Recovery Of Vision In A Young Patient With Central Retinal Artery Occlusion (Crao)

Dr Rajeshwari PardeshiDr Ketan Jathar , Dr Renu Agarkhedkar

is the occlusion of the central retinal artery (CRA) with resultant infarction of the retina and vision loss. It was first described as an embolic occlusion of the CRA in a patient with endocarditis by von Graefe .(1)

mostly seen in the elderly with clinical findings suggestive of atheromatousemboli. (2)

Uncommon in the young population. (3,4)

In a a young patient risk factors which should be considered are :diferentproatherogenic states- hyperhomocystenemia, factor V Leiden, protein C and S, antithrombin deficiencies, antiphospholipid syndrome, prothrombin gene mutations, sickle cell disease, vasculitis, oral contraceptive use, intravenous drug use, migraine due to vasospasm, and paraneoplastic syndromes.

1. Graefes AV. Ueber Embolie der Arteria centralis retinae als Ursache plotzlicher Erblindung. Arch Ophthalmol;5:136–1572. Kollarits CR, Lubow M, Hissong SL. Retinal Strokes: I: Incidence of carotid atheromata. JAMA. 1972;222:1273–5.3. Brown GC, Magargal LE, Shields JA, Goldberg RE, Walsh PN. Retinal arterial obstruction in children and young

adults. Ophthalmology. 1981;88:18–25.4. Greven CM, Slusher MM, Weaver RG. Retinal arterial occlusion in young adults. Am J Ophthalmol. 1995;120:776–83.

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Central retinal artery occlusion (CRAO):

A 21yrs old unmarried female Presentation:

- sudden painless loss of vision in Right eye since 36 hours. - H/o 3 transient ischemic attacks on the same day each lasting for 30 sec at 5min interval.

Systemic illness: k/c/o Asthma No history/evidence of any predisposing risk factors Examination on 1st visit

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RIGHT EYE LEFT EYE

BCVA CF AT 2MTRS 6/6

COLOUR VISION COULD IDENTIFY ONLY 1ST

PLATE16/16 CORRECT RESPONSES

ANTERIOR CHAMBER QUIET QUIET

PUPIL RAPD NORMAL SIZED & REACTION TO LIGHT

AMSLER GRID CENTRAL SCOTOMA WNL

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Dilated fundus examination of Right eye on 1st visit :cherry red spot retinal whitening

Dilated fundus examination of Left eye on 1st visit :normal macula , blood vessels and optic disc.

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OCT macula Right eye:Retinal edema

OCT macula Left eye:Normal findings

Haematological Investigations- FBS, PPBS, TC, DC, ESR, lipid profile, coagulation profile, vasculitis screeningall above were within normal limits

On cardiovascular evaluation- 2D ECHO was normal

Carotid Doppler Ultrasonography – normal

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Therapies that have been used in the treatment of CRAO :

carbogen inhalation, acetazolamide infusion, ocular massage , paracentesis, various vasodilators such as intravenous glyceryl trinitrate.-None of these “standard agents” have been shown to alter the natural history of disease definitively.

Recent interest :use of thrombolytic therapy either intravenously or intra-arterially by direct catheterisation of the ophthalmic artery. Recovery of vision can be quite dramatic, but intra-arterial delivery of thrombolytic may result in an increased risk of intracranial and systemic haemorrhage.

Hyperbaric Oxygen Therapy (HBO)

In this patient, considering late presentation (after 36 hrs) Hyperbaric Oxygen Therapy (HBO) was used as mode of treatment.

Preparation:-Jewellary , watch removed-cotton clothing specifically for use in the hyperbaric chamber.- vital signs recorded.

Monoplace chamber designed to treat a single person pressurized with 100% oxygen. 3 sessions of 2.5ATA HBOT for 90 min on 3 consecutive days with supplemental 100%

oxygen for 10min every 2 hourly . close monitoring of the patient including vital signs.

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12hrs after 1st

session of HBOTAfter 3 sessions of HBOT

RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE

BCVA 6/9 6/6 6/6p 6/6

COLOUR VISION 5/16 CORRECT RESPONSES

16/16 CORRECT RESPONSES

5/16 CORRECT RESPONSES

16/16 CORRECT RESPONSES

ANTERIOR CHAMBER

QUIET QUIET QUIET QUIET

PUPIL NORMAL SIZED & REACTION TO LIGHT;NO RAPD

NORMAL SIZED & REACTION TO LIGHT

NORMAL SIZED & REACTION TO LIGHT;NO RAPD

NORMAL SIZED & REACTION TO LIGHT;NO RAPD

AMSLER GRID WNL WNL WNL WNL

•After 3 sessions of HBOT , Patient was started on oral steroids started with 50mg wysolone and then tapering dose for 5 weeks..

FFA done after 3 sessions showed revascularisation of retina.

14 sec 1min 24 sec

5 min 27 sec 8 min 20 sec

5 min 27 sec 8 min 20 sec

Following 6 weeks after HBOT vision stabilized to 6/6p,N6 in Right eye 10

Rationale For Hyperbaric Oxygen Therapy (HBO) In The Management Of Central Retinal Artery Occlusion (CRAO) :

In CRAO, the inner retinal layers (ganglion cell layer and inner nuclear layer), which are normally served by the retinal circulation, may obtain enough oxygen via diffusion from the choroidal circulation to function normally if the individual is exposed to elevated partial pressures of oxygen.

Normally, the choroidal circulation supplies the majority of the oxygen to the retina. Under normoxic conditions, approximately 60% of the retina’s oxygen comes from the choroidal circulation. Under hyperoxic conditions, the choroid is capable of supplying 100% of the oxygen needed by the retina.

If supplemental O2 is provided, oxygen from choroidal circulation diffuses in adequate quantity to inner retinal layers to maintain function till revascularization and restores vision. 11

The retina has the highest rate of oxygen consumption of any organ in the body. Therefore, it is very sensitive to ischemia. In order to be effective, the administration of supplemental oxygen must be continued until such time as flow through the retinal artery has resumed to a level sufficient to maintain inner retinal viability under normoxic conditions

HBOT rapidly reduces acute tissue anoxia and mitigates reperfusion injury. As patient had presented after 36 hours of onset, traditional methods of treatment have proven to be ineffective and thus HBOT was tried as an option which helped restore vision .

Conclusion

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Discussion…

Hyperbaric oxygen therapy (HBOT) can be considered as treatment option to improve the visual outcome in central retinal artery occlusion.

Conclusion…