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Show PHOTO ESSAY Simultaneous Bilateral Retinal Artery Occlusions Associated with a Mitral Valve Mass Sachin Kedar, MD, Valerie Biousse, MD, and Nancy J. Newman, MD FIG. 1. A. Fundus OD shows a cherry red spot with macular cloudy edema. There is a cotton wool spot interiorly. B. Fundus OS shows an area of cloudy retinal edema, cotton wool spots, and hemorrhage along the inferior arcade. C. Fluorescein angiogram OD shows poor filling of the inferior retinal artery and its macular branches. The macula OD is supplied entirely by the inferior branch retinal artery through the superior and inferior divisions and appears underperfused. Venous filling is delayed in the same territory. D. Trans- esophageal echocardiogram shows a mass attached to the posterior leaflet of the mitral valve ( arrow). Abstract: A 52- year- old woman with simultaneous bilateral retinal artery occlusions and normal trans- thoracic echocardiography was found to have a mitral valve lesion on trans- esophageal echocardiography. Bilateral retinal artery occlusions suggest a source of emboli at the level of the heart or aortic arch. Such cases should be evaluated not merely by trans- thoracic echocardiography, but by transesophageal echocardiography, which better visualizes the aortic arch and left heart cavities. ( JNeuro- Ophthalmol 2005; 25: 215- 216) Departments of Ophthalmology ( SK, VB, NJN), Neurology ( VB, NJN), and Neurological Surgery ( NJN) Emory University, Atlanta, Georgia. Address correspondence to Valerie Biousse, MD, Neuro- Ophthalmology Unit, Emory Eye Center, 1365- B Clifton Rd., Atlanta, GA 30322; E- mail: vbiouss@ emory. edu Apreviously healthy 52- year- old woman presented with sudden persistent visual loss in both eyes. One week earlier, she had experienced an episode of transient visual loss in her right eye, which lasted a few minutes. J Neuro- Ophthalmol, Vol. 25, No. 3, 2005 215 J Neuro- Ophthalmol, Vol. 25, No. 3, 2005 Kedar et al FIG. 2. Trans- thoracic ( A) and transesophageal ( B) echocardiography. A. A trans- thoracic echocardiogram ( TTE) is obtained by applying a transducer to the chest. The ultrasound beam has to travel through the chest wall and lungs and evaluates best the anterior cavities of the heart. B. A trans- esophageal echocardiogram ( TEE) requires that the transducer be inserted into the esophagus, thereby producing clear images of the heart structures without interference from the lungs or chest wall. The left atrium, left ventricle, and aortic arch are better visualized with this technique than with TTE. Examination after the bilateral persistent visual loss disclosed a visual acuity of 5/ 200 OD and 20/ 25 OS. Fundus examination showed a cherry red spot with macular edema OD ( Fig. 1 A) and an area of cotton wool spot and retinal hemorrhage along the inferior arcade OS ( Fig. IB). Fluorescein angiography showed bilateral inferior hemi-retinal artery occlusions with macular hypoperfusion OD ( Fig. 1C). This appearance resulted from anatomic variations of the macular divisions of the inferior hemiretinal artery. Carotid ultrasound, magnetic resonance imaging, and magnetic resonance angiography of the brain, trans- thoracic echocardiogram, and laboratory workup, including coagulation profile, were within normal limits. Trans- esophageal echocardiography showed a left intraventricular mitral valvular mass, which was surgically removed ( Fig. ID). Histopathology showed amorphous calcified debris with no evidence of endocarditis or neoplasm. Bilateral retinal artery occlusions suggest a source of emboli at the level of the aortic arch or the heart ( 1,2). Appropriate evaluation requires a trans- esophageal echocardiogram ( 3), because trans- thoracic echocardiography may miss cardiac sources of emboli and is not adequate for the assessment of aortic arch atheroma in most cases ( Fig. 2). Acknowledgments This study was supported in part by a department grant ( Department of Ophthalmology) from Research to Prevent Blindness, Inc., New \ brk, and by core grant P30- EY06360 ( Department of Ophthalmology) from the National Institutes of Health, Bethesda, Maryland. Dr. Newman is a recipient of the Research to Prevent Blindness Lew R. Wasserman Merit Award. REFERENCES 1. Kramer M, Goldenberg- Cohen N, Shapira Y, et al. Role of transesophageal echocardiography in the evaluation of patients with retinal artery occlusion. Ophthalmology 2001; 108: 1461^ k 2. Nischal KK, Aclimandos WA. Bilateral symmetrical branch retinal artery occlusions. J R Soc Med 1995; 88: 416P- 7. 3. Wong TY, Klein R. Retinal arteriolar emboli: Epidemiology and risk of stroke. Curr Opin Ophthalmol 2002; 13: 142- 6. 216 © 2005 Lippincott Williams & Wilkins |
