Rescue vitrectomy with blocked artery massage and bloodletting for branch retinal artery occlusion

Vitrectomy and manipulation of intraocular and arterial pressures for the treatment of nonarteritic central retinal artery occlusion

The purpose of this study is to describe a surgical technique and report the functional outcome of treating nonarteritic central retinal artery occlusion (CRAO) in 2 eyes of two consecutive male patients. Two males (A) and (B) presented 6 days and few hours, respectively, after symptom onset with the clinical features typical of CRAO, including sudden severe deterioration of vision to counting fingers and a cherry-red spot in the left and right fovea, respectively. While A had been on recent treatment for hypertension and hyperlipidemia, B had no significant medical history. Both patients underwent surgery, A, 9 days, and B, <15 h after symptom onset. Surgery involved a vitrectomy, lowering of intraocular pressure (<3 mmHg), and gradual increase of arterial pressure to 165/100 mmHg (through the slow injection of intravenous adrenaline). Intraoperatively, this resulted in immediate perfusion and visible dilation of the blood-filled central retinal artery (CRA) and retinal arteriolar network and dilatation of the central retinal vein. The final vision settled to 6/60 in A and 6/36+1 in B. Although preoperative macular infarction persisted in both eyes as demonstrated by optical coherence tomography angiography, both patients claim a convincing subjective visual benefit. The procedure appeared to have positively changed the natural history of the disease in both eyes. Vitrectomy with the manipulation of intraocular and arterial pressures significantly increases ocular perfusion along the entire CRA, which can dislodge CRA thrombo-emboli and has the potential to restore retinal perfusion and improve visual outcome if undertaken before irreversible retina damage. This is a relatively straightforward technique and should join the list of surgical techniques for treating CRAO.

Intraoperative Cycling Pressure Variation in the Treatment of Central Retinal Artery Occlusion

A 45-year-old male presented to the clinic of ophthalmology with central retinal artery occlusion (CRAO). There was no response to medical treatment, ocular massage, and anterior chamber paracentesis. CRAO was resolved by pars plana vitrectomy and intraoperative cycling pressure variation. The best-corrected visual acuity improved to 20/100 on the first day and to 20/20 on the first month, postoperatively.