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“ 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

“ Was blind but now I see…”

Grand Ward Round

Dr Heng Li Wei

5th June 2008

history
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
Examination
  • VR - 6/7.5 VL - CF 3ft pH -> 6/60
  • No RAPD.
  • Anterior segment:

- Mild cataracts. Otherwise NAD

  • IOP 19mmHg BE.
examination4
Examination
  • Confrontational VF

LE

RE

HM

HM

HM

CF

CF

HM

CF

CF

HM

HM

slide7
Posterior segment:
  • RE - NAD. No DR.
  • LE
  • Disc pink, no disc edema, CDR 0.3
  • Slight pallor & edema over macula
  • Rest of retina pink.
d dx sudden painless lov
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

slide9
OCT

OD

OS

219 microns

189 microns

slide10
FFA

43s

1.5min

4min

8min

slide12
Mgmt
  • Treat as for Left CRAO
  • Mgmt?

- acute

- subsequent workup

slide13
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.
the next day
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.
r v 2 weeks later
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.
slide17
CRAO
  • Causes
  • Fundus appearance
  • Prognosis / visual outcome
  • Treatment
susac syndrome 1
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.
orbital infarction syndrome 2
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
fundus changes in crao 3
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.
prognosis visual outcome 4
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%).

treatment
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
intra arterial thrombolysis iat 5
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%.
hyperbaric oxygenation therapy hbo 6
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.

transluminal nd yag embolysis embolectomy 7
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
transcorneal electrical stimulation tes 8
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.
references
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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