ORBITAL COLOR DOPPLER IMAGING IN EMBOLIC CENTRAL RETINAL ARTERY OBLITERATION ASSOCIATED WITH NEOVASCULAR GLAUCOMA Laurent Gheck, MD,* Antoine Labbe, MD,* Patricia Koskas, MD,† Olivier Berges, MD,† Christophe Baudouin, MD, PHD*
Purpose: To describe the detection of an embolism in the retrobulbar circulation using orbital color Doppler imaging (OCDI) in a patient with an inaccessible fundus because of neovascular glaucoma. Methods: Review of the clinical, laboratory, photographic, and orbital color Doppler imaging records of a patient with central retinal artery occlusion (CRAO) associated with neovascular glaucoma. Results: A 42-year-old man had no light perception in the left eye secondary to neovascular glaucoma. The fundus was not visible because of corneal edema. Orbital color Doppler imaging established the diagnosis of embolic CRAO as the cause of neovascular glaucoma. Conclusion: Orbital color Doppler imaging is an important diagnostic procedure for establishing CRAO as the cause of neovascular glaucoma when the fundus is not accessible. This noninvasive technology enables differentiation of embolic disease from other conditions as the cause of CRAO. RETINAL CASES & BRIEF REPORTS 3:251–252, 2009
From *Service 3, Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, and †Service d’imagerie me´dicale, Fondation ophtalmologique Adolphe De Rothschild, Paris, France.
eye. He had a history of arterial hypertension without treatment. Visual acuity in the left eye was no light perception. Examination of the left eye revealed rubeosis iridis with complete iridocorneal angle closure and intraocular pressure of 70 mmHg. Funduscopy findings were not contributive because of corneal edema. Results of examination of the right eye were normal. OCDI showed a retrobulbar echogenic calcific plaque in the central retinal artery of the left eye (Figure 1). The flow velocity within the central retinal artery and vein was absent, with decreased flow velocities within the ophthalmic and the posterior ciliary circulation. Orbital color Doppler imaging of the right eye showed normal flow velocities within the central retinal artery and no echogenic material. Results of magnetic resonance imaging of the head and orbits and laboratory investigations, including complete blood cell count and erythrocyte sedimentation rate, were normal. The patient did not have hyperlipidemia or diabetes mellitus. Results of retinal fluorescein angiography of the left eye were not contributive, and those for the right eye were normal. Color Doppler imaging of the extracranial carotid artery and vertebral system showed echogenic calcific plaques in both carotid arteries without blood flow velocity modification. Findings of heart examination and color Doppler imaging were normal. To treat the neovascular glaucoma, relieve pain, and preserve the globe, the patient was initially treated with topical prednisolone
N
eovascular glaucoma is a severe complication usually associated with vascular retinal diseases such as diabetic retinopathy and central retinal vein or artery occlusion. We describe a case of neovascular glaucoma in a patient with an inaccessible fundus in whom central retinal artery occlusion (CRAO) was diagnosed by ultrasonic orbital color Doppler imaging (OCDI). Case Report A 42-year-old man from Cameroon had a severe left-sided headache with nausea and left eye pain for 3 days. Two months earlier, the patient noticed acute and painless vision loss in the left Reprint requests: Laurent Gheck, Service 3, Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, 28 rue de Charenton, 75 011 Paris, France; e-mail: [email protected]
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Fig. 1. Orbital Doppler imaging of the retrobulbar central artery of the left eye showed an echogenic plaque of embolic material (embolic plaque).
acetate administered twice a day and a topical combination of timolol and dorsolamide (cosopt).
Discussion Central retinal artery occlusion often results in profound, permanent loss of vision and is frequently associated with systemic vascular diseases.1,2 The causes of CRAO include embolism, thrombosis, vasculitis, arterial spasm, arterial dissection, and hypertensive arteriolar necrosis.3 Central retinal artery occlusions may be classified as embolic or nonembolic depending on the presence of embolic material within the retinal arterioles. Orbital color Doppler imaging is a noninvasive technique allowing evaluation of the orbital blood flow in the ophthalmic artery, central artery and vein, and short posterior ciliary circulation.4,5 Orbital color Doppler imaging not only can diagnose CRAO as the cause of neovascular glaucoma when the fundus is not accessible but also may detect hyperechoic material in the retrobulbar circulation, which can quickly differentiate embolic disease from other causes of CRAOs.6 Once an embolic cause for CRAO is established, efforts can be directed toward identifying the origin of the embolus
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(heart, carotid arteries, or aortic arch). Furthermore, OCDI accurately identifies emboli in the retrobulbar course of the central retinal artery, where they would remain undetected using other techniques even if the fundus were visible. The incidence of neovascularization of the iris and subsequent neovascular glaucoma after acute CRAO varies between 1% and 5% in the literature, but this incidence may be underestimated.7 The current case demonstrates that OCDI is an important diagnostic procedure for establishing CRAO as the cause of neovascular glaucoma when the fundus is not visible. This noninvasive technology enables prompt differentiation of embolic disease from other causes. Orbital color Doppler imaging should not be limited to patients with opaque media because this technique also may be very helpful in patients with CRAO without visible embolus or without giant cell arteritis. The recognition of emboli has important management implications for these patients. Key words: embolic central retinal artery obliteration, neovascular glaucoma, orbital color Doppler imaging. References 1.
2. 3.
4. 5.
6.
7.
Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology 1980;87: 75–78. Brown GC, Margargal LE. Central retinal artery obstruction and visual acuity. Ophthalmology 1982;89:14–19. Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and carbogen in treating acute non arteritic central retinal artery occlusion. Ophthalmology 1995;102:2029–2034. Tang WM, Topping TM. Vitreous surgery for central retinal artery occlusion. Arch Ophthalmol 2000;118:1586–1587. Peyman GA, Gremillion CM Jr. Surgical removal of a branch retinal artery embolus: a case report. Int Ophthalmol 1990;14: 295–298. Foroozan R, Savino PJ, Sergott RC. Embolic central artery occlusion detected by orbital color Doppler imaging. Ophthalmology 2002;109:744–747. Duker JS, Sivalingam A, Brown GC, Reber R. A prospective study of acute central retinal artery obstruction. Arch Ophthalmol 1991;109:339–342.
Purpose: To describe the detection of an embolism in the retrobulbar circulation using orbital color Doppler imaging (OCDI) in a patient with an inaccessible fundus because of neovascular glaucoma. Methods: Review of the clinical, laboratory, photographic, and orbital color Doppler imaging records of a patient with central retinal artery occlusion (CRAO) associated with neovascular glaucoma. Results: A 42-year-old man had no light perception in the left eye secondary to neovascular glaucoma. The fundus was not visible because of corneal edema. Orbital color Doppler imaging established the diagnosis of embolic CRAO as the cause of neovascular glaucoma. Conclusion: Orbital color Doppler imaging is an important diagnostic procedure for establishing CRAO as the cause of neovascular glaucoma when the fundus is not accessible. This noninvasive technology enables differentiation of embolic disease from other conditions as the cause of CRAO. RETINAL CASES & BRIEF REPORTS 3:251–252, 2009
From *Service 3, Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, and †Service d’imagerie me´dicale, Fondation ophtalmologique Adolphe De Rothschild, Paris, France.
eye. He had a history of arterial hypertension without treatment. Visual acuity in the left eye was no light perception. Examination of the left eye revealed rubeosis iridis with complete iridocorneal angle closure and intraocular pressure of 70 mmHg. Funduscopy findings were not contributive because of corneal edema. Results of examination of the right eye were normal. OCDI showed a retrobulbar echogenic calcific plaque in the central retinal artery of the left eye (Figure 1). The flow velocity within the central retinal artery and vein was absent, with decreased flow velocities within the ophthalmic and the posterior ciliary circulation. Orbital color Doppler imaging of the right eye showed normal flow velocities within the central retinal artery and no echogenic material. Results of magnetic resonance imaging of the head and orbits and laboratory investigations, including complete blood cell count and erythrocyte sedimentation rate, were normal. The patient did not have hyperlipidemia or diabetes mellitus. Results of retinal fluorescein angiography of the left eye were not contributive, and those for the right eye were normal. Color Doppler imaging of the extracranial carotid artery and vertebral system showed echogenic calcific plaques in both carotid arteries without blood flow velocity modification. Findings of heart examination and color Doppler imaging were normal. To treat the neovascular glaucoma, relieve pain, and preserve the globe, the patient was initially treated with topical prednisolone
N
eovascular glaucoma is a severe complication usually associated with vascular retinal diseases such as diabetic retinopathy and central retinal vein or artery occlusion. We describe a case of neovascular glaucoma in a patient with an inaccessible fundus in whom central retinal artery occlusion (CRAO) was diagnosed by ultrasonic orbital color Doppler imaging (OCDI). Case Report A 42-year-old man from Cameroon had a severe left-sided headache with nausea and left eye pain for 3 days. Two months earlier, the patient noticed acute and painless vision loss in the left Reprint requests: Laurent Gheck, Service 3, Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, 28 rue de Charenton, 75 011 Paris, France; e-mail: [email protected]
251
RETINAL CASES & BRIEF REPORTSℜ
252
Fig. 1. Orbital Doppler imaging of the retrobulbar central artery of the left eye showed an echogenic plaque of embolic material (embolic plaque).
acetate administered twice a day and a topical combination of timolol and dorsolamide (cosopt).
Discussion Central retinal artery occlusion often results in profound, permanent loss of vision and is frequently associated with systemic vascular diseases.1,2 The causes of CRAO include embolism, thrombosis, vasculitis, arterial spasm, arterial dissection, and hypertensive arteriolar necrosis.3 Central retinal artery occlusions may be classified as embolic or nonembolic depending on the presence of embolic material within the retinal arterioles. Orbital color Doppler imaging is a noninvasive technique allowing evaluation of the orbital blood flow in the ophthalmic artery, central artery and vein, and short posterior ciliary circulation.4,5 Orbital color Doppler imaging not only can diagnose CRAO as the cause of neovascular glaucoma when the fundus is not accessible but also may detect hyperechoic material in the retrobulbar circulation, which can quickly differentiate embolic disease from other causes of CRAOs.6 Once an embolic cause for CRAO is established, efforts can be directed toward identifying the origin of the embolus
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2009
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VOLUME 3
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NUMBER 3
(heart, carotid arteries, or aortic arch). Furthermore, OCDI accurately identifies emboli in the retrobulbar course of the central retinal artery, where they would remain undetected using other techniques even if the fundus were visible. The incidence of neovascularization of the iris and subsequent neovascular glaucoma after acute CRAO varies between 1% and 5% in the literature, but this incidence may be underestimated.7 The current case demonstrates that OCDI is an important diagnostic procedure for establishing CRAO as the cause of neovascular glaucoma when the fundus is not visible. This noninvasive technology enables prompt differentiation of embolic disease from other causes. Orbital color Doppler imaging should not be limited to patients with opaque media because this technique also may be very helpful in patients with CRAO without visible embolus or without giant cell arteritis. The recognition of emboli has important management implications for these patients. Key words: embolic central retinal artery obliteration, neovascular glaucoma, orbital color Doppler imaging. References 1.
2. 3.
4. 5.
6.
7.
Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology 1980;87: 75–78. Brown GC, Margargal LE. Central retinal artery obstruction and visual acuity. Ophthalmology 1982;89:14–19. Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and carbogen in treating acute non arteritic central retinal artery occlusion. Ophthalmology 1995;102:2029–2034. Tang WM, Topping TM. Vitreous surgery for central retinal artery occlusion. Arch Ophthalmol 2000;118:1586–1587. Peyman GA, Gremillion CM Jr. Surgical removal of a branch retinal artery embolus: a case report. Int Ophthalmol 1990;14: 295–298. Foroozan R, Savino PJ, Sergott RC. Embolic central artery occlusion detected by orbital color Doppler imaging. Ophthalmology 2002;109:744–747. Duker JS, Sivalingam A, Brown GC, Reber R. A prospective study of acute central retinal artery obstruction. Arch Ophthalmol 1991;109:339–342.
