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Case Report a Case of Incomplete Central Retinal Artery Occlusion Associated with Short Posterior Ciliary Artery Occlusion

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Case Report a Case of Incomplete Central Retinal Artery Occlusion Associated with Short Posterior Ciliary Artery Occlusion Hindawi Publishing Corporation Case Reports in Ophthalmological Medicine Volume 2013, Article ID 105653, 4 pages http://dx.doi.org/10.1155/2013/105653 Case Report A Case of Incomplete Central Retinal Artery Occlusion Associated with Short Posterior Ciliary Artery Occlusion Shinji Makino, Mikiko Takezawa, and Yukihiro Sato Department of Ophthalmology, Jichi Medical University, 3311-1 Yakushiji, Tochigi, Shimotsuke 329-0498, Japan Correspondence should be addressed to Shinji Makino; [email protected] Received 12 December 2012; Accepted 1 January 2013 Academic Editors: S. Machida, M. B. Parodi, and P. Venkatesh Copyright © 2013 Shinji Makino et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. To our knowledge, incomplete central retinal artery occlusion associated with short posterior ciliary artery occlusion is extremely rare. Herein, we describe a case of a 62-year-old man who was referred to our hospital with of transient blindness in his right eye. At initial examination, the patient’s best-corrected visual acuity was 18/20 in the right eye. Fundus examination showed multiple so exudates around the optic disc and mild macular retinal edema in his right eye; however, a cherry red spot on the macula was not detected. Fluorescein angiography revealed delayed dye in�ow into the nasal choroidal hemisphere that is supplied by the short posterior ciliary artery. e following day, the patient’s visual acuity improved to 20/20. So exudates around the optic disc increased during observation and gradually disappeared. His hemodynamic parameters revealed subclavian steal syndrome as examined by cervical ultrasonography and digital subtraction angiography. We speculate that his transient blindness was due to ophthalmic artery spasms. In this particular case, spasms of the ophthalmic artery and occlusion of the short posterior ciliary artery occurred simultaneously. As the short posterior ciliary artery branches from the ophthalmic artery, the anatomical location of the lesion might be near the branching of both arteries. 1. Introduction ischemic optic neuropathy [7, 9–11]. To our knowledge, incomplete CRAO associated with short posterior ciliary ere are only few reports in the Japanese literature that artery occlusion is extremely rare [1]. Herein, we describe the have presented the incomplete type of central retinal artery case of such a patient. occlusion (CRAO), including diminished visual acuity and a residual visual �eld but no complete visual loss, slight retinal edema together with a slight cherry red spot on the macula, 2. Case Report and good visual prognosis [1, 2]. e ophthalmic artery enters the orbit through the optic A 62-year-old man complaining of transient blindness in canal, usually inferotemporal to the optic nerve. e vessel his right eye on waking was referred to our hospital. e soon crosses medially over the nerve and gives rise to its patient had a history of hypertension and hyperlipidemia. At �rst branch, the central retinal artery. Aer the central initial examination, he had a best-corrected visual acuity of retinal artery branches from the ophthalmic artery, a varying 18/20 in the right eye, which was noncorrigent, and 20/20 number of posterior ciliary arteries arise. Each of these major in the le eye. Ocular pressures were normal. Slit lamp posterior ciliary arteries further divides into multiple short examination showed cortical opacities in both lenses. Fundus posterior ciliary branches that penetrate the sclera medial examination showed multiple so exudates around the optic or lateral to the optic nerve, depending on their respective disc and mild retinal edema in the macula of his right eye; deviation from the parent medial or lateral posterior ciliary however, a cherry red spot was not detected, and the optic arteries [3–5]. disc appearance was unremarkable (Figure 1). Fluorescein ere have been several reports presenting CRAO with angiography (FA) revealed a delay of arm-to-retina time and a choroidal circulatory disturbance [6–8], and/or anterior marked �lling delay of the nasal choroidal hemisphere that is 2 Case Reports in Ophthalmological Medicine (a) F 1: Right fundus photograph at the initial visit showing so exudates and retinal edema around the optic disc. supplied by nasal short posterior ciliary artery (Figure 2(a)). erefore, the choriocapillaris corresponding to the nasal choroidal area �lled slowly and patchily (Figure 2(b)), and no staining of the arterial wall was detected in the late stage. From these �ndings, the patient was diagnosed with incom- plete CRAO associated with short posterior ciliary artery occlusion. Systemic administration of a vasodilator and an (b) antiplatelet agent were started aer the initial examination. On the following day, his right visual acuity improved to F 2: Right �uorescein angiography at the �rst visit demon- 20/20. However, during observation, so exudates increased strated a marked �lling delay of the nasal choroidal hemisphere that 2 days aer the initial visit (Figure 3(a)), increased further is supplied by the nasal short posterior ciliary artery. e hemi- sphere �lled slowly and patchily; 27 s (a) and 30 s (b) aer in�ection. at1week(Figure 3(b)), gradually decreased in 2 weeks (Figure 3(c)), and �nally disappeared at 7 weeks (Figure 3(d)). e patient’s blood pressure was 95/80 mmHg in the right arm and 130/80 mmHg in the le arm. Further examina- Hagimura et al. [13] evaluated 22 patients with CRAO. tions for evaluating hemodynamics were performed; cervical �yes with poor �nal vision (�nal visual acuity 0.1, ) ultrasonography revealed right subclavian artery stenosis showed initially denser retinal opacities with a distinct cherry and reversed right vertebral artery �ow. Additionally, digital red spot. �yes with favorable visual outcome (�nal visual subtraction angiography demonstrated the stenosis of the < 푛푛푛 acuity 0.4, ) showed so exudates and faint retinal following arteries: from the right common carotid artery to opacities without a cherry red spot. e �ndings show that the bifurcation of the internal carotid artery, the right bra- the �nal visual outcome mainly depended on the initial visual chiocephalic trunk, the right subclavian artery, and the le > 푛푛 acuity and funduscopic �ndings. In our patient, so exudates common carotid artery. On the basis of these �ndings, he were de�ned during observation and the patient’s �nal visual was also diagnosed with subclavian steal syndrome. Aer acuity was 20/20. recovery from this event, he did not experience any additional ere have been few reports in the Japanese literature periods of transient blindness. presenting incomplete CRAO, including diminished visual acuity and a residual visual �eld but no complete visual loss, 3. Discussion slight retinal edema together with a slight cherry red spot on the macula, and good visual prognosis [1, 2]. e fundus In 2002, Schmidt et al. [12] classi�ed CRAO into 3 stages; changes seen in these reported cases [1, 2] were very similar stage I of his classi�cation represents �incomplete CRAO� to those seen in our case. ere have been several reports and includes diminished visual acuity and a residual visual of CRAO presenting with choroidal circulatory disturbance �eld but no complete visual loss, slight retinal edema together [6–8], and/or anterior ischemic optic neuropathy [7, 9–11]. with a slight cherry red spot on the macula, no increase in To our knowledge, incomplete CRAO associated with short retinal signs over several hours, and delayed but not com- posterior ciliary artery occlusion is extremely rare [1]. pletely interrupted blood �ow revealed by FA. ey also Our patient also had subclavian steal syndrome. Subcla- reported that spontaneous recovery usually did not occur vian steal syndrome is a function of the proximal subclavian during a followup of several hours despite minor retinal artery stenoocclusive disease with subsequent retrograde �ndings. e fundus changes in stage I described in their blood �ow in the ipsilateral vertebral artery [14]. Morita et al. literature [12] were very similar to those in our case. [15] described subclavian steal syndrome in a case of arteritis Case Reports in Ophthalmological Medicine 3 (a) (b) (c) (d) F 3: Exudate patterns on right fundus photographs aer the �rst visit. So exudates increased 2 days aer the initial visit (a), increased further at 1 week (b), gradually decreased at 2 weeks (c), and disappeared at 7 weeks (d). syndrome with bilateral occlusion of common carotid arter- [2] Y. Ueda, T. Kimura, N. Okamoto, T. Kurimoto, S. Oono, and O. ies. Souma et al. [16] described a case of reversed ophthalmic Mimura, “A case of central retinal artery occlusion with good artery �ow without occlusion of the internal carotid artery. visual acuity,” Ganka, vol. 51, no. 4, pp. 443–446, 2009. Although, in their patient, collateral circulation and reversed [3] E. Onda, G. A. Cioffi, D. R. Bacon, and E. M. van Buskirk, ophthalmic artery �ow were not blurred, stenosis of common “Microvasculature of the human optic nerve,” American Journal carotid and internal carotid arteries were detected. erefore, of Ophthalmology, vol. 120, no. 1, pp. 92–102, 1995. it is apparent that our patient had circulation disturbances [4] J.M.Olver,D.J.Spalton,andA.C.E.McCartney,“Quantitative in the right internal carotid artery and the right ophthalmic morphology of human retrolaminar optic nerve vasculature,” artery. Investigative Ophthalmology & Visual Science, vol. 35, no. 11, pp. In conclusion, we speculate that the transient blindness 3858–3866, 1994. experienced by our patient was due to spasms of the oph- [5] S. S. Hayreh, “e ophthalmic artery. III branches,” e British thalmic artery. In this case, spasms of the ophthalmic artery Journal of Ophthalmology, vol. 46, no. 4, pp. 212–247, 1962. and occlusion of the short posterior ciliary artery occurred [6] G.
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