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“ Was blind but now I see…”

“ Was blind but now I see…”. Grand Ward Round Dr Heng Li Wei 5 th June 2008. History. 74 / Indian / F DM on OHGA, hypt (diet control) Sudden onset of LE visual loss on waking up x 1 day - Painless, no eye redness, no other neurological symptoms. Examination.

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“ Was blind but now I see…”

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  1. “ Was blind but now I see…” Grand Ward Round Dr Heng Li Wei 5th June 2008

  2. History • 74 / Indian / F • DM on OHGA, hypt (diet control) • Sudden onset of LE visual loss on waking up x 1 day - Painless, no eye redness, no other neurological symptoms.

  3. Examination • VR - 6/7.5 VL - CF 3ft pH -> 6/60 • No RAPD. • Anterior segment: - Mild cataracts. Otherwise NAD • IOP 19mmHg BE.

  4. Examination • Confrontational VF LE RE HM HM HM CF CF HM CF CF HM HM

  5. Posterior segment: • RE - NAD. No DR. • LE • Disc pink, no disc edema, CDR 0.3 • Slight pallor & edema over macula • Rest of retina pink.

  6. D/dx sudden painless LOV • “ Vascular” – CRAO, CRVO • “ Neuro” – AION ( arteritic / non-arteritic) • “ Retina” - RD - Vitreous h’age ( PDR, NV, retina tear) - Wet ARMD with breakthrough h’age

  7. OCT OD OS 219 microns 189 microns

  8. FFA 43s 1.5min 4min 8min

  9. Mgmt • Treat as for Left CRAO • Mgmt? - acute - subsequent workup

  10. Ocular massage • Carbogen therapy • Timolol LE – stat & bd • T aspirin 100mg om & famotidine 20mg bd • Pt refused AC tap • Pt declined adm for CVM & Neuro r/v.

  11. The next day… • Pt was very happy, said VA improved overnight. • VR 6/9 VL 6/12 • Left RAPD grade 1 • VF by confrontation – left paracentral nasal field blurring. • Ishihara - R: 15/15 L: 9/15 • Red desaturation - R: 100% L: 40% • Posterior segment – ISQ.

  12. R/v 2 weeks later • VR 6/7.5 VL 6/9 • Left RAPD grade 1 • Ishihara - R: 15/15 L: 3/15 • LE – very mild retina edema over macula. • U/S carotids – 28/5/08 • Neuro TCU – 13/6/08 • CVM / 2DE TCU – 13/6/08 • Referred to OPD to control DM & hypt. • TCU Neuro-Oph 2 months.

  13. CRAO protocol

  14. CRAO • Causes • Fundus appearance • Prognosis / visual outcome • Treatment

  15. CRAO - CAUSES

  16. Susac syndrome 1 • Triad of retinal artery occlusion, sensorineural deafness, encephalopathy • Rare • Microangiopathy affecting pre-capillary arterioles of brain, retina & inner ear. • Young women in young adulthood. • Pathogenesis – unknown. • Clinical course – recurrent attacks, spont resolution but may have sensory & neurologic sequelae. • Rx: steriods, immunosuppressants, immunoglobulin.

  17. Orbital infarction syndrome 2 • Rare • P/w: acute blindness, orbital pain, total ophthalmoplegia, ant & post segment ischaemia. • Proposed mechanisms: • Acute perfusion failure eg. CCA occlusion • Systemic vasculitis eg GCA • Orbital cellulitis with vasculitis

  18. Fundus changes in CRAO 3 • 248 eyes: permanent CRAO (175), w cilioretinal artery sparing (35), transient CRAO (38). • Initial findings in permanent CRAO: - Cherry red spot (90%) - Retinal opacity in posterior pole (58%) - Arterial attenuation, disc edema & pallor, box-carring. • Later stage findings: - Optic atrophy, arterial attentuation, cilioretinal collaterals, macular RPE changes. • 4% of CRAO had simultaneous bilateral onset. • Intraarterial emboli observed in 20% of pts.

  19. Prognosis / Visual Outcome 4 • Poor except those with cilioretinal artery-sparing. • 15-20% of general population have cilioretinal artery. • 25% of CRAO have cilioretinal artery. • VA improvement primarily w/n first 7 days. • VA improvement: - transient NA-CRAO (82%), NA-CRAO w cilioret artery sparing (67%), NA-CRAO (22%).

  20. Treatment • Medical therapy + ocular massage + carbogen therapy + AC paracentesis. • Intra-arterial thrombolysis (IAT) • Hyperbaric O2 therapy (HBO) • Transluminal Nd:Yag embolysis/embolectomy (TYL/E) • Transcorneal electrical stimulation

  21. Intra-arterial thrombolysis (IAT) 5 • Systemic rv on literature on IAT • 23 studies, 8 selected for analysis. • 158 pts. • Rx instituted w/n average of 8.4h from onset of symptoms. • VA improvement in 93% pts -> 13% (>20/20), 25% (>20/40), 41% (>20/200). • Complication rate – 4.5%.

  22. Hyperbaric Oxygenation Therapy(HBO) 6 • Off-label use • W/n 12 hr of onset of symptoms • Early Rx (<2h) may be associated with increased visual recovery • Other uses: - retinal vein occlusion with CMO - scleral necrosis after pterygium Sx - orbital rhino-cerebral mucormycosis - anterior segment ischaemia.

  23. Transluminal Nd:Yag embolysis / embolectomy 7 • Photodisrupt emboli w/n CRA/BRA to achieve rapid retinal reperfusion • Embolysis – embolus fragmented w/n lumen • Embolectomy – embolus observed to pass into vitreous • Cx: vitreous h’age, subhyaloid h’age

  24. Transcorneal electrical stimulation (TES) 8 • Longstanding CRAO/BRAO • Jap studies • Bipolar contact lens electrode, once 1 mth x 3 mths. • Outcome measures - perimetric and/or electrophysiological exam • VA improved by >0.2 logMar units in 2/3 cases. • Visual fields improved in all 3 cases. • Multifocal ERG improved in 2/3 cases.

  25. References • Saliba et al. Susac syndrome and ocular manifestation in a 14-year-old girl. J Fr Ophtalmol. 2007 Dec;30(10):1017-22. • Borruat et al. Orbital infarction syndrome. Ophthalmology. 1993 Apr;100(4):562-8. • Havreb et al. Fundus changes in central retinal artery occlusion. Retina. 2007 Mar;27(3):276-89. • Hayreh et al. Central retinal artery occlusion: visual outcome. Am J Ophthalmol. 2005 Sep;140(3):376-91. • Noble J et al. Intra-arterial thrombolysis for central retinal artery occlusion: a systematic review. Br J Ophthalmol. 2008 May;92(5):588-93. • Oguz H et al. The use of hyperbaric oxygen therapy in ophthalmology. Surv Ophthalmol. 2008 Mar-Apr;53(2):112-20. • Opremcak et al. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion. Retina. 2008 Feb;28(2):226-35. • Inomata K et al. Transcorneal electrical stimulation of retina to treat longstanding retinal artery occlusion. Graefes Arch Clin Exp Ophthalmol. 2007 Dec;245(12):1773-80. Epub 2007 Jun 26.

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