ND-YAG LASER ARTERIOTOMY FOR CENTRAL RETINAL ARTERY OCCLUSION Levent Akduman, MD,* Matthew Currie, MD,† Clayton Scanlon, MD,† Aaron Grant, MD,‡ Ebru N. Cetin, MD§
Purpose: To report a case of central retinal artery occlusion treated with Nd-YAG arteriotomy with successful outcome. Methods: Interventional case report of a 61-year-old man with central retinal artery occlusion who underwent an arteriotomy with embolectomy/embolysis with Nd-YAG laser. Results: Best-corrected visual acuity improved to 9/200 immediately and 20/200 one day after the procedure. Two months later, the patient underwent pars plana vitrectomy for dispersed, nonclearing vitreous hemorrhage. Three months later, the patient had cataract surgery. Visual field significantly improved centrally at 5 months after Nd-YAG laser procedure. The final visual acuity was 20/40 at 15 months after the procedure. Conclusion: Nd-YAG laser may be beneficial in selected cases of retinal artery occlusion by enhancing the restoration of blood flow in the retinal vessels. RETINAL CASES & BRIEF REPORTS 7:325–327, 2013
From the *Saint Louis University Eye Institute, St. Louis, Missouri; †Vitreoretinal Foundation/Eye Specialty Group, Memphis, Tennessee; ‡Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, Missouri; and §Department of Ophthalmology, Pamukkale University, Denizli, Turkey.
Case Report A 61-year-old white male patient presented with sudden painless vision loss of 3.5 hours duration in his right eye. Best-corrected visual acuity was 1/200 in the right eye. Mild nuclear sclerosis was the only other associated ocular problem in this eye. Dilated fundus examination demonstrated a CRAO, with a visible plaque at the first bifurcation. We obtained immediate fluorescein angiogram and Goldmann visual field (Figure 1). When no improvement was observed after ocular massage, the patient underwent an arteriotomy with embolectomy or embolysis after the discussion of all other possible alternative treatments. The procedure was performed using a Mainster lens (Ocular Instruments, Bellevue, WA) and an Nd-YAG laser with energy level of 5.0 mJ. The laser was targeted at the first bifurcation of the central retinal artery into its superior and inferior arcades. This is where the white thrombus seemed to fill the intravascular space for approximately 50 mm to 100 mm into each branch, with possible extension proximally into the part of the artery inside the optic nerve. After the arteriotomy at the laser site, we were not able to observe whether the whole embolus or any part of it was flushed into the vitreous because there was an immediate pulsatile rush of blood into the vitreous cavity. Immediate extreme pressure with the lens was applied to the eye for 4 minutes to stop the bleeding. Bestcorrected visual acuity improved to 9/200 immediately and 20/200 one day after the procedure. Fluorescein angiogram and Goldmann visual field 1 day after the procedure can be seen in Figure 2. Two months later, the patient underwent pars plana vitrectomy for dispersed, nonclearing vitreous hemorrhage. Three months later, the patient underwent cataract surgery. Best-corrected visual acuity was 20/40 and fluorescein angiogram showed good perfusion at 3 months,
T
o date, there has not been any effective therapy described and practiced for central retinal artery occlusion (CRAO). There have been several published reports of embolysis or embolectomy with arteriotomy applying Nd-YAG laser to the embolus within the central retinal artery with successful outcome.1–3 However, most of these reports lack proper documentation of evidence of changes in the visual field and of vascular circulation preoperatively and sequential documentation postoperatively. We report a case of CRAO treated with Nd-YAG arteriotomy with embolectomy and/or embolysis with successful outcome.
The authors disclose no financial or proprietary interest. Reprint requests: Levent Akduman, MD, Department of Ophthalmology, Saint Louis University, 1755 S. Grand Boulevard, St. Louis, MO 63104; e-mail: [email protected]
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Fig. 1. A. Mid arteriovenous phase of fluorescein angiography shows very poor circulation in the retinal vasculature. B. Goldmann visual field at presentation shows substantial constriction of visual field with reduced threshold response centrally.
whereas visual field showed significant central improvement at 5 months (Figure 3). The final best-corrected visual acuity was 20/40 at 15 months after the procedure.
Discussion To date, there has not been any effective therapy described and practiced for CRAO. Among those attempted, we can count ocular massage to provide temporary increase followed by sudden decrease of the intraocular pressure to accomplish propagation of the embolus to a distal branch, paracentesis again to
suddenly decrease the intraocular pressure to accomplish the same, use of topical or systemic intraocular pressure–lowering medication, hyperbaric oxygen treatment, and surgical approaches including attempt to remove the embolus surgically and tissue plasminogen activator injection.4 However, none of those methods have been effective, and the invasive ones are concerning for possibly unreasonable risk associated with them. Because the Nd-YAG laser can provide disruption of the embolus, it could break it up into fragments to propagate the occlusion to a distal branch. Alternatively, it can disrupt the artery wall and extract the occlusion from the intraarterial localization, a possibly more
Fig. 2. A. Fluorescein angiogram on the first postoperative day shows some improvement in retinal circulation. Best-corrected visual acuity improved to 20/200. B. Goldmann visual field on the first postoperative day shows some improvement in the visual field.
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Fig. 3. A. Retinal circulation in the fluorescein angiogram 3 months after the procedure was basically normal. B. Significant improvement in central visual field 5 months after the procedure, with improvement in best-corrected visual acuity to 20/40 at 15-month visit.
physiological approach to address the occlusion, which has been tried in limited cases. Previous reports of embolectomy or embolysis with Nd-YAG laser for retinal artery occlusion have included approximately 12 cases. The time from onset of occlusion to the procedure varied from several hours to several months.1–3 Most of these cases reported successful outcome but lacked proper documentation or interpretation of preoperative and postoperative diagnostic testing, particularly visual fields. We were fortunate to obtain Goldmann visual field and fluorescein angiogram before the procedure, and having good documentation during the follow-up period and a successful outcome. There has been extensive debate on whether any retinal function can be expected with prolonged occlusion even if embolysis or embolectomy was technically possible with Nd-YAG arteriotomy. Despite the contradicting opinions regarding the applicability and advisability of such a procedure, we believe that there are legitimate and agreeable points to be gathered from previous publications and from our case. These can be summarized as follows: 1) There is no clearly effective and standard therapeutic intervention for CRAO. 2) If Nd-YAG embolysis/embolectomy with arteriotomy is to be considered, more success should be expected if the procedure is performed as soon as possible from the onset of the symptoms. 3) This procedure may not establish full, partial, or any increased blood flow to the retina in every case. However, to date, there have not been any eyes lost because of the procedure or its complications. The reported complication rate is high, but all complications have been manageable.1 4) Partial blood flow probably exists in some cases of CRAO
despite the near full occlusion observed clinically. Recanalization may naturally occur in some cases, which may explain the reported cases of improvement naturally or with this procedure applied weeks after the occlusion.5 The reasons why this procedure is not performed more frequently might be the late presentation of the cases, no visible embolus in the artery, unavailability of the YAG laser in the offices of retinal specialists, lack of experience and encouragement of the physician for doing this procedure, and inconsistent results in the reported cases. However, we believe that in a condition with grave natural outcome and no other effective therapeutic method, Nd-YAG laser may be beneficial in selected cases of retinal artery occlusion. It may at least partially break up the plaque, enhancing the restoration of blood flow in the retinal vessels, with a manageable complication profile for this condition. Key words: arteriotomy, central retinal artery occlusion, Nd-YAG laser. References 1. Opremcak E, Rehmar AJ, Ridenour CD, et al. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion. Retina 2008;28:226–235. 2. Feist RM, Emond TL. Translumenal Nd:YAG laser embolysis for central retinal artery occlusion. Retina 2005;25:797–799. 3. Reynard M, Hanscom TA. Neodymium:yttrium-aluminum-garnet laser arteriotomy with embolectomy for central retinal artery occlusion. Am J Ophthalmol 2004;137:196–198. 4. Cugati S, Varma DD, Chen CS, Lee AW. Treatment options for central retinal artery occlusion. Curr Treat Options Neurol 2013;15:63–77. 5. Hayreh SS, Zimmerman B. Central retinal artery occlusion: visual outcome. Am J Ophthalmol 2005;140:376–391.
Purpose: To report a case of central retinal artery occlusion treated with Nd-YAG arteriotomy with successful outcome. Methods: Interventional case report of a 61-year-old man with central retinal artery occlusion who underwent an arteriotomy with embolectomy/embolysis with Nd-YAG laser. Results: Best-corrected visual acuity improved to 9/200 immediately and 20/200 one day after the procedure. Two months later, the patient underwent pars plana vitrectomy for dispersed, nonclearing vitreous hemorrhage. Three months later, the patient had cataract surgery. Visual field significantly improved centrally at 5 months after Nd-YAG laser procedure. The final visual acuity was 20/40 at 15 months after the procedure. Conclusion: Nd-YAG laser may be beneficial in selected cases of retinal artery occlusion by enhancing the restoration of blood flow in the retinal vessels. RETINAL CASES & BRIEF REPORTS 7:325–327, 2013
From the *Saint Louis University Eye Institute, St. Louis, Missouri; †Vitreoretinal Foundation/Eye Specialty Group, Memphis, Tennessee; ‡Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, Missouri; and §Department of Ophthalmology, Pamukkale University, Denizli, Turkey.
Case Report A 61-year-old white male patient presented with sudden painless vision loss of 3.5 hours duration in his right eye. Best-corrected visual acuity was 1/200 in the right eye. Mild nuclear sclerosis was the only other associated ocular problem in this eye. Dilated fundus examination demonstrated a CRAO, with a visible plaque at the first bifurcation. We obtained immediate fluorescein angiogram and Goldmann visual field (Figure 1). When no improvement was observed after ocular massage, the patient underwent an arteriotomy with embolectomy or embolysis after the discussion of all other possible alternative treatments. The procedure was performed using a Mainster lens (Ocular Instruments, Bellevue, WA) and an Nd-YAG laser with energy level of 5.0 mJ. The laser was targeted at the first bifurcation of the central retinal artery into its superior and inferior arcades. This is where the white thrombus seemed to fill the intravascular space for approximately 50 mm to 100 mm into each branch, with possible extension proximally into the part of the artery inside the optic nerve. After the arteriotomy at the laser site, we were not able to observe whether the whole embolus or any part of it was flushed into the vitreous because there was an immediate pulsatile rush of blood into the vitreous cavity. Immediate extreme pressure with the lens was applied to the eye for 4 minutes to stop the bleeding. Bestcorrected visual acuity improved to 9/200 immediately and 20/200 one day after the procedure. Fluorescein angiogram and Goldmann visual field 1 day after the procedure can be seen in Figure 2. Two months later, the patient underwent pars plana vitrectomy for dispersed, nonclearing vitreous hemorrhage. Three months later, the patient underwent cataract surgery. Best-corrected visual acuity was 20/40 and fluorescein angiogram showed good perfusion at 3 months,
T
o date, there has not been any effective therapy described and practiced for central retinal artery occlusion (CRAO). There have been several published reports of embolysis or embolectomy with arteriotomy applying Nd-YAG laser to the embolus within the central retinal artery with successful outcome.1–3 However, most of these reports lack proper documentation of evidence of changes in the visual field and of vascular circulation preoperatively and sequential documentation postoperatively. We report a case of CRAO treated with Nd-YAG arteriotomy with embolectomy and/or embolysis with successful outcome.
The authors disclose no financial or proprietary interest. Reprint requests: Levent Akduman, MD, Department of Ophthalmology, Saint Louis University, 1755 S. Grand Boulevard, St. Louis, MO 63104; e-mail: [email protected]
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Fig. 1. A. Mid arteriovenous phase of fluorescein angiography shows very poor circulation in the retinal vasculature. B. Goldmann visual field at presentation shows substantial constriction of visual field with reduced threshold response centrally.
whereas visual field showed significant central improvement at 5 months (Figure 3). The final best-corrected visual acuity was 20/40 at 15 months after the procedure.
Discussion To date, there has not been any effective therapy described and practiced for CRAO. Among those attempted, we can count ocular massage to provide temporary increase followed by sudden decrease of the intraocular pressure to accomplish propagation of the embolus to a distal branch, paracentesis again to
suddenly decrease the intraocular pressure to accomplish the same, use of topical or systemic intraocular pressure–lowering medication, hyperbaric oxygen treatment, and surgical approaches including attempt to remove the embolus surgically and tissue plasminogen activator injection.4 However, none of those methods have been effective, and the invasive ones are concerning for possibly unreasonable risk associated with them. Because the Nd-YAG laser can provide disruption of the embolus, it could break it up into fragments to propagate the occlusion to a distal branch. Alternatively, it can disrupt the artery wall and extract the occlusion from the intraarterial localization, a possibly more
Fig. 2. A. Fluorescein angiogram on the first postoperative day shows some improvement in retinal circulation. Best-corrected visual acuity improved to 20/200. B. Goldmann visual field on the first postoperative day shows some improvement in the visual field.
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Fig. 3. A. Retinal circulation in the fluorescein angiogram 3 months after the procedure was basically normal. B. Significant improvement in central visual field 5 months after the procedure, with improvement in best-corrected visual acuity to 20/40 at 15-month visit.
physiological approach to address the occlusion, which has been tried in limited cases. Previous reports of embolectomy or embolysis with Nd-YAG laser for retinal artery occlusion have included approximately 12 cases. The time from onset of occlusion to the procedure varied from several hours to several months.1–3 Most of these cases reported successful outcome but lacked proper documentation or interpretation of preoperative and postoperative diagnostic testing, particularly visual fields. We were fortunate to obtain Goldmann visual field and fluorescein angiogram before the procedure, and having good documentation during the follow-up period and a successful outcome. There has been extensive debate on whether any retinal function can be expected with prolonged occlusion even if embolysis or embolectomy was technically possible with Nd-YAG arteriotomy. Despite the contradicting opinions regarding the applicability and advisability of such a procedure, we believe that there are legitimate and agreeable points to be gathered from previous publications and from our case. These can be summarized as follows: 1) There is no clearly effective and standard therapeutic intervention for CRAO. 2) If Nd-YAG embolysis/embolectomy with arteriotomy is to be considered, more success should be expected if the procedure is performed as soon as possible from the onset of the symptoms. 3) This procedure may not establish full, partial, or any increased blood flow to the retina in every case. However, to date, there have not been any eyes lost because of the procedure or its complications. The reported complication rate is high, but all complications have been manageable.1 4) Partial blood flow probably exists in some cases of CRAO
despite the near full occlusion observed clinically. Recanalization may naturally occur in some cases, which may explain the reported cases of improvement naturally or with this procedure applied weeks after the occlusion.5 The reasons why this procedure is not performed more frequently might be the late presentation of the cases, no visible embolus in the artery, unavailability of the YAG laser in the offices of retinal specialists, lack of experience and encouragement of the physician for doing this procedure, and inconsistent results in the reported cases. However, we believe that in a condition with grave natural outcome and no other effective therapeutic method, Nd-YAG laser may be beneficial in selected cases of retinal artery occlusion. It may at least partially break up the plaque, enhancing the restoration of blood flow in the retinal vessels, with a manageable complication profile for this condition. Key words: arteriotomy, central retinal artery occlusion, Nd-YAG laser. References 1. Opremcak E, Rehmar AJ, Ridenour CD, et al. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion. Retina 2008;28:226–235. 2. Feist RM, Emond TL. Translumenal Nd:YAG laser embolysis for central retinal artery occlusion. Retina 2005;25:797–799. 3. Reynard M, Hanscom TA. Neodymium:yttrium-aluminum-garnet laser arteriotomy with embolectomy for central retinal artery occlusion. Am J Ophthalmol 2004;137:196–198. 4. Cugati S, Varma DD, Chen CS, Lee AW. Treatment options for central retinal artery occlusion. Curr Treat Options Neurol 2013;15:63–77. 5. Hayreh SS, Zimmerman B. Central retinal artery occlusion: visual outcome. Am J Ophthalmol 2005;140:376–391.
