Use of transesophageal echocardiography for detection of a likely source of embolization to the central retinal artery

Calcified amorphous tumor: A rare cause of central retinal artery occlusion

Purpose

We report the case of a central retinal artery occlusion secondary to presumed embolus from a calcified amorphous tumor of the heart, a very rare non-neoplastic cardiac mass.

Observations

A 60-year-old female presented with acute unilateral vision loss of the left eye. Examination revealed hand motion visual acuity of the left eye and a left relative afferent pupillary defect. Fundoscopy showed whitening of the macula with a cherry red spot, consistent with a central retinal artery occlusion. Initial workup was unremarkable, including hypercoagulability labs, magnetic resonance imaging of the brain, and magnetic resonance angiography of the head and neck. Transthoracic echocardiogram (TTE) showed calcification of the mitral valve but no masses. Subsequently, transesophageal echocardiogram (TEE) was performed, which revealed a mobile calcified amorphous tumor of the heart.

Conclusions

Calcified amorphous tumor of the heart is a very rare cardiac mass that may cause retinal artery occlusion. TEE is a more sensitive imaging modality to assess for potential cardio-embolic sources if TTE is unrevealing.

Transthoracic echocardiography and carotid Doppler ultrasound for detection of cardiac and carotid artery disease in patients with acute retinal artery obstruction

We reviewed the medical records of patients with acute retinal artery obstruction (RAO) and evaluated the importance of transthoracic echocardiography (TTE) and carotid Doppler ultrasound in determining causes of cardiac and carotid artery origin in RAO. A retrospective case study conducted in the Department of Ophthalmology, Inha University Hospital, Korea comprised 26 patients presenting with acute RAO who underwent systemic evaluation, TTE and carotid Doppler ultrasound between June 1, 1997 and December 31, 2003. Among these 26 patients, abnormal cardiac findings were detected in 12 (46%) and abnormal carotid findings in 4 (15%). Furthermore, other risk factors for RAO were found in 2 (8%) and stroke broke out within 7 months after experiencing RAO in 4 (15%) of the 26 patients. In patients with acute RAO, TTE and carotid Doppler ultrasound play an important role in pinpointing the origins of retinal emboli. It is thought that TTE and carotid Doppler ultrasound may be essential examinations for determining the underlying cause, planning treatment strategies, and preventing stroke and death.

Accuracy of visible retinal emboli for the detection of cardioembolic lesions requiring anticoagulation or cardiac surgery. Retinal Emboli of Cardiac Origin Study Group

AIM

To determine the accuracy of visible retinal emboli as a diagnostic "test" for the likelihood of receiving anticoagulation or cardiac surgery based on the results of transthoracic echocardiography, in the setting of acute retinal arterial occlusion.

METHODS

A multicentre retrospective diagnostic study at Kingston Eye Centre, Queen's University, Kingston, Ontario; Wills Eye Hospital, Philadelphia; Ottawa Eye Institute, Ottawa, Ontario; and the Halifax Infirmary, Halifax, Nova Scotia of 104 patients with both embolic and nonembolic acute retinal arterial obstruction who underwent transthoracic echocardiography was performed, to determine the accuracy of visible retinal emboli as a diagnostic "test" for anticoagulation or cardiac surgery. Anticoagulation or surgical intervention on the basis of abnormalities was detected solely through the technology of transthoracic echocardiography.

RESULTS

41 patients had visible retinal emboli (calcific, cholesterol, or fibrin). The remaining 63 had no evidence of embolic disease. The sensitivity of emboli for the likelihood of a patient receiving anticoagulation or cardiac surgery was 50%. The specificity, positive predictive value, and negative predictive value were 62%, 15%, and 90%, respectively. The likelihood ratio (LR = 1.31) obtained given the presence of a visible retinal embolus was neither clinically nor statistically significant (LR+ve = 1.31; 95% CI (0.91, 3.16)). This likelihood ratio, when applied to a patient with a pretest probability of 50%, results in a post-test probability of 56.7%.

CONCLUSIONS

These results demonstrate that the presence of a visible retinal embolus should not be the sole determinant of whether to order transthoracic echocardiography, as the likelihood ratio for a patient receiving anticoagulation or cardiac surgery, given the presence of a visible retinal embolus was only 1.31.

Idiopathic recurrent branch retinal arterial occlusion. Natural history and laboratory evaluation

PURPOSE

To investigate the long-term visual and systemic prognosis of patients with idiopathic recurrent branch retinal artery occlusions, and to test recent hypotheses regarding possible causes of this syndrome.

METHODS

The authors retrospectively reviewed the medical and photographic records of 16 eligible patients. Each of 15 living patients was interviewed by one of the authors, then underwent follow-up ophthalmic examination, formal visual field testing, and a battery of clinical laboratory tests.

RESULTS

Over a mean follow-up of 9 years, only three eyes (9%) lost visual acuity from foveal ischemia, although nine eyes (28%) had central and/or extensive peripheral visual field loss at final examination. Ocular neovascular complications developed in eight eyes (25%). Eight patients (50%) had associated vestibuloauditory and/or transient sensorimotor symptoms, but serious permanent neurologic deficits or recurrent systemic thromboembolic events did not develop. Although most patients had one or more vaso-occlusive risk factors, extensive laboratory testing failed to define the etiology of the arterial occlusions.

CONCLUSIONS

On long-term follow-up, the visual, neurologic, and systemic prognosis for most patients with idiopathic recurrent branch retinal arterial occlusions remains favorable. Although it is probable that such patients are etiologically heterogeneous, the authors theorize that many have mild or partial manifestations of the microangiopathic syndrome of encephalopathy, hearing loss, and retinal arteriolar occlusions.

The source of embolism in amaurosis fugax and retinal artery occlusion

To assess the diagnostic value of an extensive cardiac screening and of carotid artery duplex scanning in patients suspected of suffering from retinal embolism, we examined 41 consecutive patients (mean age 59.6 years, range 36-74) who presented either with amaurosis fugax or with a retinal artery occlusion. In spite of extensive investigations, we found no cause in 27 patients (66%). In 11 patients (27%), symptoms were likely to be due to a stenosis or an occlusion of the ipsilateral carotid artery. In only 1 patient (2%), the heart was likely to be a source of embolism. We conclude that in patients in this age group suffering from either amaurosis fugax or a retinal artery occlusion, a carotid artery duplex scanning should be performed first as this investigation is more likely to provide useful information than an extensive cardiac screening (ECG, Holter 24-hour monitoring and precordial echocardiography).

Transesophageal echocardiography in the diagnosis of branch retinal artery obstruction

We examined a 28-year-old man and a 19-year-old woman with branch retinal artery obstruction. Both were examined exhaustively. In each patient, a patent foramen ovale was demonstrated by transesophageal echocardiography after a transthoracic study disclosed no abnormalities. These observations suggest that transesophageal echocardiography is valuable in examining young patients with retinal emboli in whom cardiac abnormalities are suspected.