Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion.

BACKGROUND: Central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO) may be a result of platelet-fibrin emboli, cholesterol plaques, or calcific emboli that typically lodge at the bifurcation of retinal arterioles or at a location as the vessel narrows. Hollenhorst plaques (cholesterol emboli) can often be seen at the site of vessel obstruction. Obstruction of blood flow results in partial or complete retinal ischemia and sudden loss of vision. There is no effective therapy for CRAO and BRAO. The authors employed the Nd:YAG laser to photodisrupt emboli within the central retinal artery (CRA) and branch retinal arteries (BRA) to achieve rapid reperfusion of the retina. METHODS: Translumenal Nd:YAG embolysis (TYL) or embolectomy (TYE) was performed on 19 patients with sight-threatening CRAO or BRAO. All patients had a visible embolus within the CRA or BRA. A fundus contact lens was used to focus the Nd:YAG laser on the embolus within the retinal arteriole. Laser applications were delivered directly to the embolus with increasing energy until the embolus was either fragmented within the lumen (embolysis) or was observed to pass into the vitreous through a small opening in the arteriole (embolectomy). RESULTS: TYL/E was achieved in all 19 patients. In 8 patients the emboli was fragmented (embolysis) and in 11 the embolus was transplaced into the vitreous (embolectomy). Reperfusion of the retina was observed in all patients as determined by fundus examination, fundus photography, and fluorescein angiography. Snellen visual acuity improved by an average of 4.7 lines (range, 1-11 lines) in 17/19 (89%) patients. Eleven of the patients (58%) gained greater than 4 lines. One patient had no improvement and another lost one line due to a persistent vitreous hemorrhage. Vitreous hemorrhage (VH) occurred in seven patients, and subhyaloid hemorrhage (SH) occurred in one patient. In five of the patients an early vitrectomy was performed to allow clinical assessment and documentation of the successful TYL/E. CONCLUSION: Photodisruption of an embolus within an occluded CRA or BRA can be achieved via TYL/E. Rapid reperfusion of the retina is associated with anatomic and visual acuity improvement. Translumenal Nd:YAG embolysis or embolectomy of a visible embolus in patients with CRAO or BRAO can be achieved resulting in restoration of retinal blood flow and improved visual function.

Radial optic neurotomy for central retinal vein occlusion: 117 consecutive cases.

PURPOSE: Venous occlusive disease is the second leading cause of permanent retinal vascular blindness. The anatomy of the optic disk including the cribriform plate and scleral ring may contribute to the development of retinal vasoocclusive diseases. Neurovascular compression within the confined space at this location (scleral outlet) may play a pathoetiologic role in central retinal vein occlusion (CRVO). We developed a surgical procedure (radial optic neurotomy [RON]) to open this space and relieve pressure on the central retinal vein. METHODS: Pars plana vitrectomy with RON was performed on 117 consecutive patients with CRVO and severe loss of vision (defined as 20/200 or worse). Patients were observed with serial fundus photography, fluorescein angiography, determination of Snellen visual acuity, and biomicroscopy for anterior segment neovascularization. RESULTS: There were no serious complications noted with this procedure. Anatomical and clinical improvement as determined by fundus examination, fundus photography, and fluorescein angiography was found in 95% of patients. Snellen visual acuity improved by an average of 2.5 lines (range, 1-12 lines) in 71% of patients. Two or more lines were gained in 53% of patients, and > or = 4 lines were gained in 25%. Anterior segment neovascularization was found in 6% of patients with CRVO. CONCLUSIONS: Surgical decompression of CRVO via RON is a technically feasible and safe procedure that was associated with anatomical resolution of CRVO in 95% patients and improved visual function in 71%.

Radial optic neurotomy with adjunctive intraocular triamcinolone for central retinal vein occlusion: 63 consecutive cases.

PURPOSE: Central retinal vein occlusion (CRVO) is a leading cause of permanent retinal vascular blindness. In a previous communication the authors reported the results of radial optic neurotomy (RON) in 117 consecutive patients with severe CRVO. Persistent cystoid macular edema (CME) and macular pigmentation (MP) were observed and correlated with worse macular function. Intraocular triamcinolone (IOK) has been used to treat patients with CME and CRVO. The authors performed RON with simultaneous, adjunctive IOK (RON/IOK) in patients with CRVO to ascertain any anatomic or visual benefit of this combined approach. METHODS: Pars plana vitrectomy and RON were performed on a case-by-case basis on 63 consecutive patients with CRVO and visual acuity of 20/200 or worse. At the end of the case, 4 mg of triamcinolone was injected into the vitreous cavity (RON/IOK). Patients were observed with serial fundus photographs, fluorescein angiography (FA), Snellen visual acuity (VA), intraocular pressures (IOP), and biomicroscopy for anterior segment neovascularization (ANV). Anatomic and visual outcomes were compared to a previous series of 117 patients with severe CRVO undergoing RON alone. RESULTS: Clinical improvement as determined by fundus examination, photography, and FA was noted in 93% of patients following RON/IOK. Snellen VA improved by an average of three lines (range one to seven) in 68% of all patients. Two or more lines were gained in 44% of patients and four or more lines were gained in 20% of patients. ANV developed in 7% of patients following RON/IOK. Persistent CME and MP were noted in 17% and 28% of patients, respectively. These outcomes were similar to patients undergoing RON alone without IOK. Elevated IOP was noted in 25% of patients and one patient developed endophthalmitis following RON/IOK. CONCLUSIONS: Surgical decompression of CRVO via RON/IOK is a technically feasible procedure. Clinical resolution of the CRVO and improved visual function noted in RON/IOK paralleled outcomes following RON alone. RON/IOK was associated with a higher incidence of elevated IOP and endophthalmitis.