Retinal Artery and Vein Occlusion Risks after Coronavirus Disease 2019 or Coronavirus Disease 2019 Vaccination.

PURPOSE: To evaluate the incidence of new retinal artery occlusion (RAO) and retinal vein occlusion (RVO) after the diagnosis of coronavirus disease 2019 (COVID-19) or vaccination against COVID-19 and compare the incidences with the population with neither. DESIGN: Nationwide population-based cohort study. PARTICIPANTS: From a nationwide population-based cohort, 8 418 590 patients were categorized into control (group 1), COVID-19 infection (group 2), and COVID-19 vaccination (group 3) groups. METHODS: The cumulative incidence of RAO and RVO was calculated in groups 1, 2, and 3 using the Kaplan-Meier method. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) based on the Poisson distribution for RAO and RVO according to each group and subgroup using Cox proportional hazards models, with group 1 as the reference. We conducted univariable and multivariable analyses for the risk factors of RAO and RVO according to each subgroup. MAIN OUTCOME MEASURES: Cumulative incidence and risks of incidence of RAO and RVO from the index date to day 60. RESULTS: In multivariable analysis, no significant increase in RAO and RVO risks after COVID-19 or COVID-19 vaccination were observed in either men or women. These results were observed consistently across various conditions in sensitivity analyses. In subgroup analysis, individuals who were vaccinated before infection showed no significant increase in RAO or RVO risks in both sexes compared with the control group. In the subgroup analysis of vaccinated patients, the HRs of RAO and RVO for different vaccine types did not show an increase compared with the control group; however, an exception was observed in women who received mRNA-1273 vaccines, who showed a higher RAO HR (4.65; 95% CI, 1.27-17.03; P = 0.021). CONCLUSIONS: Within 60 days of COVID-19 diagnosis or vaccination, RAO and RVO occurred rarely. We observed no increase in the HR of RVO and RAO relative to COVID-19 or COVID-19 vaccination except for a possible increase in the RAO HR in women who received mRNA-1273, for which the raw incidence was extremely low. Further investigation is required to validate this result. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Exploring Patient Demographics and Presence of Retinal Vascular Disease in Paracentral Acute Middle Maculopathy.

PURPOSE: To investigate the sociodemographic profile, the association with retinal vascular diseases (RVD) and systemic comorbidities, and visual outcomes of patients with paracentral acute middle maculopathy (PAMM) in a large, ethnically diverse single-center cohort. DESIGN: Retrospective cohort study. METHODS: Electronic health record query for all patients presenting with PAMM at Moorfields Eye Hospital, London, was completed. Detailed demographic, clinical, and systemic information were collected and analyzed. RESULTS: A total of 78 eyes of 78 patients with confirmed PAMM were included in the study. Forty patients (51.3%) presented with no RVD, 20 patients (25.6%) with retinal vein occlusion (RVO), 16 patients (20.5%) with retinal artery occlusion (RAO), and 2 patients (2.6%) with concomitant RAO and RVO. Patients with PAMM+RAO were older than those with RVO (P = .02) and more likely to have a history of major adverse cardiovascular events (MACE) (P = .01), with a significantly worse presenting best corrected visual acuity (BCVA) (20/50) compared to patients with RVO (P = .02) and no RVD (P < .001). Individuals with isolated PAMM had a significantly higher prevalence of previous MACE (P = .04) and sickle cell disease (SCD) (P = .04) compared to those with RVO. At the last follow-up, 64 patients (85.3%) had a good BCVA (>20/32). CONCLUSIONS: The significant association of PAMM with RVD supports the hypothesis of an ischemic etiology. Individuals with isolated PAMM had a higher prevalence of MACE and SCD. Thus, it is important to prompt immediate referral for a comprehensive systemic evaluation. Across the whole cohort, PAMM was associated with good BCVA improvement during follow-up, indicating a good visual prognosis.

LISDEXAMFETAMINE (VYVANSE) USE ASSOCIATED WITH BRANCH RETINAL ARTERY OCCLUSION.

BACKGROUND/PURPOSE: Branch retinal artery occlusions (BRAO) are primarily associated with the aging population and are rare in young adults. The etiology of BRAO includes embolic or nonembolic sources. Lisdexamfetamine has been associated with vasospastic ischemic events in multiple areas of the body. However, there are currently no reported cases of BRAO associated with lisdexamfetamine use. Here, we present a case that suggests a correlation between lisdexamfetamine use and a nonembolic BRAO in a young adult man. METHODS/RESULTS: A 32-year-old man presented with sudden left eye blurred vision 17 days after beginning lisdexamfetamine. Fundus examination confirmed the BRAO diagnosis. Following evaluation by a retina specialist, vasospasm was considered the most likely cause for the BRAO. Other possible etiologies were unlikely due to diagnostic testing. CONCLUSION: The temporal association between lisdexamfetamine and BRAO symptom onset suggests vasospastic occlusion. Lisdexamfetamine-associated adverse events should be considered as a possible etiology for BRAO.

Atrial fibrillation as a novel risk factor for retinal stroke: A protocol for a population-based retrospective cohort study.

Central retinal artery occlusion (CRAO; retinal stroke or eye stroke) is an under-recognized, disabling form of acute ischemic stroke which causes severe visual loss in one eye. The classical risk factor for CRAO is ipsilateral carotid stenosis; however, nearly half of patients with CRAO do not have high-grade carotid stenosis, suggesting that other cardiovascular risk factors may exist for CRAO. Specifically, prior studies have suggested that cardioembolism, driven by underlying atrial fibrillation, may predispose patients to CRAO. We describe the design of an observational, population-based study in this protocol. We evaluate two specific objectives: 1) To determine if atrial fibrillation is an independent risk factor for CRAO after adjusting for medical and cardiovascular risk; 2) To determine if use of oral anticoagulation can modify the risk of CRAO for patients with atrial fibrillation. This protocol lays out our strategy for cohort definition, case and control definition, comorbidity ascertainment, and statistical methods.

Hemorrhagic retinal arterial macroaneurysm combined with branch retinal artery occlusion treated with intravitreal conbercept injection: A case report.

RATIONALE: Branch retinal artery occlusion (BRAO) is a rare complication of retinal arterial macroaneurysm (RAM), a low-incidence ocular disease. PATIENT CONCERNS: A 75-year-old woman presented with a chief complaint of blurred vision. DIAGNOSES: The patient for 4 days received a diagnosis of RAM combined with BRAO. INTERVENTIONS: The patient was treated with two successive intravitreal conbercept injections. OUTCOMES: The patient's best-corrected visual acuity improved, and the RAM diminished. LESSONS: Administration of conbercept injection might be an effective treatment for complex RAM with BRAO.

Risk of Stroke, Myocardial Infarction, and Death After Retinal Artery Occlusion.

Importance: Patients with retinal artery occlusions (RAOs) are recommended to have emergent stroke workup, although the true risk of death and subsequent vascular events post-RAO is not clear. Objective: To determine short-term and long-term rates of stroke, myocardial infarction (MI), and death in patients after RAO compared with a control cohort. Design, Setting, and Participants: This retrospective cohort study used aggregated electronic health records from January 1, 2003, through April 14, 2023, from TriNetX, a network with data from more than 111 million patients. Patients with RAO and a cataract control group were identified and matched for age, sex, race, and comorbidities, including hypertension, diabetes, hyperlipidemia, and smoking status. Patients were excluded if they had a stroke or MI within 2 years before the diagnosis of RAO or cataract. Exposure: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis code for RAO or age-related cataract. Main Outcomes and Measures: Rate of death, stroke, and MI at 2 weeks, 30 days, 1 year, 5 years, and 10 years after RAO compared with matched controls. Results: There were a total of 34 874 patients with at least 1 year of follow-up in the RAO cohort. The mean (SD) age at the RAO event was 66 (15.2) years. The rate of death after RAO diagnosis was higher than after cataract diagnosis at 2 weeks (0.14% vs 0.06%; relative risk [RR], 2.45; 95% CI, 1.46-4.12; risk difference [RD], 0.08%; 95% CI, 0.04%-0.13%; P < .001), 30 days (0.29% vs 0.14%; RR, 2.10; 95% CI, 1.49-2.97; RD, 0.15%; 95% CI, 0.08%-0.22%; P < .001), 1 year (3.51% vs 1.99%; RR, 1.78; 95% CI, 1.61-1.94; RD, 1.41%; 95% CI, 1.17%-1.66%; P < .001), 5 years (22.74% vs 17.82%; RR, 1.28; 95% CI, 1.23-1.33; RD, 4.93%; 95% CI, 4.17%-5.68%; P < .001), and 10 years (57.86% vs 55.38%; RR, 1.05; 95% CI, 1.02-1.07; RD, 2.47%; 95% CI, 1.25%-3.69%; P < .001). Risk of stroke after RAO was higher at 2 weeks (1.72% vs 0.08%; RR, 21.43; 95% CI, 14.67-31.29; RD, 1.64%; 95% CI, 1.50%-1.78%; P < .001), 30 days (2.48% vs 0.18%; RR, 14.18; 95% CI, 10.94-18.48; RD, 2.31%; 95% CI, 2.14%-2.47%; P < .001), 1 year (5.89% vs 1.13%; RR, 5.20; 95% CI, 4.67-5.79; RD, 4.64%; 95% CI, 4.37%-4.91%; P < .001), 5 years (10.85% vs 4.86%; RR, 2.24; 95% CI, 2.09-2.40; RD, 6.00%; 95% CI, 5.50%-6.50%; P < .001), and 10 years (14.59% vs 9.18%; RR, 1.59; 95% CI, 1.48-1.70; RD, 5.41%; 95% CI, 4.62%-6.21%; P < .001). Risk of MI after RAO was higher at 2 weeks (0.16% vs 0.06%; RR, 3.00; 95% CI, 1.79-5.04; RD, 0.11%; 95% CI, 0.06%-0.16%; P < .001), 30 days (0.27% vs 0.10%; RR, 2.61; 95% CI, 1.78-3.83; RD, 0.17%; 95% CI, 0.10%-0.23%; P < .001), 1 year (1.66% vs 0.97%; RR, 1.72; 95% CI, 1.51-1.97; RD, 0.59%; 95% CI, 0.42%-0.76%; P < .001), 5 years (6.06% vs 5.00%; RR, 1.21; 95% CI, 1.12-1.31; RD, 1.07%; 95% CI, 0.64%-1.50%; P < .001), and 10 years (10.55% vs 9.43%; RR, 1.12; 95% CI, 1.04-1.21; RD, 1.13%; 95% CI, 0.39%-1.87%; P = .003). Conclusions and Relevance: This study showed an increased risk of death, stroke, and MI in patients with RAO at both short-term and long-term intervals after RAO compared with a matched control population diagnosed with cataract. These findings suggest a potential need for multidisciplinary evaluation and long-term systemic follow-up of patients post-RAO.

Case report: acute isolated cilioretinal artery occlusion secondary to percutaneous coronary intervention.

INTRODUCTION: This case report aims to describe in detail the acute isolated cilioretinal artery occlusion (CLRAO) secondary to complicated therapeutic percutaneous coronary intervention (PCI). CASE DESCRIPTION: A 68-year-old Chinese man with coronary artery disease (CAD) complained of sudden, sharp chest pain. Coronary angiography revealed severe stenoses of the coronary arteries. The patient was then treated with PCI. One hour after the procedure, the patient presented with a sudden reduction in vision in the right eye. The patient was diagnosed with acute isolated CLRAO and treated with Salvia miltiorrhiza injections. CONCLUSIONS: This is the report to provide a detailed description of acute isolated CLRAO secondary to therapeutic PCI treated with Salvia miltiorrhiza. The visual prognosis of the untreated patients is poor. Suitable management and prevention are essential for interventional cardiologists to prevent these complications.

Analysis of the Association between Retinal Artery Occlusion and Acute Ischaemic Stroke/ST-Elevation Myocardial Infarction and Risk Factors in Hungarian Patients.

Background and Objectives: We aimed to analyse data on retinal artery occlusion (RAO) patients to explore correlations with acute ischaemic stroke (AIS), ST-elevation myocardial infarction (STEMI), and cardio/cerebrovascular comorbidities. Patients and Methods: Our retrospective cohort study included 169 RAO and 169 age- and gender-matched control patients. We examined the association of AIS, STEMI, and related comorbidities such as hypertension (HT), type 1 and type 2 diabetes (T1DM and T2DM, respectively), hyperlipidaemia, and ischaemic heart disease (IHD) with RAO. We also recorded atrial fibrillation in our RAO patients. Results: Our results demonstrated that RAO patients developed both AIS and STEMI at a significantly higher rate compared to controls (p < 0.001 for both). We also found that RAO patients had a significantly higher prevalence of HT and hyperlipidaemia (p1 = 0.005, p2 < 0.001) compared to controls. Multiple risk factors together significantly increased the odds of developing AIS and STEMI. Conclusions: Our results suggest that through identifying and treating the risk factors for RAO patients, we can reduce the risk of AIS, STEMI, and RAO of the fellow eye. Considering that ophthalmologists are often the first detectors of these cardiovascularly burdened patients, collaboration with colleagues from internal medicine, cardiology, and neurology is essential to achieve secondary prevention.

Sex differences in major adverse cardiovascular and cerebrovascular event risk among central retinal artery occlusion patients.

To estimate the association between central retinal artery occlusion (CRAO) and major adverse cardiovascular and cerebrovascular events (MACCE), including their clinical characteristics, blood markers, and the contribution of CRAO to MACCE, as well as to assess any sex differences. This retrospective cohort study included continuous new-onset CRAO patients and 1:4 controls during the same period. Correlations of CRAO with the incidence of MACCE during follow-up and the sex-related differences were studied. One hundred and twenty-four CRAO patients and four hundred and ninety-six controls were enrolled. Neutrophil-to-lymphocyte ratio (NLR, P = 0.014) and high-sensitivity C-reactive protein (hs-CRP, P = 0.038) were tended to be higher in CRAO patients. After the follow-up period, 78 patients experienced MACCE. Multivariate Cox regression analysis showed that CRAO was a predictor of the occurrence of MACCE (HR 2.321, 95% CI 1.439-3.744, P = 0.001). Sex subgroups indicated that age, diabetes, current smoking, CRAO, NLR and hs-CRP increased the risk factor of MACCE in males (All P < 0.05) and CRAO, NLR, low-density lipoprotein cholesterol (LDL-C) and hs-CRP were independent influencing factors for females (All P < 0.05). New-onset CRAO significantly increases the probability of MACCE and is associated with a poor prognosis. The sex-related differences suggested that effective prevention of the occurrence of MACCE in high-risk patients requires that attention be given to individualized risk factors corresponding to sexes.

Presence of Embolic Source and Outcome in Central Retinal Artery Occlusion.

OBJECTIVES: The etiology of central retinal artery occlusion (CRAO) is unclear in approximately 50% of patients, suggesting pathomechanical heterogeneity; moreover, little is known about outcomes according to etiology. This study investigated whether the presence of an embolic source affects outcome in CRAO. METHODS: CRAO patients within 7 days of symptom onset were retrospectively enrolled. Clinical parameters, including initial and 1-month visual acuity, CRAO subtype, and brain images, were reviewed. CRAO etiology was categorized as CRAO with or without an embolic source (CRAO-E+ and CRAO-E-). Visual improvement was defined as a decrease in logarithm of the minimum angle of resolution ≥0.3 at 1 month. RESULTS: A total of 114 patients with CRAO were included. Visual improvement was noted in 40.4% of patients. Embolic sources were identified in 55.3% of patients, and visual improvement group rather than no improvement group was more commonly associated with the presence of an embolic source. In multivariable logistic regression analysis, CRAO-E+ independently predicted visual improvement (odds ratio 3.00, 95% CI 1.15-7.81, p = 0.025). DISCUSSION: CRAO-E+ was found to be associated with a better outcome. CRAO-E+ may be more prone to recanalization than that CRAO-E-.

Prevalence and systemic associations of retinal vascular occlusions in Sub-Saharan Africa.

Background: Retinal vascular occlusions are a common cause of visual impairment. Studies on retinal vascular occlusions in sub-Saharan Africa (SSA) have primarily been retrospective and on retinal vein occlusion (RVO) only. The aim of this study, therefore, was to determine the prevalence and pattern of retinal vascular occlusions and their systemic associations in SSA. Materials and Methods: This was a hospital-based, cross-sectional study involving all new patients presenting at the general ophthalmic and specialty retina clinics in four hospitals in Nigeria over a 1 year period. All the patients underwent a comprehensive eye examination. The demographic and clinical data of patients with retinal vascular occlusions were entered into an excel sheet and analyzed using the Statistical Package for the Social Sciences (SPSS) software version 22.0. Statistical significance was indicated by P < 0.05. Results: A total of 8614 new patients were seen, and a diagnosis of retinal vascular occlusion was made in 90 eyes of 81 patients giving a disease prevalence of 0.9%. Eighty-one eyes of 72 (88.9%) patients had RVO, while 9 eyes of 9 (11.1%) patients had retinal artery occlusion (RAO). The mean age of patients with RVO and RAO was 59.5 years and 52.4 years, respectively. Increasing age, hypertension, and diabetes were the significant associations with retinal vascular occlusion with P < 0.0001. Conclusion: Retinal vascular occlusions are an increasing cause of retinal disease in SSA and tend to occur at an earlier age. They are associated with hypertension, diabetes, and increasing age. Further studies will, however, be required to establish the demographic and clinical profile of patients with RAO in the region.

Résumé Contexte: Les occlusions vasculaires rétiniennes sont une cause fréquente de la déficience visuelle. Les études sur les occlusions vasculaires rétiniennes en Afrique subsaharienne (SSA) ont été principalement rétrospectives et uniquemment sur l'occlusion veineuse rétinienne (RVO). Le but de cette étude était donc de determiner la prévalence et le schéma des occlusions vasculaires rétiniennes et leurs associations systémiques en Afrique subsaharienne. Matériels et méthodes: Il s'agissait d'une étude transversale hospitalière portant sur tous les nouveaux patients se présentant aux cliniques d'ophtalmologie générale et de rétine spécialisée dans quatre hôpitaux au Nigéria sur une période d'un an. Tous les patients ont subi un examen ophtalmologique complet. Les données démographiques et cliniques des patients avec des occlusions vasculaires rétiniennes ont été saisies dans une feuille excel et elles ont été analysées à l'aide du paquet statistique pour les sciences sociales (SPSS) logiciel version 22.0. La signification statistique était indiquée par P < 0,05. Résultats: Au total, 8614 nouveaux patients ont été vus et un diagnostic d'une occlusion vasculaire rétinienne a été réalisée dans 90 yeux de 81 patients donnant une prévalence de la maladie de 0,9 %. Quatre-vingt-un yeux de 72 (88,9 %) patients avaient RVO, tandis que 9 yeux de 9 (11,1%) patients avaient une occlusion de l'artère rétinienne (RAO). L'âge moyen des patients avec RVO et RAO était de 59,5 ans et 52,4 ans, respectivement. L'augmentation de l'âge, l'hypertension et le diabète étaient les associations significatives avec l'occlusion vasculaire rétinienne avec P < 0,0001. Conclusion: Les occlusions vasculaires rétiniennes sont une cause croissante de maladie rétinienne en Afrique subsaharienne et elles ont tendance à survenir à un âge plus précoce. Elles sont associées à l'hypertension, au diabète et à l'âge. D'autres études seront cependant nécessaires pour établir la démographie et le profil clinique des patients atteints de RAO dans la région. Mots-clés: Diabète, hypertension, occlusion artérielle rétinienne, occlusion veineuse rétinienne.

Risk of acute stroke in patients with retinal artery occlusion: a systematic review and meta-analysis.

OBJECTIVE: In this systematic review and subsequent meta-analysis, we evaluated studies that showed a relationship between stroke and renal artery occlusion in order to determine the risk of acute stroke in patients with retinal artery occlusion (RAO). MATERIALS AND METHODS: The guiding principles of PRISMA were followed in this investigation. Using the keywords, 850 similar articles from the years 2004 to 2022 during the initial screening. The remaining research underwent additional screening, and 350 studies were excluded for not meeting our inclusion criteria. In the end, 12 papers were chosen for analysis. RESULTS: The odd ratios were calculated using a random effect model. Then the I2 test was used to determine heterogeneity. To generate the conclusions, one sizable cohort of French studies was taken from the meta-analysis. Every study found a strong link. In half of the chosen trials, we found a marginal connection between stroke risk and retinal artery obstruction. The remaining research, however, reveals a considerable positive association between the two factors. CONCLUSIONS: The meta-analysis demonstrated that people with RAO are significantly more likely to get an acute stroke than patients without RAO. In addition, patients with RAO are substantially more likely than those without RAO to develop an acute stroke following an occlusion episode, especially if they are under 75 years old. However, given that only a small number of the studies in our review did not show a clear correlation between the two, we believe more research is required to conclusively link RAO and the prevalence of acute stroke.

Bilateral central retinal artery occlusion as a presenting manifestation of systemic lupus erythematosus: a case-based review.

Central retinal artery occlusion (CRAO) is an ophthalmic emergency that typically results in permanent vision damage even despite vigorous treatment. In this article, we describe a case of acute vaso-occlusive retinopathy that presented as the primary manifestation of SLE in the absence of elevated levels of APLAs. After treatment with intravenous steroids, immunoglobulin, intrathecal injection of dexamethasone, plasma exchange, and intravenous cyclophosphamide, SLE was well controlled in the patient, but her vision was permanently lost in the left eye. We also go over a brief review of the currently available literature on retinal vaso-occlusive disease present in SLE. The pathology mechanism of CRAO is related to immune complex-mediated "vasculitis", which is typically associated with neuropsychiatric lupus. However, the literature review identified antiphospholipid antibody syndrome (APS) in only 6 of 19 patients, indicating that other mechanisms besides APS are associated with CRAO. Systemic immunosuppression and anticoagulants are required for the treatment of this severe vaso-occlusive retinopathy. Early recognition and aggressive intervention may prevent severe loss of vision.

Frequency of visual involvement in a 10-year interdisciplinary cohort of patients with giant cell arteritis.

BACKGROUND: We present the largest study of the frequency and nature of visual complications in a cohort of 350 patients consecutively diagnosed with giant cell arteritis (GCA). METHODS: All individuals were assessed using structured forms and diagnosed using imaging or biopsy. A binary logistic regression model was used to analyse data for predicting visual loss. RESULTS: Visual symptoms occurred in 101 (28.9%) patients, with visual loss in one or both eyes in 48 (13.7%) patients. Four patients had binocular visual loss. Anterior ischaemic optic neuropathy (N=31), retinal artery obstruction (N=8) and occipital stroke (N=2) were the main causes of visual loss. Of the 47 individuals who had repeat visual acuity testing at 7 days, three individuals had improvement to 6/9 or better. After introducing the fast-track pathway, the frequency of visual loss decreased from 18.7% to 11.5%. Age at diagnosis (odds ratio (OR) 1.12) and headache (OR 0.22) were significant determinants of visual loss in a multivariate model. Jaw claudication trended to significance (OR 1.96, p=0.054). CONCLUSIONS: We recorded a visual loss frequency of 13.7% in the largest cohort of patients with GCA examined from a single centre. Although improvement in vision was rare, a dedicated fast-track pathway reduced visual loss. Headache could result in earlier diagnosis and protect against visual loss.

Central retinal artery occlusion as a result of symptomatic patent foramen ovale.

Objective: The objective of this case report is to highlight the importance of patent foramen ovale (PFO) as a potential cause of central retinal artery occlusion (CRAO). Methods: A teenage girl presented with a sudden painless onset of vision loss in the right eye, which was accompanied by frontal headaches and vertigo. The patient was referred to the Ophthalmology Department, where subsequent examination revealed a best corrected visual acuity of 20/ 400 and a positive relative afferent pupillary defect (RAPD) in the right eye. Fundoscopy and optical coherence tomography confirmed the diagnosis of central retinal artery occlusion following which investigations to rule out hematologic, vascular, and cardiac causes were performed. Results: Transoesophageal echocardiography revealed PFO as the cause of this cryptogenic stroke. All the necessary blood testing work was performed (complete blood counts, erythrocyte sedimentation rate, C-reactive protein, lipid profile, homocysteine levels, prothrombin time, activated partial thromboplastin time, international normalized ratio, liver, renal and thyroid function tests, antinuclear antibodies, anti-smooth muscle antibodies, anti-mitochondrial antibodies, p-ANCA, c-ANCA, anti-cardiolipin antibodies, protein C, Protein S, activated protein C resistance, anti-thrombin III, VDRL, antibodies for viral retinitis, angiotensin converting enzyme, Mantoux test, detailed urine and electrolyte reports). Transoesophageal echocardiography revealed right to left shunt. Conclusions: This case along with other reported evidence in literature support the strong connection between PFO and CRAO. Closure of symptomatic PFO may result in prevention of severe visual loss. Abbreviations: CRAO = central retinal artery occlusion, PFO = patent foramen ovale, RAPD = relative afferent pupillary defect, BCVA = best corrected visual acuity, OCT = Optical coherence tomography, IOP = Intraocular pressures, TTE = transthoracic echocardiography, HM = hand motion, TEE = transesophageal echocardiogram.