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Transesophageal Echocardiography for Detecting Mitral Valve Prolapse With Retinal Artery Occlusions
LETTERS TO THE JOURNAL Transesophageal Echocardiography for D e t e c t i n g i\/litral Valve P r o l a p s e W i t h Retinal A r t e r y O c c l u s i o n s
o c c l u s i o n . R e s u l t s o f e x a m i n a t i o n at t h a t t i m e were normal, including surface echocardiogra p h y . O n e x a m i n a t i o n , v i s u a l a c u i t y was R . E . : 2 0 / 2 0 a n d L.E.: 2 0 / 2 0 . R e s u l t s o f s l i t - l a m p a n d pupillary examinations were normal. Small paracentral inferior scotomas were present bi laterally. Although results of retinal examina tion at this t i m e w e r e n o r m a l , fluorescein a n g i ography of the right eye showed abrupt t e r m i n a t i o n o f the fluorescein a n d n o n f i l l i n g o f t w o s u p e r i o r b r a n c h r e t i n a l a r t e r i o l e s that c o r r e s p o n d e d e x a c t l y w i t h t h e a r e a o f the s c o t o m a ( F i g s . 1 a n d 2 ) . R e s u l t s o f an e x a m i n a t i o n a n d
Craig M. Greven, M.D., Richard G. Weaver, M.D., William R. Harris, M.D., L. Earl Walts, M.D., and M. Madison Slusher, M.D. Departments of Ophthalmology (C.M.G., R.G.W., M.M.S.) and Cardiology (L.E.W.), Wake Forest Uni versity Medical Center, and Graystone Ophthalmolo gy Associates (W.R.H.). Inquiries to Craig M. Greven, M.D., Department of Ophthalmology, Wake Forest University Eye Center, 300 S. Hawthorne Rd., Winston-Salem, NC 27103. M i t r a l v a l v e p r o l a p s e is the m o s t c o m m o n form o f v a l v u l a r h e a r t d i s e a s e . ' R e t i n a l a r t e r i a l obstruction and central retinal venous occlu sive d i s e a s e h a v e b e e n a s s o c i a t e d w i t h m i t r a l valve prolapse.'"* T h e d i a g n o s i s o f m i t r a l v a l v e p r o l a p s e can b e m a d e o n c l i n i c a l g r o u n d s , b u t e c h o c a r d i o g r a p h y is r e q u i r e d t o c o n f i r m t h e d i a g n o s i s . We t r e a t e d a p a t i e n t w i t h b i l a t e r a l retinal arterial occlusion w h o h a d n o r m a l re sults o f s u r f a c e e c h o c a r d i o g r a p h y o n two o c c a sions. However, transesophageal echocardiog r a p h y , an i m p r o v e d m e t h o d o f i m a g i n g the c a r d i a c v a l v e s , was a b l e to d o c u m e n t m i t r a l valve p r o l a p s e i n t h i s p a t i e n t . A 35-year-old man had a three-week history of a c u t e o n s e t o f an i n f e r i o r s c o t o m a in the r i g h t eye. Two y e a r s p r e v i o u s l y , the p a t i e n t h a d d e v e l o p e d an i n f e r i o r s c o t o m a in t h e left e y e p r e s u m e d to b e s e c o n d a r y t o a r e t i n a l v a s c u l a r
Fig. 1 (Greven and associates). Normal appearance of retinal vasculature and site of occlusion of the superotemporal artery.
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of T H E JOURNAL. Letters must be typewritten, double-spaced, on 8 1/2 χ 11-inch bond paper with 1 1/2-inch margins on all four sides. (See instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, T H E JOURNAL does not publish correspondence concerning previously published letters.
103
104
January, 1991
AMERICAN JOURNAL OF OPHTHALMOLOGY
References
Fig. 2 (Greven and associates). Fluorescein angio gram of right eye showing abrupt termination of a branch of the superotemporal artery (arrow).
surface echocardiography were normal. How ever, t r a n s e s o p h a g e a l e c h o c a r d i o g r a p h y d i s c l o s e d m y x o m a t o u s c h a n g e s in the m i t r a l v a l v e w i t h m i t r a l valve p r o l a p s e . T h e p a t i e n t w a s s u b s e q u e n t l y g i v e n aspirin a n d d i p y r i d a m o l e and has had no additional vascular occlusive events. Transesophageal echocardiography has been s h o w n to b e b e t t e r t h a n s u r f a c e e c h o c a r d i o g r a p h y in d e t e c t i n g m i t r a l v a l v e p r o l a p s e a n d o t h e r c a r d i a c a b n o r m a l i t i e s in y o u n g p a t i e n t s with c e r e b r a l i s c h e m i c events.^ T h e t r a n s e s o p h a g e a l e c h o t r a n s d u c e r is in c l o s e r p r o x i m i t y to the posterior heart structures, which allows the u s e o f a high t r a n s d u c e r f r e q u e n c y (5 m H z ) to i m p r o v e the r e s o l u t i o n o f the p o s t e r i o r h e a r t s t r u c t u r e s as well as the m i t r a l v a l v e , left a t r i um, a n d a o r t i c valve. T h e findings in o u r c a s e d e m o n s t r a t e that this t e c h n o l o g i c a d v a n c e w a s better than traditional transthoracic echocardi o g r a p h y in d o c u m e n t i n g the s o u r c e o f the retinal arterial occlusion. Ophthalmologists s h o u l d b e aware o f t r a n s e s o p h a g e a l e c h o c a r d i o g r a p h y a n d c o n s i d e r this i m p r o v e d d i a g n o s t i c m o d a l i t y for p a t i e n t s with u n e x p l a i n e d r e t i n a l artery occlusions, even with normal results of surface e c h o c a r d i o g r a p h y .
1. Rackley, C. E.: Valvular heart disease. In Wyngaarden, J. B., and Smith, L. H. (eds.): Cecil Textbook of Medicine, ed. 18. Philadelphia, W. B. Saunders, 1988, p. 3 4 0 . 2. Woldoff, H. S., Gerber, Μ., Desser, Κ. Β., and Benchimol, Α.: Retinal vascular lesions in two pa tients with mitral valve leaflets. Am. J. Ophthalmol. 79:382, 1 9 7 5 . 3. Caltrider, N. D., Irvine, A. R., Kline, H. J., and Rosenblatt, Α.: Retinal emboli in patients with mitral valve prolapse. Am. ] . Ophthalmol. 90:534, 1 9 8 0 . 4. Gonder, J. R., Magargal, L. E., Walsh, P. N., Rao, K., and Denenberg, B. E.: Central retinal vein obstruction associated with mitral valve prolapse. Can. J. Ophthalmol. 18:220, 1983. 5. Zenker, G., Erbel, R., Kramer, G., Mohr-Kahaly, S., Drexler, M., Harnoncourt, K., and Meyer, J . : Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events. Stroke 19:345, 1988.
Use of T r a n s e s o p h a g e a l E c h o c a r d i o g r a p h y for D e t e c t i o n of a Likely S o u r c e of E m b o l i z a t i o n to t h e C e n t r a l Retinal A r t e r y Robert A. Wiznia, M.D., and W. Neil Pearson, M.D. Departments of Ophthalmology and Visual Science (R.A.W.) and Internal Medicine (W.N.P.), Yale Uni versity School of Medicine. Inquiries to Robert A. Wiznia, M.D., 850 Howard New Haven, CT 06519-1193.
Ave.,
Transesophageal echocardiography provides a substantially clearer view of cardiac struc tures t h a n d o e s t r a n s t h o r a c i c e c h o c a r d i o g r a phy. Transesophageal echocardiography uses a 5 - M H z u l t r a s o u n d t r a n s d u c e r a t t a c h e d to the distal tip o f a s t a n d a r d flexible g a s t r o s c o p e . B y p l a c i n g the t r a n s d u c e r in the e s o p h a g u s d i r e c t ly b e h i n d the h e a r t , t h e t e c h n i q u e avoids the tissue, b o n e , and air interfaces that attenuate transthoracic echocardiography ultrasound im a g e s . ' We u s e d this t e c h n i q u e to d e t e c t a l i k e l y cardiac source of embolization to the central retinal artery, which was not evident with transthoracic echocardiography.
o c c l u s i o n . R e s u l t s o f e x a m i n a t i o n at t h a t t i m e were normal, including surface echocardiogra p h y . O n e x a m i n a t i o n , v i s u a l a c u i t y was R . E . : 2 0 / 2 0 a n d L.E.: 2 0 / 2 0 . R e s u l t s o f s l i t - l a m p a n d pupillary examinations were normal. Small paracentral inferior scotomas were present bi laterally. Although results of retinal examina tion at this t i m e w e r e n o r m a l , fluorescein a n g i ography of the right eye showed abrupt t e r m i n a t i o n o f the fluorescein a n d n o n f i l l i n g o f t w o s u p e r i o r b r a n c h r e t i n a l a r t e r i o l e s that c o r r e s p o n d e d e x a c t l y w i t h t h e a r e a o f the s c o t o m a ( F i g s . 1 a n d 2 ) . R e s u l t s o f an e x a m i n a t i o n a n d
Craig M. Greven, M.D., Richard G. Weaver, M.D., William R. Harris, M.D., L. Earl Walts, M.D., and M. Madison Slusher, M.D. Departments of Ophthalmology (C.M.G., R.G.W., M.M.S.) and Cardiology (L.E.W.), Wake Forest Uni versity Medical Center, and Graystone Ophthalmolo gy Associates (W.R.H.). Inquiries to Craig M. Greven, M.D., Department of Ophthalmology, Wake Forest University Eye Center, 300 S. Hawthorne Rd., Winston-Salem, NC 27103. M i t r a l v a l v e p r o l a p s e is the m o s t c o m m o n form o f v a l v u l a r h e a r t d i s e a s e . ' R e t i n a l a r t e r i a l obstruction and central retinal venous occlu sive d i s e a s e h a v e b e e n a s s o c i a t e d w i t h m i t r a l valve prolapse.'"* T h e d i a g n o s i s o f m i t r a l v a l v e p r o l a p s e can b e m a d e o n c l i n i c a l g r o u n d s , b u t e c h o c a r d i o g r a p h y is r e q u i r e d t o c o n f i r m t h e d i a g n o s i s . We t r e a t e d a p a t i e n t w i t h b i l a t e r a l retinal arterial occlusion w h o h a d n o r m a l re sults o f s u r f a c e e c h o c a r d i o g r a p h y o n two o c c a sions. However, transesophageal echocardiog r a p h y , an i m p r o v e d m e t h o d o f i m a g i n g the c a r d i a c v a l v e s , was a b l e to d o c u m e n t m i t r a l valve p r o l a p s e i n t h i s p a t i e n t . A 35-year-old man had a three-week history of a c u t e o n s e t o f an i n f e r i o r s c o t o m a in the r i g h t eye. Two y e a r s p r e v i o u s l y , the p a t i e n t h a d d e v e l o p e d an i n f e r i o r s c o t o m a in t h e left e y e p r e s u m e d to b e s e c o n d a r y t o a r e t i n a l v a s c u l a r
Fig. 1 (Greven and associates). Normal appearance of retinal vasculature and site of occlusion of the superotemporal artery.
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of T H E JOURNAL. Letters must be typewritten, double-spaced, on 8 1/2 χ 11-inch bond paper with 1 1/2-inch margins on all four sides. (See instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, T H E JOURNAL does not publish correspondence concerning previously published letters.
103
104
January, 1991
AMERICAN JOURNAL OF OPHTHALMOLOGY
References
Fig. 2 (Greven and associates). Fluorescein angio gram of right eye showing abrupt termination of a branch of the superotemporal artery (arrow).
surface echocardiography were normal. How ever, t r a n s e s o p h a g e a l e c h o c a r d i o g r a p h y d i s c l o s e d m y x o m a t o u s c h a n g e s in the m i t r a l v a l v e w i t h m i t r a l valve p r o l a p s e . T h e p a t i e n t w a s s u b s e q u e n t l y g i v e n aspirin a n d d i p y r i d a m o l e and has had no additional vascular occlusive events. Transesophageal echocardiography has been s h o w n to b e b e t t e r t h a n s u r f a c e e c h o c a r d i o g r a p h y in d e t e c t i n g m i t r a l v a l v e p r o l a p s e a n d o t h e r c a r d i a c a b n o r m a l i t i e s in y o u n g p a t i e n t s with c e r e b r a l i s c h e m i c events.^ T h e t r a n s e s o p h a g e a l e c h o t r a n s d u c e r is in c l o s e r p r o x i m i t y to the posterior heart structures, which allows the u s e o f a high t r a n s d u c e r f r e q u e n c y (5 m H z ) to i m p r o v e the r e s o l u t i o n o f the p o s t e r i o r h e a r t s t r u c t u r e s as well as the m i t r a l v a l v e , left a t r i um, a n d a o r t i c valve. T h e findings in o u r c a s e d e m o n s t r a t e that this t e c h n o l o g i c a d v a n c e w a s better than traditional transthoracic echocardi o g r a p h y in d o c u m e n t i n g the s o u r c e o f the retinal arterial occlusion. Ophthalmologists s h o u l d b e aware o f t r a n s e s o p h a g e a l e c h o c a r d i o g r a p h y a n d c o n s i d e r this i m p r o v e d d i a g n o s t i c m o d a l i t y for p a t i e n t s with u n e x p l a i n e d r e t i n a l artery occlusions, even with normal results of surface e c h o c a r d i o g r a p h y .
1. Rackley, C. E.: Valvular heart disease. In Wyngaarden, J. B., and Smith, L. H. (eds.): Cecil Textbook of Medicine, ed. 18. Philadelphia, W. B. Saunders, 1988, p. 3 4 0 . 2. Woldoff, H. S., Gerber, Μ., Desser, Κ. Β., and Benchimol, Α.: Retinal vascular lesions in two pa tients with mitral valve leaflets. Am. J. Ophthalmol. 79:382, 1 9 7 5 . 3. Caltrider, N. D., Irvine, A. R., Kline, H. J., and Rosenblatt, Α.: Retinal emboli in patients with mitral valve prolapse. Am. ] . Ophthalmol. 90:534, 1 9 8 0 . 4. Gonder, J. R., Magargal, L. E., Walsh, P. N., Rao, K., and Denenberg, B. E.: Central retinal vein obstruction associated with mitral valve prolapse. Can. J. Ophthalmol. 18:220, 1983. 5. Zenker, G., Erbel, R., Kramer, G., Mohr-Kahaly, S., Drexler, M., Harnoncourt, K., and Meyer, J . : Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events. Stroke 19:345, 1988.
Use of T r a n s e s o p h a g e a l E c h o c a r d i o g r a p h y for D e t e c t i o n of a Likely S o u r c e of E m b o l i z a t i o n to t h e C e n t r a l Retinal A r t e r y Robert A. Wiznia, M.D., and W. Neil Pearson, M.D. Departments of Ophthalmology and Visual Science (R.A.W.) and Internal Medicine (W.N.P.), Yale Uni versity School of Medicine. Inquiries to Robert A. Wiznia, M.D., 850 Howard New Haven, CT 06519-1193.
Ave.,
Transesophageal echocardiography provides a substantially clearer view of cardiac struc tures t h a n d o e s t r a n s t h o r a c i c e c h o c a r d i o g r a phy. Transesophageal echocardiography uses a 5 - M H z u l t r a s o u n d t r a n s d u c e r a t t a c h e d to the distal tip o f a s t a n d a r d flexible g a s t r o s c o p e . B y p l a c i n g the t r a n s d u c e r in the e s o p h a g u s d i r e c t ly b e h i n d the h e a r t , t h e t e c h n i q u e avoids the tissue, b o n e , and air interfaces that attenuate transthoracic echocardiography ultrasound im a g e s . ' We u s e d this t e c h n i q u e to d e t e c t a l i k e l y cardiac source of embolization to the central retinal artery, which was not evident with transthoracic echocardiography.