Central Retinal Artery Occlusion in Rhino-Orbital-Cerebral Mucormycosis: An Inflammatory-Prothrombotic State.

PURPOSE: The aim was to evaluate patient profiles of rhino-orbital-cerebral mucormycosis (ROCM) cases with central retinal artery occlusion (CRAO) postcoronavirus disease 2019. DESIGN: A nonrandomized retrospective case-control study. METHODS: The ROCM cases presenting with CRAO were compared with a control ROCM group without CRAO at a tertiary care center. Demography, systemic status, clinical features, histopathology, imaging, and blood profile were assessed for any specific risk factors. RESULTS: A total of 12 patients were seen in the CRAO group and 16 in the non-CRAO group. The male-to-female ratio was 3:1 with a mean age of 49.5 years. In the CRAO group, 75% had diabetes mellitus with mean hemoglobin A1c of 9.03%, and 66.7% had received steroid treatment. All cases were histopathologically confirmed positive for mucor. There was a significant difference in mean D-dimer and serum ferritin between the 2 groups, with higher level in the CRAO group. All patients with CRAO had light perception-negative vision, with total ophthalmoplegia and proptosis seen in 66.7% of cases. Four patients had orbital apex involvement, 5 had cavernous sinus involvement, and 8 had intracranial involvement in the CRAO group. CONCLUSIONS: Inflammatory markers D-dimer and serum ferritin were significantly associated with CRAO, suggestive of hyperinflammatory and hypercoagulable state. A high index of suspicion should be maintained in cases with elevated markers and prophylactic anticoagulants can be started to prevent CRAO in a subset of patients.

Serum sortilin as a predictor of stroke in patients with intermediate carotid artery stenosis.

BACKGROUND: Sortilin was an important molecular protein involved in the pathogenesis of atherosclerosis. Besides, serum sortilin was associated with adverse cerebrovascular events. Atherosclerotic stenosis in the carotid artery is a major etiology for ischemic stroke. The risk of stroke in patients with intermediate carotid artery stenosis (CAS) was unknown. Hence, the aim of the present study was to evaluate the relationship between serum sortilin levels and stroke in patients with intermediate CAS. METHODS: A total of 195 intermediate CAS patients were included in this cross-sectional study. The patients were divided into two groups as symptomatic (N = 95) and asymptomatic (N = 100) patients. Patients with a transient ischemic attack (TIA), retinal ischemic event, or ischemic stroke resulting from the narrowed carotid artery were considered to be symptomatic. Serum sortilin concentrations were measured using the enzyme-linked immunosorbent assay. RESULTS: Serum sortilin level was significantly higher in the symptomatic group than in the severe asymptomatic group (1.53 ± 0.25 ng/mL vs 1.34 ± 0.19 ng/mL, p < 0.001). Besides, high serum sortilin levels (odds ratio = 4.91, 95% confidence intervals 1.24-19.51, p = 0.023) were identified as independent predictors of symptomatic carotid plaque. In the receiver operating characteristic curve analysis, serum sortilin levels higher than 1.34 ng/mL predicted stroke/TIA with a sensitivity of 66.3% and a specificity of 67% (AUC = 0.725, p < 0.001). CONCLUSIONS: Serum sortilin level is increased in the presence of symptomatic intermediate CAS and may have clinical value in the management of patients with carotid artery disease.

Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) are more prominent in retinal artery occlusion (RAO) compared to retinal vein occlusion (RVO).

AIM: To evaluate the association between the value of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), monocyte to high-density lipoprotein ratio (MHR) and the development of retinal artery occlusion (RAO) and retinal vein occlusion (RVO). METHODS: This retrospective study assessed 41 RAO, 50 RVO and 50 control (age and gender matched senile cataract) participants. The NLR, PLR and MHR parameters of patients' peripheral blood were analyzed. A receiver operating characteristics (ROC) curve analysis and the best cutoff value were used to specify the predictive value of NLR, PLR and MHR in RAO and RVO. RESULTS: The NLR, PLR and MHR were significantly higher in RAO group compared to the control group (p<0.001, p<0.001 and p = 0.008; respectively). The NLR, PLR and MHR were also significantly higher in the RVO group compared to the control group (p<0.001, p = 0.001 and p = 0.012, respectively). The NLR and PLR were significantly higher in the RAO group compared to the RVO group (p<0.001 and p = 0.022, respectively). The optimal cut-off value of NLR to predict RAO was >2.99, with 90.2% sensitivity and 100% specificity. The PLR to predict RAO was > 145.52, with 75.6% sensitivity and 80.0% specificity. CONCLUSION: Higher NLR, PLR and MHR are related to the occurrence of RAO and RVO. NLR and PLR are more prominent in RAO compared to RVO.

Complete blood cell count measures in retinal artey occlusions.

PURPOSE: To investigate the role of complete blood cell count (CBC) measures in retinal artery occlusion (RAO). METHODS: This was a case-control study, including 73 newly diagnosed RAO patients and 73 sex- and age-matched subjects without RAO. On the same day of RAO diagnosis, a blood sample was collected and CBC was determined using an automatic blood counter. Dimensional CBC indices, such as mean platelet volume (MPV) and red cell distribution width (RDW), and some CBC-combined indices, including neutrophil/lymphocyte ratio (NLR), derived NLR [dNLR = neutrophils/(white blood cells - neutrophils)] and platelet/lymphocyte ratio (PLR), were evaluated. Erythrocyte sedimentation rate (ESR) was also measured. RESULTS: Median neutrophils, red cell distribution width (RDW), NLR and dNLR were 4.5x109 /L (IQR = 3.8-5.8), 13.4% (IQR = 12.7-14.75), 2.47 (IQR = 1.85-3.13) and 1.70 (IQR = 1.26-2.18) in RAO patients and 4x109 /L (IQR = 3.18-4.93), 12.9% (IQR = 12-14), 1.86 (IQR = 1.42-2.44) and 1.32 (IQR = 1.02-1.64) in controls. RAO patients had significantly higher values of neutrophils (p = 0.003), RDW (p = 0.0011), NLR (p = 0.0001) and dNLR (p = 0.0001). There were no significant differences between the values of white blood cells, lymphocytes, platelet count, MPV and PLR. Multivariate logistic regression models revealed a statistically significant correlation between RAO and increased RDW (OR = 1.36, 95% CI = 1.06-1.73, p = 0.015), NLR (OR = 2.02, 95% CI = 1.34-3.06, p = 0.0009) and dNLR (OR = 3.4, 95% CI = 1.71-6.75, p = 0.0005). CONCLUSION: Results suggest that RDW, NLR and dNLR may be involved in the pathogenesis of RAO and predict its occurrence. However, high-quality epidemiologic studies, preferably of cohort design, are warranted to confirm whether, or not, an RDW, NLR and dNLR may be considered potential biomarkers of RAO.

Neutrophil to Lymphocyte Ratio (NLR) is a Better Tool Rather than Monocyte to High-Density Lipoprotein Ratio (MHR) and Platelet to Lymphocyte Ratio (PLR) in Central Retinal Artery Occlusions.

Purpose: To evaluate the predictive value of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), monocyte to high-density lipoprotein (HDL) ratio (MHR) and blood lipid profile in central retinal artery occlusion (CRAO) patients.Methods: We included 37 patients with a diagnosis of CRAO and 36 healthy subjects with similar age-sex in the study. We analyzed the medical records of peripheral blood samples retrospectively. NLR, PLR, MHR were obtained by simple manually calculations.Results: CRAO patients had significantly higher mean NLR in comparison with healthy subjects (p: 0.009). The groups were similar in regard to mean PLR (p: 0.864) and mean MHR (p: 0.581). A cutoff value of >1.62 for NLR was found to be a diagnostic tool in CRAO. The sensitivity and specificity for this cutoff point was 83.8% and 55.6%, respectively.Conclusion: NLR rather than MHR and PLR may be a beneficial marker for the development of CRAO.

Carotid artery intima-media thickness, HDL cholesterol levels, and gender associated with poor visual acuity in patients with branch retinal artery occlusion.

PURPOSE: To investigate factors associated with poor visual acuity (VA) in branch retinal artery occlusion (BRAO). METHODS: This was a retrospective cross-sectional study of 72 eyes with BRAO of 72 patients. For statistical comparison, we divided the patients into worse-VA (decimal VA < 0.5) and better-VA (decimal VA > = 0.5) groups. We examined the association of clinical findings, including blood biochemical test data and carotid artery ultrasound parameters, with poor VA. RESULTS: Median age, hematocrit, hemoglobin and high-density lipoprotein (HDL) differed significantly between the groups (P = 0.018, P < 0.01, P < 0.01, and P = 0.025). There was a tendency towards higher median IMT-Bmax in the worse-VA group (worse-VA vs. better-VA: 2.70 mm vs. 1.60 mm, P = 0.152). Spearman's rank correlation test revealed that logMAR VA was significantly correlated to IMT-Bmax (rs = 0.31, P < 0.01) and IMT-Cmax (rs = 0.24, P = 0.035). Furthermore, logMAR VA was significantly correlated to HDL level (rs = -0.33, P < 0.01). Multivariate logistic regression analysis revealed that IMT-Bmax (odds ratio [OR] = 2.70, P = 0.049), HDL level (OR = 0.91, P = 0.032), and female gender (OR = 15.63, P = 0.032) were independently associated with worse VA in BRAO. CONCLUSIONS: We found that increased IMT-Bmax, decreased HDL, and female sex were associated with poor VA in BRAO patients. Our findings might suggest novel risk factors for visual dysfunction in BRAO and may provide new insights into the pathomechanisms underlying BRAO.

Non-Occlusive Retinal Vascular Inflammation and Role of Red Blood Cell Deformability in Birdshot Chorioretinopathy.

Purpose: To investigate differences in red blood cell (RBC) deformability between birdshot chorioretinopathy (BCR) subjects and matched controls, and to postulate its relationship with lack of vascular occlusion in BCR. Methods: In a single center, prospective, non-randomized mechanistic study, blood samples were collected from eight healthy controls and nine BCR patients, and subjected to biochemical and hematological tests, as well as RBC indices assessment using dual-beam optical tweezers. Results: The mean age of the controls was 52.37 ± 10.70 years and BCR patients was 53.44 ± 12.39 years. Initial cell size (Io) for the controls was 8.48 ± 0.25 µm and 8.87 ± 0.31 µm for BCR RBCs (p = 0.014). The deformability index (DI) for the controls was 0.066 ± 0.02 and that for BCR RBCs was 0.063 ± 0.03 (p = 0.441). Conclusion: There was no statistically significant difference in DI between RBCs from BCR and healthy controls. This may explain the rare occurrence of retinal vascular occlusion despite the underlying vasculitic pathophysiology of BCR.

A case report of branch retinal artery occlusion in a teenager due to hyperhomocysteinaemia; the interplay of genetic and nutritional defects.

BACKGROUND: Retinal vascular occlusions are uncommon in young people and require more in-depth investigation into the cause. Studies have revealed that a high level of circulating homocysteine poses a risk for retinal vaso-occlusive events across a wide age range. This case report reflects on how the interplay of genetic mutation and vitamin deficiency can cause a pathological level of homocysteine with resultant branch retinal artery occlusion in a young patient. CASE PRESENTATION: A 16-year-old boy presented to eye casualty with acute inferior visual field loss in the left eye. Visual acuity remained normal at 6/6 each eye and the event was painless. Initial assessment, and retinal photography revealed a left superior hemi-field branch retinal artery occlusion with macular sparing. Given the patient's age, extensive investigation into the cause was carried out. Positive findings were of an elevated level of homocysteine as a result of vitamin B12 and folic acid deficiency as well as a genetic mutation in the MTHFR gene (encoding MTHFR enzyme which is vital in normal homocysteine metabolism). Vitamin B12 and folic acid were replaced which in turn normalized the patient's homocysteine levels. At two months, the patient's visual fields had also improved, and no further vascular event had occurred. CONCLUSIONS: This case report has highlighted the link between hyperhomocysteinaemia and retinal artery occlusion. However, despite vitamin replacement being shown to normalize homocysteine levels, no evidence exists to date as to whether this will reduce the risk of further retinal vascular occlusion.

Homocysteine in retinal artery occlusive disease: A meta-analysis of cohort studies.

Few studies have reported the relationship between retinal artery occlusion (RAO) and plasma homocysteine (Hcy) levels. Our goal was to evaluate the association between the plasma Hcy level and the risk of RAO disease. Several databases were searched for all published studies that involved Hcy and RAO. Six studies evaluated hyperhomocysteinemia (hHcy) in retinal artery occlusion patients and controls; the incidence of hHcy in patients with RAO was higher than the control and the pooled odds ratio (OR) was 6.64 (95% confidence interval (CI): 3.42, 12.89). Subgroup analyses showed that the ORs were 4.77 (95% CI: 2.69, 8.46) in Western countries, 22.19 (95% CI: 2.46, 200.37) in Asian countries, 9.70 (95% CI: 4.43, 21.20) in the age matched group, 11.41 (95% CI: 3.32, 39.18) in the sex matched group, 9.70 (95% CI: 4.37, 21.53) in the healthy control group, and 6.82 (95% CI: 4.19, 11.10) in the sample size >30. The mean plasma Hcy level from 5 case-control studies was higher than controls, and the weighted mean difference (WMD) was 6.54 (95% CI: 2.79, 10.29). Retinal artery occlusion is associated with elevated plasma Hcy levels. Our study results suggest that hHcy is probably an independent risk factor for RAO.

Mean platelet volume in patients with retinal artery occlusion.

PURPOSE: The aim of this study was to investigate the mean platelet volume (MPV) of patients with retinal artery occlusion (RAO). METHODS: Thirty-seven patients diagnosed with RAO and 32 control subjects were included in this retrospective study. Retinal artery occlusion was diagnosed on the basis of clinical examination and fundus fluorescein angiography. All participants underwent complete ocular examination, and MPV, hematocrit, hemoglobin, and platelet counts were recorded. RAO patient data were compared with those of the control subjects. RESULTS: Patients with RAO had significantly higher MPV values (7.96 ± 1.2 fL) compared with control subjects (7.33 ± 0.7 fL, p<0.001). No significant difference was found with regard to platelet count between the RAO group and the control group (262 ± 70.1 × 109/L and 251 ± 56.6 × 109/L, respectively, p=0.50). MPV was an independent predictor of RAO [odds ratio (OR)=0.50; 95% confidence interval (CI)=0.28-0.89; p=0.019). CONCLUSIONS: Our results demonstrated that MPV values were significantly higher in patients with RAO, suggesting that larger platelets may contribute to the pathogenesis of the RAOs.

Mean platelet volume in patients with retinal artery occlusion / Volume médio de plaquetas em pacientes com oclusão da artéria da retina

ABSTRACT Purpose: The aim of this study was to investigate the mean platelet volume (MPV) of patients with retinal artery occlusion (RAO). Methods: Thirty-seven patients diagnosed with RAO and 32 control subjects were included in this retrospective study. Retinal artery occlusion was diagnosed on the basis of clinical examination and fundus fluorescein angiography. All participants underwent complete ocular examination, and MPV, hematocrit, hemoglobin, and platelet counts were recorded. RAO patient data were compared with those of the control subjects. Results: Patients with RAO had significantly higher MPV values (7.96 ± 1.2 fL) compared with control subjects (7.33 ± 0.7 fL, p<0.001). No significant difference was found with regard to platelet count between the RAO group and the control group (262 ± 70.1 × 109/L and 251 ± 56.6 × 109/L, respectively, p=0.50). MPV was an independent predictor of RAO [odds ratio (OR)=0.50; 95% confidence interval (CI)=0.28-0.89; p=0.019). Conclusions: Our results demonstrated that MPV values were significantly higher in patients with RAO, suggesting that larger platelets may contribute to the pathogenesis of the RAOs.

RESUMO Objetivo: O objetivo deste estudo foi investigar o volume plaquetário médio (MPV) de pacientes com oclusão da artéria da retina (RAO). Métodos: Trinta e sete pacientes com diagnóstico de RAO e 32 indivíduos do grupo controle foram incluídos neste estudo retrospectivo. A oclusão da artéria da retina foi diagnosticada com base em exame clínico e angiofluoresceinografia. Todos os participantes foram submetidos ao exame ocular completo. MPV, hematócrito, hemoglobina e contagem de plaquetas dos participantes foram registrados. Os dados dos pacientes com RAO foi comparado com os de sujeitos do grupo controle. Resultados: Pacientes com RAO apresentaram valores significativamente mais elevados MPV (7,96 ± 1,2 fL) em comparação aos indivíduos do grupo controle (7,33 ± 0,7 fL) (p<0,001). Nenhuma diferença significativa foi encontrada no número de plaquetas entre os grupos RAO e controle (262 ± 70,1 109/L and 251 ± 56,6 109/L, respectivamente, p=0,50). MPV foi um preditor independente de RAO (odds ratio (OR)=0,50; intervalo de confiança de 95% (IC)=0,28-0,89; p=0,019). Conclusões: Os resultados demonstraram que os valores de MPV foram significativamente maiores nos pacientes com RAO, sugerindo que plaquetas maiores podem contribuir na patogênese da RAO.

Central retinal artery occlusion in a 13-year-old child as a presenting sign of hyperhomocysteinemia together with high lipoprotein(a) level.

BACKGROUND: We describe a child with central retinal artery occlusion and hyperhomocysteinemia. METHODS: A 13-year-old girl developed sudden vision loss and was hospitalized for diagnosis and treatment. RESULTS: Her physical examination was normal except for her ophthalmologic examination. Her serum homocysteine level and lipoprotein(a) were elevated to 45.27 µmol/L and 61 mg/dL 0-29 mg/dL, respectively. A homozygous mutation was identified for methylenetetrahydrofolate reductase at position C677T. CONCLUSION: This report documents central retinal artery occlusion associated with the risk factors of hyperhomocysteinemia caused by methylenetetrahydrofolate reductase C677 T mutation and high lipoprotein(a) level in a child. Retinal artery occlusion is rare in children. This patient emphasizes the need for a systemic evaluation for hyperhomocysteinemia and lipoprotein(a) levels in children with retinal vascular occlusion of uncertain etiology.

[Evaluation of body mass index and lipid fractions levels in patients with retinal artery occlusion].

BACKGROUND/AIM: There are studies stressing out that atherosclerosis is most common associated systemic condition in patients with retinal artery occlusion. The aim of this study was to analyze values of body mass index and lipid fractions in healthy individuals and patients with retinal artery occlusion. METHODS: This study included 90 participants during a 6-year period. The population was divided into 2 groups: the group with the diagnosed retinal artery occlusion and the group without retinal artery occlusion. The observed parameters were as follows: body mass index, low and high density lipoproteins and triglycerides. RESULTS: The study revealed no significant difference regarding body mass index and triglycerides values between the two evaluated groups, while low and high density lipoproteins values were significantly higher in the group of patients with retinal artery occlusion. CONCLUSIONS: The study demonstrated that body mass index and triglycerides have less important role in atherogenic pathogenesis of retinal artery occlusion, while low density lipoprotein is the fraction that is shown to be most potent in such etiological processes.

[Hemicentral retinal artery occlusion due to oral contraceptives]. / Hemizentralarterienverschluss bei Einnahme der "Pille"--Mitteilungen über Komplikationen von Kontrazeptiva.

BACKGROUND: Low-dose oral contraceptives can still cause thromboembolic disorders with serious neurologic or ocular disabilities. PATIENT: A 22-year-old woman having used oral contraceptives for several months noticed sudden painless visual loss in her left eye. One tablet of her contraceptive contained ethinylestradiol (0.03 mg) and chlormadinonacetate (2 mg). RESULT: Because of the lower left eye visual field defect, the patient could only read with her right eye. She presented complete left inferior hemianopia, indicating a hemicentral retinal artery obstruction. Visual acuity in both eyes was 20 / 20. The left fundus revealed a distinct retinal edema in the area superior to the optic disc and macula due to vascular disturbances of the superior temporal superior and superior nasal retinal arteries. The right eye was normal. Fluorescein angiography revealed recanalized arteries in the superior retinal area with conspiciously early dye filling as a paradoxical sign. Doppler sonography of the neck and orbital arteries and transesophageal echocardiography (TEE) findings were inconspicious. However, blood examination revealed an elevated thrombin-antithrombin complex and reduced free protein S. CONCLUSION: Coagulopathy can be a side effect of oral contraceptives. Even nowadays, women taking contraceptives risk the danger of vascular occlusions especially if the women suffers from arterial hypertension, diabetes mellitus, have a coagulation anomaly, or if she is a chronic smoker. Before treatment with oral contraceptives commences, a thorough medical examination is necessary. If the family history reveals prominent cardiovascular risk factors, testing for thrombophilia is recommended. Even nowadays, patients should be warned of the risk of visual field defects as a potential side-effect associated with oral contraceptives.

[Haemoglobin oxygenation of retinal vessels in branch retinal artery occlusions over time and correlation with clinical outcome]. / Nichtinvasive Messung der Sauerstoffsättigung retinaler Gefäße bei retinalen Astarterienverschlüssen unter Therapie.

OBJECTIVE: Purpose of these study was the evaluation of a new method for the measurement of haemoglobin oxygenation in retinal vessels. Patients with branch retinal artery occlusion have been measured before and after a rheological therapy. METHODS: The haemoglobin oxygenation in retinal vessels was measured by the "oxygen module" (Imedos GmbH, Jena, Germany) which uses a special filter (transmission at 548 and 610 nm, band width 10 nm) in the illumination path of a fundus camera. Fundus images were acquired by a colour CCD camera and specific software was used for vessel tracking and calculation of their haemoglobin oxygen saturation. 11 patients with branch retinal artery occlusions, average age 63.4 ± 11.7 years were investigated at time of diagnosis and at the 5th day of a rheological and intraocular pressure reduction therapy. RESULTS: 10 out of 11 patients have shown an increase of haemoglobin oxygenation over time (on average from 73 ± 16 % to 87 ± 11 %). This increase was statistically significant (p < 0.05, Wilcoxon test). Non-affected retinal areas have also shown an increase of haemoglobin oxygenation. The visual acuity improved by one line. This increase in visual acuity was, however, not statistically significant. CONCLUSIONS: We observed an increase of the arterial haemoglobin oxygenation. One possible reason of the improvement of the haemoglobin oxygenation by the therapy may be an increase of the rheological properties of the blood. All patients showed an increase or at least a stabilisation of their visual acuity. Retinal vessel oximetry might be used as an additional parameter in the follow-up of retinal artery occlusion.