Was blind but now i see
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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 l.jpg

“ Was blind but now I see…”

Grand Ward Round

Dr Heng Li Wei

5th June 2008


History l.jpg
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 l.jpg
Examination

  • VR - 6/7.5 VL - CF 3ft pH -> 6/60

  • No RAPD.

  • Anterior segment:

    - Mild cataracts. Otherwise NAD

  • IOP 19mmHg BE.


Examination4 l.jpg
Examination

  • Confrontational VF

LE

RE

HM

HM

HM

CF

CF

HM

CF

CF

HM

HM


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  • 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 l.jpg
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


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OCT

OD

OS

219 microns

189 microns


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FFA

43s

1.5min

4min

8min


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Mgmt

  • Treat as for Left CRAO

  • Mgmt?

    - acute

    - subsequent workup


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  • 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.


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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.


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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.



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CRAO

  • Causes

  • Fundus appearance

  • Prognosis / visual outcome

  • Treatment



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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 l.jpg
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


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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.


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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%).


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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


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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%.


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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 l.jpg
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


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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 l.jpg
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.