- Email: [email protected]
A case of dry eye secondary to ocular ischemic syndrome due to carotid artery occlusion
Contact Lens & Anterior Eye 38 (2015) 226–227
Contents lists available at ScienceDirect
Contact Lens & Anterior Eye journal homepage: www.elsevier.com/locate/clae
Case report
A case of dry eye secondary to ocular ischemic syndrome due to carotid artery occlusion Sumith Perera ∗ , Hala Ali, Jeremy Hoffman, Andrew Ceccherini Surrey and Sussex NHS TRUST, Redhill, Surrey, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 July 2014 Received in revised form 17 December 2014 Accepted 18 December 2014
a b s t r a c t A case of unilateral dry eye associated with ipsilateral carotid artery occlusion. © 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Keywords: Dry eye Ocular ischemic syndrome Carotid artery occlusion
Ocular ischemic syndrome (OIS) is a well recognized complication of carotid occlusive disease. Patients who develop OIS show decreased blood flow in the retro bulbar vessels and reversal of blood flow in the ophthalmic artery [1–6]. Anterior segment ischemia may be the first and only manifestation of carotid artery disease [7]. Common anterior segment manifestations include conjunctival and episcleral injection, corneal edema, corneo-scleral melting, iris atrophy, anterior and posterior synechiae, rubeosis iridis, neovascular glaucoma iridocyclitis and cataracts. We report a case of dry eye with reduced tear production on the ipsilateral eye of a patient with unilateral carotid artery occlusion. To the best of our knowledge tear deficiency has not being previously recognized as a complication of OIS. 1. Case report A 66-year-old male presented with pain, irritation redness, discomfort and visual loss in the right eye. Two months prior to this he has had an episode of iritis in this eye which had been treated with G dexamethasone and tapered off over six weeks. He had not had any ocular symptoms prior to this. Specifically he had not experienced any dry eye symptoms. He was in good health and the only medication he was on was statins for hypercholesterolemia.
∗ Corresponding author. Tel.: +44 7803936829. E-mail address: [email protected] (S. Perera).
Visual acuity was 6/36 in the right and 6/6 in the left. Slit lamp examination showed a reduced tear meniscus with epitheliopathy, marked rubeosis iridies, posterior synechiae, peripheral anterior synechiae with partial angle closure and cataracts in the right eye. The left anterior segment was normal with a normal tear meniscus. The intra ocular pressures were normal on both sides. Retinal examination showed deep mid peripheral hemorrhages in the right eye and a normal retina in the left. A Schirmer 1 test showed a reduction of tear production in the right eye compared to the left (5 mm in the right and 13 mm in the left). A fluorescein staining score of 3 (Efron system) was noted in the central, inferior, nasal and temporal corneal zones of the right cornea whilst there was no fluorescein staining in the left cornea. A Doppler ultrasound followed by a CT angiogram showed complete occlusion of the right common carotid from its origin. The left carotid was normal (Fig. 1). This patient has not had any dry eye symptoms prior to his present ocular episode. At the time of examination he was not on any ocular medication to either eye. All tear producing glands are supplied by branches of the ophthalmic artery, the lacrimal gland by the lacrimal artery and the conjunctival glands by the anterior ciliary arteries The poor blood supply to all tear producing glands in IOS may lead to compromised tear production and tear deficiency. Dry eye disease may have contributed to the ocular pain and discomfort experienced by this patient with OIS. This association should be actively looked for and treated if present. This report also shows that unilateral tear deficiency may be caused or exacerbated by, carotid artery occlusive disease.
http://dx.doi.org/10.1016/j.clae.2014.12.004 1367-0484/© 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
S. Perera et al. / Contact Lens & Anterior Eye 38 (2015) 226–227
227
Conflicts of interest None. References [1] Kerty E, Horven I. Ocular haemodynamic changes in patients with high grade carotid occlusive disease and development of chronic ocular ischaemia. 1 Doppler and dynamic tonometry findings. Acta Ophthalmol Scand 1995;73(1): 66–71. [2] Kerty E, Eide N, Horven I. Ocular haemodynamic changes in patients with high grade carotid occlusive disease and development of chronic ocular ischaemia II. Doppler and dynamic tonometry findings. Acta Ophthalmol Scand 1995;73(1):72–6. [3] Huckman MS, Haas J. Reversed flow through the ophthalmic artery as a cause of rubeosis iridis. Am J Ophthalmol 1972;74(6):1094–9. [4] Hashimoto M, Ohtsuka K, Ohtsuka H, Nakagawa T. Normal tension Glaucoma with reversed ophthalmic artery flow. Am J Ophthalmol 2000;130(5): 670–2. [5] Costa VP, Kuzniec S, Molnar LJ, Cerri GG, Puech-Leao P, Carvalho CA. Clinical findings and hemodynamic changes associated with severe occlusive carotid artery disease. Ophthalmology 1997;104(12):1994–2004. [6] Costa VP, Kuzniec S, Molnar LJ, Cerri GG, Puech-Leao P, Carvalho CA. Collateral blood supply through the ophthalmic artery: a steal phenomenon analysed by colour Doppler imaging. Ophthalmology 1998;105(4):689–93. [7] Lopez Sanchez E, Frances Munoz E, Mondejar Garcia JJ, Espana Gregori E, Menezo JL. Anterior pole ischemia and carotid stenosis. Arch Soc Esp Oftalmol 2000;6:421–4.
Fig. 1. CTA of the carotid arteries: (1) narrowed right common carotid artery (CCA), (2) left CCA, (3) level of occlusion of right CCA, (4) right external carotid artery, (5) right vertebral artery.
Contents lists available at ScienceDirect
Contact Lens & Anterior Eye journal homepage: www.elsevier.com/locate/clae
Case report
A case of dry eye secondary to ocular ischemic syndrome due to carotid artery occlusion Sumith Perera ∗ , Hala Ali, Jeremy Hoffman, Andrew Ceccherini Surrey and Sussex NHS TRUST, Redhill, Surrey, United Kingdom
a r t i c l e
i n f o
Article history: Received 20 July 2014 Received in revised form 17 December 2014 Accepted 18 December 2014
a b s t r a c t A case of unilateral dry eye associated with ipsilateral carotid artery occlusion. © 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Keywords: Dry eye Ocular ischemic syndrome Carotid artery occlusion
Ocular ischemic syndrome (OIS) is a well recognized complication of carotid occlusive disease. Patients who develop OIS show decreased blood flow in the retro bulbar vessels and reversal of blood flow in the ophthalmic artery [1–6]. Anterior segment ischemia may be the first and only manifestation of carotid artery disease [7]. Common anterior segment manifestations include conjunctival and episcleral injection, corneal edema, corneo-scleral melting, iris atrophy, anterior and posterior synechiae, rubeosis iridis, neovascular glaucoma iridocyclitis and cataracts. We report a case of dry eye with reduced tear production on the ipsilateral eye of a patient with unilateral carotid artery occlusion. To the best of our knowledge tear deficiency has not being previously recognized as a complication of OIS. 1. Case report A 66-year-old male presented with pain, irritation redness, discomfort and visual loss in the right eye. Two months prior to this he has had an episode of iritis in this eye which had been treated with G dexamethasone and tapered off over six weeks. He had not had any ocular symptoms prior to this. Specifically he had not experienced any dry eye symptoms. He was in good health and the only medication he was on was statins for hypercholesterolemia.
∗ Corresponding author. Tel.: +44 7803936829. E-mail address: [email protected] (S. Perera).
Visual acuity was 6/36 in the right and 6/6 in the left. Slit lamp examination showed a reduced tear meniscus with epitheliopathy, marked rubeosis iridies, posterior synechiae, peripheral anterior synechiae with partial angle closure and cataracts in the right eye. The left anterior segment was normal with a normal tear meniscus. The intra ocular pressures were normal on both sides. Retinal examination showed deep mid peripheral hemorrhages in the right eye and a normal retina in the left. A Schirmer 1 test showed a reduction of tear production in the right eye compared to the left (5 mm in the right and 13 mm in the left). A fluorescein staining score of 3 (Efron system) was noted in the central, inferior, nasal and temporal corneal zones of the right cornea whilst there was no fluorescein staining in the left cornea. A Doppler ultrasound followed by a CT angiogram showed complete occlusion of the right common carotid from its origin. The left carotid was normal (Fig. 1). This patient has not had any dry eye symptoms prior to his present ocular episode. At the time of examination he was not on any ocular medication to either eye. All tear producing glands are supplied by branches of the ophthalmic artery, the lacrimal gland by the lacrimal artery and the conjunctival glands by the anterior ciliary arteries The poor blood supply to all tear producing glands in IOS may lead to compromised tear production and tear deficiency. Dry eye disease may have contributed to the ocular pain and discomfort experienced by this patient with OIS. This association should be actively looked for and treated if present. This report also shows that unilateral tear deficiency may be caused or exacerbated by, carotid artery occlusive disease.
http://dx.doi.org/10.1016/j.clae.2014.12.004 1367-0484/© 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
S. Perera et al. / Contact Lens & Anterior Eye 38 (2015) 226–227
227
Conflicts of interest None. References [1] Kerty E, Horven I. Ocular haemodynamic changes in patients with high grade carotid occlusive disease and development of chronic ocular ischaemia. 1 Doppler and dynamic tonometry findings. Acta Ophthalmol Scand 1995;73(1): 66–71. [2] Kerty E, Eide N, Horven I. Ocular haemodynamic changes in patients with high grade carotid occlusive disease and development of chronic ocular ischaemia II. Doppler and dynamic tonometry findings. Acta Ophthalmol Scand 1995;73(1):72–6. [3] Huckman MS, Haas J. Reversed flow through the ophthalmic artery as a cause of rubeosis iridis. Am J Ophthalmol 1972;74(6):1094–9. [4] Hashimoto M, Ohtsuka K, Ohtsuka H, Nakagawa T. Normal tension Glaucoma with reversed ophthalmic artery flow. Am J Ophthalmol 2000;130(5): 670–2. [5] Costa VP, Kuzniec S, Molnar LJ, Cerri GG, Puech-Leao P, Carvalho CA. Clinical findings and hemodynamic changes associated with severe occlusive carotid artery disease. Ophthalmology 1997;104(12):1994–2004. [6] Costa VP, Kuzniec S, Molnar LJ, Cerri GG, Puech-Leao P, Carvalho CA. Collateral blood supply through the ophthalmic artery: a steal phenomenon analysed by colour Doppler imaging. Ophthalmology 1998;105(4):689–93. [7] Lopez Sanchez E, Frances Munoz E, Mondejar Garcia JJ, Espana Gregori E, Menezo JL. Anterior pole ischemia and carotid stenosis. Arch Soc Esp Oftalmol 2000;6:421–4.
Fig. 1. CTA of the carotid arteries: (1) narrowed right common carotid artery (CCA), (2) left CCA, (3) level of occlusion of right CCA, (4) right external carotid artery, (5) right vertebral artery.