Grand Rounds Eddie Apenbrinck M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 6/20/2014
Subjective CC: sudden painless loss of vision OD HPI: 75 year old white male transferred to UL from Taylor Regional Hospital with acute painless loss of vision OD. Loss of vision occurred over seconds and was not associated with any pain, flashes or floaters.
POH: Presbyopia PMHx: HTN, NIDDM, arthritis ROS: denies any temporal artery tenderness, headaches, jaw claudication, fatigue, weight loss, appetite changes Allergies: NKDA Meds: Glucophage, Lasix, Peroxicam Labs: ESR=15 CRP=0.74 (0-0.75)
Exam OD OS VA(cc,n): LP 20/25 +2 Pupils: 4 2 4 2 +RAPD OD IOP: 15 14 EOM: Full OU
Exam Anterior Segment OD OS L/L: C/S: Cornea: AC: I/L: Vitreous: WNL OU WNL OU WNL OU No cell or flare OU 2+ nuclear sclerotic cataracts OU WNL OU
Fundus Photos OD OS Cherry Red Spot; Retinal whitening Normal
OCT OD Diffuse retina edema and increased reflectivity of the inner retina
OCT OS
Fluorescein Angiography OD
FA OD Late AV Phase Late Phase Delayed venous filling No leakage
Assessment Assessment: : 75 year old white with sudden painless loss of vision OD that occurred over seconds, not associated with any other symptoms. DDx Central retinal artery occlusion (CRAO) Giant cell arteritis Ophthalmic artery occlusion
Central Retinal Artery Occlusion First describe in 1859 by von Graefe s report of multiple systemic emboli in the setting of endocarditis causing obstruction of the central retinal artery. Characterized by sudden painless loss of vision in one eye Visual acuity at the time of initial presentation ranges from counting fingers to light perception in 74-90% of eyes
Central Retinal Artery Occlusion CRAO is often caused by arthrosclerosis-related thrombosis occurring at the level of the lamina cribrosa Emboli are present in the retinal arterial system in approximately 20% of eyes with CRAO Based on experimental models of CRAO in rhesus monkeys, the retina suffers no damage up to 97 minutes after an acute CRAO but after 4 hours the retina suffers massive irreversible damage
Epidemiology The estimated incidence of CRAO is 1 in 10,000 cases at tertiary referral centers. The average age at presentation is in the early sixties Men are affected more frequently than women 1-2% of cases may manifest bilaterally
CRAO Treatment Current conventional therapy Dislodging emboli: ocular massage, Yag laser embolectomy Reducing IOP: anterior chamber paracentesis Vasodilation: Carbogen (95% O 2 & 5% CO 2 ), nitrates Maintaining retinal oxygenation: hyperbaric oxygen Thrombolytics: streptokinase, urokinase, and tissue plasminogen activator None of these treatments have proven effective and their use is largely based on anecdotal reports and small case series.
Plan Plan Perform small gauge vitrectomy, membrane peel, plaque removal, and air fluid exchange of the right eye Primary care to arrange for cardiovascular workup including carotid ultrasound
Age Gender Type Hours Initial VA Final VA FU(mo) 77 M NA with intact CRA 72 LP 20/60 18 55 M NA with intact CRA 21 CF 20/40 15 64 M NA with intact CRA 30 HM 20/40 12 74 F NA 18 CF 20/200 11 47 M NA 28 HM 20/160 11 74 F NA 48 HM 20/30 11 56 M NA 48 20/400 CF 7 61 M NA 16 HM 20/40 6 54 M NA 72 HM 20/250 5 47 F NA 45 HM 20/300 4 62 M NA 12 CF 20/30 2 61±10 37±21 9±5
Results Correlations Spearman Rank Order Correlation Rs p Initial VA/Final VA -0.147 0.653 Initial VA/Change in VA -0.889 <0.0001 Time/ Initial VA 0.448 0.159 Time/ Final VA 0.394 0.221 Time/ Change in VA -0.303 0.353 Age/Change in VA -0.383 0.233 Age/Initial VA 0.128 0.693
1 week follow-up Retina flat under 60% air OD OS VA(cc): HM 20/25 Pupils: 4 3 OU; + RAPD IOP: 2 15 DFE: cherry red spot wnl retina flat under air (60%) Plan: follow up in 1 month with repeat FA
References 1. BCSC: Retina and Vitreous. Central Retinal Artery Occlusion. Pgs 138-140 2. Ryan SJ. Retina. 4th ed. Philadelphia: Elsevier/Mosby; 2013. 3. Rumelt S, Dorenboim Y, Rehany U. Aggressive systematic treatment for central retinal artery occlusion. Am J Ophthalmol 1999;128:733 8. 4. Brown GC, Magargal LE. Central retinal artery obstruction and visual acuity. Ophthalmology 1982;89:14 9. 5. Brown GC, Magargal LE. Central retinal artery obstruction and visual acuity. Ophthalmology 1982;89:14 9. 6. Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome. Am J Ophthalmol 2005;140:376 91. 7. Biousse V, Calvetti O, Bruce BB, et al. Thrombolysis for central retinal artery occlusion. J Neuroophthalmol 2007;27:215 30. 8. Park SJ, Choi NK, Seo KH, Park KH, Woo SJ. Nationwide Incidence of Clinically Diagnosed Central Retinal Artery Occlusion in Korea, 2008 to 2011. Ophthalmology. 2014 Jun 7. pii: S0161-6420(14)00383-2. doi: 10.1016/j.ophtha.2014.04.029. [Epub ahead of print] 9. Tang WM, Topping TM, Vitreous surgery for central retinal artery occlusion. Arch Ophthalmol 2000 Nov;118(11):1586-7. 10. Hayreh SS, Jonas JB. Optic disk and retinal nerve fiber layer damage after transient central retinal artery occlusion: an experimental study in rhesus monkeys. Am J Ophthalmol 2000;129:786 95.