1
|
Padhy SK, Sahu S. Cilioretinal Artery Occlusion Following Diagnostic Lumbar Puncture in a Patient of Idiopathic Intracranial Hypertension. J Neuroophthalmol 2023; 43:e175-e176. [PMID: 35234678 DOI: 10.1097/wno.0000000000001491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
2
|
Hayreh SS, Hayreh SB. Uveal vascular bed in health and disease: lesions produced by occlusion of the uveal vascular bed and acute uveal ischaemic lesions seen clinically. Paper 2 of 2. Eye (Lond) 2023; 37:2617-2648. [PMID: 37185956 PMCID: PMC10482881 DOI: 10.1038/s41433-023-02417-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 05/06/2023] Open
Abstract
From studies on postmortem anatomical descriptions of the uveal vascular bed, it was generally concluded that occlusion of PCA or its branches should not produce an ischemic lesion. However, in vivo studies have recorded that the PCAs and their branches, right down to the terminal choroidal arterioles, and the choriocapillaris, have a segmental distribution in the choroid, and that PCAs and choroidal arteries function as end-arteries. This explains the basis of the occurrence of isolated inflammatory, ischemic, metastatic, and degenerative choroidal lesions, which are usually localized. Thus, in vivo studies have completely revolutionized our concept of the uveal vascular bed in disease.
Collapse
Affiliation(s)
- Sohan Singh Hayreh
- Departments of Ophthalmology and Visual Scence, College of Medicine, University of Iowa, Iowa City, 52242, USA
| | | |
Collapse
|
3
|
Riazi-Esfahani H, Ebrahimiadib N, Hamzeh N, Fadakar K, Khalili Pour E. Henle fiber layer hemorrhage associated with combined central retinal vein occlusion and cilioretinal artery occlusion: a case report. J Med Case Rep 2023; 17:355. [PMID: 37598197 PMCID: PMC10440029 DOI: 10.1186/s13256-023-04100-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/24/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND The purpose of this study is to describe a patient who experienced simultaneous central retinal vein and cilioretinal artery occlusions, as well as perifoveal hemorrhage in the Henle fiber. CASE PRESENTATION A 67-year-old Iranian woman presented with a 3-day history of reduced vision in her left eye. Venous tortuosity and retinal hemorrhage were observed in the retina, together with whitened regions around the fovea, consistent with the diagnosis of central retinal vein occlusion in conjunction with cilioretinal artery occlusion. In structural and en face optical coherence tomography, star-shaped hemorrhages were observed around the fovea, which looked hyperreflective in the Henle fiber layer. CONCLUSIONS We present a case of central retinal vein occlusion exacerbated by cilioretinal occlusion and hemorrhage in the Henle fiber layer. The hemorrhage is most likely the result of increased intraluminal pressure in the deep capillary plexus.
Collapse
Affiliation(s)
- Hamid Riazi-Esfahani
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Kargar Street, Tehran, Iran
| | - Nazanin Ebrahimiadib
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Kargar Street, Tehran, Iran
| | - Nikoo Hamzeh
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Kargar Street, Tehran, Iran
| | - Kaveh Fadakar
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Kargar Street, Tehran, Iran
| | - Elias Khalili Pour
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Kargar Street, Tehran, Iran.
| |
Collapse
|
4
|
Galler B. [A mysterious central retinal vein occlusion]. DIE OPHTHALMOLOGIE 2023; 120:743-746. [PMID: 36074168 DOI: 10.1007/s00347-022-01722-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023]
Affiliation(s)
- B Galler
- Universitäts-Augenklinik Tübingen, Elfriede-Aulhorn-Str. 7, 72076, Tübingen, Deutschland.
| |
Collapse
|
5
|
Retinal ischemic cascade: New insights into the pathophysiology and imaging findings. Surv Ophthalmol 2022; 68:380-387. [PMID: 36464134 DOI: 10.1016/j.survophthal.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Retinal ischemia gives rise to a complex spectrum in which the cumulative profile of ischemia of the middle and inner retina can be highly variable. We reviewed the current knowledge on paracentral acute middle maculopathy (PAMM) pathophysiology and accompanying risk factors, the middle and inner retinal vasculature and blood flow, and the vulnerability of the middle retina in vaso-occlusive disorders. The inner nuclear layer (INL) is easily affected by slight degrees of retinal hypoperfusion and ischemia. INL infarction starts at perivenular sites, manifesting as skip PAMM lesions and a fern-like appearance in cross-sectional and en face views, respectively. With horizontal progression, INL infarction may develop into diffuse globular PAMM. If vertical progression occurs, the entire middle and inner portions of the retina can be affected. Transmural infarction of the middle and inner retina would be at the end of this spectrum. This gradient of ischemic progression resembles an ischemic cascade. We review the evidence supporting the term "retinal ischemic cascade," which encompasses a broad continuum of manifestations with roots in middle retinal infarction. With this terminology, variations in spatial and temporal progression and resolution of ischemia can also be delivered; it further enables addressing the possible associations between the middle and inner retinal ischemic patterns.
Collapse
|
6
|
Gaier ED, Rasool N, Rizzo JF. Sectoral Sparing Associated With a Cilioretinal Artery in Arteritic Anterior Ischemic Optic Neuropathy. J Neuroophthalmol 2022; 42:e514-e516. [PMID: 34860740 PMCID: PMC10311077 DOI: 10.1097/wno.0000000000001418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Giant cell arteritis (GCA) is a life-threatening vasculitis occurring in older adults that can cause blindness by ischemia of the choroid, retina, and optic nerve. We report a case of a patient who presented with "occult" GCA with severe anterior ischemic optic neuropathy affecting both optic nerves, delayed choroidal filling, and a concomitant cilioretinal artery occlusion in the left eye. The retinal territory supplied by the affected cilioretinal artery was hypoperfused, yet this retinal territory at least partially corresponded to the only preserved visual field in that eye. The sector of the optic disc corresponding to the emergence of the cilioretinal artery was the only sector spared by pallid edema. This pattern of sectoral sparing associated with a cilioretinal artery has been observed in other patients with GCA and in animal models of posterior ciliary artery occlusion. This case serves as a clear example of an incompletely understood phenomenon in posterior pole circulation in vascular occlusive disease that deserves further study.
Collapse
Affiliation(s)
- Eric D Gaier
- Department of Ophthalmology (EDG), Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School (EDG, JFR), Boston, Massachusetts; Department of Ophthalmology (EDG, JFR), Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Picower Institute for Learning and Memory (EDG), Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts; Departments of Ophthalmology and Neurology (NR), University of California San Francisco, San Francisco, California
| | | | | |
Collapse
|
7
|
Khallouli A, Khelifi K, Saidane R, Choura R, Maalej A, Sassi RB. Hyperbaric oxygen treatment of central retinal vein occlusion with cilioretinal artery occlusion secondary to hormonal treatment: Case report and review. Diving Hyperb Med 2020; 50:431-436. [PMID: 33325028 DOI: 10.28920/dhm50.4.431-436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/16/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION This report describes a case of central retinal vein occlusion (CRVO) and cilioretinal artery occlusion (CLRAO) after hormonal treatment for induction of ovulation that was successfully treated with hyperbaric oxygen. CASE REPORT A 48 year-old woman was admitted to our department for sudden blurred vision in her left eye. The patient had a history of 3-months hormonal treatment for induction of ovulation. The best corrected visual acuity was 7/10 (20/32) in the left eye and 10/10 (20/20) in the right eye. Fundus examination of the left eye revealed flame-shaped haemorrhages, whitening of the retina along the distribution of cilioretinal artery and tortuous retinal veins. Fluorescein angiography confirmed the combination of a non-ischaemic CRVO with CLRAO. The patient was treated with a 2 h session of hyperbaric oxygen at 253 kPa (2.5 atmospheres absolute) once daily for a total of 30 sessions. Best corrected visual acuity improved to 10/10 (20/20) in the left eye. CONCLUSIONS CRVO and CLRAO are both occlusive disorders. HBOT is a safe low-cost treatment modality that can be beneficial in some ocular pathologies. It can maintain oxygenation of the retina through the choroidal blood supply, decrease oedema and preserve compromised tissue adjacent to the ischaemic area.
Collapse
Affiliation(s)
- Asma Khallouli
- Department of Ophthalmology, Military Hospital of Tunis, Tunisia
| | - Khaled Khelifi
- Department of Ophthalmology, Military Hospital of Tunis, Tunisia
| | - Rahma Saidane
- Department of Ophthalmology, Military Hospital of Tunis, Tunisia
| | - Racem Choura
- Department of Ophthalmology, Military Hospital of Tunis, Tunisia.,Corresponding author: Dr Racem Choura, Department of Ophthalmology, Military Hospital of Tunis, Mont Fleury- 1008, Tunisia,
| | - Afef Maalej
- Department of Ophthalmology, Military Hospital of Tunis, Tunisia
| | - Raja Ben Sassi
- Department of Hyperbaric Oxygen Therapy, Military Hospital of Tunis, Tunisia
| |
Collapse
|
8
|
Unravelling the mechanism of combined cilioretinal artery and retinal vein occlusion: documentation of the oscillating blood flow column and a review of the literature. Can J Ophthalmol 2019; 54:e251-e254. [DOI: 10.1016/j.jcjo.2018.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/27/2018] [Indexed: 11/23/2022]
|
9
|
McLeod D. Misery Perfusion, Diffusive Oxygen Shunting and Interarterial Watershed Infarction Underlie Oxygenation-Based Hypoperfusion Maculopathy. Am J Ophthalmol 2019; 205:153-164. [PMID: 30905727 DOI: 10.1016/j.ajo.2019.03.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe and explain the entire range of acute ischemic macular damage that follows panretinal hypoperfusion from central retinal artery or vein occlusion. DESIGN Perspective article. METHODS To correlate the fundoscopic, fluorescein angiographic, oximetric, and optical coherence tomographic (OCT) features developing within the posterior inner retina following incremental reductions in arteriovenous perfusion pressure across the retinal circulation. RESULTS The spectrum of acute oxygenation-based hypoperfusion maculopathy (OHM) is consistent with that predictable from a modified Krogh cylinder model of tissue oxygenation. Diffusive oxygen shunting plays a significant role in the "artery-dominated" generation of ischemic signs during misery perfusion. Three major grades of OHM severity can be discerned according to the predominant oxygenation status of ganglion cells within the superficial inner retina, whether this is normoxic (OHM1), hypoxic (OHM2), or anoxic (OHM3). Densely opaque axoplasmic sentinels are arranged along normoxic/hypoxic interfaces in OHM2. In OHM1 and OHM2, relative hypermetabolism and interarterial watershed infarction of fundal interneurons (WIFI) underpin subtle middle-retinal opacification with periarterial sparing. The fundal signs are optimally displayed en face using autofluorescence imaging whereas cross-sectional OCT reveals Paques' plaque formation. CONCLUSIONS An exquisite and supremely accessible exhibition of classical oxygen physiopathology unfolds in eyes with panretinal hypoperfusion courtesy of the transparent ocular media and the pattern of macular neuroretinal opacification that evolves as upstream tissues extract oxygen to the detriment of tissues downstream. Recent attempts to overrule the simple conceptual framework embodied in WIFI have no plausible anatomical nor physiological basis. Overreliance on OCT can result in misdiagnosis.
Collapse
Affiliation(s)
- David McLeod
- Academic Department of Ophthalmology, Manchester Royal Eye Hospital, Manchester University National Health Service Foundation Trust, and Centre for Ophthalmology and Vision Research, Institute of Human Development, University of Manchester, Manchester, United Kingdom.
| |
Collapse
|
10
|
Pichi F, Fragiotta S, Freund KB, Au A, Lembo A, Nucci P, Sebastiani S, Gutierrez Hernandez JC, Interlandi E, Pellegrini F, Dolz-Marco R, Gallego-Pinazo R, Orellana-Rios J, Adatia FA, Munro M, Abboud EB, Ghazi N, Cunha Souza E, Amer R, Neri P, Sarraf D. Cilioretinal artery hypoperfusion and its association with paracentral acute middle maculopathy. Br J Ophthalmol 2018; 103:1137-1145. [PMID: 30257961 DOI: 10.1136/bjophthalmol-2018-312774] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS To study the multimodal imaging findings of a large series of eyes with cilioretinal artery obstruction (CILRAO) and describe the systemic associations. METHODS Multicentre, retrospective chart review from 12 different retina clinics worldwide of eyes with CILRAO, defined as acute retinal whitening in the distribution of the cilioretinal artery, were identified. The clinical, systemic information and multimodal retinal imaging findings were collected and analysed. RESULTS A total of 53 eyes of 53 patients with CILRAO were included in the study. In 100% of eyes, fundus photography illustrated deep retinal whitening corresponding to the course of the cilioretinal artery. Twenty-eight patients (52.8%) presented with isolated CILRAO (baseline best-corrected visual acuity (BCVA) 20/50, final BCVA 20/25) associated with nocturnal hypotension, 23 patients (43.4%) with CILRAO secondary to central retinal vein occlusion (CRVO) (baseline BCVA 20/40, final BCVA 20/20) and two patients with CILRAO due to biopsy-proven giant cell arteritis (GCA) (baseline BCVA 20/175, final BCVA 20/75). With spectral domain optical coherence tomography (SD-OCT), a hyper-reflective band involving the inner nuclear layer (ie, paracentral acute middle maculopathy or PAMM) was noted in 51 eyes (28/28 eyes with isolated CILRAO and 23/23 eyes with CILRAO+CRVO) corresponding to the retinal whitening. In the two eyes with CILRAO+GCA, SD-OCT illustrated hyper-reflective ischaemia of both the middle and inner retina. CONCLUSIONS Isolated CILRAO and CILRAO secondary to CRVO are the result of hypoperfusion or insufficiency, rather than occlusion, of the cilioretinal artery and are associated with PAMM or selective infarction of the the inner nuclear layer. With GCA, there is complete occlusion of the cilioretinal artery producing ischaemia involving both the middle and inner retina associated with worse visual outcomes.
Collapse
Affiliation(s)
- Francesco Pichi
- Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates .,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Serena Fragiotta
- Vitreous Retina Macula Consultants of New York, New York City, New York, USA
| | - K Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York City, New York, USA
| | - Adrian Au
- Stein Eye Institute, University of California, Los Angeles, California, USA.,Greater Los Angeles VA Healthcare Center, Los Angeles, California, USA
| | - Andrea Lembo
- San Giuseppe Hospital, University Eye Clinic, Milan, Italy
| | - Paolo Nucci
- San Giuseppe Hospital, University Eye Clinic, Milan, Italy
| | - Stefano Sebastiani
- University Eye Clinic of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | | | | | | | | | - Jorge Orellana-Rios
- New York Eye and Ear Infirmary of Mount Sinai, New York City, New York, USA.,University of Antofagasta, Antofagasta, Chile
| | | | - Monique Munro
- Mitchell Eye Center and Rockyview, Calgary, Alberta, Canada
| | - Emad B Abboud
- Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates
| | - Nicola Ghazi
- Lebanese American University, Medical Center, Rizk Hospital, Beirut, Lebanon
| | | | | | - Piergiorgio Neri
- Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates
| | - David Sarraf
- Stein Eye Institute, University of California, Los Angeles, California, USA.,Greater Los Angeles VA Healthcare Center, Los Angeles, California, USA
| |
Collapse
|
11
|
Grzybowski A, Elikowski W, Gaca-Wysocka M. Cardiovascular risk factors in patients with combined central retinal vein occlusion and cilioretinal artery occlusion: Case report. Medicine (Baltimore) 2018; 97:e9255. [PMID: 29505511 PMCID: PMC5943110 DOI: 10.1097/md.0000000000009255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE To analyze cardiovascular risk factors and comorbidity of acute unilateral visual loss due to combined central retinal vein occlusion (CRVO) and cilioretinal artery occlusion (CLRAO). PATIENT CONCERNS Among patients with retinal vein or artery occlusion hospitalized at the Department of Ophthalmology between January 2011 and August 2017, subjects with combined CRVO/CLRAO were selected. All of them underwent ophthalmologic and cardiologic examination, including fluorescein angiography, optical coherence tomography, 12-lead electrocardiogram, transthoracic and transesophageal echocardiography, carotid Doppler sonography, cerebral magnetic resonance imaging, and a panel of laboratory tests. DIAGNOSES Four subjects with coexisting CRVO and CLRAO were found among 146 patients with retinal vein or artery occlusion. There were no other types of concomitance of CRVO and retinal artery occlusion. INTERVENTIONS All patients were treated with low molecular heparin in a full dose for 2 weeks, then with 1 mg/kg once daily for the next 2 weeks, followed by acetylsalicylic acid 75 mg/kg/d. Other medication included long-term statins, angiotensin-converting-enzyme inhibitor in 3 patients and beta-blocker in one patient. OUTCOMES All patients with CRVO/CLRAO presented multiple cardiovascular risk factors, including hypertension, obesity, hyperlipidemia, chronic nicotine addiction, and a positive family history of coronary artery disease or stroke. In all of them, echocardiography revealed left ventricular hypertrophy and atherosclerotic lesions in the descending aorta; in addition, 3 patients had insignificant atherosclerotic plaques in the carotid artery. Also, in 3 subjects, focal ischemic cerebral changes were diagnosed. LESSONS Patients with combined CRVO and CLRAO present numerous cardiovascular risk factors and abnormalities on imaging examinations, which should be routinely evaluated and treated.
Collapse
Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, Poznań City Hospital, Poznań
- University of Warmia and Mazury, Olsztyn
| | | | | |
Collapse
|
12
|
Ravani R, Chawla R, Jain S, Kumar A. "Dye front reciprocation" in combined central retinal vein occlusion with cilioretinal artery infarction. Indian J Ophthalmol 2017; 65:1211-1212. [PMID: 29133654 PMCID: PMC5700596 DOI: 10.4103/ijo.ijo_552_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Raghav Ravani
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Chawla
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Shreyans Jain
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Kumar
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
13
|
|
14
|
Sengupta S, Pan U. Combined branch retinal vein and branch retinal artery occlusion - clinical features, systemic associations, and outcomes. Indian J Ophthalmol 2017; 65:238-241. [PMID: 28440254 PMCID: PMC5426130 DOI: 10.4103/ijo.ijo_340_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 03/13/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Retinal vascular occlusions affecting both the arterial and venous systems are rare events. Combined branch retinal artery (BRAO) and vein (BRVO) occlusion are exceedingly rare and not well characterized. METHODS Six patients with combined BRAO and BRVO underwent a comprehensive eye examination, fundus fluorescein angiography, optical coherence tomography, and cardiovascular evaluation. RESULTS Mean age at presentation was 54 ± 7.8 years (range: 39-60), and five of the six were men. Patients had a combination of systemic comorbidities such as diabetes (5), hypertension (4), dyslipidemia (5), and hyperhomocysteinemia (1). All had unilateral combined occlusion characterized by narrowing and cattle tracking of blood in arteries and dilated tortuous veins in the involved quadrant. Fluorescein angiography demonstrated complete capillary drop out and a clear demarcation between the perfused and nonperfused retina. Presenting vision ranged from 6/9 to 1/60 Snellen's, and final vision depended on the macular perfusion status. All eyes were treated with angiography-guided sectoral laser photocoagulation, and three eyes required intravitreal bevacizumab due to macular edema or retinal neovascularization. CONCLUSIONS Combined BRAO and BRVO is rare, may have unique underlying pathogenetic mechanisms, is associated with multiple systemic comorbidities and can yield good visual outcome if macula remains well perfused.
Collapse
Affiliation(s)
| | - Utsab Pan
- Vitreoretina Services, Aravind Eye Hospital, Puducherry, India
| |
Collapse
|
15
|
|
16
|
Cilioretinal Artery Territory Infarction Associated With Papilledema in a Patient With Neurofibromatosis Type 2. J Neuroophthalmol 2015; 36:58-60. [PMID: 26295608 DOI: 10.1097/wno.0000000000000279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cilioretinal artery territory infarction can occur in isolation or in association with other vascular compromise of the retinal circulation. Our patient, an 18-year-old woman with neurofibromatosis type 2, developed a cilioretinal artery territory infarction in the setting of papilledema. Our case, together with one previous report, suggests that cilioretinal artery territory infarction in the context of papilledema, although rare, is a real entity.
Collapse
|
17
|
Evidence for an enduring ischaemic penumbra following central retinal artery occlusion, with implications for fibrinolytic therapy. Prog Retin Eye Res 2015; 49:82-119. [PMID: 26113210 DOI: 10.1016/j.preteyeres.2015.06.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/13/2015] [Accepted: 06/18/2015] [Indexed: 12/15/2022]
Abstract
The rationale behind hyperacute fibrinolytic therapy for cerebral and retinal arterial occlusion is to rescue ischaemic cells from irreversible damage through timely restitution of tissue perfusion. In cerebral stroke, an anoxic tissue compartment (the "infarct core") is surrounded by a hypoxic compartment (the "ischaemic penumbra"). The latter comprises electrically-silent neurons that undergo delayed apoptotic cell death within 1-6 h unless salvaged by arterial recanalisation. Establishment of an equivalent hypoxic compartment within the inner retina following central retinal artery occlusion (CRAO) isn't widely acknowledged. During experimental CRAO, electroretinography reveals 3 oxygenation-based tissue compartments (anoxic, hypoxic and normoxic) that contribute 32%, 27% and 41% respectively to the pre-occlusion b-wave amplitude. Thus, once the anoxia survival time (≈2 h) expires, the contribution from the infarcted posterior retina is irreversibly extinguished, but electrical activity continues in the normoxic periphery. Inbetween these compartments, an annular hypoxic zone (the "penumbra obscura") endures in a structurally-intact but functionally-impaired state until retinal reperfusion allows rapid recovery from electrical silence. Clinically, residual circulation of sufficient volume flow rate generates the heterogeneous fundus picture of "partial" CRAO. Persistent retinal venous hypoxaemia signifies maximal extraction of oxygen by an enduring "polar penumbra" that permeates or largely replaces the infarct core. On retinal reperfusion some days later, the retinal venous oxygen saturation reverts to normal and vision improves. Thus, penumbral inner retina, marginally oxygenated by the choroid or by residual circulation, isn't at risk of delayed apoptotic infarction (unlike hypoxic cerebral cortex). Emergency fibrinolytic intervention is inappropriate, therefore, once the duration of CRAO exceeds 2 h.
Collapse
|
18
|
Peral MJ, Reche A, Crespo MJ, Carpio R, Gutierrez O, Espino A, Toledano N. [Cilioretinal artery occlusion in hemochromatosis]. ACTA ACUST UNITED AC 2014; 90:237-40. [PMID: 25443202 DOI: 10.1016/j.oftal.2014.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 04/19/2012] [Accepted: 04/09/2014] [Indexed: 11/18/2022]
Abstract
CLINICAL CASE We report a case of a 31 year-old woman with a sudden visual loss due to a cilioretinal artery occlusion. The physical examinination showed hepatomegaly. Serum iron and ferritin and transferrin saturation were unusually high. The doppler scan of carotid arteries showed no relevant signs of atheromatous disease. Dilated cardiomiopaty was revealed in the B-scan with subendocardial calcium deposits. Genetic tests were positive for hemochromatosis. DISCUSSION Subendocardial calcification due to hemochromatosis could be the embolic source in our patient. This embolic ocular disease is the first presentation of hemochromatosis in this patient.
Collapse
Affiliation(s)
- M J Peral
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España.
| | - A Reche
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España
| | - M J Crespo
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España
| | - R Carpio
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España
| | - O Gutierrez
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España
| | - A Espino
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España
| | - N Toledano
- Servicio de Oftalmología, Hospital Universitario de Fuenlabrada, Madrid, España
| |
Collapse
|
19
|
Abstract
Gender medicine has been a major focus of research in recent years. The present review focuses on gender differences in the epidemiology of the most frequent ocular diseases that have been found to be associated with impaired ocular blood flow, such as age-related macular degeneration, glaucoma and diabetic retinopathy. Data have accumulated indicating that hormones have an important role in these diseases, since there are major differences in the prevalence and incidence between men and pre- and post-menopausal women. Whether this is related to vascular factors is, however, not entirely clear. Interestingly, the current knowledge about differences in ocular vascular parameters between men and women is sparse. Although little data is available, estrogen, progesterone and testosterone are most likely important regulators of blood flow in the retina and choroid, because they are key regulators of vascular tone in other organs. Estrogen seems to play a protective role since it decreases vascular resistance in large ocular vessels. Some studies indicate that hormone therapy is beneficial for ocular vascular disease in post-menopausal women. This evidence is, however, not sufficient to give any recommendation. Generally, remarkably few data are available on the role of sex hormones on ocular blood flow regulation, a topic that requires more attention in the future.
Collapse
Affiliation(s)
- Doreen Schmidl
- Department of Clinical Pharmacology, Medical University of Vienna , Vienna , Austria
| | | | | | | |
Collapse
|
20
|
Gokce G, Metin S, Erdem U, Sobaci G, Durukan AH, Cagatay HH, Ekinci M. Late hyperbaric oxygen treatment of cilioretinal artery occlusion with nonischemic central retinal vein occlusion secondary to high altitude. High Alt Med Biol 2014; 15:84-8. [PMID: 24673536 DOI: 10.1089/ham.2013.1086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM To report a case of cilioretinal artery occlusion (CRAO) with central retinal vein occlusion (CRVO) after a journey to high altitude region and the use of late period hyperbaric oxygen (HBO) therapy successfully. CASE REPORT A previously healthy 48-year-old lowlander woman was admitted to our department for sudden blurred vision in her right eye started at 2 weeks prior to examination. The patient had a history of 1-month exposure to high altitude that finished a day before the onset of her complaints. The best corrected visual acuity (BCVA) was 10/20 in the right eye (RE) and 10/10 in the left eye. Fundus examination of the RE revealed whitening of the retina along the distribution of cilioretinal artery, sparing fovea, flame-shaped hemorrhages, and roth spots with minimally dilated and tortuous retinal veins. Visual field analysis revealed centrocecal scotoma. The patient was treated by a daily session of 2 h of HBO at 2.5 atmosphere absolute for 11 days. BCVA rised to a level of 20/20 for the RE and the scotomas were disappeared immediately after using of the HBO treatment. CONCLUSION CRVO related CRAO should be regarded as a rare complication of exposure to high altitude and HBO seems to be the treatment of choice of high altitude related co-occurence of CRVO and CRAO in the late period.
Collapse
Affiliation(s)
- Gokcen Gokce
- 1 Department of Ophthalmology, Sarikamis Military Hospital , Kars, Turkey
| | | | | | | | | | | | | |
Collapse
|
21
|
Schmidt D. Comorbidities in combined retinal artery and vein occlusions. Eur J Med Res 2013; 18:27. [PMID: 23947749 PMCID: PMC3751822 DOI: 10.1186/2047-783x-18-27] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 07/26/2013] [Indexed: 11/10/2022] Open
Abstract
Background Several general diseases cause blindness in patients with simultaneous combined retinal artery and vein occlusion. Methods/patients We examined 14 patients with acute unilateral visual loss due to combined retinal artery and venous occlusions. All 14 patients presented at the Polyclinic over a period of about 3 years. Fluorescein angiography was carried out in 12 patients to confirm the diagnosis. Ten patients underwent Doppler sonography and 11 echocardiography. Results Concerning systemic diseases, 11 of our 14 patients presented several cardiovascular risk factors, i.e., immunocytoma and arterial hypertension and hypercholesterolemia in one patient; another patient had chronic bronchitis, tachycardia and hypercholesterolemia. Six patients presented coagulation anomalies, and eight patients had arterial hypertension. Doppler sonography revealed normal carotid arteries in nine of ten patients. In 8 of 11 patients, echocardiography displayed no cardiac abnormalities. Ophthalmoscopy revealed no emboli in any of these patients. Conclusion Unilateral simultaneous combined incomplete retinal artery and venous occlusions should be considered as one entity. Eleven of our patients presented comorbidities reflecting several cardiovascular risk factors. Immunological diseases, malignancies and coagulopathies can cause this ocular disorder, resulting in blindness. No emboli were found in any of these patients. Patients suffering from acute visual loss must be examined for the presence of systemic diseases to enable therapy at an early stage.
Collapse
Affiliation(s)
- Dieter Schmidt
- University-Augenklinik, Killianstr, 5, Freiburg D-79106, Germany.
| |
Collapse
|
22
|
Berkani Z, Kitouni Y, Belhadj A, Sifi K, Abbadi N, Bellatrache C, Hartani D, Kherroubi R. [Cilioretinal artery occlusion and central retinal vein occlusion complicating hyperhomocysteinemia: a case report]. J Fr Ophtalmol 2013; 36:e119-27. [PMID: 23731792 DOI: 10.1016/j.jfo.2012.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 10/26/2012] [Accepted: 11/05/2012] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Hyperhomocysteinemia is known to be a risk factor in both retinal artery and retinal vein occlusions. We report the case of a young patient with combined occlusion of the cilioretinal artery and the central retinal vein due to hyperhomocysteinemia. PATIENTS AND METHODS A 23-year-old patient without significant medical history, presented for sudden, painless visual loss in the right eye. Ophthalmologic examination revealed best-corrected visual acuity of the right eye 8/10 P2, and 10/10 P2 on the left. Anterior segment exam was normal in both eyes, while the right fundus revealed white, ischemic edema, centered around a cilioretinal artery, sparing the fovea, with some hemorrhagic spots and disc edema. Fluorescein angiography confirmed delayed filling of the right cilioretinal artery and revealed a normal disc on the left. Two weeks later, the clinical picture had evolved into a right ischemic CRVO, confirmed by a second angiogram, with a decrease in visual acuity to 3/10. RESULTS A work-up was performed, including: a full lipid profile, serum electrolytes, ESR, CRP, a complete blood count (leukocytes, platelets, hemoglobin were normal), a coagulation work-up (PT, PTT, protein C, protein S, antithrombin III, factor V Leiden were normal), ANCA, antiphospholipid antibodies and antinuclear antibodies were negative, and finally cardiology studies (cardiac echo, carotid Doppler) and neurology (brain MRI) were ordered and came back normal. Otherwise, plasma homocysteine was moderately high on two samples, at 18.3 μmol/L and 17.78 μmol/L. Thyroid and renal work-ups were ordered. Urgent PRP was performed, and vitamin therapy (vitB12, vitB6, folic acid) was instituted. The subsequent course was remarkable for recovery of visual acuity to 10/10, P2 with persistence of an inferior altitudinal central scotoma. MTHFR C677T polymorphism was negative. DISCUSSION Retinal vascular occlusions (RVO) are serious events, which require investigation for underlying systemic disease, which can be life-threatening. The clinical picture is variable depending on the location of the occlusion, the extent of the ischemic area and the degree of macular involvement. The etiologies of RVO are varied, requiring a thorough biological assessment in young subjects. The association between hyperhomocysteinemia and RVO is proven, while this association with the MTHFR C677T polymorphism was not found. Vitamin therapy reduces plasma levels of homocysteine by 25% but its role in the treatment and prevention of RVO remains to be demonstrated. CONCLUSION Several cases of occlusion of the central retinal vein or one of its branches have been published. Combined occlusion of the central retinal vein and cilioretinal artery secondary to hyperhomocysteinemia does not appear to have been published, which would make our case unique.
Collapse
Affiliation(s)
- Z Berkani
- Service d'ophtalmologie, faculté de médecine, université Mentouri de Constantine, CHU Constantine, BP 325, route Ain El Bey, 25017 Constantine, Algérie; Laboratoire de recherche en maladies métaboliques, université Mentouri de Constantine, BP 325, route Ain El Bey, 25017 Constantine, Algérie.
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Gandhi JS. Cilioretinal infarction as a sequel to central retinal vein occlusion in a patient exposed to thrombogenic medication. Indian J Ophthalmol 2012. [PMID: 23202413 PMCID: PMC3545152 DOI: 10.4103/0301-4738.103810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
24
|
Zhang L, Sun Y, Johnson MW, Richards JE, Moroi SE. Combined cilioretinal artery and central vein occlusions in juvenile glaucoma. ACTA ACUST UNITED AC 2011; 129:1231-4. [PMID: 21911678 DOI: 10.1001/archophthalmol.2011.284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
25
|
Hayreh SS. Acute retinal arterial occlusive disorders. Prog Retin Eye Res 2011; 30:359-94. [PMID: 21620994 DOI: 10.1016/j.preteyeres.2011.05.001] [Citation(s) in RCA: 214] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 05/09/2011] [Accepted: 05/12/2011] [Indexed: 12/22/2022]
Abstract
The initial section deals with basic sciences; among the various topics briefly discussed are the anatomical features of ophthalmic, central retinal and cilioretinal arteries which may play a role in acute retinal arterial ischemic disorders. Crucial information required in the management of central retinal artery occlusion (CRAO) is the length of time the retina can survive following that. An experimental study shows that CRAO for 97min produces no detectable permanent retinal damage but there is a progressive ischemic damage thereafter, and by 4h the retina has suffered irreversible damage. In the clinical section, I discuss at length various controversies on acute retinal arterial ischemic disorders. Classification of acute retinal arterial ischemic disorders: These are of 4 types: CRAO, branch retinal artery occlusion (BRAO), cotton wool spots and amaurosis fugax. Both CRAO and BRAO further comprise multiple clinical entities. Contrary to the universal belief, pathogenetically, clinically and for management, CRAO is not one clinical entity but 4 distinct clinical entities - non-arteritic CRAO, non-arteritic CRAO with cilioretinal artery sparing, arteritic CRAO associated with giant cell arteritis (GCA) and transient non-arteritic CRAO. Similarly, BRAO comprises permanent BRAO, transient BRAO and cilioretinal artery occlusion (CLRAO), and the latter further consists of 3 distinct clinical entities - non-arteritic CLRAO alone, non-arteritic CLRAO associated with central retinal vein occlusion and arteritic CLRAO associated with GCA. Understanding these classifications is essential to comprehend fully various aspects of these disorders. Central retinal artery occlusion: The pathogeneses, clinical features and management of the various types of CRAO are discussed in detail. Contrary to the prevalent belief, spontaneous improvement in both visual acuity and visual fields does occur, mainly during the first 7 days. The incidence of spontaneous visual acuity improvement during the first 7 days differs significantly (p<0.001) among the 4 types of CRAO; among them, in eyes with initial visual acuity of counting finger or worse, visual acuity improved, remained stable or deteriorated in non-arteritic CRAO in 22%, 66% and 12% respectively; in non-arteritic CRAO with cilioretinal artery sparing in 67%, 33% and none respectively; and in transient non-arteritic CRAO in 82%, 18% and none respectively. Arteritic CRAO shows no change. Recent studies have shown that administration of local intra-arterial thrombolytic agent not only has no beneficial effect but also can be harmful. Prevalent multiple misconceptions on CRAO are discussed. Branch retinal artery occlusion: Pathogeneses, clinical features and management of various types of BRAO are discussed at length. The natural history of visual acuity outcome shows a final visual acuity of 20/40 or better in 89% of permanent BRAO cases, 100% of transient BRAO and 100% of non-arteritic CLRAO alone. Cotton wools spots: These are common, non-specific acute focal retinal ischemic lesions, seen in many retinopathies. Their pathogenesis and clinical features are discussed in detail. Amaurosis fugax: Its pathogenesis, clinical features and management are described.
Collapse
Affiliation(s)
- Sohan Singh Hayreh
- Department of Ophthalmology and Visual Sciences, College of Medicine, University Hospitals and Clinics, 200 Hawkins Drive, University of Iowa, Iowa City, IA 52242-1091, USA.
| |
Collapse
|
26
|
Abstract
The volume of cells that a length of capillary supplies with O(2) is called a Krogh cylinder. This geometric 'tissue unit' was named after the Danish zoophysiologist and Nobel laureate August Krogh who made important discoveries in the fields of external and internal respiration in the first half of the last century. Krogh's ideas concerning tissue O(2) distribution can be extrapolated to retinal oxygenation by larger vessels (including arterioles, arteries and even veins) and by vessel groups within higher-order 'microvascular units' (including the choroid). During retinal development, for example, the difference in pO(2) levels within arteries and capillaries determines Krogh cylinders of different radius and establishes the periarterial capillary-free zone of His. The O(2) supply to the venous end of a tissue unit may be compromised during periods of reduced perfusion, increased O(2) consumption or hypoxaemia, resulting in an 'anoxic corner' of the Krogh cylinder. A funnel of hypometabolic (and therefore hypoxia-tolerant) cells will likely intervene between the necrotic cells and unaffected cells located closer to the O(2) source. Macular perivenular whitening heralds anoxic corners and/or hypoxic funnels owing to hypoperfusion within second-order microvascular units. In eyes with extensive retinal capillary closure from diabetes, Krogh cylinders surround the medium-sized arteries and veins that form arteriovenous shunts while traversing the midperipheral retina. These isolated tissue units incorporate an outer sheath of hypoxic cells within which vascular endothelial growth factor is upregulated. This 'angiogenic sheath' expands following retinal detachment; it corresponds to the hypoxia-tolerant funnel within capillary-based tissue units and to the cerebral penumbra after stroke.
Collapse
Affiliation(s)
- David McLeod
- Academic Department of Ophthalmology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| |
Collapse
|
27
|
Postoperative cilioretinal artery occlusion in Sturge Weber-associated glaucoma. J AAPOS 2010; 14:358-60. [PMID: 20621528 DOI: 10.1016/j.jaapos.2010.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Revised: 04/29/2010] [Accepted: 04/29/2010] [Indexed: 11/24/2022]
Abstract
Surgical management of Sturge Weber-associated glaucoma is challenging. Choroidal effusion and expulsive choroidal hemorrhage are commonly cited potential risks. We report a case of a cilioretinal artery occlusion associated with glaucoma drainage device surgery in a child with refractory Sturge Weber-associated glaucoma.
Collapse
|