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Show Reversal of Ischemic Retinopathy Following Balloon Angioplasty of a Stenotic Ophthalmic Artery Gyo Jun Hwang, MD, Se Joon Woo, MD, Jeong-Min Hwang, MD, PhD, Cheolkyu Jung, MD, Kyu Hyung Park, MD, PhD, O-Ki Kwon, MD, PhD Abstract: A 65-year-old woman who had undergone in-ternal carotid artery stenting and was being maintained on antiplatelet therapy developed features suggesting ipsilateral reduced retinal artery perfusion. Injection of urokinase into the ophthalmic artery provided temporary improvement. When manifestations of retinal arterial is-chemia recurred, angiography revealed worsening ste-nosis at the origin of the ophthalmic artery. Balloon angioplasty at that site successfully restored visual acuity and reversed the ischemic fundus abnormalities. This is the first report of ophthalmic artery balloon an-gioplasty in this setting. Journal of Neuro-Ophthalmology 2010;30:228-230 doi: 10.1097/WNO.0b013e3181dc2078 2010 by North American Neuro-Ophthalmology Society Ophthalmic artery stenosis is a rare finding in patients with retinal ischemic symptoms (1). Antiplatelet agents have been a standard therapy (2,4,5). We describe a patient with ophthalmic artery origin stenosis who ex-perienced episodic ipsilateral visual loss despite antiplatelet therapy and who achieved improvement in ischemic manifestations following balloon angioplasty of the oph-thalmic artery origin, an intervention not previously reported. CASE REPORT A 65-year old woman presented with findings of a central retinal artery occlusion (CRAO) in the right eye (Fig. 1). Retinal fluorescein angiography revealed a patent cilioretinal artery, suggesting that the ophthalmic artery still provided some perfusion of the eye. Two months earlier, she had undergone ipsilateral stenting for severe stenosis of the ipsilateral proximal cer-vical internal carotid artery. Following the procedure, she was taking aspirin, clopidogrel, and cilostazol. Carotid angiography at the time of presentation with CRAO showed no thrombotic clot or restenosis around the carotid bifurcation. However, 70% stenosis was found at the origin of the ophthalmic artery (Fig. 2). A microcatheter was introduced into the proximal oph-thalmic artery for bougination, and a fibrinolytic agent (300,000-unit urokinase) was injected into the ophthal-mic artery. Following the thrombolysis, the patient's visual acuity gradually improved from hand motion to 20/50 in the affected eye. Antiplatelet agents were maintained. However, 2 months after thrombolysis, she com-plained of gradual deterioration of visual acuity in the right eye for 3 days. Visual acuity had declined to finger counting in that eye, and ophthalmoscopy showed mul-tiple cotton wool patches (Fig. 3A). Fluorescein angiog-raphy (Fig. 3B) showed that filling of the cilioretinal artery was more prolonged than prior to the thrombolysis (14 seconds rather than 8 seconds after dye injection). Carotid angiography revealed no remarkable findings at the carotid bifurcation but demonstrated that stenosis at the ophthalmic artery origin had increased to about 90% (Fig. 4). Balloon angioplasty was successfully performed with a coronary balloon (1.5 3 10 mm), and tirofiban was injected at the stenotic segment. Residual stenosis amounted to 30% on the final angiogram. At 1 month following this procedure, visual acuity had improved to 20/60. The cotton wool patches had disappeared and fluorescein angiographic retinal arterial perfusion had improved (Figs. 3C, 3D). Departments of Neurosurgery (GJH, O-KK); Ophthalmology (SJW, J-MH, KHP); and Radiology (C-KJ), Seoul National University Col-lege of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. Address correspondence to Se Joon Woo, MD, Seoul National University Bundang Hospital. 300 Gumi-dong, Bundang-gu, Seongnam, Gyunggi-do 463-707, Korea; E-mail: sejoon1@ hanmail.net 228 Hwang et al: J Neuro-Ophthalmol 2010; 30: 228-230 Original Contribution Copyright © North American Neuro-ophthalmology Society.Unauthorized reproduction of this article is prohibited. DISCUSSION We have described a patient with ophthalmic artery stenosis that induced sequential attacks of reduced retinal perfusion attributed to ophthalmic artery stenosis. Retinal ischemic manifestations initially improved following intra-arterial thrombolysis but recurred and later improved again fol-lowing balloon angioplasty of the ophthalmic artery. Ophthalmic artery stenosis could cause an abrupt decline of vision by acting as an embolic source or by reducing perfusion. Ophthalmic artery stenosis, without concomitant proximal carotid artery stenosis, may manifest as cotton wool patches in the ipsilateral fundus (3). In our patient, balloon angioplasty of the ophthalmic artery improved vi-sual function and retinal perfusion. We are unaware of a previous report showing its efficacy in this setting. REFERENCES 1. Adams HP Jr, Putman SF, Corbett JJ, Sires BP, Thompson HS. Amaurosis fugax: the results of arteriography in 59 patients. Stroke. 1983;14:742-744. 2. Braat AE, Hoogland PH, de Vries AC, de Mol van Otterloo JC. Amaurosis fugax and stenosis of the ophthalmic artery- a case report. Vasc Surg. 2001;35:141-143. FIG. 1. A. Before treatment, fundus photograph of the right eye shows retinal opacification around the fovea. B. At 23 seconds, fluorescein angiography of the right eye shows marked retinal arterial perfusion delay. C. Ten days after intra-arterial thrombolysis therapy, fundus photograph of the right eye shows a normal macular appearance. D. At 20 seconds, fluorescein angiography shows marked reduction in retinal arterial perfusion delay. An arm-to-retina time was shortened from 22 to 8 seconds and an artery-vein transit time from 56 to 12 seconds. FIG. 2. Cerebral angiography during intra-arterial thrombolysis. A. The cervical carotid segment shows no abnormalities. B. The right ophthalmic artery shows 70% stenosis at its origin (arrow). C. Bougination with a microcatheter and wire is performed on the stenotic ophthalmic artery, and urokinase is slowly hand-injected. D. Afterward, the stenosis (arrow) is reduced to 50%, and the luminal irregularity has improved. Original Contribution Hwang et al: J Neuro-Ophthalmol 2010; 30: 228-230 229 Copyright © North American Neuro-ophthalmology Society.Unauthorized reproduction of this article is prohibited. 3. McLeod D. Why cotton wool spots should not be regarded as retinal nerve fibre layer infarcts. Br J Ophthalmol. 2005;89: 229-237. 4. Nakajima M, Kimura K, Minematsu K, Saito K, Takada T, Tanaka M. A case of frequently recurring amaurosis fugax with atherothrombotic ophthalmic artery occlusion. Neurology. 2004;62:117-118. 5. Park MS, Kim JT, Lee KR, Lee SH, Choi SM, Kim BC, Kim MK, Cho KH. Recurrent transient monocular blindness with ophthalmic artery stenosis. Eur Neurol. 2008;59:202-204. FIG. 3. A. Fundus photography of the right eye 2 months after thrombolysis shows multiple cotton wool spots. B. Fundus fluorescein angiography shows delayed retinal arterial perfusion. C. One month after balloon angioplasty of the right ophthalmic artery, fundus photography shows disappearance of cotton wool spots. D. Fluorescein angiogram shows improvement in retinal perfusion. FIG. 4. Angiography of balloon angioplasty. A. Prior to angioplasty, stenosis (arrow) at the ophthalmic artery origin is estimated to be 90%. B. A coronary balloon (arrowheads) is introduced into the stenotic portion. C. Immediately after balloon angioplasty, angiography shows that stenosis (arrow) is reduced to an estimated 30%. Original Contribution 230 Hwang et al: J Neuro-Ophthalmol 2010; 30: 228-230 Copyright © North American Neuro-ophthalmology Society.Unauthorized reproduction of this article is prohibited. |
