Portal de Periódicos da CAPES

Risk factors for central retinal artery occlusion in young patients

2020; Elsevier BV; Volume: 56; Issue: 4 Linguagem: Inglês

10.1016/j.jcjo.2020.11.008

1715-3360

Aditya Uppuluri, Tian Xia, Marco A. Zarbin, Neelakshi Bhagat,

Retinal Imaging and Analysis

The acute irreversible loss of vision associated with central retinal artery occlusion (CRAO) can be devastating, especially in young patients. The literature has revealed potential risk factors, including hypercoagulability, trauma, sickle cell disorders, cardiac valvular disease, carotid stenosis, use of oral contraceptives, pregnancy, collagen vascular disease, increased intraocular pressure, optic nerve drusen, congenital prepapillary arterial loop, intravenous drug abuse, migraine, vasculitis, and perioperative factors in young patients with CRAO.1Brown GC Magargal LE Shields JA Goldberg RE Walsh PN Retinal arterial obstruction in children and young adults.Ophthalmology. 1981; 88: 18-25Abstract Full Text PDF PubMed Scopus (203) Google Scholar, 2Xia T Zarbin MA Bhagat N Retinal artery occlusion in young patients: a 6-year review.J Vitreoret Dis. 2019; 3: 63-68Crossref Google Scholar, 3Ratra D Dhupper M. Retinal arterial occlusions in the young: systemic associations in Indian population.Indian J Ophthalmol. 2012; 60: 95-100Crossref PubMed Scopus (26) Google Scholar This retrospective case-control study aims to evaluate systemic and ocular comorbidities associated with CRAO in young patients. This study was performed using data from the 2002–2014 National Inpatient Sample (NIS) Database.4HCUP Nationwide Inpatient Sample (NIS)Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD2011Google Scholar,5HCUP National Inpatient Sample (NIS)Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD2012Google Scholar Cases included 522 (weighted) hospitalized young adults between the ages of 20 and 45 years with an admitting diagnosis of acute CRAO, and controls, matched by age and sex, were 5430 (weighted) individuals who did not have any diagnosis of retinal artery occlusion. The average age of subjects in the CRAO and non-CRAO cohorts was 37.3 and 37.4 years, respectively (p = 0.800). Men constituted 58.4% and 56.6% of the non-CRAO and CRAO cohorts, respectively (p = 0.400). The ethnic background of the CRAO cases versus controls included White participants 42.1% versus 55.9% (p < 0.001), Black participants 28.1% versus 8.2% (p < 0.001), Hispanic participants 4.5% versus 25.6% (p < 0.001), Asian/Pacific Islander participants 4.7% versus 2.0% (p < 0.001), and Native American participants 0% versus 6.9% (p < 0.001). A higher prevalence of certain systemic comorbidities was noted in CRAO cases compared with controls (Table 1); these comorbidities included hypertension 41.4% versus 23.3%, tobacco use 32.3% versus 23.7%, hyperlipidemia 21.0 versus 9.2, cardiac valvular disease 9.6 versus 2.2, and migraine 6.7 versus 2.7. Carotid stenosis, history of cerebral stroke, sickle cell disease, atherosclerosis, and aortic disease/aneurysm were significantly more prevalent in CRAO cases. Acute thromboembolic events were reported during hospitalization of CRAO patients and included Deep Vein Thrombosis or Pulmonary Embolism (4.7%), ischemic stroke (4.0%), and Transient Ischemic Attack (1.1%). Furthermore, 9.6% of cases underwent cerebral angiography, and 29.1% echocardiography. No patients underwent endarterectomy, and no in-hospital deaths were reported. The length of hospitalization varied significantly between cases and controls (3.45 days vs 4.29 days; p < 0.001), and no significant difference was found in the hospital cost per day between the cases and controls ($9964 vs $9283; p = 0.083).Table 1Comparison of patients with and without CRAOVariableControls (n = 5430)Cases (n = 522)pCount%Count%AgeAverage age (y)37.3037.380.800Age group (y)0.56620–29105519.409618.4030–45437580.6042681.60Sex0.400Men317258.4029556.60Women225841.6022743.40EthnicityWhite303355.9022042.10<0.001Black4448.2014728.10<0.001Hispanic139125.60244.50<0.001Asian/Pacific Islander1082.00254.70<0.001Native American3776.9000.00<0.001Other50.10303.90<0.001Systemic comorbiditiesAortic dissection aneurysm50.10101.90<0.001Atherosclerosis320.60101.900.001Atrial fibrillation/flutter1152.1051.000.072Carotid dissection50.1000.000.488Carotid stenosis50.10305.80<0.001Cocaine use1011.9050.900.137Bleeding diathesis1993.70203.900.814Congestive heart failure891.60142.800.076DVT/PE (history)1572.90254.700.017Diabetes with chronic complications1623.00142.800.719Diabetes without chronic complications5299.70295.600.002Intravenous drug use1102.0050.900.094Hyperlipidemia5019.2010921.00<0.001Primary hypercoagulable state190.30254.90<0.001Hypertension126723.3021441.40<0.001Leukemia631.2000.000.013Non-Hodgkin lymphoma290.5000.000.094Migraine1492.70356.70<0.001Obesity4989.206011.500.072Pregnancy140.3000.000.245Pseudotumour cerebri100.2000.000.326Rheumatoid arthritis/collagen vascular diseases711.3040.900.299Sickle cell disease trait430.8091.800.029Stroke (history)430.80193.70<0.001Syphilis100.2091.80<0.001Systemic vasculitides00.0050.90<0.001Tobacco use128823.7016932.30<0.001Cardiac valve disease1202.20509.60<0.001Glaucoma with NVG40.10101.80<0.001In-hospital complicationsDVT/PE (acute)2113.90254.700.317Myocardial infarction (acute)430.8000.000.041Ischemic stroke50.10214.00<0.001Hemorrhagic stroke100.2000.000.326Transient ischemic attack190.4061.100.007Systemic venous thrombosis521.00132.500.001In-hospital proceduresCerebral angiography440.80509.60<0.001Carotid ultrasound00.00152.80<0.001Echocardiography480.9015229.10<0.001MedicationAnticoagulation1222.30305.70<0.001Antiplatelet140.3000.000.245Aspirin591.1040.800.495Hospital courseMean length of stay (days)4.293.45<0.001Mean cost per day (dollars)928399640.083Died during hospitalization190.4000.000.176DVT = Deep Vein Thrombosis. PE = Pulmonary Embolism. Open table in a new tab DVT = Deep Vein Thrombosis. PE = Pulmonary Embolism. Comorbidities that significantly increased the risk of CRAO included systemic vasculitides (Odds Ratio (OR) = 164.68), carotid stenosis (OR = 61.66), glaucoma (OR = 26.48), hypercoagulable state (OR = 14.82), syphilis (OR = 5.40), cardiac valve disease (OR = 3.36), migraine (OR = 3.14), and hypertension (OR = 1.97) (Table 2).Table 2Results of regression analysisVariableUnivariablepMultivariablep*Bonferroni correction: p = 0.003.Age group (y)20–291.00Ref1.00Ref30–451.06 (0.84–1.34)0.597——SexWomen1.00RefMen1.08 (0.90–1.29)0.413——EthnicityWhite1.00RefBlack4.39 (3.54–5.44)<0.0013.56 (2.77–4.56)<0.001Hispanic0.14 (0.09–0.21)<0.0010.23 (0.15–0.36)<0.001Asian/Pacific Islander2.47 (1.58–3.86)<0.0012.86 (1.78–4.59)<0.001Native American0.01 (0.00–0.21)<0.0010.02 (0.00–0.35)0.007Other40.93 (15.55–107.71)<0.00150.67 (18.96–135.4)<0.001Systemic comorbiditiesAortic dissection aneurysm19.92 (6.75–58.81)<0.0014.55 (1.07–19.41)0.041Atherosclerosis3.38 (1.65–6.91)<0.0013.06 (1.20–7.76)0.019Atrial fibrillation flutter0.49 (0.21–1.16)0.106——Carotid dissection0.96 (0.04–23.12)0.980——Carotid stenosis62.86 (24.76–159.61)<0.00161.66 (23.83–159.54)<0.001Bleeding diathesis1.10 (0.70–1.75)0.678——Congestive heart failure1.76 (1.00–3.07)0.0481.19 (0.64–2.19)0.584DVT/PE (history)1.68 (1.09–2.59)0.0190.65 (0.36–1.17)0.147Diabetes with chronic complications0.96 (0.56–1.64)0.870——Diabetes without chronic complications0.56 (0.38–0.82)0.0030.44 (0.29–0.69)<0.001Intravenous drug use0.47 (0.19–1.17)0.104——Hyperlipidemia2.61 (2.08–3.29)<0.0011.37 (1.02–1.84)0.035Primary hypercoagulable state14.5 (7.94–26.47)<0.00114.82 (6.52–33.71)<0.001Hypertension2.32 (1.93–2.79)<0.0011.97 (1.58–2.46)<0.001Leukemia0.08 (0.00–1.34)0.079——Non-Hodgkin lymphoma0.17 (0.01–2.97)0.227——Migraine without cerebral infarction2.56 (1.75–3.74)<0.0013.14 (2.04–4.82)<0.001Obesity1.30 (0.97–1.72)0.075——Peripheral artery disease2.97 (1.80–4.89)<0.0010.42 (0.18–0.99)0.048Pregnancy0.36 (0.02–6.59)0.488——Pseudotumour cerebri0.50 (0.03–9.92)0.652——Rheumatoid arthritis0.72 (0.29–1.82)0.492——Sickle cell disease trait2.35 (1.16–4.75)0.0180.35 (0.13–0.97)0.044Stroke (history)4.87 (2.83–8.38)<0.0012.20 (1.11–4.34)0.024Syphilis10.24 (4.16–25.17)<0.0015.40 (1.89–15.45)0.002Systemic vasculitides108.98 (4.45–2666.38)0.04164.68 (5.60–4846.00)0.003Tobacco use1.54 (1.27–1.87)<0.0011.21 (0.97–1.52)0.088Cardiac valve disease4.73 (3.36–6.66)<0.0013.36 (2.19–5.16)<0.001Glaucoma (includes neovascular glaucoma)23.27 (7.35–73.66)<0.00126.48 (7.95–88.19)<0.001DVT = Deep Vein Thrombosis. PE = Pulmonary Embolism. Bonferroni correction: p = 0.003. Open table in a new tab DVT = Deep Vein Thrombosis. PE = Pulmonary Embolism. Recent evidence suggests that cerebrovascular accidents may occur within a month of acute CRAO in up to 25% of cases; the American Heart Association and American Academy of Ophthalmology recommend that, irrespective of age, all of these patients should undergo urgent stroke work-up.6Flaxel CJ Adelman RA Bailey ST et al.Retinal and Ophthalmic Artery Occlusions Preferred Practice Pattern.Ophthalmology. 2020; 127: P259-P287Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar This study showed that a myriad of systemic conditions and glaucoma are risk factors for acute CRAO in young adults. Because the present study uses a national database, it is retrospective in nature, and one cannot determine causality. Furthermore, the accuracy of the analysis depends on the accuracy of the health care providers coding the diagnoses. These limitations are not unique to this database or study. Additionally, although the control group was matched by sex and age, it was not matched by ethnicity, which may introduce variation; however, the variation is likely modest and unlikely to affect the regression analysis, which includes ethnicity. Lastly, because the cases and controls of this study are inpatients, there is likely to be a higher prevalence of chronic conditions requiring multiple hospitalizations than what would be seen in a study of outpatients. Marco A. Zarbin reports personal fees from Genentech/Roche, Novartis Pharma AG, Iveric Bio, Perfuse Therapeutics, Selphagy/Life Biosciences, Frequency Therapeutics, and Chengdu Kanghong Biotech, and is cofounder of NVasc. The other authors have no financial disclosures.