Central retinal vein occlusion: report of two familial cases

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1 Europen Journl of Ophthlmology / Vol. 9 no. 3, 1999 / pp Centrl retinl vein olusion: report of two fmilil ses N. BHAGAT 1, M.F. GOLDBERG 2, P. GASCON 3, W. BELL 4, J. HABERMAN 1, M.A. ZARBIN 1 1 Deprtment of Ophthlmology, New Jersey Medil Shool 2 Wilmer Ophthlmologil Institute, the Johns Hopkins Hospitl 3 Deprtment of Mediine, New Jersey Medil Shool 4 Deprtment of Mediine, the Johns Hopkins Hospitl, Newrk, NJ - U.S.A. ABSTRACT: The uthors report 46-yer-old fther nd 17-yer-old son who eh presented with unilterl entrl retinl vein olusion (CRVO) nd ilterl normlities of retinl vsulr perfusion. The son presented with nonperfused CRVO in the left eye, developed trtion-rhegmtogenous retinl dethment treted with vitreous surgery, nd developed prolonged rteriovenous filling in the retin of the fellow eye. The fther presented with progressive CRVO in the right eye, developed horoido-vitrel neovsulriztion following lser tretment to rete horioretinl nstomosis, underwent vitretomy for retinl dethment nd vitreous hemorrhge in tht eye, nd developed prolonged rm-eye nd retinl rteriovenous irultion times in the fellow eye. An extensive evlution (inluding hemtologil studies nd imging of the mjor vessels of the nek) filed to revel predisposing use in either ptient lthough ehordiogrphy dislosed mitrl vlve thromus in the fther. After institution of oumdin therpy, the irultory prmeters in the fellow eye of eh ptient improved. (Eur J Ophthlmol 1999; 9: ) KEY WORDS: Retinl vein olusion, Fmilil, Coumdin, Surgery Aepted: July 1, 1999 INTRODUCTION Centrl retinl vein olusion (CRVO) usully ours in older dults ut does our in young dults (1). Bilterl normlities of retinl venous perfusion often indites n underlying systemi normlity (1). Fmilil ourrene of CRVO is highly unusul. We report middle-ged fther nd teenge son who eh presented with unilterl CRVO nd ilterl normlities of retinl vsulr perfusion. Cse report Son A 17-yer-old Portuguese mn ws referred y his ophthlmologist (JH) to rule out CRVO in Mrh The ptient notied deresed vision in his left eye fter eing hit y wve while on eh seven months erlier. The pst medil nd oulr history were unremrkle. Visul uity ws 20/20 OD nd 2/200 OS. A left reltive fferent pupillry defet ws present. Slit lmp nd fundus exmintion of the right eye were norml. Slit lmp exmintion of the left eye ws unremrkle. No neovsulriztion ws noted on the iris or in the ngle y goniosopy. The vitreous ws synereti with 1+ ells. Indiret ophthlmosopy of the left eye dislosed ler medi nd flt retin. Biomirosopy of the left eye dislosed mrked swelling of the opti nervehed, prominent mulr edem, nd retinl whitening interpreted s ishemi mulr infrtion. Moderte intrretinl hemorrhge surrounded the mul nd the opti nervehed, nd sttered dot nd lot hemorrhges were present s y Wihtig Editore, /181-15$07.50/0

2 Fmilil CRVO Fig. 1 - ) Apperne of son s left fundus on presenttion (3/96). Retinl whitening in the mul n rely e diserned t this mgnifition. ) Fluoresein ngiogrm of son s left fundus on presenttion. Dye fills the retinl rtery t 13.4 s. ) Venous filling is omplete y 25.1 s. fr peripherlly s the or serrt for 360 degrees (Fig. 1). There ws smll re of neovsulriztion inferonslly t the equtor t 8:00 o lok. Vsulr shething ws not present. B-sn ehogrphy did not show evidene of opti nerve drusen in either eye. A dignosis of CRVO ws mde. No signifint pst medil history ws eliited. There ws no fmily history of hyperogulle disorders. An extensive medil evlution ws norml exept for the eye findings. The omplete lood ount, lood hemistry, lipid profile, nd erythroyte sedimenttion rte (ESR) were norml (T. I). A fluoresein ngiogrm showed norml rm-eye irultion time, nd norml rteriovenous trnsit time on the left, suggesting tht there hd een renliztion of the vein with reperfusion (Fig. 1). There ws no evidene for vsulitis in either eye. At follow-up exmintion in My 1996, trtionrhegmtogenous retinl dethment involving the mul ws noted, rising from rek t the equtor in the 3:15 o lok meridin ssoited with n re of lolized vitreoretinl dhesion (not shown). The dethment extended s fr s the opti dis nslly nd ws onfined within the temporl rdes. The ptient underwent prs pln vitretomy, fluid-gs exhnge, nd endolser to retth the retin (MAZ). The etiologi rek ws ssoited with n re of vitreoretinl trtion rising from dherent retinl neovsulriztion. One month lter, visul uity ws 20/20 OD nd HM OS. The introulr pressure ws 18 mm Hg OD nd 12 mm Hg OS. The exm of the right eye ws unhnged. Fundus exm of the left eye dislosed ler medi nd flt retin with extensive pnretinl photoogultion. Mrked mulr edem persisted with newly evident suretinl firosis under the mul. At follow-up exmintion in Septemer 1996, the entrl retinl rtery of the right eye ollpsed with miniml digitl pressure. A fluoresein ngiogrm trnsiting the right eye reveled slightly prolonged rteriovenous trnsit time with norml rm-eye irultion time (Fig. 2). The ptient ws referred to hemtologist (PG) for further evlution (T. I) nd ws strted on 125 mg spirin PO qam. In Deemer 1996, the visul uity ws 20/20 OD nd 20/200 OS. The introulr pressure nd slit lmp 182

3 Bhgt et l Fig. 2 - Fluoresein ngiogrm of son s right eye in Septemer ) Dye is first evident in the retinl rtery t 14.5 s. ) Lminr venous filling is evident in the next frme t 20.7 s. ) Lminr venous filling is evident t 32.3 s. exm were norml in eh eye. Fundusopi exm of the right eye ws norml. Fundusopi exm of the left eye dislosed ler medi, flt retin, stle sumulr firosis, nd n epiretinl memrne long the superotemporl rde with some fovel trtion (Fig. 3). A repet fluoresein ngiogrm showed normlly prolonged rteriovenous trnsit time in the right eye (Fig. 4). Beuse of the progressive normlities in the right eye, the ptient ws strted on oumdin titrted suh tht the interntionl rtio (INR) ws etween , t the suggestion of his hemtologist (PG). In Ferury 1997, the visul uity ws 20/20 OD nd 20/200 OS. A repet fluoresein ngiogrm of the right eye (with the ptient ntiogulted), showed mild improvement in the rteriovenous trnsit time (Fig. 5). Fig. 3 - Apperne of son s left fundus 7 months fter vitreous surgery. Prominent perippillry epiretinl firosis nd sumulr firosis re evident. Fther In My 1996, the 46-yer-old fther ws referred y his generl ophthlmologist (JH) for evlution of three episodes of murosis fugx OD. Eh episode lsted from 1.5 to 3 hours nd ws not ssoited with other systemi symptoms. The visul uity ws 20/20 in eh eye. Amsler grid testing, olor vision (Ishihr pseudoisohromti pltes), nd slit lmp exmintion were norml in oth eyes. The introulr pressure (pplntion) ws 13 mm Hg 183

4 Fmilil CRVO TABLE I - HEMATOLOGICAL EVALUATION OF THE SON Test Result Norml rnge CBC WBC 7.8 T/ul T/ul Hemogloin 15.3 g/dl g/dl Hemtorit 43.4% % Pltelets 194 T/ul T/ul Chemistry Sodium 134 meq/l meq/l Potssium 4.0 meq/l meq/l Chloride 100 meq/l meq/l BUN 16 mg/dl 8-20 mg/dl Cretinine 0.6 mg/dl mg/dl Gluose 90 mg/dl mg/dl Uri id 4.9 mg/dl mg/dl SGOT 12 U/L 5-37 U/L SGPT 11 U/L 0-48 U/L LDH 123 U/L U/L Clium 9.0 mg/dl mg/dl Phosphorus 2.9 mg/dl mg/dl PT 12.6 se se PT 24.8 se se Cholesterol 147 mg/dl mg/dl Triglyerides 126 mg/dl mg/dl LDL 88 mg/dl mg/dl HDL 34 mg/dl >34 mg/dl Iron, totl 82 mg/dl mg/dl Iron inding pity 368 mg/dl mg/dl ESR 14 mm/hr 0-20 mm/hr ANA Negtive negtive Rheumtoid ftor Negtive negtive Hemogloin A1 6.8% 6.5% Compliment CH U/ml U/ml Sikle ell sreen Negtive negtive Hemogloin A 100% 100% RPR non-retive non-retive Protein C ntigen 126% % Protein S ntigen 98% % Protein S tivity 93% % Ativted Protein C 4.05 rtio rtio Resistne Lupus-type ntiogulnt Negtive negtive Crdiolipin A IgG <15 GPL <15 GPL Crdiolipin A IgM <10 MPL <10 MPL Crdiolipin A IgA <10 APL <10 APL 184

5 Bhgt et l Test Result Norml rnge Antithromin pnel tivity 120 % % ntigen 29 mg/dl mg/dl Phosphotidylserine A IgG <2.0 SD <2.0 SD Phosphotidylserine A IgM <2.0 SD <2.0 SD Phosphotidylserine A IgA <2.0 SD <2.0 SD Firinogen 321 mg/dl mg/dl Ftor V gene no Arg 506 to Gln muttion no Arg 506 to Gln muttion Serum homoysteine 9.4 mmol/l mmol/l Crotid doppler Norml norml Trnsesophgel negtive for rdi lots or norml ehordiogrm ny vlvulr normlity Pltelet ggregtion ollgen 26 ohms ohms rhidoni id 20 ohms 4-32 ohms ristoetin 27 ohms 5-35 ohms Pltelet relese thromin 1.9 nmoles of ATP >0.5 nmoles of ATP ollgen 1.1 nmoles of ATP nmoles of ATP rhidoni id 0.2 nmoles of ATP nmoles of ATP OD nd 19 mm Hg OS. Fundusopi exmintion of the right eye dislosed tht the veins were somewht engorged t the opti nervehed, nd there were sttered intrretinl hemorrhges long the temporl rdes nd in the midperiphery, prtiulrly superiorly (Fig. 6). The mul ppered norml. Fundus exm of the left eye lso reveled ler medi nd flt retin. The veins ppered slightly engorged in the posterior pole ut were not tortuous. A venous shunt vessel ws present t the opti nervehed (Fig. 7). There were no peripherl normlities. B-sn ehogrphy dislosed no uried drusen of the opti nerveheds. A fluoresein ngiogrm dislosed prolonged rteriovenous trnsit time in the right eye (Fig. 8). The ptient s symptoms were presumed to e due to intermittent CRVO OD. The vsulr nomly t the opti nervehed in the left eye ws thought to e either ongenitl mlformtion or n quired mnifesttion of oult venous olusive disese. The ptient ws ontinued on Timopti nd spirin, whih hd een strted y his generl ophthlmologist (JH). The ptient ws seen y n internist, nd the generl medil exmintion ws norml. Over the next four weeks the vision delined, s the CRVO progressed on the right. By July 1996, the visul uity ws 20/160; pinhole, 20/50-1 OD nd 20/20 OS. Amsler grid testing showed entrl reltive sotom OD. The introulr pressure ws 15 mm Hg OD nd 14 mm Hg OS. Slit lmp exm of the eh eye ws notle for the sene of rueosis iridis. Fundusopi exm of the right eye dislosed inresed intrretinl hemorrhge nd the presene of mulr edem (Fig. 9). Fundus exm of the left eye dislosed few intrretinl hemorrhges in the temporl prmulr re (Fig. 9). The ptient ws dignosed s hving impending CRVO OS. The ptient ws referred to hemtologist (PG) for further evlution (T. II). A fluoresein ngiogrm trnsiting the right eye dislosed prolonged rm-eye irultion time OD, prolonged rteriovenous trnsit time OD, nd no definite mirovsulr normlities OS (Fig. 10). A lser (rgon lue-green) horoiretinl venous nstomosis ws ttempted in the right eye t this time (not shown). At follow-up exmintion on July 26, the visul uity ws 5/160 OD nd 20/20 OS. The introulr pressure ws 11 mm Hg OD nd 18 mm Hg OS. Slit lmp 185

6 Fmilil CRVO TABLE II - HEMATOLOGICAL EVALUATION OF THE FATHER Test Result Norml rnge CBC WBC 6.4 T/ul T/ul Hemogloin 15.1 gm/dl gm/dl Hemtorit 43.9% % Pltelets 211 T/ul T/ul Chemistry Sodium 138 meq/l meq/l Potssium 4.5 meq/l meq/l Chloride 98 meq/l meq/l BUN 26 mg/dl 8-20 mg/dl Cretinine 0.9 mg/dl mg/dl Gluose 96 mg/dl mg/dl Uri id 8.9 mg/dl mg/dl SGOT 24 U/L 5-37 U/L SGPT 12 U/L 0-48 U/L LDH 124 U/L U/L Clium 9.8 mg/dl mg/dl Phosphorus 2.7 mg/dl mg/dl PT 13.2 se se PTT 32.6 se se Bleeding time 4.5 min min Cholesterol 178 mg/dl <200 mg/dl Triglyerides 102 mg/dl <200 mg/dl LDL 117 mg/dl mg/dl HDL 41 mg/dl >34 mg/dl Serum eletrophoresis Protein, totl 7.1 g/dl g/dl Alumin 4.0 g/dl g/dl Alph-1-Gloulin 0.3 g/dl g/dl Alph-2-Gloulin 0.8 g/dl g/dl Bet Gloulin 0.8 g/dl g/dl Gmm Gloulin 1.0 g/dl g/dl Iron, totl 103 mg/dl mg/dl Iron inding pity 345 mg/dl mg/dl ESR 5 mm/hr 0-20 mm/hr ANA Negtive negtive Rheumtoid ftor Negtive negtive VDRL non-retive non-retive Sikle ell sreen Negtive negtive Hemogloin A 100% 100% Protein S, totl 76 mg/dl mg/dl tivity 150% % free 55% % 186

7 Bhgt et l Test Result Norml rnge Protein C ntigen 98% >70% Protein C tivity 124% % Ativted protein C resistne rtio Lupus nti-ogulnt Negtive negtive Crdiolipin ntiody IgG 2 GPL units 0-12 GPL units IgM 3 MPL units 0-6 MPL units IgA <10 SDU <10 SDU Antithromin pnel tivity 137% % ntigen 23 mg/dl mg/dl Russell s viper venom 27.3 se se Plsminogen tivity 110% % Plsminogen tivtor 20.0 UL/ml UL/ml inhiitory ftor Alph-2 nti-plsmin 112% % Firinogen 379 mg/dl mg/dl Ftor V gene no rg 506 to gln muttion no rg 506 to gln muttion Serum homoysteine 10.4 mmol/l mmol/l Pltelet ggregtion ollgen 30 ohms ohms rhidoni id 19 ohms 4-32 ohms ristoetin 34 ohms 5-35 ohms Pltelet relese thromin 1.5 nmoles of ATP >0.5 nmoles of ATP ollgen 0.8 nmoles of ATP nmoles of ATP rhidoni id 0.4 nmoles of ATP nmoles of ATP exm of eh eye ws norml. Fundusopi exm of the right eye dislosed dilted, tortuous veins with retinl hemorrhge in ll four qudrnts nd n inrese in mulr edem. Fundusopi exm of the left eye dislosed mildly inresed intrretinl hemorrhge nd three mironeurysms temporl to the fove (Fig. 11). The venous loop t the opti nervehed ws unhnged in pperne. Fluoresein ngiogrphy dislosed no evidene for horioretinl venous nstomosis, so lser photoogultion ws repeted superonslly (not shown). The ptient ws referred to the Wilmer Ophthlmologil Institute (MFG) on July 29, 1997 for further evlution nd mngement. His visul uity ws 1/200 OD nd 20/16 OS. The introulr pressure ws 15 mm Hg OD nd 16 mm Hg OS. Fundus exm of the right eye dislosed dilted, tortuous veins with flmeshped moderte intrretinl hemorrhges in ll four qudrnts nd mrked ystoid mulr edem. An re of horoido-vitrel neovsulriztion ws evident t the site of the horioretinl nstomosis inferonsl to the opti dis. Fundusopi exmintion of the left eye dislosed new finding of some sttered dot nd lot hemorrhges in the inferior periphery temporlly nd nslly, posterior to the equtor. Extensive hemtologil studies were done t the Johns Hopkins Hospitl (WB). The evlution ws within norml limits exept for mildly elevted ntithromin nd protein S tivity. These normlities were not felt to e linilly signifint. On the ptient s return visit to the New Jersey Medil Shool on August 2, the vision ws 5/200 OD 187

8 Fmilil CRVO Fig. 4 - Fluoresein ngiogrm of son s right fundus in Deemer 1996 showing prolonged rteriovenous trnsit time OD. ) Dye is first evident in the retinl rtery t 16.4 s. ) Lminr venous filling is evident t 26.1 s. ) Lminr venous filling is evident t 39.9 s. nd 20/20 OS. Fundusopi exm showed CRVO nd n inferonsl horoido-vitrel neovsulr memrne t the site of previous lser photoogultion (Fig. 12). Fluoresein ngiogrphy reveled horoido-vitrel neovsulr memrne pproximtely 1 1/2 dis res in size t the nstomosis site (Fig. 12). Using Krypton red lser, the horoido-vitrel neovsulr memrne ws treted with onfluent white lser urns. Fluoresein ngiogrphy on August 6, 1996 showed prolonged rm-eye nd rteriovenous trnsit times of the left eye, for the first time (Fig. 13). The ptient went to Portugl for further medil evlution. During the evlution, hert murmur ws noted, nd ehordiogrphy reveled n extensive thromus emnting from the mitrl vlve. Coumdin therpy ws instituted suh tht INR ws etween When the ptient returned to the United Sttes in Septemer 1996, his visul uity ws finger ounting t 1 foot OD nd 20/20 OS. There ws new finding of erly posterior vitreous seprtion with suhyloid hemorrhge in the right eye. Fundusopi exm of the left eye dislosed retinl mirovsulr normlities in the superotemporl nd inferonsl periphery. There hd een mild ut definite worsening of the linil pperne of the left fundus. A repet fluoresein ngiogrm reveled tht the rm-eye irultion time hd normlized, nd the rteriovenous trnsit time hd improved sustntilly following the initition of oumdin therpy in Portugl (Fig. 14). At follow-up in Novemer 1996, the visul uity ws re light pereption OD nd 20/20 OS. Slit lmp exm of oth eyes ws within norml limits. The introulr pressure ws 15 mm Hg OU. Fundusopi exm OD showed dull ornge reflex. Fundusopi exm OS reveled ler medi nd few mironeurysms in the mul nd within the superotemporl rde. The veins were slightly dilted. Comined A nd B sn ehogrphy of the right eye reveled dispersed lood in the vitreous vity, suhyloid hemorrhge, nd trtionl retinl elevtion involving the mul. Repet lood testing reveled tht the ptient ws exessively ntiogulted. The prothromin time ws 21.7 seonds with n INR of The oumdin dose ws 188

9 Bhgt et l Fig. 5 - Fluoresein ngiogrm of son s right fundus in Ferury 1997 showing mild improvement in the rteriovenous trnsit time fter initition of oumdin therpy. ) Dye is first evident in the retinl rtery t 17.9 s. ) Lminr venous filling is evident t 26.5 s. ) Venous filling is omplete y 39.9 s. djusted. The ptient underwent prs pln vitretomy, memrne peeling, endolser tretment (round retinl rek nsl to the opti nervehed), slerl uking (#42 nd), nd fluid-gs exhnge. At surgery, dense vitreous hemorrhge ws present. The posterior hyloid ws exised out to the equtor for 360 degrees. Extensive firovsulr prolifertion ws present long the temporl rdes, over the opti nervehed, nd in the nsl mid-periphery, nd ppered to hve emnted from the retino-horoidl nstomosis. In ddition, the vsulr lier t the opti nerve-hed ws mrkedly ttenuted. There ws mild pllor of the opti nervehed, nd the retin ppered ishemi. Postopertively, the ptient lost light pereption despite omplete retinl retthment nd norml periopertive introulr pressure. In Jnury 1997, the visul uity ws no light pereption OD nd 20/20 OS. The introulr pressure ws 6 mm Hg OD nd 15 mm Hg OS. Slit lmp exm ws unremrkle OU. Fundusopi exm of the right eye dislosed ler medi nd flt retin with moderte enirling slerl ukle. Regressed neovsulr tissue ws present nsl to the opti nervehed, whih ws ple temporlly. Fundusopi exm of the left eye ppered stle nd dislosed numer of mironeurysms in the inferonsl nd superotemporl periphery. A repet fluoresein ngiogrm showed definite improvement in the rteriovenous trnsit time in the left eye s well s in the rm eye irultion time ompred to the studies of Novemer A repet exmintion in Novemer 1997 lso dislosed stle fundusopi exmintion with nerly norml rteriovenous trnsit time in the left eye (Fig. 15). Thus, the fther s rm-eye irultion time nd rteriovenous trnsit time in the left eye improved sustntilly following the initition of oumdin therpy. In view of the ilterl nture of the vsulr nomlies nd the prolonged rm-eye irultion time, the possiility of orti rh disese (e.g., Tkysu disese or disese with similr ntomi onsequenes) ws onsidered. A mgneti resonne ngiogrm (inluding visuliztion of the rotid system) ws done in oth the fther nd the son, nd no mjor ongenitl struturl normlities were deteted in either ptient. 189

10 Fmilil CRVO CRVO in young dults is unommon: 10-15% of ptients with CRVO re under 40 yers of ge (2-4). Although CRVO is osionlly ssoited with systemi disese, the use is unknown in the mjority of ses. Bilterl CRVO hs een reported in ptient with sleroderm who lso hd pulmonry firosis, or pulmonle, rdi deompenstion, nd seondry polyythemi (5). This ptient lso hd delyed retinl rteril filling on fluoresein ngiogrphy. Our ptients did not hve evidene of sleroderm. Heritle onditions tht might oneivly led to fmilil CRVO inlude hyperogulle sttes suh s protein C defiieny, protein S defiieny, tivted protein C resistne, ntithromin defiieny, hyper d Fig. 6 - ) Apperne of fther s right fundus on presenttion (5/96). The nerve nd mul pper norml lthough the veins re somewht engorged. ) Superonsl periphery of photo in showing intrretinl hemorrhges long the superotemporl rde nd in the nsl periphery. ) Inferonsl periphery showing intrretinl hemorrhge. d) Intrretinl hemorrhge ner superotemporl rde. The hemorrhge is slightly out of fous. DISCUSSION Fig. 7 - Apperne of fther s left fundus on presenttion (5/96). Note venous shunt vessels on the opti dis nslly in ddition to the horoidl nevus inferior to the dis. 190

11 Bhgt et l Fig. 8 - Fluoresein ngiogrm of the fther s right fundus dislosing prolonged rteriovenous trnsit time (5/96). ) Dye first ppers in the retinl rteries t 20.7 s. ) Erly lminr venous filling is still evident t 29.3 s. ) Lte venous filling phse shows dye lekge from the entrl retinl vein t the opti nervehed (1 min., 12.3 s). Fig. 9 - ) Apperne of fther s right fundus in June CRVO ws present. ) Apperne of fther s left fundus in June A few retinl mironeurysms re present temporl to the fove in the 3:45 o lok meridin. 191

12 Fmilil CRVO Fig Fundus fluoresein ngiogrm of fther in July ) Dye first ppers in the retinl rteries t 25.0 s. ) Lminr venous filling is evident t 37.0 s. ) Are of intrretinl hemorrhge temporl to the left mul loks fluoresene. Fig Fundus photogrph of fther s left eye in July Note inresed intrretinl hemorrhge temporl to the fove ompred to Figure 9. lipoproteinemi (), hyperhomoysteinemi, nd inresed plsminogen tivtor inhiitor tivity (1, 6-18). Fmilil CRVO hs een reported y Cstell nd Othenin-Girrd (19). Three memers of fmily with type II hyperlipoproteinemi, two of whom were less thn 40 yers of ge, presented with CRVO. Our ptients did not hve these predisposing onditions. The fmily history in the ses reported here suggests the possiility of n utosoml dominnt gene predisposing to vsulr olusion. The fther might e the first person in his fmily to rry this puttive gene, or there my e other symptomti rriers due to vrile penetrne. The only normlity present in oth the fther nd son ppers to e redued relese of ATP with rhidoni id s hllenger. The isolted finding of redued ggregtion to rhidoni id does not fit ny of the known pltelet defets. This normlity is seen in Glnzmnn s thromstheni nd storge-pool defiieny or in spirin effet (20). If ny of the three onditions were present, there would hve een other normlities esides redued response to rhidoni id. In the se of heterozygotes, one lso n expet normlities in pltelet funtion, ut in more thn one prmeter. In summry, we find no logil explntion for this in vitro result of redued ATP relese in response to rhidoni id hllenge, espeilly s unique feture. In ny se, ny of the three onditions mentioned ove would predispose the ptient towrds leeding, quite the opposite of wht we oserved in this fther nd son. 192

13 Bhgt et l The presene of CRVO in the fther nd son represents n interesting nd infrequently reported finding. The heritle uses of CRVO mentioned ove were ruled out in these two ptients. The fther hd signs of impending CRVO in the other helthy eye, the progress of whih hlted following the initition of the ntiogulnt therpy, oumdin. The prolonged rm-eye irultion time nd rteriovenous trnsit time improved fter few weeks of therpy. The son hd prolonged reti Fig ) Fundus photogrph of fther s right eye in August 1996 showing horoido-vitrel neovsulriztion t the site of previous lser photoogultion. ) Fluoresein ngiogrm of the re shown in. Fig Fundus fluoresein ngiogrm of the fther s left eye showing prolonged rm-eye nd rteriovenous trnsit times (8/6/96). ) Retinl rteril filling is first evident t 31.7 s. ) Erly lminr venous filling is evident t 50.6 s. ) Venous filling is omplete t 1 min., 2.2 s. 193

14 Fmilil CRVO Fig Fundus fluoresein ngiogrm of the fther s left eye showing improved rm-eye nd rteriovenous trnsit times fter initition of oumdin therpy (9/13/96). ) Dye first ppers in the retinl rteries t 21.3 s. ) Venous filling is nerly omplete y 36.4 s. Fig Fundus fluoresein ngiogrm of fther s left eye in Novemer Note the sustined improvement in the rm-eye nd rteriovenous trnsit times. ) Dye first ppers in the retinl rteries t 16.2 s. ) Venous filling is nerly omplete y 34.4 s. nl rteriovenous filling in the fellow eye, ut no intrretinl hemorrhge or mirovsulr normlities. The retinl rteriovenous filling time improved following oumdin therpy. Antiogulnts hve een used to tret some ptients with retinl vsulr olusion (1). Antiogultion with oumdin my use inresed intrretinl nd intrvitrel hemorrhge in some ptients. The signifine of the response to oumdin regrding the pthogenesis of the ondition in these two ptients is unknown. ACKNOWLEDGEMENTS The uthors thnk Alex Ho, Mxine Wnner, nd Ilene Sugino for exellent editoril nd photogrphi ssistne nd Dr. JDM Gss for expert onsulttion nd suggestions for mngement of these ptients. Supported y Reserh to Prevent Blindness, In., the New Jersey Lions Eye Reserh Foundtion, the Eye Institute of New Jersey, nd the Guerrieri Retinl Reserh Fund. 194

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