- Email: [email protected]
Branch retinal artery occlusion in a patient with one eye. Laser Nd:YAG approach
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(6):295–297
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Branch retinal artery occlusion in a patient with one eye. Laser Nd:YAG approach夽 A.M. Solans Pérez-Larraya ∗ , J.M. Ortega-Molina, A.D. Salgado-Miranda, J.L. García-Serrano Servicio de Oftalmología, Hospital Universitario San Cecilio, Granada, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Clinical case: An 82-year-old man was admitted to the emergency department complaining of
Received 25 March 2015
a sudden painless visual loss in his left eye (OS). He was diagnosed with branch retinal artery
Accepted 4 January 2016
occlusion (BRAO) with a visible embolus. In 2012, he had a central artery occlusion (CRAO)
Available online 4 May 2016
in his right eye (OD). An embolysis with Nd:YAG laser was attempted, the retinal arterial
Keywords:
complications.
Embolus
Conclusions: Nd:YAG laser embolysis is a treatment to be considered in patients with BRAO
Embolysis
with a visible embolus. The risks and benefits of the procedure should be evaluated, com-
blood flow was restored completely and the visual field was improved, with no secondary
Nd:YAG laser
paring it with possible permanent loss of visual acuity and other vascular complications
Vascular occlusion
caused by BRAO.
Blanch retinal artery occlusion
˜ ˜ S.L.U. All rights © 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.
Oclusión de rama arterial retiniana en un paciente con ojo único. Abordaje mediante láser Nd:YAG r e s u m e n Palabras clave:
˜ Caso clínico: Varón de 82 anos que acude de urgencia al servicio de oftalmología por dismin-
Émbolo
ución súbita e indolora de la agudeza visual de su ojo izquierdo (OI), fue diagnosticado de
Embólisis
una oclusión de rama arterial retiniana (ORAR) con émbolo visible. En 2012 padeció de una
Láser Nd:YAG
oclusión de arteria central retiniana (OACR) en el ojo derecho (OD). Se realizó embólisis con
Oclusión vascular
láser Nd:YAG en el OI, recuperando completamente el flujo arterial retiniano y mejorando
Oclusión de rama arterial retiniana
el campo visual sin complicaciones secundarias. Conclusiones: La embólisis mediante láser Nd:YAG debe ser considerada en pacientes con ORAR con émbolo visible. Los riesgos y beneficios deben ser evaluados y comparados con la posible pérdida de agudeza visual, y otras complicaciones producidas por la oclusión arterial. ˜ ˜ S.L.U. Todos © 2016 Sociedad Espanola de Oftalmolog´ıa. Publicado por Elsevier Espana, los derechos reservados.
夽 Please cite this article as: Solans Pérez-Larraya AM, Ortega-Molina JM, Salgado-Miranda AD, García-Serrano JL. Oclusión de rama arterial retiniana en un paciente con ojo único. Abordaje mediante láser Nd:YAG. Arch Soc Esp Oftalmol. 2016;91: 295–297. ∗ Corresponding author. E-mail address: [email protected] (A.M. Solans Pérez-Larraya). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
296
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(6):295–297
Introduction Branch retinal artery occlusion (BRAO) causes partial or complete vision loss due to the interruption of retinal arterial blood flow, which causes irreversible damage if it is not resolved within the first few hours. Arterial hypertension, atherosclerosis and hypercholesterolemia are risk factors for its onset.2,3 This case summarizes our experience in the use of Nd:YAG laser in a patient with BRAO in a single eye, after experiencing central retinal artery occlusion (CRAO) in the other eye 2 years ago.
Clinical case An 82-year-old man was admitted to the emergency department complaining of a sudden painless loss of visual acuity (VA) in the left eye (OS) of 6 hours’ evolution, accompanied by a loss of the upper visual field. His ophthalmological history included a diagnosis of CRAO in the right eye (OD) in 2012. The best corrected visual acuity (BCVA) of his OD was obtained during the hand motion test and that of the OS was of 0.1 using the lower hemifield. Moreover, he also had an afferent pupillary defect in his OD as well as nuclear sclerosis of the crystalline lens in the anterior pole. The ophthalmoscopic examination of the OS revealed the presence of an embolus of the lower temporal artery, along with narrowing of the arterioles located distally to the embolus and a lower retinal oedema (Fig. 1). The visual field revealed an almost complete loss of sensitivity in the upper hemifield (Fig. 2). The conduct of an Nd:YAG laser embolysis (VISULAS® YAG III, Carl Zeiss Meditec, Jena, Alemania) was proposed, previously obtaining the patient’s informed consent. Using Goldman’s 3-mirror lens (G-3 Three-Mirror Glass Gonio Fundus Lens from Volk Optical, Inc., EE.UU.) the laser beam was aimed at the centre of the embolus initiating treatment at 0.5 mJ pulses, increasing the power by 0.2 mJ with each pulse
Fig. 2 – Initial visual campimetry prior to treatment initiation: almost complete loss in the upper field.
until reaching a maximum of 2 mJ, moment at which the embolus was ruptured and mobilized to a more distal area, restoring the retinal arterial blood flow completely. A total of 7 h elapsed between the onset of the patient’s symptoms and the conduct of this procedure. Five minutes after undergoing the embolysis procedure, the BCVA of the patient’s OS was of 0.3, and he reported a subjective improvement in his upper hemifield. An angiographic study was carried out twenty-four hours later revealing a normal retinal arterial blood flow in the inferotemporal region without signs of ischaemia. At present, 5 months after the procedure, the patient’s BCVA is of 0.6, his retinal arterial blood flow is normal and no signs of ischaemia are evidenced (Fig. 3). The loss of the upper hemifield has gradually decreased (Fig. 4).
Discussion
Fig. 1 – Examination of the back of the left eye. The presence of an embolus of the lower temporary artery was identified associated with narrowing of the blood flow of the distal arterioles and an oedema of the lower hemiretina.
The main objective of the treatment of occlusive arterial diseases is to rapidly restore blood flow. In the case of retinal arterial circulation, visual prognosis depends on the duration and severity of the occlusion, given that, if the occlusion is complete and has persisted for over 240 min, nerve fibres suffer irreversible damage.4 BRAO is associated with a greater risk of developing an ischaemic stroke; thus, patients with this condition would benefit from a thorough examination, as the episode can reoccur if the condition is not resolved in time.5,6 Our patient had experienced a loss of hand motion VA in the OD due to a BRAO 2 years ago; hence, we had to choose an adequate therapeutic option that would allow for an appropriate visual recovery. Standard treatments for this condition
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(6):295–297
Fig. 3 – Examination of the back of the left eye, 5 months after the Nd:YAG laser embolysis, revealing a normal retinal arterial blood flow without secondary complications.
297
Based on available scientific evidence,1–3,5,6,8,10 treatment with Nd:YAG restores arterial blood flow and avoids complications secondary to ischaemia. Hayreh and Jonas,4 report that it is only effective when it is performed within the first 3 h. The good results obtained with the therapies administered subsequently depend on the disease’s natural history. Nevertheless, authors such as Opremcak et al.,8 state that the aim of vascular procedures is to restore blood flow and enable the reperfusion of viable tissue. He indicates that complete occlusion of arterial blood flow does not occur in vivo and that the remaining blood flow ensures the survival of the affected tissue for a longer period of time, thus achieving immediate complete resolution of VA. In conclusion, treatment of ORAR with Nd:YAG laser embolysis is an effective alternative procedure to surgery and no treatment. Moreover, it is an accessible and quick technique, which justifies the development of studies providing a greater quality of scientific evidence.
Conflict of interest The authors of this paper declare no conflict of interest.
include eye massages, carbonic anhydrase inhibitors, inhalation of oxygen/carbon dioxide and antiglaucoma agents.1,7 However, none of these options ensure complete functional recovery, and results are usually unsatisfactory. Several papers on surgical embolectomy support that this is an effective and relatively safe technique. Nonetheless, the time elapsed between the diagnosis and the conduct of the procedure tends to be excessive, and there are few specialists trained in this surgical intervention.8,9
Fig. 4 – Progressive improvement of the loss of the upper visual field after 5 months of treatment.
references
1. Shalchi MH, Daneshvar R. Transluminal Nd:YAG laser embolysis in a case of hemiretinal arterial occlusion. East Mediterr Health J. 2009;15:1613–6. 2. Mason JO, Nixon PA, Albert MA. Transluminal ND:YAG laser embolysis for branch retinal artery occlusion. Retina. 2007;27:573–7. 3. Lim JY, Lee JY, Chung HW, Yoon YH, Kim JG. Treatment of branch retinal artery occlusion with transluminal ND:YAG laser embolysis. Korean J Ophthalmol. 2009;23:315–7. 4. Hayreh SS, Jonas JB. Optic disk and retinal nerve fiber layer damage after transient central artery occlusion: an experimental study in rhesus monkeys. Am J Ophthalmol. 2000;129:786–95. 5. Opremcak EM, Benner JD. Translumenal Nd:YAG laser embolysis for branch retinal artery occlusion. Retina. 2002;22:213–6. 6. Reynard M, Hanscom TA. Neodymium:yttrium–aluminum–garnet laser arteriotomy with embolectomy for central retinal artery occlusion. Am J Ophthalmol. 2004;137:196–8. 7. Cugati S, Varma D, Chen C, Lee A. Treatment options for central retinal artery occlusion. Curr Treat Options Neurol. 2013;15:63–77. 8. Opremcak E, Rehmar AJ, Ridenour CD, Borkowski LM, Kelley JK. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion. Retina. 2008;28:226–35. 9. Matonti F, Hoffart L, Nadeau S, Hamdan J, Denis D. Surgical embolectomy for central retinal artery occlusion. Can J Opthalmol. 2013;48:25–32. 10. Much MM, Hesse L. Behandlung retinaler Arterienastverschlüsse mittels transluminaler Nd:YAG-Laser-Embolektomie. Ophthalmologe. 2014;111:144–50.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Branch retinal artery occlusion in a patient with one eye. Laser Nd:YAG approach夽 A.M. Solans Pérez-Larraya ∗ , J.M. Ortega-Molina, A.D. Salgado-Miranda, J.L. García-Serrano Servicio de Oftalmología, Hospital Universitario San Cecilio, Granada, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Clinical case: An 82-year-old man was admitted to the emergency department complaining of
Received 25 March 2015
a sudden painless visual loss in his left eye (OS). He was diagnosed with branch retinal artery
Accepted 4 January 2016
occlusion (BRAO) with a visible embolus. In 2012, he had a central artery occlusion (CRAO)
Available online 4 May 2016
in his right eye (OD). An embolysis with Nd:YAG laser was attempted, the retinal arterial
Keywords:
complications.
Embolus
Conclusions: Nd:YAG laser embolysis is a treatment to be considered in patients with BRAO
Embolysis
with a visible embolus. The risks and benefits of the procedure should be evaluated, com-
blood flow was restored completely and the visual field was improved, with no secondary
Nd:YAG laser
paring it with possible permanent loss of visual acuity and other vascular complications
Vascular occlusion
caused by BRAO.
Blanch retinal artery occlusion
˜ ˜ S.L.U. All rights © 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.
Oclusión de rama arterial retiniana en un paciente con ojo único. Abordaje mediante láser Nd:YAG r e s u m e n Palabras clave:
˜ Caso clínico: Varón de 82 anos que acude de urgencia al servicio de oftalmología por dismin-
Émbolo
ución súbita e indolora de la agudeza visual de su ojo izquierdo (OI), fue diagnosticado de
Embólisis
una oclusión de rama arterial retiniana (ORAR) con émbolo visible. En 2012 padeció de una
Láser Nd:YAG
oclusión de arteria central retiniana (OACR) en el ojo derecho (OD). Se realizó embólisis con
Oclusión vascular
láser Nd:YAG en el OI, recuperando completamente el flujo arterial retiniano y mejorando
Oclusión de rama arterial retiniana
el campo visual sin complicaciones secundarias. Conclusiones: La embólisis mediante láser Nd:YAG debe ser considerada en pacientes con ORAR con émbolo visible. Los riesgos y beneficios deben ser evaluados y comparados con la posible pérdida de agudeza visual, y otras complicaciones producidas por la oclusión arterial. ˜ ˜ S.L.U. Todos © 2016 Sociedad Espanola de Oftalmolog´ıa. Publicado por Elsevier Espana, los derechos reservados.
夽 Please cite this article as: Solans Pérez-Larraya AM, Ortega-Molina JM, Salgado-Miranda AD, García-Serrano JL. Oclusión de rama arterial retiniana en un paciente con ojo único. Abordaje mediante láser Nd:YAG. Arch Soc Esp Oftalmol. 2016;91: 295–297. ∗ Corresponding author. E-mail address: [email protected] (A.M. Solans Pérez-Larraya). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
296
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(6):295–297
Introduction Branch retinal artery occlusion (BRAO) causes partial or complete vision loss due to the interruption of retinal arterial blood flow, which causes irreversible damage if it is not resolved within the first few hours. Arterial hypertension, atherosclerosis and hypercholesterolemia are risk factors for its onset.2,3 This case summarizes our experience in the use of Nd:YAG laser in a patient with BRAO in a single eye, after experiencing central retinal artery occlusion (CRAO) in the other eye 2 years ago.
Clinical case An 82-year-old man was admitted to the emergency department complaining of a sudden painless loss of visual acuity (VA) in the left eye (OS) of 6 hours’ evolution, accompanied by a loss of the upper visual field. His ophthalmological history included a diagnosis of CRAO in the right eye (OD) in 2012. The best corrected visual acuity (BCVA) of his OD was obtained during the hand motion test and that of the OS was of 0.1 using the lower hemifield. Moreover, he also had an afferent pupillary defect in his OD as well as nuclear sclerosis of the crystalline lens in the anterior pole. The ophthalmoscopic examination of the OS revealed the presence of an embolus of the lower temporal artery, along with narrowing of the arterioles located distally to the embolus and a lower retinal oedema (Fig. 1). The visual field revealed an almost complete loss of sensitivity in the upper hemifield (Fig. 2). The conduct of an Nd:YAG laser embolysis (VISULAS® YAG III, Carl Zeiss Meditec, Jena, Alemania) was proposed, previously obtaining the patient’s informed consent. Using Goldman’s 3-mirror lens (G-3 Three-Mirror Glass Gonio Fundus Lens from Volk Optical, Inc., EE.UU.) the laser beam was aimed at the centre of the embolus initiating treatment at 0.5 mJ pulses, increasing the power by 0.2 mJ with each pulse
Fig. 2 – Initial visual campimetry prior to treatment initiation: almost complete loss in the upper field.
until reaching a maximum of 2 mJ, moment at which the embolus was ruptured and mobilized to a more distal area, restoring the retinal arterial blood flow completely. A total of 7 h elapsed between the onset of the patient’s symptoms and the conduct of this procedure. Five minutes after undergoing the embolysis procedure, the BCVA of the patient’s OS was of 0.3, and he reported a subjective improvement in his upper hemifield. An angiographic study was carried out twenty-four hours later revealing a normal retinal arterial blood flow in the inferotemporal region without signs of ischaemia. At present, 5 months after the procedure, the patient’s BCVA is of 0.6, his retinal arterial blood flow is normal and no signs of ischaemia are evidenced (Fig. 3). The loss of the upper hemifield has gradually decreased (Fig. 4).
Discussion
Fig. 1 – Examination of the back of the left eye. The presence of an embolus of the lower temporary artery was identified associated with narrowing of the blood flow of the distal arterioles and an oedema of the lower hemiretina.
The main objective of the treatment of occlusive arterial diseases is to rapidly restore blood flow. In the case of retinal arterial circulation, visual prognosis depends on the duration and severity of the occlusion, given that, if the occlusion is complete and has persisted for over 240 min, nerve fibres suffer irreversible damage.4 BRAO is associated with a greater risk of developing an ischaemic stroke; thus, patients with this condition would benefit from a thorough examination, as the episode can reoccur if the condition is not resolved in time.5,6 Our patient had experienced a loss of hand motion VA in the OD due to a BRAO 2 years ago; hence, we had to choose an adequate therapeutic option that would allow for an appropriate visual recovery. Standard treatments for this condition
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(6):295–297
Fig. 3 – Examination of the back of the left eye, 5 months after the Nd:YAG laser embolysis, revealing a normal retinal arterial blood flow without secondary complications.
297
Based on available scientific evidence,1–3,5,6,8,10 treatment with Nd:YAG restores arterial blood flow and avoids complications secondary to ischaemia. Hayreh and Jonas,4 report that it is only effective when it is performed within the first 3 h. The good results obtained with the therapies administered subsequently depend on the disease’s natural history. Nevertheless, authors such as Opremcak et al.,8 state that the aim of vascular procedures is to restore blood flow and enable the reperfusion of viable tissue. He indicates that complete occlusion of arterial blood flow does not occur in vivo and that the remaining blood flow ensures the survival of the affected tissue for a longer period of time, thus achieving immediate complete resolution of VA. In conclusion, treatment of ORAR with Nd:YAG laser embolysis is an effective alternative procedure to surgery and no treatment. Moreover, it is an accessible and quick technique, which justifies the development of studies providing a greater quality of scientific evidence.
Conflict of interest The authors of this paper declare no conflict of interest.
include eye massages, carbonic anhydrase inhibitors, inhalation of oxygen/carbon dioxide and antiglaucoma agents.1,7 However, none of these options ensure complete functional recovery, and results are usually unsatisfactory. Several papers on surgical embolectomy support that this is an effective and relatively safe technique. Nonetheless, the time elapsed between the diagnosis and the conduct of the procedure tends to be excessive, and there are few specialists trained in this surgical intervention.8,9
Fig. 4 – Progressive improvement of the loss of the upper visual field after 5 months of treatment.
references
1. Shalchi MH, Daneshvar R. Transluminal Nd:YAG laser embolysis in a case of hemiretinal arterial occlusion. East Mediterr Health J. 2009;15:1613–6. 2. Mason JO, Nixon PA, Albert MA. Transluminal ND:YAG laser embolysis for branch retinal artery occlusion. Retina. 2007;27:573–7. 3. Lim JY, Lee JY, Chung HW, Yoon YH, Kim JG. Treatment of branch retinal artery occlusion with transluminal ND:YAG laser embolysis. Korean J Ophthalmol. 2009;23:315–7. 4. Hayreh SS, Jonas JB. Optic disk and retinal nerve fiber layer damage after transient central artery occlusion: an experimental study in rhesus monkeys. Am J Ophthalmol. 2000;129:786–95. 5. Opremcak EM, Benner JD. Translumenal Nd:YAG laser embolysis for branch retinal artery occlusion. Retina. 2002;22:213–6. 6. Reynard M, Hanscom TA. Neodymium:yttrium–aluminum–garnet laser arteriotomy with embolectomy for central retinal artery occlusion. Am J Ophthalmol. 2004;137:196–8. 7. Cugati S, Varma D, Chen C, Lee A. Treatment options for central retinal artery occlusion. Curr Treat Options Neurol. 2013;15:63–77. 8. Opremcak E, Rehmar AJ, Ridenour CD, Borkowski LM, Kelley JK. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion. Retina. 2008;28:226–35. 9. Matonti F, Hoffart L, Nadeau S, Hamdan J, Denis D. Surgical embolectomy for central retinal artery occlusion. Can J Opthalmol. 2013;48:25–32. 10. Much MM, Hesse L. Behandlung retinaler Arterienastverschlüsse mittels transluminaler Nd:YAG-Laser-Embolektomie. Ophthalmologe. 2014;111:144–50.