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Ocular Ischaemic Syndrome

Ocular Ischaemic Syndrome. Dr Gulrez Ansari Department of Ophthalmology Watford General Hospital 3 rd November 2004. Ocular Ischaemic Syndrome.

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Ocular Ischaemic Syndrome

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  1. Ocular Ischaemic Syndrome Dr Gulrez Ansari Department of Ophthalmology Watford General Hospital 3rd November 2004

  2. Ocular Ischaemic Syndrome • A severe form of chronic ischaemia of both anterior and posterior segments of the eye as well as other orbital structures supplied by the ophthalmic artery. • Chronic hypoperfusion when carotid artery stenosis > 90% • Usually unilateral • Age: 50-80 yrs • Male:Female::2:1

  3. Symptoms • Vision loss – Sudden (41%) Gradual (28%) Transient (15%) Precipitated by exposure to bright lights (“bright light amaurosis) • ± Pain – Ocular / Orbital • Incidental asymptomatic finding

  4. Signs Anterior Segment • Dilated Episcleral vessels • Corneal edema • AC Cells • Flare (“ischemic pseudoinflammatory uveitis”) • Mid-dilated poorly reactive pupil • Cataract • Iris atrophy • Iris neovascularisation ± angle neovascularisation • Neovasuclar Glaucoma

  5. Gonioscopy – Angle neovascularisation

  6. Signs Posterior Segment • Disc – NVD, Easily inducible retinal artery pulsation, AION (rare) • Vessels – Venous dilatation (no tortuosity) • Periphery – Mid peripheral haemorrhages, Microaneurysms • Macular oedema • Ischaemic changes – Retinal arteriolar narrowing, retinal capillary non-perfusion

  7. Retinal Haemorrhages:

  8. Differential Diagnosis: Other causes of iris neovascularisation: • Proliferative diabetic retinopathy • Ischaemic CRVO

  9. Systemic evaluation: Systemic associations: • Diabetes mellitus (56%) • Hypertension (50-73%) • Ischaemic heart disease (38-48%) • Cerebrovascular disease (27-31%) • Giant cell arteritis (rare)

  10. Investigations: FFA Aid in confirmation of diagnosis, Demonstrate retinal capillary non-perfusion – to validate PRP • Delayed & patchy choroidal filling • ed retinal arteriovenous circulation times • Areas of retinal capillary non-perfusion • Late leakage from arterioles and veins • Macular oedema

  11. FFA

  12. Visual Fields: • Normal (23%) • Central scotomas (27%) • Nasal defects (23%) • Centrocaecal defects (5%) • Central or temporal islands (22%)

  13. Carotid artery ultrasound • Carotid occlusion, usually 90% or more Colour Doppler Imaging (CDI)of retrobulbar circulation • Reduced peak systolic velocities in ophthalmic & central retinal arteries • Conitnuous / intermittent reversal of ophthalmic artery blood flow Limitation: Difficult to reliably reproduce orbital blood flow measurements ERG Diminished b- and a- waves

  14. Management: • Ophthalmologist • Physician/Neurologist • Vascular surgeon

  15. Ocular treatment • Anterior segment inflammation Topical steroids and cycloplegics • Ablation of retinal ischaemia Early FFA, Only if retinal ischaemia >> 3000-5000 burns of 200-500μm spot size • Control of IOP & Neovascular glaucoma Medical therapy (topical β blockers, cycloplegics, oral carbonic anhydrase inhibitors) Surgery (trab with mitomycin C, Tube shunt procedure) Ciliary body ablation (cyclocryotherapy, laser cyclophotocoagulation – Nd:YAG / Diode laser)

  16. Medical Treatment • Full medical and neurological assessment • Aspirin • Treatment of hypertension, diabetes • Stop smoking

  17. Carotid Surgery • Of benefit in symptomatic Cerebral ischaemia when there is >70% carotid artery stenosis • Pts with severe carotid stenosis and a recent cerebral rather than ocular event had a greater risk of stroke when taking medical treatment & therefore a greater benefit from surgery • Impact on visual prognosis unclear (no randomized controlled studies) In one series – 7% improved Vn, 33% no change, 60% worsened

  18. Conclusion • Rare, but severe condition • Leads to significant visual loss and chronic ocular pain • Iris neovascularisation is an indicator of poor visual prognosis • 5 year mortality rate 40% • Majority of deaths are due to cardiac disease

  19. THANK YOU

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