Transcript CRAO NVI – Dr. Tala Kassm - University of Louisville Ophthalmology

Grand Rounds Conference
Tala Kassm DO
December 10th, 2015
University of Louisville
Department of Ophthalmology and Visual Sciences
Subjective
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CC: “I can’t see since last night.”
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HPI: 81 year old male presents to clinic with
complaint of sudden painless vision loss in his
left eye for one day. Denies headaches, fevers,
weight loss, jaw claudication or temporal
tenderness. No associated pain, flashes or
floaters.
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Review of Systems: per HPI.
History
POH:
- HRVO with CME OD s/p avastin
- POHS OU with macular scar OS
- PCIOL OU
- BRVO OS (2008)
- Mild NPDR OU
History
PMH: DMII, HTN, hypothyroidism, CVA, HLD
Family Hx: noncontributory
Meds: insulin, lisinopril, levothyroxine, xarelto,
simvastatin
Allergies: NKDA
Clinical Exam
VA(cc,D):
OD
20/40
OS
HM
(-1.25+0.75x160) (-1.00+1.00x180)
Pupils:
3->2
3->2
2+rAPD OS
IOP:
15
14
EOM:
FULL
FULL
CVF:
FULL
unable to assess
Anterior Segment:
PCIOL OU
Clinical Exam
Dilated Fundus Exam:
OD
ON
c/d- 0.4
Macula
Vessels
Periphery
OS
c/d- 0.5
cotton wool spots
juxtafoveal POHS scar
mild edema
retinal whitening perifoveally
Superior HRVO
small emboli in
primary superotemporal artery,
box carring
POHS scars OU
OCT Retina - OS
FA OS
FA OS
FA - OS
Assessment
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81 year old male with sudden painless vision loss
of left eye.
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Diagnosis: Central retinal artery occlusion OS
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Differential also includes:
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Giant Cell Arteritis
Plan
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Treatment options discussed at length with
patient – 25 gauge pars plana vitrectomy
Patient declined surgery.
Ocular massage attempted.
AC paracentesis performed.
Carotid doppler ultrasound ordered and 2-D
echocardiogram
Follow Up: Three Days
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Vision: HM OS
Pressure OS: 14 mmHg
Vessels appeared narrow with box carring,
diffuse retinal edema
Patient reports he ran out of xarelto three weeks
ago
Started on a baby aspirin
Follow up: 5 weeks
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Vision still HM OS but IOP now 38 mmHg OS
Gonioscopy showed NVA
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Diagnosis:
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NVG OS secondary to CRAO
Plan:
Avastin OS, PRP in the future
 Start Cosopt BID OS
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Central Retina Artery Obstruction
 Defined
as an abrupt decrease of blood flow
through the central retinal artery severe enough
to cause ischemia of the inner retina
 Hallmark symptom: abrupt painless loss of
vision in one eye
 Initial presenting vision of 20/800 or worse
 Light perception to counting fingers in 90%
of patients
Presentation
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Fundus may appear relatively normal in the first
few minutes to hours after obstruction
Axonal swelling in the nerve fiber layer results in
whitening of the retina and arteries appear
attenuated
In severe obstruction, veins and arteries
manifest box-carring or segmentation of blood
flow
Cherry-red spot: orange reflex from intact
choroidal vasculature beneath the fovea
Epidemiology
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Accounts for an estimate of 1 in 10,000
outpatient visits to the ophthalmologist
Incidence of 1.9 per 100,000
Men to women 2:1 ratio
Mean age 60 years
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Has been reported to occur from first to ninth
decade
Bilateral involvement in 1-2% of cases
Pathogenesis
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Believed that majority are caused by thrombus
formation at or proximal to the lamina cribrosa.
An embolus is visible in the central retinal artery
in 20-25% of cases.
Other causes:
Inflammation in the form of vasculitis (Ie. varicella)
 Local trauma to the optic nerve or blood vessels
 Dissecting aneurysm or arterial spasm within central
retinal artery
 Giant cell arteritis
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Management of CRAO
 Reduce
IOP
IOP- lowering medications
 Anterior chamber paracentesis
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Ocular massage
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Thought to possibly dislodge emboli
25 gauge vitrectomy
 No longer recommended
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Carbinogen vasodilatory inhalation therapy
 Hyperbaric oxygen therapy
 Catheterization of ophthalmic artery with tPA infusion
 Transvitreal Nd:YAG embolysis
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Course and Outcome
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Vision loss is permanent due to infarct of inner
retina
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Irreversible damage to sensory retina after 90-100
minutes of complete CRAO
Vision of 20/400 or worse in 66% of cases
Complications
Iris neovascularization occurs in 18% of eyes
 Less than five percent develop neovascular glaucoma
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Neovascularization of the Iris
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Also known as rubeosis iridis
Occurs after retinal ischemia – most commonly
caused by proliferative diabetic retinopathy
(PDR), central retinal vein occlusion (CRVO) or
carotid artery occlusive disease (CAOD)
Less commonly:
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CRAO, sickle cell retinopathy, anterior segment
ischemia
Can also occur with tumors, uveitis, chronic RD
Neovascular Glaucoma
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Neovascularization of the iris and the angle
leads to fibrovascular membranes
Obstruct trabecular meshwork -> secondary
open-angle glaucoma
With disease progression the fibrovascular
membranes mature and contract, tenting the iris
toward the trabecular meshwork -> Peripheral
anterior synechiae and angle closure->
secondary angle-closure glaucoma
Neovascular Glaucoma Treatment
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Indentify and address underlying etiology
Systemic workup for CRVO, PDR, CRAO and
carotid artery occlusive disease
Mainstay of treatment and prevention is
panretinal photocoagulation (PRP) or
cryotherapy
Medical therapy with atropine 1%, topical
steroids and antiglaucoma medications
Mason, John O; Patel, Shyam A; Feist, Richard M; Albert Jr.,
Michael A; Huishingh, Carrie; McGwin Jr, Gerald, Thomley,
Martin L.
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Investigate the ocular neovascularization rate in
eyes with a branch retinal artery occlusion or a
central retinal artery occlusion
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Study factors that influence ONV rate secondary
to CRAO.
Retrospective case series – 83 CRAO’s and 203
BRAO’s.
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In the CRAO group, 14.5% developed ONV
Average time for development of ONV was 30.7
days
Diabetes mellitus type 2 was a risk factor for
ONV development after CRAO – odds ratio of
5.2
Patients with DMII should be monitored closely
for first 6 months after CRAO for ONV
References
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Falkenberry SM, Ip MS, Blodi BA, Gunther JB. Optical coherence tomography
findings in central retinal artery occlusion. Ophthalmic Surg Lasers Imaging. 2006;
37(6):502-505.
BCSC: Retina and Vitreous pages 131-135
Mason, Jason O. Patel, Shyam A. Feist, Richard M. Albert Jr, Michael A. Huisingh,
Carrie. McGwin Jr, Gerald. Thomley, Martin L. Ocular neovascularization in eyes with
a central retinal artery occlusion or a branch retinal artery occlusion. Clinical
Ophthalmology 2015 (9): 995-1000.
Ryan SJ. Retina. 4th ed. Philadelphia: Elsevier/Mosby; 2013.
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]
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