Local Intra-arterial Fibrinolysis in Treatment of Incomplete Ophthalmic Artery Occlusion A Case Report

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1 CASE REPORT Local Intra-arterial Fibrinolysis in Treatment of Incomplete Ophthalmic Artery Occlusion A Case Report Shih-Ting Fang, Pao-Sheng Yen 1, Chien-Chung Chen, Yuan-Chieh Lee Department of Ophthalmology, Radiology 1, Buddhist Tzu Chi General Hospital, Hualien, Taiwan ABSTRACT Ophthalmic artery occlusion usually causes severe permanent visual loss, and conservative treatments generally have poor prognoses in most cases. We present a patient with incomplete ophthalmic artery occlusion, who achieved significant visual improvement after receiving local intraarterial fibrinolysis (LIF) in the ophthalmic artery after a delay of two weeks. LIF is one of the treatments to salvage vision in patients with incomplete ophthalmic artery occlusion if no contraindications for thrombolysis exist. (Tzu Chi Med J 2004; 16: ) Key words: local intraarterial fibrinolysis (LIF), ophthalmic artery occlusion, fluorescein angiography, urokinase INTRODUCTION Ophthalmic artery occlusion, presenting with both central retinal artery occlusion and choroidal vascular insufficiency, usually causes severe permanent visual loss. Conservative treatments generally have poor prognoses in most cases. We present a patient with incomplete ophthalmic artery occlusion, who achieved significant visual improvement after receiving local intraarterial fibrinolysis in the ophthalmic artery. CASE REPORT A 37-year-old man presented with painless visual loss in the right eye for 2 weeks. He had diabetic mellitus and chronic pancreatitis and denied previous similar episodes in either eye. On examination, the best-corrected visual acuity was 20/200 in the right eye and 20/25 in the left. The light reflex in the right eye was sluggish with relative afferent pupillary defect. The intraocular pressure was 12 mmhg in both eyes. Slit-lamp examination of the anterior segment was unremarkable in both eyes. Indirect ophthalmoscopic examination of the right eye showed arteriolar attenuation, relatively dark choroid, and some retinal hemorrhages on the posterior pole (Fig. 1A). No cherry-red spot was seen. There were some cotton-wool spots, and retinal hemorrhages in the left eye (Fig. 1B). Fluorescein angiography revealed delayed arterial filling (27.2 seconds) with delayed and incomplete choroidal perfusion in the right eye (Fig. 2A). The late phase of fluorescein angiography demonstrated segmental leakage in both eyes (Fig. 2B, 2C). Erythrocyte sedimentation rate (ESR) was 10 mm/hour. Under the impression of incomplete ophthalmic artery occlusion of the right eye, carotid angiography was performed and it showed patent carotid arteries on both sides. There was retrograde flow through the right ophthalmic artery with decreased choroidal "blush" in the right eye, which was compatible with the impression of Received: January 12, 2004, Revised: March 22, 2004, Accepted: April 12, 2004 Address reprint requests and correspondence to: Dr. Yuan-Chieh Lee, Department of Ophthalmology, Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan Tzu Chi Med J No. 6! QNT

2 S. T. Fang, P. S. Yen, C. C. Chen, et al Fig. 1. 1A 1B (A) Photograph of the right eye demonstrating attenuation of the retinal arteries and relatively dark choroids. (B) Photograph of the left eye demonstrating some hemorrhage and cotton wool spots. 2A 2B incomplete ophthalmic artery occlusion. Local intraarterial fibrinolysis (LIF) was performed concomitantly and 250,000 IU of urokinase was injected into the right ophthalmic artery. An increased chorioretinal "blush" was recorded afterward. On the second day after LIF, the best-corrected visual acuity in his right eye improved to 20/40. Followup fluorescein angiography revealed more rapid filling of the retinal artery and choroids (14.9 seconds, Fig. 3). No neovascular glaucoma was noted. The visual acuity was stable at 6 months after LIF. 2C DISCUSSION Fig. 2. (A) Fluorescein angiography of the right eye shows a significant delay in filling (to 27.2 seconds) of the retinal artery and choroids. (B, C) Late phase fluorescein angiography demonstrates segmental leakage in both eyes. The ophthalmic artery, branching into the central retinal artery and short posterior ciliary arteries, provides blood supply to the entire layer of the retina and choroid. Occlusion of the ophthalmic artery presents with both central retinal artery occlusion (CRAO) and choroidal vascular insufficiency, and therefore has an even worse QNU! Tzu Chi Med J No. 6

3 Fig. 3. Fluorescein angiography of the right eye after LIF shows more rapid filling of the retinal artery and choroids (14.9 Seconds). visual prognosis than CRAO. There is still no definite treatment available for this devastating disease. Most conservative maneuvers directed against CRAO have no effect upon ophthalmic artery occlusion, although maneuvers that increase retinal perfusion such as carbogen therapy (5% CO2, 95% O2) and hyperbaric oxygen therapy may have limited benefits. Local intraarterial fibrinolysis (LIF), which was developed in the early 1990s, has been applied in cases of CRAO. It has been reported to provide significantly better visual outcomes than conservative treatments [1-4]. It is more beneficial for patients with incomplete CRAO who achieve better initial vision than those with more pronounced occlusion. Other associated prognostic factors in the literature are age and time of intervention. Visual outcome is worse with advancing age. Patients treated within 6 hours of onset show better results than patients treated later. However, the results are not always satisfactory. In the series of Butz et al, no change in visual acuity as a result of treatment was observed in 59.1% of patients [5]. In LIF, urokinase or recombinant tissue plasminogen activator (r-tpa) is injected into the proximal segment of the ophthalmic artery through a microcather [1-4]. The dosages of medication have varied in different reported series. Schmidt et al administered 1 ml/min of urokinase with a total amount between 0.2 million and 1.3 million IU during a 1 to 2.5 hour period or 40 to 80 mg of r-tpa for 60 to 90 minutes. Treatment was stopped as soon as improvement of vision occurred or increased flow through the retinal vessels was noted ophthalmoscopically [1,2]. Weber et al gave 100,000 to 900,000 IU of urokinase during a period of 10 to 90 minutes [3]. Richard et al applied 10- to 20-mg of r- TPA per hour for a maximum dose of 40 mg during a maximum of 3 hours [4]. No researcher has yet com- pared urokinase and r-tpa in regard to effectiveness and safety. Reported complications of LIF include transient ischemic attack (TIA), hypertensive crisis, stroke and intracerebral bleeding [1-4]. These neurological complications occurred because of emboli produced during catheter manipulation. Weber et al suggested that LIF is contraindicated when there is high-grade carotid stenosis (>70%) or occlusion because of the increased risk of arterio-arterial embolism and stroke [3]. On the other hand, Schmidt et al placed a microcatheter in the internal maxillary artery instead of the ophthalmic artery and delivered the fibrinolytics indirectly through the maxilloophthalmic anastomoses in those patients with highgrade carotid stenosis [1,2]. Our patient presented with an acute episode of unilateral incomplete ophthalmic artery occlusion and bilateral chronic retino-choroidal hypoperfusion. Although improvement in systemic circulation might contributed to the visual recovery, we believe LIF did play a role because of the rapid dramatic visual improvement after LIF. During the six-month follow-up, the choroids darkening lessened and resolution of cotton-wool spots and hemorrhages was noted. Recently, Kattah et al presented a small pilot series of intravenous fibrinolysis in CRAO or ophthalmic artery occlusion [6]. They administered 0.9 mg/kg of r- TPA during a 1-hour period (maximum dose, 90 mg) intravenously. In the 12 enrolled patients, the visual acuity of 10 patients improved more than 2 lines. No systemic or neurological complications were reported. The major risk was highly fatal cerebral hemorrhage. The chance for this dose-related complication has been reported to range from 0.6% to 5% after TPA treatment at doses of 100 mg. If the effectiveness and safety of intravenous fibrinolysis for CRAO and ophthalmic artery occlusion are established by further studies, it can be considered as an alternative choice when LIF is not promptly available. However, strict selection of patients to exclude those with higher risks of intracranial hemorrhage is important. In summary, LIF is one of the treatments to salvage vision in patients with incomplete ophthalmic artery occlusion. It can be used if no contraindications for thrombolysis exist. REFERENCES.. 1. Schmidt DP, Schulte-Monting J, Schumacher M: Prognosis of central retinal artery occlusion: Local intraarterial fibrinolysis versus conservative treatment. Am J Neuroradiol 2002; 23: Tzu Chi Med J No. 6! QNV

4 S. T. Fang, P. S. Yen, C. C. Chen, et al 2. Schmidt D, Schumacher M: Stage-dependent efficacy of intra-arterial fibrinolysis in central retinal artery occlusion (CRAO). Neuro-ophthalmol 1998; 20: Weber J, Remonda L, Mattle HP, et al: Selective intraarterial fibrinolysis of acute central retinal artery occlusion. Stroke 1998; 29: Richard G, Lerche RC, Knospe V, Zeumer H: Treatment of retinal artery occlusion with local fibrinolysis using recombinant tissue plasminogen activator. Ophthalmology 1999; 106: Butz B, Strotzer M, Manke C, Roider J, Link J, Lenhart M: Selective intraarterial fibrinolysis of acute central retinal artery occlusion. Acta Radiol 2003; 44: Kattah JC, Wang DZ, Reddy C: Intravenous recombinant tissue-type plasminogen activator thrombolysis in treatment of central retinal artery occlusion. Arch Ophthalmol 2002; 120: QOM! Tzu Chi Med J No. 6

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