A case of nonarteritic anterior ischemic optic neuropathy with cilioretinal artery occlusion

We report a case of nonarteritic anterior ischemic optic neuropathy (AION) with cilioretinal artery occlusion. The patient was a 61-year-old man with sudden visual loss in his right eye. Funduscopy showed pale swelling of the entire optic disc with retinal ischemic edema of the upper half of the retina, and fluorescein angiography revealed faint filling of the dye in the optic disc in the retinal arterial phase, and dye staining of the optic disc in the late phase. We initially diagnosed the disease as AION with branch retinal artery occlusion, but systemic administration of a corticosteroid and urokinase were ineffective and the optic disc became atrophic. As the optic disc swelling decreased and the course of arteries in the optic disc became clear, we repeated fluorescein angiography which proved that the involved upper retinal artery was a cilioretinal artery having earlier dye appearance than the lower retinal artery. Thus, we finally diagnosed the disease as AION with cilioretinal artery occlusion. We believe that Hayreh's view that AION may result from occlusion of the posterior ciliary artery is supported by the intraocular findings in this case.     

Morphogenesis of membrane-bound bodies in belladonna (Atropa belladonna L.) plastids

Besides the acute arterial occlusion and simple venous thrombosis, the clinical symptomatology may include signs of chronic arterial insufficiency, i.e. progressive blurring of vision, absolute visual field defects, cotton wool exudates, capillary occlusion and increased retinal circulation time. The poor visual prognosis is caused by progressive macular degeneration. In the case of acute arterial thrombosis, fragmentation of the blood column and absence of arterial pulsation are indicative of pronounced retinal ischemia. The ophthalmoscopic aspect of a visible embolus may be a hint for the prognosis of eventual recanalisation.     

Synchronous bilateral fluorescein angiography. A new technique

Simultaneous angiography of both eyes allows the synchronous measurement of the arm-retina-time and the retinal circulation time in each eye. The dye-filling pattern of retinal arteries, choroid, disc, and cilioretinal vessels can be compared. A new method of simultaneous fluorescein angiography of both eyes, using two fundus cameras, is demonstrated. Each camera is operated by a separate power unit, thereby providing sufficient light energy for one picture every 0.6 second. The fluorescein is injected by means of an automatic injector in order to create a compact dye bolus. Simultaneous angiograms of a healthy patient and of a patient with unilateral carotid occlusion are shown.     

Prothrombotic states associated with retinal venous occlusion in young adults

BACKGROUND: The etiology of retinal venous occlusion in young patients is not well understood although thrombosis does occur histologically. A search for the risk factors that may lead to thrombosis is highly desirable may contribute to our understanding of the pathogenesis of this complication and may improve our therapeutic strategies. METHODS: We studied 17 patients with retinal venous occlusion. All patients were under 45 years of age (mean 37.8 +/- 7.1). Antiphospholipid antibodies (APAs) and certain hemostatic factors were determined. The results obtained in these patients were compared to those of normal controls. RESULTS: We found APAs in 8 out of 17 patients compared to 5 out of 60 controls (p = 0.0002). In patients with major trunk occlusion, there was a trend for the presence of APAs in those with poor visual acuity at presentation. Deficiencies of the coagulation inhibitor proteins C and S and antithrombin III activities were detected in 6 patients, and reduced levels of Factor XII were found in 4 patients. Levels of hematocrit, erythrocyte sedimentation rate. Fibrinogen, alpha 1-globulin, and alpha 2-globulin were significantly higher in patients compared to the controls (p = 0.019; 0.014; 0.0001; 0.011; 0.047), indicating increased blood viscosity in patients with retinal venous occlusion. CONCLUSION: Prothrombotic changes in the form of APAs and/or deficiencies of coagulation inhibitors and Factor XII may contribute to the etiology of retinal venous occlusion in young adults. Young patients with retinal venous occlusion should be evaluated for these prothrombotic states.     

The effect of posterior vitreous detachment on the prognosis of branch retinal vein occlusion

PURPOSE: Two important complications causing visual loss in retinal branch vein occlusions are vitreous hemorrhage due to retinal neovascularization and persistent macular edema. The aim of this study was to identify the effect of the total posterior vitreous detachment on the disease prognosis. METHODS: Fifty-three patients with temporal branch vein obstruction were followed for eighteen months on average. The vitreous conditions of all patients were established, and the effect on persistent macular edema and retinal neovascularization development was statistically investigated. RESULTS: This prospective study shows that total posterior vitreous detachment has a clear preventive effect on both complications. CONCLUSION: Careful vitreous examinations of all patients with branch retinal vein occlusion give us important information about the prognosis and patient management.     

Glaucoma and visual outcome in central retinal vein occlusion

Glaucoma is a recognized risk factor for central retinal vein occlusion. The authors retrospectively reviewed charts of fifty patients with central vein occlusion examined over a 5-year period. The visual outcome and clinical characteristics of eyes with and without glaucoma were compared. There were 32 eyes without glaucoma and 18 eyes with glaucoma. Final visual acuity of 20/100 or better was obtained in 22% of eyes with glaucoma, compared with 34% of eyes without glaucoma, and final visual acuity of finger counting and less was found in 56% and 22%, respectively (p = 0.02). The rate of ischemic occlusion was higher in the glaucoma group, 44% and 28% respectively, but the difference did not reach statistical significance. There was no difference in the rate of neovascular complications and macular edema between the two groups. The results suggest that glaucoma has an adverse effect on the visual outcome of eyes with central vein occlusion.     

Predicting outcome in central retinal vein occlusion using the flicker electroretinogram

OBJECTIVE: To evaluate the usefulness of the 30-Hz flicker electroretinogram (ERG) in predicting outcome in patients with central retinal vein occlusion using an automated system previously developed to measure parameters of the flicker ERG and using information about the a priori probability of developing neovascularization of the iris in central retinal vein occlusion. METHODS: Amplitude and timing were extracted from 30-Hz flicker ERGs of 76 patients with acute central retinal vein occlusion from a previous study. The ability of the ERG to predict the development of neovascularization of the iris based on derived parameters was measured using the area under the receiver operating characteristic curve. RESULTS: The predictive ability of the 30-Hz ERG amplitude, as judged by a two-alternative forced-choice procedure, was 92%. The corresponding value for implicit time was 89%. Using Bayes' theorem, we computed the probability of developing neovascularization of the iris based on a single 30-Hz flicker ERG measurement at initial patient presentation. CONCLUSIONS: The 30-Hz flicker ERG provides useful information about the patients with central retinal vein occlusion.     

Hemoglobinopathies affecting maternal-fetal oxygen gradient during pregnancy: molecular, biochemical and clinical studies

OBJECTIVES: Evaluate the efficacy of chorioretinal venous anastomosis in patients with nonischemic retinal vein occlusions with progressive visual loss and to concentrate on complications. DESIGN: Case series of 6 patients, retrospective study. Six patients with nonischemic central retinal vein occlusions and progressive visual loss. Laser photocoagulation was performed to create a chorioretinal venous anastomosis to be able to supply venous blood to the choroid, bypassing the occlusion. Visual acuity, funduscopic appearance and fluorescein angiographic appearance were determined. RESULTS: Two patients showed a chorioretinal anastomosis (33%), whereas in the other 4 patients the anastomosis could not be created. Yet 1 patient consequently had a neovascular tuft under the laser site. These new vessels caused minor vitreous hemorrhage and a tractional membrane which regressed after 10 months. CONCLUSION: The utilization of a chorioretinal venous anastomosis by laser as a therapeutic modality should be further questioned and thoroughly evaluated and caution must be exercised to avoid vision-threatening complications.     

Pharmacokinetics of once-daily amikacin dosing in patients with cystic fibrosis

PURPOSE: To report the injection of tissue plasminogen activator into a retinal vein to treat central retinal vein occlusion. METHODS: An 81-year-old woman with visual loss of the right eye secondary to central retinal vein occlusion developed central retinal vein occlusion and visual loss in her left eye. Treatment of her left eye with topical ocular hypotensive medications, pentoxifylline, and laser chorioretinal anastomosis was without benefit. Thereafter, she underwent vitreoretinal surgery, including tissue plasminogen activator injection into a branch retinal vein of her left eye. RESULTS: The patient reported subjective improvement in the vision of her left eye. Ophthalmoscopic and fluorescein angiographic improvement were also noted. CONCLUSION: The feasibility of cannulating a retinal vein for treatment has been demonstrated.     

Retinal arteriovenous shunt at the arteriovenous crossing

OBJECTIVE: The purpose of the study was to demonstrate that the arteriovenous shunt at the arteriovenous crossing could occur in major retinal vascular diseases other than Takayasu disease. DESIGN: Clinical review of consecutive case series. PARTICIPANTS: The authors studied 1885 eyes with retinal vascular diseases such as diabetic retinopathy, branch retinal vein occlusion, central retinal vein occlusion, central retinal artery occlusion, Leber's miliary aneurysms, Eales disease, Beh?et disease, and systemic lupus erythematosus retinopathy. INTERVENTION: Fluorescein fundus angiography using a wide-field fundus camera (60 degrees) was performed. MAIN OUTCOME MEASURES: Dye transit from artery to vein through sequential angiography. RESULTS: The arteriovenous shunt at the arteriovenous crossing was found in 8 eyes with proliferative diabetic retinopathy, 27 eyes with branch retinal vein occlusion in the chronic stage, 2 eyes with central retinal vein occlusion, 2 eyes with central retinal artery occlusion, and 2 eyes with miliary aneurysms. The arteriovenous shunt was formed by a direct inflow from artery to vein, showing vasodilation and hyperpermeability, followed by obliteration peripheral to the shunts. The pattern of initial inflow was classified into axial flow and laminar flow, and the inflow became wider and more rapid in the advanced stage. CONCLUSIONS: These findings indicate that the arteriovenous shunt at the arteriovenous crossing is not a unique phenomenon in Takayasu disease but rather is a basic pattern of retinal vascular reaction pathologic states.     

Iatrogenic central retinal vein occlusion and hyperviscosity associated with high-dose intravenous immunoglobulin administration

PURPOSE: To describe a patient with iatrogenically induced central retinal vein occlusions secondary to serum hyperviscosity from intravenous immunoglobulin administration. METHOD: Case report. RESULTS: The patient developed bilateral central retinal vein occlusions in association with high-dose intravenous immunoglobulins. The central retinal vein occlusions resolved when the immunoglobulins were withheld and serum hyperviscosity decreased. CONCLUSION: Administration of high-dose intravenous immunoglobulins can be associated with hyperviscosity syndrome manifested by central retinal vein occlusion.     

Role of electroretinography in the prognosis of central retinal vein occlusion

The aim of the study is to evaluate the role of electroretinography in diagnosis of central retinal vein occlusion CRVO. There are two forms of this entity, each of them having a different prognosis. While haemorrhagic form has a better outcome, with fairly good prognosis for vision, ischaemic form usually develops many complications: macular oedema, neovascularisation of the retina or optic disk, neovascular glaucoma, and possible blindness. Three months after the onset, when oedema and retinal haemorrhages are usually resolved, it is possible to perform fundus fluorescein angiography (FFA) and make differentiation between the two forms of the disease. However, neovascular glaucoma may challenge the vision even before the diagnosis of ischaemic form becomes possible by observing the fundus or by performing FFA. Trying to foresee the course of the disease, and thus to help a patient with panretinal photocoagulation, we performed electroretinography (ERG) in each patient just after the onset of the disease. The prospective study included 40 patients with CROV which lasted less than three months and without any complication. Two parameters were examined: scotopic "b" wave and photopic b/a ration. By ERG action potentials from the retina after its stimulation with light, are recorded. Scotopic "b" wave generates in bipolar layer from Muller's and bipolar cells. Photopic b/a ratio is a ration of two waves, "b" and "a" in photopic conditions and is a good indicator of saturation of the retina with blood and oxygen. Visual acuity, applanation tonometry, examination of the fundus after dilatation of pupils with Sol. Mydriacili were performed in each patient. Each patient was examined by ERG in scotopic and photopic conditions. The results were as follows: Scotopic b wave per se could not indicate potential complications, while b/a ratio was a good predictor of possible complications when its value was less than 1.25. CONCLUSION: Electroretinography, which can be performed at any time after the onset of the disease may be a good indicator of retinal perfusion and oxygen saturation, by giving the ratio of b and a waves under photopic conditions. The status of Muller's cells and bipolar cells is reflected in the scotopic b wave. In a prospective study forty patients with CRVO of less than three months duration and without neovascularisation were studied with the use of ERG, both in scotopic and photopic conditions. Our results suggest that the b/a ratio may be a good predictor of the development of retinal, disk and iris neovascularisation by showing the degree of retinal ischaemia, while the scotopic b wave cannot be used for such evaluation. Predicting the new vessel development by ERG may save the useful vision and prevent a disastrous outcome, blinding and painful neovascular glaucoma by performing panretinal photocoagulation.     

Acute visual change

Changes in vision or loss of vision are common complaints for patients presenting to the emergency department. Such complaints may represent a simple problem related to recent trauma, early evidence of a systemic disease, or may be a vision-threatening lesion. A logical and organized approach to the history and the physical examination of the patient with eye complaints is key to the diagnosis and treatment of the more significant causes of these complaints. This article reviews an organized approach to the patient with complaint of visual loss and considers the wide differential diagnosis. It focuses specifically on the evaluation of the patient complaining of visual changes resulting from central retinal artery occlusion, central retinal vein occlusion, retinal detachment, acute angle-closure glaucoma, giant cell temporal arteritis, and retrobulbar hemorrhage.     

Central retinal artery occlusion (reversible in sickle trait with glaucoma

We report a case of central retinal artery occlusion in an 18-year-old black woman with sickle-trait haemoglobinopathy and acute glaucoma after hyphaema. The central retinal artery occlusion occurred immediately after treatment of the glaucoma with osmotic agents, raising the possibility that they played a precipitating role. We suggest that osmotic agents be used with extreme caution in sickle patients with glaucoma. The occlusion was treated by anterior chamber paracentesis with eventual return of good vision. The reversibility of retinal and optic nerve function after total ischaemia is discussed.     

Effect of local exercise and vessel occlusion on fibrinolytic activity

Arterial occlusion of the upper limb did not affect the fibrinolytic activity in the venous blood of that limb; venous occlusion associated with venous distension resulted in a marked rise in activity. Local fibrinolytic activity was increased substantially by active exercise; passive exercise induced a smaller increase. Active exercise undertaken during arterial occlusion did not result in a rise in activator level. It is concluded from these results that blood flow into the venous system rather than accumulation of metabolites is responsible for the increased release of activator into the blood during local exercise and vessel occlusion.     

Regression of advanced refractory ovarian cancer treated with iodine-131-labeled anti-CEA monoclonal antibody

PURPOSE: To report a 24-year-old man with bilateral central retinal vein occlusions who had preceding episodes of prolonged transient monocular visual loss during which ophthalmoscopic findings were not suggestive of vein occlusion. METHOD: Case report. RESULT: Extensive hematologic studies for causes of vein occlusion were unremarkable with the exception of increased plasma homocysteine in the patient and in his asymptomatic father. CONCLUSIONS: Impending vein occlusion should be considered in the differential diagnosis of transient monocular visual loss regardless of ophthalmoscopic appearance, and hyperhomocystinemia should be considered as a possible cause of retinal vein occlusion.     

Central retinal vein occlusion complicating systemic lupus erythematosus

Retinal lesions occur in 25 to 30% of patients with systemic lupus erythematosus (SLE). Visual loss, however, is rare. A patient who developed central retinal vein occlusion and blindness during the course of active SLE is described. The pertinent literature is reviewed with attention to possible pathophysiologic mechanisms.     

Thrombin-antithrombin III complex in acute retinal vein occlusion

PURPOSE: To determine whether quantitative differences in systemic hypercoagulable state could be identified among patients with retinal vein occlusion at various sites of occlusion. METHODS: The value of thrombin-antithrombin III complex was determined in 57 patients with retinal vein occlusion within 1 month after the subjective onset of retinal vein occlusion and in 15 age-matched normal controls. RESULTS: Levels of log thrombin-antithrombin III complex were significantly higher in the patients with proximal retinal vein occlusion in which the occlusion site is at the optic disc (mean +/- SD, 0.493 +/- 0.389) than in those with distal retinal vein occlusion in which the occlusion site is away from the optic disc (0.312 +/- 0.150, P = .025) and in the normal controls (0.294 +/- 0.151, P = .020). There was no significant difference between the distal retinal vein occlusion and the normal controls (P = .720). More patients with proximal retinal vein occlusion showed elevated thrombin-antithrombin III complex values more than 3.9 ng/ml than those with distal retinal vein occlusion (8/29 vs 1/28, P = .025). Of nine patients showing an initial value of thrombin-antithrombin III complex of more than 3.9 ng/ml, repeated measurements were obtained in eight patients, who showed reduced value of thrombin-antithrombin III complex in the normal range in several months. CONCLUSIONS: A systemic hypercoagulable state, which could be demonstrated with the elevation of thrombin-antithrombin III complex value, may contribute more to the development of retinal vein occlusion with thrombus at or near the trunk of the central retinal vein than those with thrombus at branch veins away from the optic disc in the retina.     

The stroke syndrome of cortical vein thrombosis

Cortical vein thrombosis without sinus involvement is rarely diagnosed, although it may commonly be overlooked. We report four cases of cerebral venous thrombosis limited to the cortical veins. The diagnosis was made on surgical intervention in one patient and by angiography in three patients. Together with a survey of the published cases, the clinical and neuroimaging patterns of our patients allow delineation of several features suggestive of cortical venous stroke. Focal or generalized seizures followed by hemiparesis, aphasia, hemianopia, or other focal neurologic dysfunction in the absence of signs of increased intracranial pressure should suggest this possibility. Neuroimaging (CT, MRI) shows an ischemic lesion that does not follow the boundary of arterial territories and often has a hemorrhagic component, without signs of venous sinus thrombosis. Conventional angiography demonstrates no arterial occlusion but may show cortical vein thrombosis corresponding to the infarct, although these may also be nonspecific findings. The role of MR angiography, which is well-established in sinus thrombosis, remains to be assessed in patients with brain ischemia due to isolated cortical vein occlusion.