Results: The patient was seen for visual loss of both eyes after endovascular therapy for a congenital malformation located at the tip of her nose, which was presented from birth. The fluorescein angiographic showed a central retinal artery occlusion in both eyes. Conclusion: Most of the obstruction of the central retinal arteries result in severe and permanent loss of vision, for that reason and considering account potential embolic complications of interventional procedures, patients need to be aware of the risk that this treatment it may involve. Ophthalmologists, radiologists and other healthcare physicians should have a high index of suspicion of CRAO after a sudden decrease of visual acuity during or immediately after the interventional procedures. Careful evaluation of angiography to detect any abnormal collateral vessel before embolization is recommended.

Cilioretinal artery occlusion following intranasal cocaine insufflations.

Cocaine is used to produce a euphoric effect by abusers, who may be unaware of the devastating systemic and ocular side effects of this drug. We describe the first known case of cilioretinal artery occlusion after intranasal cocaine abuse.

Hemi-central retinal artery occlusion in young adults.

Amongst the clinical presentations of retinal artery occlusion, hemi-central retinal artery occlusion (Hemi-CRAO) is rarely described. This case series of four adults aged between 22 and 36 years attempts to describe the clinical profile, etiology and management of Hemi-CRAO. Case 1 had an artificial mitral valve implant. Polycythemia and malignant hypertension were noted in Case 2. The third patient had Leiden mutation while the fourth patient had Eisenmenger’s syndrome. Clinical examination and fundus fluorescein angiography revealed a bifurcated central retinal artery at emergence from the optic nerve head, in all cases. Color Doppler examination of the central retinal artery confirmed branching of the artery behind the lamina cribrosa. It is hypothesized that bifurcation of central retinal artery behind the lamina cribrosa may predispose these hemi-trunks to develop an acute occlusion if associated with underlying risk factors. The prognosis depends upon arterial recanalisation and etiology of the thromboembolic event.

Idiopathic pediatric retinal artery occlusion.

We report a case of branch retinal artery occlusion (BRAO) in a healthy young girl. An eight-year-old girl presented with sudden loss of vision in her left eye. She had a pale retina with macular edema consistent with extensive BRAO. A thorough workup was performed to determine any etiologic factor. All test results were within normal limits. Her visual acuity improved from finger counting to 20/40 over two weeks, on immediate treatment with intravenous steroids (methyl prednisolone). This case suggests that BRAO can occur in healthy children without any detectable systemic or ocular disorders and a dramatic improvement may be achieved with prompt treatment with intravenous steroids.

Obstrucción de arteria central de la retina: casos clínicos y controversias respecto a su manejo / Central retinal artery occlusion: clinical cases

Se presentan 3 casos clínicos de obstrucción de arteria central de la retina del ojo izquierdo: Una paciente con patología cardiovascular concomitante, sin posibilidad de fibrinolisis selectiva, con antecedentes de amaurosis fugax y secuelas neurológicas por episodios previos de tromboembolismo a territorio superior no detectados, y 2 pacientes que consultaron tardíamente en los cuales no se efectuó ningún tratamiento, sólo búsqueda del origen del cuadro ocular, en forma ambulatoria. Se discute acerca del tratamiento actual de las obstrucciones arteriales retinales agudas y la controversia referente a los ensayos clínicos en curso.

We present three clinical cases about central retinal artery occlusion all in the left eye: A female patient with concomitant cardiovascular disease, without chance selective fibrinolysis, who suffered amaurosis fugax and neurologic consequences from undetectable previous events of thromboembolism upward central nervous system, and two male patients with late consultation which no treatment was applied, only seeking origin of the ocular disease, by n outpatient basis. We discuss about current treatment of acute central retinal artery occlusion and controversy referring to ongoing clinical trials.

[Retinal artery occlusion as part of susac's syndrome]

We report a single case of Susac's syndrome wich is a microangiopathy of the brain, retina and cochlea. A 45 years old women developed central retinal artery occlusion in the left eye, associated with bilateral hearing loss that mostly involved low and middle frequencies. MRI of the brain revealed numerous under-cortical, paraventricular and callous lesions. The treatment consisted of anticoagulation and antiplatelet drugs

Obstrucción de rama macular de arteria central de la retina / Occlusion of the macular branch of the central retinal artery

We report a 54 years old female on oral anticoagulant treatment with a mitral valve disease, with a history of two transient ischemic attacks and a decreased visual acuity. She was assessed by an ophthalmologist and signs of retinal vascular disease were found. During follow up, the patient experienced an acute unilateral loss of vision in the left eye. Fundoscopy revealed an obstruction of a macular branch of central retinal artery. Aspirin was added to oral anticoagulants and one month later, the patient experienced an upper gastrointestinal bleeding. After four months of follow up, there is no recovery of left eye vision

Oclusiones arteriales de la retina. Enfoque clínico y seguimiento / Arterial occlusions of the retina. Clinical approach and follow-up

Occlusion of the central retinal artery or from one of its branches is most commonly caused by atherosclerosis or emboli. Central retinal vein occlusions are observed usually in the elderly and as a frequent cause of visual loss, and clinicians should determine firts whether the conditions is due to hypertension, diabetes or atherosclerosis. The aim of this report is to inform to general physcians clear and updated concepts about this disorder, in orden to receive information refered to prevention, diagnosis and treatment of the disease

Oclusäo de artéria central da retina secundária a um bloqueio anestésico loco-regional para rinoplastia / Central retina artery occlusion secondary to a loco-regional anesthetic block for rhinoplasty

Os autores descrevem o caso clínico de um paciente que apresentou um acidente vascular oclusivo da artéria central da retina durante uma injeçäo anestésica trans-nasal com Lidocaína a 2//para uma intervençäo corretiva do osso nasal. Apesar do tempo transcorrido entre o momento da oclusäo arterial e a consulta de urgência, iniciamos um tratamento com oxigênio hiperbárico a 2 atm., corticoterapia sistêmica e terapêutica vasodilatadora, com resultado desencorajante. Discutimos as possíveis teorias etiológicas desta rara complicaçäo