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A case of bilateral central retinal artery obstruction with patent foramen ovale

2004; Wiley; Volume: 82; Issue: 1 Linguagem: Inglês

10.1111/j.1395-3907.2004.0189f.x

1600-0420

Takako Nakagawa, Akira Hirata, Nobuhiro Inoue, Yoichiro Hashimoto, Hidenobu Tanihara,

Cerebrovascular and Carotid Artery Diseases

Sir, Central retinal artery obstruction (CRAO) is a severe ocular disease with poor prognosis. It is usually caused by an embolus derived from atheromatous plaque in the carotid rtery and valvular heart disease in elderly patients and by collagen disease and arteritis in young patients. Here, we present a patient with bilateral CRAO probably caused by paradoxical embolism through a patent foramen ovale (PFO) that was detected by transoesophageal echocardiography. A 43-year-old woman was referred to Hitoyoshi General Hospital because of severe visual loss in the right eye that had occurred 7 hours prior to presentation on December 17, 2002. Corrected visual acuity was 4/200 in the right eye and 20/20 in the left eye. A diagnosis of CRAO was made, based on the existence of a cherry-red spot and a delay in retinal arteriovenous transit time as revealed by fluorescein angiography (Fig. 1A). The patient was treated with urokinase on the day of occurrence, and with an anticoagulant over the next 2 weeks. Corrected VA recovered to 50/50 in the right eye. The patient left the hospital on January 1, 2003. However, during a visit to the hospital on January 7, 2003, she complained of visual loss in the left eye. Corrected VA was 20/20 in the right eye and hand motion in the left eye. Fluorescein angiography showed CRAO in the left eye (Fig. 1B). The left eye was treated using the same therapy. Corrected VA recovered to 90/100 over the next 3 weeks. (A) Fluorescein angiogram of the right eye 31 seconds after injection demonstrates non-filling retinal vessels. (B) Fluorescein angiogram of the left eye 40 seconds after injection demonstrates non-filling retinal vessels. A choroidal perfusion defect was also noted. (C) Transoesophageal echocardiography before injection of microbubbles. (D) Transoesophageal echocardiography showing microbubbles crossing the interatrial septum during the Valsalva manoeuvre, indicating a right to left shunt (arrowheads). RA = right atrium; LA = left atrium. Routine examinations were performed according to standard screening protocols for CRAO and included blood pressure, haemogram, blood chemistry, MRI, MRA and Doppler examination of the carotid and cardiac arteries. Although the patient had hypertension, her blood pressure was well controlled with a Ca-blocker. All other results of the tests described above were within normal ranges. Tests for anti-nuclear antibody, anti-DNA antibody, lupus anticoagulant and anticardiolipin antibody were all negative. Test results for antithrombin III complex, Alpha-2-plasmin inhibitor complex, protein S and protein C were also within normal ranges. Transoesophageal echocardiography performed on January 27, 2003 revealed a right to left shunt through a patent foramen ovale (Fig. 1C, D). The patient is now being treated with anticoagulants and has suffered no recurrence of CRAO during the past 6 months. Bilateral CRAO is relatively rare. Patients with CRAO who are under 45 years of age are more likely to have cardiac disease compared with those over 45 years of age. In a recent study, PFO was found in 45% of patients with cryptogenic stroke (Meier & Lock 2003). The literature suggests that PFO has been diagnosed in 17–23% of patients with CRAO (Steuber et al. 1997; Kramer et al. 2001). A pooled analysis of autopsy studies yielded an average prevalence of PFO of 26% (Meier & Lock 2003). Although PFO can be considered a normal variant, it should be taken into account as a possible cause of recurrent or bilateral CRAO in patients who have no causative factors. Transoesophageal echocardiography is a potentially useful procedure for detecting possible causes of retinal artery obstruction.