Advanced Interventional Treatments in Retinoblastoma Management: A Comprehensive Review.

Retinoblastoma is the most common eye malignancy in children that if left untreated can invade intraocular structures, metastasize, and rarely lead to death. Traditionally treated with systemic chemotherapy, Intra-arterial chemotherapy is gaining popularity as it allows for the direct administration of chemotherapy through the ophthalmic artery, thus reducing systemic side effects. Intra-arterial chemotherapy procedures have evolved, with refinements to reduce risks and radiation exposure. Intra-arterial chemotherapy boasts an impressive technical success rate and one year ocular survival even amongst advanced cases. This review offers a thorough examination of the technique, indications, contraindications, outcomes, and alternative options for Intra-arterial chemotherapy.

Ligation of the ethmoid arteries in superselective intra-arterial infusion of cisplatin for advanced maxillary sinus cancer fed by the ophthalmic artery.

BACKGROUND: Superselective cisplatin (CDDP) infusion via the external carotid artery system and concomitant radiotherapy (RADPLAT) provides favorable oncological and functional outcomes in patients with maxillary sinus cancer. However, targeted lesions are occasionally fed by the branch of the internal carotid artery. METHODS: In RADPLAT for maxillary sinus cancer partly fed by the ophthalmic artery, the ethmoid arteries were ligated in two patients without medial orbital wall involvement. In four patients with that, CDDP was administered via the ophthalmic artery. RESULTS: A complete response was obtained in all six patients. Locoregional recurrence was not observed in any cases. However, visual acuity was lost in four patients who received the ophthalmic artery infusion. CONCLUSIONS: Ligation of the ethmoid arteries is recommended in RADPLAT for maxillary sinus cancer with lesions fed by the ophthalmic artery. CDDP administered via the ophthalmic artery may be considered if a patient accepts the possibility of visual loss.

Endovascular treatment of anterior cranial base dural arteriovenous fistulas as a first-line approach: a multicenter study.

OBJECTIVE: Anterior cranial fossa dural arteriovenous fistulas (DAVFs) have been almost exclusively considered as surgical lesions. However, new advances in endovascular technology have made the endovascular treatment (EVT) of ethmoidal DAVFs feasible. The aim of this study was to report the clinical and angiographic outcomes of patients harboring DAVFs of the anterior cranial fossa who had undergone EVT as a first-line approach. METHODS: This was a retrospective study of a consecutive series of patients harboring anterior cranial base DAVFs who had undergone EVT as a first-line approach at four institutions. Angiographic follow-up was performed at 6 months. Immediate and late serious clinical events were assessed during follow-up, including death and stroke. Special emphasis was given to visual status before and after the treatment. RESULTS: Between 2008 and 2020, 37 patients with ethmoidal DAVFs were admitted to the participating centers. In 2 patients, EVT was not attempted; therefore, 35 patients underwent EVT as a first-line procedure. An isolated transarterial approach was performed in 19 (54.3%) patients. The transvenous approach was performed exclusively in 12 (34.3%) patients, and combined access was used in 4 (11.4%) patients. The most frequently used arterial access route was the ophthalmic artery in 82.6% of the patients. Immediately, complete angiographic occlusion was achieved in 31 (91.2%) of 34 patients whose treatment was accomplished. Six-month control angiography revealed that 30 (88.2%) DAVFs were totally occluded. Complications occurred in 3 (8.8%) patients, including 1 (2.9%) patient who had central retinal artery occlusion. No significant difference in complications or occlusion rates was noted between the transarterial and transvenous approaches. CONCLUSIONS: Most anterior cranial base DAVFs can be successfully treated via an endovascular approach. Neurological and visual complications are rare, even if the ophthalmic artery is used as the primary access route. Efforts should be focused on prospectively comparing the results of EVT and surgical management.

Simultaneous Bilateral Primary Occlusion of the Ophthalmic Artery due to Florid Giant Cell Arteritis.

PURPOSE: To report a case of simultaneous bilateral ophthalmic artery occlusion in diagnosed giant cell arteritis (GCA). OBSERVATIONS: A 77-year-old male patient presented to the emergency department with simultaneous vision loss in both eyes for 3 hours. Headache at both temples and jaw claudication had been present for 3 weeks. Laboratory values demonstrated an initially increased C-reactive protein (CRP) of 202.0 mg/L and an erythrocyte sedimentation rate (ESR) of 100 mm within the first 20 minutes. Duplex sonography of the right and left temporal arteries revealed a "halo sign." A case of GCA was suspected, and intravenous high-dose methylprednisolone therapy was immediately administered. The clinical examination revealed a bilateral central retinal artery occlusion and fluorescein angiography showed a hot optic disc in the right eye and patchy choroidal hypoperfusion in both eyes. Biopsy of the left temporal artery was performed, which confirmed a florid temporal arteritis with complete thrombotic occlusion of the vascular lumen. Despite a good response to the administered therapy (CRP 17.0 mg/L 1 week after initiation), the visual prognosis was significantly limited through retinal and optic nerve involvement. By the follow-up examination 8 weeks later, the near visual acuity was 20/400 in the right and left eye at a distance of 16 inches. CONCLUSION AND IMPORTANCE: We hereby present a simultaneous bilateral ophthalmic artery occlusion as a rare complication of GCA. The combination of central retinal artery occlusion, arteritic anterior ischemic optic neuropathy, and choroidal hypoperfusion suggests an acute inflammatory involvement of the ophthalmic artery. In cases of the slightest suspicion of giant cell arteritis, an immediate high-dose steroid therapy initiation is of utmost importance.

Visual loss from dermal fillers.

BACKGROUND: An increasing number of people are undergoing non-surgical aesthetic procedures, especially injections of botulinum toxin and dermal fillers. While toxin injections have lower rates of complications, profound and serious consequences can arise with the use of dermal fillers. CASE: A 29-year-old woman presented to the eye casualty department with sudden visual loss, ptosis and ophthalmoplegia after having had non-surgical rhinoplasty in a beauty salon in West London. The filler was administered by a healthcare professional not registered with the General Medical Council (GMC) or similar governing body. DISCUSSION: Despite prompt measures on arrival at our service, the symptoms of visual loss, ptosis and ophthalmoplegia persisted. Attempts from the patient and medical services to report the incident (to trading standards and the police) were to no avail. CONCLUSION: This case highlights the poor treatment response to filler-related ophthalmic complications. It is also evident that in the United Kingdom, there appears to be poor regulation in the use of these products, a lack of clear guidelines for the management of their complications and finally no recourse for patients to challenge practitioners who lack medical registration and are not held accountable.

Generation of Filler Emboli as a Mechanism for Filler-Related Blindness.

BACKGROUND: Intra-arterial injection of fillers can lead to occlusion of the ophthalmic artery or its branches supplying the retina or the optic nerve. The mechanism through which this occurs is incompletely understood. We investigated the possibility of generating microparticles after injecting commercially available fillers into a flowing system in vitro. METHODS: Three hyaluronic acid fillers and one calcium hydroxylapatite filler were injected into an artificial saline flow system mimicking arterial systolic blood pressure and corresponding to the diameter of the facial artery. All the saline at the end of the tube was collected, centrifuged, and inspected for filler particles. RESULTS: After injection into the system, all fillers immediately disintegrated into small particles that were carried downstream with the flow of the saline. The saline at the end of the tube contained collections of filler. CONCLUSION: Hyaluronic acid and hydroxylapatite fillers break up into small particles immediately after injection into a flowing system, generating emboli rather than a column of filler. The results of this study lead us to hypothesize another potential mechanism leading to filler-related blindness.

Detailed Arterial Anatomy and Its Anastomoses of the Sphenoid Ridge and Olfactory Groove Meningiomas with Special Reference to the Recurrent Branches from the Ophthalmic Artery.

BACKGROUND AND PURPOSE: Detailed arterial anatomy of the sphenoid ridge and olfactory groove meningiomas is complicated due to the fine angioarchitecture and anastomoses between each feeder. Herein, we present details of the arterial anatomy and the relationships of feeders in these lesions. MATERIALS AND METHODS: This study included 20 patients admitted to our department between April 2015 and March 2020. Conditions of subjects consisted of 16 sphenoid ridge meningiomas and 4 olfactory groove meningiomas. We mainly analyzed arterial anatomy using 3D rotational angiography and slab MIP images of these lesions. We also analyzed the anastomoses of each feeder. RESULTS: We found that 19 (95%), 15 (75%), and 15 (75%) lesions had feeders from the ophthalmic, internal carotid, and external carotid arteries, respectively. As feeders from the ophthalmic artery, recurrent meningeal arteries were involved in 18 lesions (90%). Fifteen lesions (75%) had anastomoses between each feeder. CONCLUSIONS: Most of the meningiomas in the sphenoid ridge and olfactory groove had feeders from the ophthalmic and internal carotid arteries. There were various anastomoses between each feeder. This is the first report to demonstrate the detailed arterial anatomy and frequency of recurrent branches from the ophthalmic artery and their anastomoses using detailed imaging techniques.

Rare Transsellar Collateral Artery and Secondary Ophthalmic Artery Aneurysm in a Young Adult with Internal Carotid Artery Aplasia.

Internal carotid artery (ICA) aplasia is a rare congenital abnormality in which the third aortic arch fails to develop. Most collateral circulation will originate from the circle of Willis, with other sites being rare. Changes in flow through the collateral vasculature result in aneurysm formation at a young age. A 38-year-old woman had an incidental diagnosis of left ICA aplasia and right ophthalmic artery aneurysm. Arteriography demonstrated that the left supraclinoid ICA originated from the right cavernous ICA and appeared as an anomalous hypertrophied transsellar artery on angiography. Her flow-related aneurysm was treated uneventfully. The present case demonstrates an extremely rare Lie type D collateralization pattern and secondary flow-rated aneurysm in the context of ICA aplasia. Patients identified with this anatomic variant should be monitored for subsequent aneurysm formation. Identification of this variant before endovascular and transsphenoidal procedures is crucial to prevent major intracranial vessel injury.

Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach.

BACKGROUND: Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results. METHODS: We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach. CONCLUSION: The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.

Evaluation of Intraarterial Thrombolysis in Treatment of Cosmetic Facial Filler-Related Ophthalmic Artery Occlusion.

BACKGROUND: With an increase in recent years in the number of people receiving cosmetic facial injection treatments of hyaluronic acid, the incidence of hyaluronic acid embolism has also increased commensurately. Hyaluronic acid embolism leads to serious complications, including blindness, eye and eyelid movement disorders, skin necrosis, and cerebral embolism. However, there is a lack of robust clinical evidence regarding the benefits of treatment for hyaluronic acid embolism by intraarterial thrombolysis therapy. METHODS: This study included 24 patients with a decrease in visual acuity and other complications induced by facial hyaluronic acid injection. Patients underwent emergency intraarterial thrombolysis therapy by injection of hyaluronidase (500 to 1500 units) alone or hyaluronidase (750 to 1500 units) combined with urokinase (100,000 to 250,000 units), followed in both cases by a general symptomatic treatment and nutritional therapy. RESULTS: Ten (42 percent) of 24 patients ultimately had improvements to visual acuity, even when the clinical application of the thrombolytic treatments had passed the recommended window for optimal treatment. In all cases, patients' facial skin necrosis was restored to nearly normal appearance. In addition, the authors found that hyaluronidase combined with urokinase was a more effective therapy than hyaluronidase alone. CONCLUSIONS: The authors' results indicate that intraarterial thrombolysis therapy is beneficial to patients suffering from blindness induced by hyaluronic acid embolism. The therapy was shown to be worthy of clinical application because it alleviated the impairment to patients' vision and was also beneficial in the recovery from other serious complications, including eye movement disorder, eye edema, headaches, and skin necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Double Ophthalmic Arteries Arising from the Internal Carotid Artery and the Accessory Meningeal Artery: A Case Report of a New Anatomic Variation.

BACKGROUND: Variant origin of the ophthalmic artery (OA) is uncommon. The majority of variant origins are from the middle meningeal artery and from the infraclinoid segment of the internal carotid artery. An OA arising from the accessory meningeal artery is an extremely rare vascular variation that has not been described previously in the English literature. CASE DESCRIPTION: We report the first case of double origin of the OA from the supraclinoid segment of the internal carotid artery and from the accessory meningeal artery branch of the maxillary artery. A 33-year-old woman was referred to our clinic with suspicion of a middle cerebral artery aneurysm. She had nonspecific neurologic symptoms. The patient underwent cerebral magnetic resonance imaging and magnetic resonance angiography. CONCLUSIONS: Being aware of variant origin of the OA from the accessory meningeal artery is very important for transarterial chemoembolization in the external carotid artery territory. Reconstructed images from magnetic resonance angiography are very useful to reveal the variant origin of the OA.

Intraorbital aneurysm of the ophthalmic artery.

Intraorbital ophthalmic artery (OA) aneurysms are rare. They can be asymptomatic or present with visual disturbances, exophthalmos and headaches. We present a case of a 57-year-old man who presented with reduced vision, diplopia and exophthalmos. A carotid artery angiogram identified a right OA aneurysm. Due to the low risk of rupture and the patient's comorbidities including cardiac and renal impairment, a conservative approach was followed. A few weeks post presentation, the patient's vision and optic nerve function had improved. This case reiterates the importance of considering conservative treatment for patients with intraorbital OA aneurysms.

Microsurgical Clipping of Ophthalmic Aneurysms in an Endovascular Era: Sonopet-Assisted Intradural Clinoidectomy and Other Tenets.

These video cases present some unique technical tenets for microsurgical clipping of proximal internal carotid artery aneurysms (Video 1). The first patient is a 49-year-old woman with a history of a prior ruptured and treated right middle cerebral artery aneurysm who was found to have growth of known left middle cerebral artery and left internal carotid artery ophthalmic segment aneurysms on radiographic studies. An intradural clinoidectomy with Sonopet, with proximal control at cervical carotid and wide sylvian fissure exposure with ample sharp dissection of the aneurysm anatomy, allowed safe clipping of the ophthalmic aneurysm in this case. The second patient is a 39-year-old woman with a history of a prior left middle cerebral artery M2 occlusion with recent mechanical thrombectomy. The patient was found to have a 6-mm incidental, unruptured right internal cerebral artery paraophthalmic segment and 3-mm right posterior communicating artery aneurysm on radiographic studies. This patient underwent microsurgical clipping given unique patient factors. A similar controlled intradural clinoidectomy, with proximal cervical ICA control and aneurysmal segment trapping, allowed safe aneurysm exclusion. For patients with multiple aneurysms such as in these cases, the deeper proximal aneurysm should generally be treated first. The videos illustrate some key technical points in this regard.

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.

Application of the Willis Covered Stent in the Treatment of Ophthalmic Artery Segment Aneurysms: A Single-Center Experience.

OBJECTIVE: The purpose of this study is to introduce our initial experience with the evaluation of the feasibility of using Willis covered stents (WCSs) in the treatment of complicated ophthalmic artery (OA) segment aneurysms. METHODS: Of the 162 patients with OA segment aneurysms treated by endovascular techniques in West China Hospital from January 2015 to August 2017, a total of 26 patients treated with WCSs were included in the study. RESULTS: Twenty-six patients with 26 aneurysms were included (mean age, 57.0 years; range, 22-76 years). The cohort had 20 patients with large or giant aneurysms, 3 patients with blood blister aneurysms, and 3 patients with pseudoaneurysms. Ten aneurysms were OA type, and 16 were internal carotid artery (ICA) type. Twenty-four patients were treated with 1 stent, and 2 patients were treated with 2 stents. Among the 26 patients, 2 patients had minimal endoleak, and 24 patients had complete occlusion after immediate postoperative angiography. One patient who had complete occlusion experienced contrast agent extravasation, and this phenomenon disappeared by balloon compression during the procedure. The 3- to 15-month angiographic follow-up showed that all patients experienced complete occlusion, including 2 patients with minimal endoleak during immediate postprocedural angiography. Two patient showed signs of in-stent stenosis. Clinical follow-up demonstrated that no delayed thromboembolic or ischemic events were recorded in the stent-grafted vascular region and no bleeding occurred in any of the patients (except 1 patient who experienced subarachnoid hemorrhage, left frontal lobe hemorrhage, and hydrocephalus 10 days after the procedure). CONCLUSIONS: WCSs may provide an alternative solution for treating complex OA segment aneurysms by reconstruction and preservation of the ICA. Our study also confirms the safety, efficacy, and midterm durability of WCSs for complex OA segment aneurysms.