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Retinal Arterial Occlusion with Multiple Retinal Emboli and Carotid Artery Occlusion Disease

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Retinal Arterial Occlusion with Multiple Retinal Emboli and Carotid Artery Occlusion Disease Original research BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000467 on 27 July 2020. Downloaded from Retinal arterial occlusion with multiple retinal emboli and carotid artery occlusion disease. Haemodynamic changes and pathways of embolism San- Ni Chen ,1,2,3 Jiunn- Feng Hwang ,1 Jeff Huang,4 Shey- Lin Wu5 To cite: Chen S- N, Hwang J- F, ABSTRACT Huang J, et al. Retinal arterial Objective To introduce a special subgroup, retinal artery Key messages occlusion with multiple occlusion (RAO) with multiple emboli, which is highly retinal emboli and carotid associated with ipsilateral carotid artery occlusion disease What is already known about this subject? artery occlusion disease. (CAOD). ► Around 16%~35% patients with retinal artery oc- Haemodynamic changes clusion (RAO) were reported to have ipsilateral flow- and pathways of embolism. Methods and analysis This is a cohort study. Cases of RAO with multiple retinal emboli were consecutively limiting carotid stenosis; however, retinal embolus BMJ Open Ophthalmology and type of RAO are poor predictors of haemody- 2020;5:e000467. doi:10.1136/ enrolled. All patients underwent at least one of the carotid/ namically significant carotid artery occlusion dis- bmjophth-2020-000467 cerebral evaluations: carotid arteriography, orbital/carotid colour Doppler ultrasonography and CT angiography to ease (CAOD). Additional material is ► demonstrate haemodynamic changes and to discuss What are the new findings? published online only. To view, possible mechanisms and pathways of the emboli. please visit the journal online ► RAO with multiple emboli is rare but highly (91.6%) (http:// dx. doi. org/ 10. 1136/ Results Among 208 RAO eyes, 12 eyes (5.7%) in 11 associated with severe CAOD and flow changes. bmjophth- 2020- 000467). patients had multiple emboli were recruited in this study. Eleven eyes (91.6%) had ipsilateral carotid plaques and How might these results change the focus of atherosclerosis with high-grade stenosis; among them, research or clinical practice? Received 19 March 2020 five were total carotid occlusion. Haemodynamic changes ► Embolism may arise from either the carotid lesions Revised 22 June 2020 were found in nine patients with RAO (81.8%) with carotid directly or via the collateral pathways indirectly as Accepted 10 July 2020 stenosis 60% or greater. Most compensatory intracranial an important warning of haemodynamic changes of circulations were re-established via the circle of Willi severe CAOD. with antegrade ophthalmic flows, but the direction of ► Immediate action should start to manage these patients. ophthalmic flow reversed in three eyes indicating the http://bmjophth.bmj.com/ © Author(s) (or their recruitment of external collaterals. Two cases underwent employer(s)) 2020. Re- use carotid stent successfully. permitted under CC BY- NC. No Conclusion RAOs with multiple emboli are rare but in profound and permanent loss of vision. commercial re- use. See rights highly associated with severe CAOD with haemodynamic and permissions. Published by flow changes, warning critical condition in carotid/cerebral Embolism originating from carotid or cardiac BMJ. circulations. Either direct embolism from the carotid or lesion is the most common cause. In the liter- 1 Department of Ophthalmology, cardiac lesions or indirect embolism via the collateral ature, RAO served as a significant marker Changhua Christian Medical pathways is the mechanism of pathogenesis. Immediate for carotid artery occlusion disease (CAOD) Foundation Changhua Christian action should start to manage these patients to prevent and a predisposing factor of cerebrovas- on October 4, 2021 by guest. Protected copyright. Hospital, Changhua, Taiwan 1–6 2School of Medicine, Chung further deterioration. cular accident (CVA). Most patients with Shan Medical University, RAO had ipsilateral carotid lesions, athero- Changhua, Taiwan sclerotic plaque or stenosis; and in a few 3 Department of Optometry, SUMMARY STATEMENT cases (16%~35%), the carotid stenosis was College of Nursing and Health Cases of retinal artery occlusion with multiple flow- limiting or even totally occluded with Sciences, Da- Yeh University, Changhua, Taiwan emboli are rare but highly associated with haemodynamically significant intracranial 2–6 4Centre for Neuroscience severe carotid artery occlusion disease and flow changes. In the literature, investiga- Studies, Queen's University, haemodynamic flow changes. Embolism may tors had attempted to find out what clinical Kingston, Ontario, Canada 5 arise from either the carotid lesions directly features of RAO were related to haemody- Department of Neurology, or via the collateral pathways indirectly. namically significant CAOD. However, they Changhua Christian Medical Foundation Changhua Christian Immediate action should start to manage concluded that ocular symptoms and findings Hospital, Changhua City, Taiwan these patients. including retinal embolus and type of RAO are poor predictors of haemodynamically 6–10 Correspondence to INTRODUCTION significant CAOD. Dr Jiunn- Feng Hwang; Retinal artery occlusion (RAO) is an emer- In recent years, great advances in the devel- hwangjf@ cch. org. tw gent ocular disorder that frequently results opment of carotid/cerebral imaging and flow Chen S- N, et al. BMJ Open Ophth 2020;5:e000467. doi:10.1136/bmjophth-2020-000467 1 Open access BMJ Open Ophth: first published as 10.1136/bmjophth-2020-000467 on 27 July 2020. Downloaded from studies, more timely clinical information and evidence stenosis with decreased cerebral blood perfusion and/or can be collected and surveyed to facilitate the under- the presence of responsive compensatory flow to redis- standing of relationships between RAO and CAOD. tribute the intracranial circulations. During review of our cases at a single medical centre Patient and public involvement (Changhua Christian Hospital), we found a special subgroup, RAO with multiple retinal emboli, was highly Patients were not directly involved in the design of this associated with ipsilateral haemodynamically significant study. CAOD. Herein, we introduce these cases with findings RESULT of carotid/cerebral evaluations to discuss the association From January 2004 to December 2017, among a total of and the possible mechanisms and pathways of retinal 208 eyes of acute RAO, 12 eyes (5.7 %) in 11 patients with emboli as a preliminary report. Issues about the retinal multiple retinal emboli were consecutively enrolled in manifestations of this special subgroup will be discussed this study. Patients’ age, gender, visual acuity at presenting in the subsequent report. and results of carotid evaluation were recorded as shown in table 1. PATIENTS AND METHODS There were two female and nine males, the average We conducted a retrospective cohort study of carotid/cere- age was 66.0±11.9 years (range 50–88 years). All these bral/ophthalmic flow evaluations in cases of acute RAO RAOs were non- arteritic. Most associated systemic with multiple retinal emboli found at Changhua Christian condition was arterial hypertension. Two cases (#7, #9) Hospital. All patients had the typical clinical presenta- underwent ipsilateral neck radiotherapy for neoplasm 10 tions of RAO including sudden onset of visual loss, retinal years ago. Prior to the RAO attack, CT and CDI for case whitening and visible retinal emboli. At least one of the 7 demonstrated already- occluded CCA and high-grade carotid/cerebral evaluations including carotid/cerebral ICA stenosis as a result of therapeutic embolisation with arteriography, colour Doppler imaging (CDI), CT angi- balloons to occlude the left carotid aneurysm. Except ography (CTA) and magnetic resonance angiography case 7, all other patients were full ambulatory when (MRA) was performed to find out the presence of plaque, visiting our hospital. Most cases had no neurological the degree of vascular stenosis at common carotid artery deficit, only case 2 reported transient limb weakness and (CCA), internal carotid artery (ICA) and external carotid case 11 presented with persistent slurred speech. Eight artery (ECA), and if possible, to determine the supply of cases were afflicted in the right eye while two cases (#7, compensatory flow and the pattern of collateral pathways #11) in the left eye. One case (#2) had visual loss succes- for the intracranial circulation. Additional orbital CDI was sively in his both eyes within an interval of 1 day (table 1). also performed for these cases to detect blood flow signals parallel to the optic nerve to find out the flow velocity and Fundus features the direction of ophthalmic blood flow. Haemodynami- All RAO eyes had acute retinal ischaemia manifested cally significant COAD is defined as flow-limiting carotid by retinal whitening in the posterior pole (figure 1A). http://bmjophth.bmj.com/ Table 1 Demographic characteristics data and results of carotid/cerebral evaluations Affected Visual No. of Degree % of No./Age/Gender eye acuity emboli CAOD (R/L) Intracranial circulation and compensatory flow of collaterals 1/88/M Right 0.02 4 60/45 High flow from left ICA a left vertebral artery. 2/58/M Right HM >10 Total/Total No ICA flow, compensatory flow from bilateral vertebral on October 4, 2021 by guest. Protected copyright. Left 0.02 >15 artery, reversed bilateral ophthalmic flow. 3/50/F Right 0.2 3 No stenosis Normal carotid and cerebral circulation. 4/71/F Right LP >10 >70/23 Decreased right ICA and cerebral flow. 5/57/M Right LP >10 >95/48 Decreased right ICA and cerebral flow, low vertebral flow,
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