Central Retinal Artery Occlusion after Peribulbar Injection of Triamcinolone Acetonide in Thyroid-associated Ophthalmopathy.

Central retinal artery occlusion (CRAO) is a form of acute ocular ischemic syndrome that causes visual loss. Timely treatment is of great importance for visual recovery, but the prognosis is usually poor. By analyzing the pathogenesis, diagnosis, and treatment process of a CRAO case after peribulbar injection of triamcinolone acetonide in thyroid-associated ophthalmopathy (TAO), this study aims to investigate the association of CRAO with hemodynamics and orbital pressure, thereby providing references in safety improvement of diagnosis and treatment on TAO.

Central retinal artery occlusion after intravitreal brolucizumab injection for treatment-naïve neovascular age-related macular degeneration; a case report.

BACKGROUND: To report a case of central retinal artery occlusion (CRAO) after intravitreal injection of brolucizumab for a treatment-naïve neovascular age-related macular degeneration (nAMD) patient without comorbid cardiovascular disease history. CASE PRESENTATION: A 79-year-old Asian male without a cardiovascular disease history such as diabetes or hypertension underwent three times of monthly consecutive intravitreal brolucizumab injections for treatment of progressed nAMD in his left eye. Two days after the third injection, the patient presented with acute painless visual loss. Typical retinal whitening with a cherry red spot was observed on the fundus photograph, and retinal swelling with hyper-reflectivity was also identified on the optical coherence tomography (OCT) scan. On the fundus fluorescein angiography, arm-to-retina time and arteriovenous transit time were remarkedly delayed, but clinical findings suggesting an intraocular inflammation (IOI) were not observed. Therefore, CRAO was diagnosed, and anterior chamber paracentesis was administrated immediately. However, there had been no improvement in visual acuity during the follow-up period of three months, despite prolonged oral steroid and anti-platelet agent medication. CONCLUSIONS: In rare cases, patients without cardiovascular comorbidities can develop CRAO after intravitreal brolucizumab injection without gross evidence of IOI. Therefore, CRAO should always be in consideration and careful observation is required after intravitreal brolucizumab injection for nAMD patients with old age, even if the patient does not have any other cardiovascular disease history.

Association of Occlusive Retinal Vasculitis With Intravitreal Faricimab.

This case report describes a patient with attenuation of retinal arterioles and veins associated with 2 blot hemorrhages and pallor of the inferotemporal retina without emboli.

Superselective Arterial Hyaluronidase Thrombolysis is an Effective Treatment for Hyaluronic Acid-Induced Retinal Artery Occlusion: Study in a Rabbit Model.

BACKGROUND: There are serious complications associated with hyaluronic acid (HA) facial injections, including vision impairment due to retinal artery ischemia. In this study, we put forth a clinically relevant model of retinal ischemia and reperfusion in rabbit. We used this to verify the efficacy of hyaluronidase intra-artery thrombolysis in the treatment of hyaluronic acid-induced retinal artery occlusion. METHODS: Retinal artery ischemia was induced by injecting HA into the ophthalmic artery (OA) of adult chinchilla rabbit, and reperfusion was achieved by intra-artery thrombolysis therapy with hyaluronidase following 60 min and 4 h of occlusion. Digital subtraction angiography (DSA) and fundus fluorescein angiography (FFA) were used to evaluate blood flow in the retina. Electroretinogram (ERG), hematoxylin and eosin staining and transmission electron microscope were used to evaluate the structure and function of the retina after ischemia and reperfusion following 60 min and 4 h of occlusion. RESULTS: DSA and FFA images confirmed occlusion of the ophthalmic and central retinal arteries, as well as reperfusion after hyaluronidase thrombolysis. ERG indicated retinal dysfunction following ischemia, and thrombolysis partially rescued its impairment following 4 h of occlusion. Hematoxylin and eosin staining and TUNEL staining revealed ischemia-induced histological damages in the retina at different time windows, and hyaluronidase thrombolysis partially mitigated these damages. CONCLUSIONS: We report a method to establish a HA-induced retinal artery occlusion animal model. Hyaluronidase intra-artery thrombolysis was used to recanalize the embolized OA at different time points. Using our method, we achieved retinal reperfusion, and an improvement was observed in the visual function of rabbits after hyaluronidase thrombolysis following 4 h of occlusion. We believe that hyaluronidase intra-artery thrombolysis is an effective method to treat HA-induced retinal artery occlusion in clinic. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

LISDEXAMFETAMINE (VYVANSE) USE ASSOCIATED WITH BRANCH RETINAL ARTERY OCCLUSION.

BACKGROUND/PURPOSE: Branch retinal artery occlusions (BRAO) are primarily associated with the aging population and are rare in young adults. The etiology of BRAO includes embolic or nonembolic sources. Lisdexamfetamine has been associated with vasospastic ischemic events in multiple areas of the body. However, there are currently no reported cases of BRAO associated with lisdexamfetamine use. Here, we present a case that suggests a correlation between lisdexamfetamine use and a nonembolic BRAO in a young adult man. METHODS/RESULTS: A 32-year-old man presented with sudden left eye blurred vision 17 days after beginning lisdexamfetamine. Fundus examination confirmed the BRAO diagnosis. Following evaluation by a retina specialist, vasospasm was considered the most likely cause for the BRAO. Other possible etiologies were unlikely due to diagnostic testing. CONCLUSION: The temporal association between lisdexamfetamine and BRAO symptom onset suggests vasospastic occlusion. Lisdexamfetamine-associated adverse events should be considered as a possible etiology for BRAO.

Central retinal vein and artery occlusion associated with sildenafil: a case report and review of the literature.

BACKGROUND: Sildenafil is a selective phosphodiesterase type 5 inhibitor used for the treatment of erectile dysfunction and pulmonary hypertension. It is available over the counter in many countries. While there have been a few reports of retinal vascular occlusion following sildenafil consumption, most cases have other comorbidities as risk factors for the disease, and the exact causal role of this drug in these conditions remains unclear. CASE PRESENTATION: We present the case of a healthy 32-year-old Iranian man who developed combined central retinal vein occlusion and retinal artery occlusion following sildenafil exposure. The patient underwent a hypercoagulative state workup for possible underlying risk factors. Additionally, we conducted a literature search on PubMed using the keywords: retinal vein occlusion AND Sildenafil OR Viagra, retinal artery occlusion AND Sildenafil OR Viagra, retinal vascular occlusion AND Sildenafil OR Viagra. To obtain more objective results in the reviews, we employed an adverse drug reaction possibility algorithm. The patient was found to be otherwise healthy, and ancillary tests were unremarkable. A literature review identified seven reports of retinal vascular occlusion following sildenafil use. In most of these cases, the role of sildenafil was not clearly established. To the best of our knowledge, our case achieved the highest score based on the algorithm compared with previous reports. CONCLUSION: Sildenafil may be associated with severe retinal vascular accidents in otherwise healthy young individuals.

Retinal artery occlusion after facial filler injection in a patient with patent foramen ovale: a case report and literature review.

We describe a young woman with patent foramen ovale who developed multiple retinal artery occlusion in the right eye after injection of hyaluronic acid into the nasal root. She reported a gradual decline in visual acuity, with visual field defects that had developed in two stages. Multiple retinal artery occlusion was confirmed by slit-lamp examination, dilated fundus examination, optical coherence tomography, visual field examination, and fundus fluorescein angiography. A patent foramen ovale was detected by electrocardiography, transesophageal echocardiography, and transthoracic sonography. The patient was treated with intravenous dexamethasone and cobamamide, as well as extracorporeal counterpulsation therapy; this approach has not been described in previous literature regarding retinal artery occlusion. The patient's visual acuity improved from counting fingers at 30 cm to 20/133 within 3 days. Our report emphasizes the need for better understanding of vascular anatomy to minimize the risk of complications. Moreover, patients undergoing hyaluronic acid injection should receive information regarding the potential for mild and severe complications; relevant tests should be performed before surgery to exclude vulnerable patients. Finally, a nursing system is needed to facilitate the emergency recognition, triage, and management of retinal artery occlusion.

Oclusión de la arteria central de la retina tras inyección facial de ácido hialurónico / Central retinal artery occlusion following facial injection of hyaluronic acid

Mujer de 57 años sin premorbilidades que acude por pérdida de visión súbita e indolora en el ojo derecho (OD). La agudeza visual mejor corregida fue de contar dedos a 10cm. En el OD se observó un defecto pupilar aferente relativo. El examen de fondo de ojo en el OD fue sugestivo de oclusión central de la arteria retiniana. La evaluación sistémica fue normal. Lo más interesante en este caso es que un edema hemorrágico en la región glabelar derecha fue la base de la sospecha diagnóstica. La paciente reconoció la pérdida de visión a las 24horas de la inyección de ácido hialurónico como tratamiento de rejuvenecimiento facial (AU)

A 57-year-old woman with no premorbidities presented with symptoms of sudden painless vision loss in the right eye (RE). Best-corrected visual acuity in the RE was counting fingers to 10cm. A relative afferent pupillary defect was observed in the RE. Ocular fundus examination of RE was suggestive of central retinal artery occlusion. Systemic evaluation was normal. The most interesting fact in this case is that a hemorrhagic edema in the right glabellar region was the basis for the diagnostic suspicion. The patient recognized the loss of vision 24hours after hyaluronic acid injection as a facial rejuvenation treatment (AU)

Central retinal artery occlusion following facial injection of hyaluronic acid.

A 57-year-old woman with no premorbidities presented with symptoms of sudden painless vision loss in the right eye (RE). Best-corrected visual acuity in the RE was counting fingers to. A relative afferent pupillary defect was observed in the RE. Ocular fundus examination of RE was suggestive of central retinal artery occlusion. Systemic evaluation was normal. The most interesting fact in this case is that a hemorrhagic edema in the right glabellar region was the basis for the diagnostic suspicion. The patient recognized the loss of vision 24 h after hyaluronic acid injection as a facial rejuvenation treatment.

Multiple branch retinal artery occlusions following the new facial cosmetic filler (Poly-D, L-lactic Acid) injection a case report.

BACKGROUND: Poly-D, L-lactic acid is (PDLLA) a new cosmetic filler. We reported the first case of PDLLA-related devastating complication of multiple branch retinal artery occlusion (BRAO). CASE PRESENTATION: A 23-year-old female had sudden blindness after injection of PDLLA at the glabella. After emergency intraocular pressure-lowering medicine, ocular massage, steroid pulse therapy, heparin and alprostadil infusion, and subsequent treatments including acupuncture and 40 sessions of hyperbaric oxygen therapy, her best-corrected visual acuity improved from hand motion at 30 cm to 0.3 within 2 months. CONCLUSION: Although safety of PDLLA was evaluated in animal studies and in 16,000 human cases, it could still cause rare but devastating retinal artery occlusion as in the present case. Proper and immediate therapies could still improve patient's vision and scotoma. Surgeons should keep in mind the possibility of iatrogenic filler-related retinal artery occlusion.

Early onset monocular hydroxychloroquine maculopathy in a systemic lupus erythematosus patient with history of central retinal artery occlusion: a case report.

BACKGROUND: Hydroxychloroquine is a widely used medication for various clinical conditions mainly rheumatological and dermatological autoimmune diseases e.g. systemic lupus erythematosus, rheumatoid arthritis and psoriasis. While it is considered a safe medication, it is well-established that it can cause retinal toxicity i.e. HCQ maculopathy. Guidelines for HCQ retinal toxicity screening include factors like body weight, daily dose, duration, systemic diseases and retinal diseases. In this case study, we report a specific association between CRAO as a retinal disease and early onset HCQ maculopathy in a SLE patient. CASE PRESENTATION: A 42-year-old Caucasian female SLE patient presented with a complaint of gradual progressive painless diminution of vision in the left eye that started 16 months earlier. Clinical evaluation of the patient revealed a history of sudden profound painless diminution of vision in the same eye 18 months earlier after which the patient experienced only partial improvement of vision. That episode of sudden diminution of vision was attributed to left CRAO, complicating SLE-related thrombophilia, confirmed by fundus fluorescein angiography. Based on that diagnosis, the patient had been prescribed HCQ. At the time of presentation, fundus examination revealed left bull's eye maculopathy and right normal fundus. Therefore, a diagnosis of HCQ maculopathy in the left eye was made after exclusion of other causes of unilateral bull's eye maculopathy. CONCLUSION: Our case study is the first to report an association between CRAO as a specific retinal disease and early onset of HCQ maculopathy in a SLE patient. The unilateral bull's eye presentation which occurred in the eye with CRAO after only 16 months of HCQ treatment highly suggests that CRAO is probably the cause of such unusually early maculopathy. This case report highlights the importance of retinal diseases as risk factors for HCQ maculopathy. It also points out the lack of specific evidence concerning the association between specific retinal diseases and HCQ maculopathy.

Case Report: Central retinal artery occlusion following sildenafil intake.

Purpose: To report a case of central retinal artery occlusion associated with sildenafil intake and briefly discuss its causative pathogenesis. Methods: A 50-year-old man with no premorbidities presented with symptoms of sudden severe visual field constriction in the left eye (LE). Best-corrected visual acuity in the LE was 20/25. Fundus examination and fluorescein angiography of the LE were suggestive of central retinal artery occlusion (CRAO) with cilioretinal artery sparing. Further investigation revealed that 100 mg of sildenafil had been taken for the first time three hours before the onset of symptoms. Results: The patient was treated promptly with intravenous acetazolamide, sublingual isosorbide dinitrate and ocular massage, but without visual recovery. No other associated systemic or local risk factors were found, and the case was classified as a potential complication of sildenafil. Conclusion: Although no direct link could be established, the aim of this report is to highlight the incidence and to consider this issue when evaluating any case of central retinal artery occlusion.

Central retinal artery occlusion after vaccination with whole virion inactivated SARSCoV- 2 vaccine Covaxin.

Coronavirus disease 2019 (COVID-19) vaccinations have been associated with a higher risk of thromboembolic events. There have been no reports of central retinal artery occlusion (CRAO) after vaccination with the indigenously developed Covaxin, and worldwide, there has been only one such isolated case after administration of the AstraZeneca vaccine. We report a case of a 44-year-old healthy man who presented with sudden painless vision loss in his left eye 10 days after receiving Covaxin. His best-corrected visual acuity was minimal perception of light, with a relative afferent pupillary defect. Fundus examination revealed arterial attenuation and macular cherry red spot, suggesting an acute CRAO. Optical coherence tomography showed macular swelling and disorganization of the inner layers due to ischemic sequelae. Blood work was normal and cardiovascular examination was unremarkable. The patient was kept on follow-up. To our knowledge, this is the first case of an isolated CRAO after Covaxin administration, but further studies are needed to evaluate this potential association.

Iatrogenic central retinal artery occlusion following retrobulbar anesthesia with adrenaline for vitreoretinal surgery: a case report.

BACKGROUND: We describe a patient presenting with central retinal artery occlusion (CRAO) of the right eye after retrobulbar anesthesia with adrenaline for macular pucker surgery. CASE PRESENTATION: The patient, a 67-year-old Caucasian man, developed a CRAO postoperatively by the next-day control likely due to the retrobulbar injection of a combination of Xylocaine and Bupivacaine with adrenaline as anesthetic. CONCLUSIONS: The addition of adrenaline to the standard anesthetic solution could be a risk factor for serious complications, such as CRAO.

Transient central retina artery occlusion in patients undergoing intravitreal anti vegf injections.

PURPOSE: To evaluate the occurrence of transient central retinal artery occlusion following intravitreal anti-vascular endothelial growth factor injection. METHODS: Prospective, observational study of 807 patients (807 eyes) who were given intravitreal injections of ranibizumab or aflibercept to treat any cause of retinal vascular diseases between 1 January 2017 and 30 November 2018 at the Federal Fluminense University Hospital in Niteroi, and a private facility in Rio de Janeiro, Brazil. Patients who did not present transient central retinal artery occlusion were excluded. RESULTS: Among 4069 injections, only 18 patients (0.44%) presented transient central retinal artery occlusion, 14 mild cases (77.7%), and 4 severe cases (22.3%). The clinical factors associated with more severe cases of transient central retinal artery occlusion were the duration of the transient central retinal artery occlusion (p = 0.001), number of prior injections (p = 0.01), and a positive carotid Doppler test (p = 0.01). Twelve cases (66.6%) had positive carotid artery obstruction (atheroma plaque size ≥70%) while 6 cases (33.3%) had negative carotid artery obstruction (atheroma plaque size <70%). The age group >60 years old (p = 0.06), cup/disc ratio >0.6 (p = 0.06), and pseudophakic lens status were also factors with association with transient central retinal artery occlusion, although did not meet criteria for statistical significance. The only patient who experienced a recurrent episode of transient central retinal artery occlusion had diabetic macular edema, positive carotid Doppler test, and cup/optic disc ratio >0.6. CONCLUSION: Transient central retinal artery occlusion is a rare adverse event that can appear in patients with retinal vascular disease receiving anti-vascular endothelial growth factor therapy. The atheroma plaque size and the number of prior injections can be associated with the severity of the event.

BRANCH RETINAL ARTERY OCCLUSION WITH PARACENTRAL ACUTE MIDDLE MACULOPATHY PRESUMABLY RELATED TO HEAVY CANNABIS USE.

PURPOSE: To report a case of branch retinal artery occlusion associated with paracentral acute middle maculopathy on spectral-domain optical coherence tomography presumably related to heavy cannabis consumption. METHODS: Retrospective case report. Spectral-domain optical coherence tomography, fluorescein angiography, and optical coherence tomography angiography were performed. RESULTS: A 21-year-old healthy man described the acute onset of superior visual field loss in his right eye. He admitted smoking approximately 15 g daily of cannabis for several weeks during COVID-19 confinement. Ophthalmoscopic examination of the right eye showed inferotemporal retinal whitening. Spectral-domain optical coherence tomography illustrated evidence of the ischemic cascade with diffuse hyperreflectivity of the inner and middle retinal layers within the central region of the retinal infarct and paracentral acute middle maculopathy at the border of the infarct. Optical coherence tomography angiography demonstrated predominant flow signal loss at the level of the deep retinal capillary plexus. Fluorescein angiography and complete systemic workup were unremarkable. CONCLUSION: Branch retinal artery occlusion and paracentral acute middle maculopathy may be related to heavy cannabis use as the result of transient arterial vasospasm.

Standardized approach to treatment of retinal artery occlusion after intraarterial injection of soft tissue fillers: EYE-CODE.

BACKGROUND: Inadvertent intraarterial injection of soft tissue fillers during facial aesthetic procedures can result in serious adverse events including visual impairment and blindness. Once the retinal artery has been occluded, only a short window of opportunity exists before blindness becomes irreversible. All physicians should be prepared for the eventuality of intraarterial injection, despite its rarity. OBJECTIVE: The aim of this document is to provide a simple and evidence-based protocol using the easy to remember acronym EYE-CODE: EYE (I call retinal referral center), C (check vision), O (optic nerve function), D (decrease intraocular pressure), and E (erase filler). METHODS: The EYE-CODE acronym incorporates 2 key components: (1) a systematic office-based protocol to first determine whether vision loss is present and to what extent and (2) a treatment strategy that can be started in the acute office setting and continued by an emergency ophthalmologist. RESULTS: The protocol incorporates a crash kit of treatments readily available to an aesthetic physician combining measures to rapidly reduce intraocular pressure to allow the emboli to dislodge downstream with measures to improve retinal perfusion. CONCLUSION: EYE-CODE provides an up-to-date, one-stop reference for appropriate management of retinal artery occlusion induced by injection of soft tissue fillers.