Acute Vision Loss After Ophthalmic Artery Embolization of Meningioma

A 40-year-old man presented with acute-onset painless visual loss after preoperative embolization for a large skull base meningioma through the ophthalmic artery. We describe the clinical presentation of an isolated ipsilateral afferent and efferent pupillary defect in this patient who had radiographic documentation of embolization material in the intraorbital ophthalmic artery. Although ophthalmic and retinal artery occlusions have been described previously after endovascular embolization, our patient had a unique clinicoradiologic presentation.

Photo Essay Section Editors: Melissa W. Ko, MD Dean M. Cestari, MD Acute Vision Loss After Ophthalmic Artery Embolization of Meningioma Guadalupe Torres, BS, Ashwini T. Kini, MD, Bayan Al Othman, MD, Andrew G. Lee, MD FIG. 1. MRI brain. T1 MRI with contrast revealed an extra-axial, dural-based, right sphenoid wing/petroclival mass with right optic nerve compression consistent with meningioma. Abstract: A 40-year-old man presented with acute-onset painless visual loss after preoperative embolization for a large skull base meningioma through the ophthalmic artery. We describe the clinical presentation of an isolated ipsilateral afferent and efferent pupillary defect in this patient who had radiographic documentation of Baylor College of Medicine (GT), Houston, Texas; Department of Ophthalmology (ATK, BAO, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; The Houston Methodist Research Institute (AGL), Houston Methodist Hospital, Houston, Texas; Departments of Ophthalmology (AGL), Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa. The authors report no conflicts of interest. Address correspondence to Andrew G. Lee, MD, Blanton Eye Institute, Houston Methodist Hospital, 6560 Fannin Street Suite Scurlock 450, Houston, TX 77030; E-mail: [e-mail] 520 embolization material in the intraorbital ophthalmic artery. Although ophthalmic and retinal artery occlusions have been described previously after endovascular embolization, our patient had a unique clinicoradiologic presentation. Journal of Neuro-Ophthalmology 2019;39:520–522 doi: 10.1097/WNO.0000000000000772 © 2019 by North American Neuro-Ophthalmology Society A 40-year-old previously healthy man presented with recurrent headache and chronic, slowly progressive deterioration of vision in the right eye. MRI of the brain with contrast revealed an extra-axial dural-based right sphenoid wing/petroclival mass with right optic nerve compression (Fig. 1). The findings were consistent with meningioma. The mass was hypervascular, and preoperative endovascular embolization was performed to devascularize Torres et al: J Neuro-Ophthalmol 2019; 39: 520-522 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay FIG. 2. Fundus photograph of the right eye revealing multiple areas of retinal whitening consistent with multiple branch retinal artery occlusions. the tumor before definitive surgical resection. During catheter angiography, a microcatheter was advanced through the middle meningeal artery, and Onyx-18 liquid embolic material was injected into the feeding vessels of the tumor. After the embolization procedure, however, the patient noted vision loss in the right eye. A neuroophthalmology consult was requested. Visual acuity was 20/800 in the right eye initially but progressed to light perception only. The right pupil was dilated at 5 mm and was poorly reactive to light. The left pupil was 3 mm in the light with a brisk light reaction; the anisocoria was worse in the light. External examination was normal without ptosis or proptosis. Motility examination showed a 10-prism diopter exotropia, but ductions and versions were full. Slit-lamp biomicroscopy and intraocular pressure measurements were normal. Visual acuity in the left eye was 20/20, and the remainder of the examination, including automated perimetry for the left eye, was normal. Ophthalmoscopy revealed retinal whitening in the right eye consistent with a central retinal artery occlusion (Fig. 2). The combination of efferent (anisocoria) and afferent findings (visual loss, relative afferent pupillary defect) suggested intraorbital ophthalmic artery occlusion. Postprocedure computed tomography (CT) scans of the orbit demonstrated linear hyperdensities consistent with Onyx embolic material in the branches of the right ophthalmic artery (Fig. 3A, B). The patient’s vision did not improve and remains limited to light perception in the affected right eye. Anterior and middle skull base meningiomas may be hypervascular and receive significant feeders from the ophthalmic artery (1). Preoperative superselective embolization of vascular meningiomas has been shown to be beneficial in facilitating surgery and reducing intraoperative blood loss (2). Embolization through the ophthalmic artery, however, carries some risk of blindness from iatrogenic ophthalmic or retinal arterial occlusion (2–5). Although ophthalmic and retinal artery occlusions have been described previously after endovascular embolization, our patient also demonstrated orbital CT findings confirming ophthalmic artery embolization. The patient also presented with both afferent and efferent pupillary defects. The presence of both an afferent and an efferent defect of the pupil on the same side narrows the differential diagnosis to lesions in the orbit, dorsal midbrain (tectal RAPD) or a carotid artery dissection causing an oculosympathetic paresis and a central retinal artery occlusion on the same side. Several articles have recommended that the microcatheter tip be advanced to a “safe position” beyond the origin of the central retinal artery from the FIG. 3. A and B. Postprocedure computed tomography brain and orbit demonstrate linear hyperdensities consistent with Onyx embolic material in the branches of the ophthalmic artery of the right eye. Torres et al: J Neuro-Ophthalmol 2019; 39: 520-522 521 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay ophthalmic and with angiographic confirmation of a preserved “choroidal blush” before proceeding with very slow, intermittent, infusion of embolic material (including Onyx) to avoid excessive reflux into the ophthalmic artery (3). The risk of vision loss due to inadvertent embolization of the ophthalmic artery branches can be decreased with an understanding of the anatomy and selective modifications to spare the vital central retinal artery during embolization. STATEMENT OF AUTHORSHIP Category 1: a. conception and design: A. T. Kini; b. acquisition of data: G. Torres; c. analysis and interpretation of data: B. Al Othman. Category 2: a. drafting the manuscript: G. Torres; b. revising it for intellectual content: A. T. Kini. Category 3: a. final approval of the completed manuscript: A. G. Lee. 522 REFERENCES 1. Carli DF, Sluzewski M, Beute GN, van Rooij WJ. Complications of particle embolization of meningiomas: frequency, risk factors, and outcome. 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