A cluster of central retinal artery occlusions following cataract surgery

Retinal artery occlusion after ophthalmic surgery under regional anaesthesia: A narrative review

Two recent cases of central retinal artery occlusion under otherwise uncomplicated sub-Tenon's block that resulted in significant visual loss after cataract surgery prompted us to undertake a literature review of such cases. We identified 97 cases of retinal artery occlusion after ophthalmic surgery under regional anaesthesia that had no immediate signs of block-related complications. These occurred after various intraocular (87%) and extraocular (13%) operations, across a wide range of ages (19-89 years) on patients with (59%) or without (39%) known risk factors. The anaesthetic techniques included 40 retrobulbar blocks, 36 peribulbar blocks, 19 sub-Tenon's blocks, one topical anaesthetic and one unspecified local anaesthetic. Different strengths of lidocaine, bupivacaine, mepivacaine and ropivacaine, either alone or in various combinations, were used. The details of the anaesthetic techniques were often incomplete in the reports, which made comparison and analysis difficult. Only nine cases had their cause (optic nerve sheath injury) identified, while the mechanism of injury was unclear in the remaining patients. Various mechanisms were postulated; however, the cause was likely to be multifactorial due to patient, surgical and anaesthetic risk factors, especially in those with compromised retinal circulation. As there were no definite risk factors identified, no specific recommendations could be made to avoid this devastating outcome. We have provided rationales for some general considerations, which may reduce this risk, and propose anaesthetic options for ophthalmic surgery on the fellow eye if required, based both on our literature review and our personal experience.

Visual Recovery in 2 Cases of Central Retinal Artery Occlusion Treated With Prompt Intra-ophthalmic Artery Fibrinolysis

BACKGROUND

Central retinal artery occlusion (CRAO) rapidly produces inner retinal ischemia and irreversible vision loss. Although many therapeutic interventions have been proposed, no interventions have proven effective in restoring vision in large randomized controlled trials and final visual outcome in most patients is very poor.

METHODS

Retrospective case series.

RESULTS

We describe 2 cases of CRAO occurring after uncomplicated cataract surgery under topical anesthesia and rapidly diagnosed. Both had very severe vision loss at presentation with dramatic improvement after intra-ophthalmic artery fibrinolysis administered 2.75 and 5.5 hours after symptom onset.

CONCLUSIONS

Sudden monocular vision loss is an ophthalmologic emergency as CRAO must be ruled out and if diagnosed, rapid intervention should be performed. Devastating vision loss can be prevented if interventional neuroradiology is trained and available on a 24-hour basis for administration of local intra-arterial thrombolysis.

Received anti-VEGF therapy in a patient with CRAO sparing the CLRA with subretinal fluid: A case report

RATIONALE

Central retinal artery occlusion (CRAO) sparing the cilioretinal artery (CLRA) with severe subretinal fluid and non-characteristic cherry-red spot is uncommon. In the present case, the patient received an intravitreal injection of anti- vascular endothelial growth factor, which is very rare.

PATIENT CONCERNS

A 59-year-old man underwent vitrectomy of the left eye for diabetic retinopathy and vitreous hemorrhage. Six months after the operation, the patient presented with sudden painless visual-acuity decline in his left eye and was diagnosed with CRAO; his best corrected visual acuity was weak light perception. Whole retinal edema was seen on the fundus, and macular gray retinal opacification was present without a characteristic cherry-red spot. Optical coherence tomography revealed subretinal fluid (SRF) in the papillomacular bundle and inner retinal thickening. Fundus fluorescein angiography confirmed that the central retinal artery was not filled at 40 seconds and that the CLRA supplied a part of the macular area. Eight months after the second intravitreal injection of ranibizumab, Optical coherence tomography showed a significant reduction in inner retinal hyperreflectivity and the thickness of the nasal macular retina. The SRF was clearly absorbed, and the visual acuity improved to 1.1 logMAR units.

DIAGNOSIS

Atypical CRAO.

INTERVENTIONS

The patient was treated with intravitreal injection of anti-VEGF in his left eye. The thickness of the nasal macular retina decreased.

OUTCOMES

The SRF was clearly absorbed, and the patient's visual acuity significantly improved.

LESSONS

When CRAO occurs in patients with diabetic retinopathy sparing the CLRA, the non-characteristic cherry-red spot may be due to macular inner retinal edema, SRF and other factors. According to the patient's condition, anti-vascular endothelial growth factor can be administered as appropriate to inhibit choroidal neovascularization, reduce SRF in the macular retina, and save some vision.

Endophthalmitis after pars plana vitrectomy with reused single-use devices: a 13-year retrospective study

BACKGROUND

To describe the incidence, clinical characteristics, and treatment outcomes of endophthalmitis after pars plana vitrectomy (PPV) with recycled single-use devices. The recommended sterilization process as well as safety measures are discussed.

METHODS

Medical charts of patients who developed endophthalmitis after PPV were retrospectively reviewed and reported in a descriptive manner. Cases undergoing PPV for preexisting endophthalmitis or open globe injury were excluded. Data collection included patient demographics, operative details, ocular findings, microbiological profiles, treatment modalities, and visual outcomes.

RESULTS

Over the past thirteen years, a total of 12,989 pars plana vitrectomy operations were included. In total, 13 eyes of 13 cases (0.10%) experienced endophthalmitis after vitrectomy. These occurred in 3 cases (0.11%) using 20-gauge vitrectomy compared to 8 cases (0.09%) using 23-gauge vitrectomy and 2 cases (0.18%) using 25-gauge vitrectomy. There were no statistically significant differences between the 20-gauge and microincisional vitrectomy surgery (MIVS) group (P = 0.64), and the 23- and 25-gauge approach (P = 0.34). Causative pathogens were positive by culture in 5 cases (45%): 3 g-positive cases, 1 g-negative case, and 1 fungus case.

CONCLUSIONS

The rate of endophthalmitis in patients who underwent 23-gauge PPV was comparable to those who underwent 25-gauge PPV. With our standardized protocol for instrument sterilization, endophthalmitis rates in those undergoing PPV using recycled single-use instruments were within the range of previously published results in which vitrectomy tools were disposed of after one use.

Central retinal artery occlusion after Descemet membrane reposition by intracameral air: A case report

PURPOSE

To report a case of central retinal artery occlusion after Descemet membrane reposition by intracameral air.

METHODS

An otherwise healthy 60-year-old woman presented with white mature cataract in her left eye. Ocular exam of both eyes was within normal limits. After an uneventful topical phacoemulsification, a moderate-grade striate keratopathy and non-planar Descemet membrane detachment was noted on first postoperative day, which was confirmed on anterior segment optical coherence tomography. The Descemet membrane was repositioned within 24 h of cataract extraction by intracameral air tamponade (pneumatic descematopexy) under topical anesthesia, and partial air release was done after 2 h. The patient was evaluated for decreased immediate postoperative vision of perception of light.

RESULTS

After pneumatic descematopexy, the stromal edema relatively cleared. The intraocular pressure before releasing the intracameral air was 38 mmHg and antiglaucoma medication was started. Dilated fundus exam showed retinal pallor and a cherry-red spot over the macula. A diagnosis of central retinal artery occlusion was confirmed, and thorough systemic workup was done. Systemic investigations were within normal limits. The patient was managed conservatively, but the final visual acuity remained at 1/60.

CONCLUSION

Central retinal artery occlusion is not a reported complication after pneumatic descematopexy for Descemet membrane detachment management. The possible mechanism could be sudden increase in intraocular pressure due to pupil block by air, and thus, ocular surgeries with use of intracameral air for prolonged duration warrants close monitoring of intraocular pressure and its subsequent management.