Branch retinal artery occlusion in a patient undergoing Methotrexate therapy for ectopic pregnancy: A case report.

Methotrexate is a commonly used agent in the treatment of an un-ruptured ectopic pregnancy. Thromboembolic events are rarely seen side effects of such a medicine. We report the case of the 22-year-old woman who underwent Methotrexate therapy for an un-ruptured ectopic pregnancy without any history of thromboembolic risk factors. A second dose (50 mg/m2) was administered to the patient showing a nondecreasing pattern of ß-HCG levels after an initial standard dosage of Methotrexate (50 mg/m2). On the 12th day of the treatment, a sudden onset of painless vision loss was seen in the right eye. Fundal imaging and fluorescein angiography revealed an occlusion of the superior temporal branch of the right retinal artery. After a month of hyperbaric oxygen therapy, complete recovery without loss of vision was achieved.

Transient Retinal Artery Occlusion After Uncomplicated Rhinoplasty.

PURPOSE: Loss of vision is an extremely rare and unexpected complication following a routine uncomplicated nasal surgery. In majority of patients, visual loss has attributed to retinal emboli which occur with retrograde flow of the intra-arterially injected agents into the nasal cavity or direct trauma to the optic nerve. In this report, the authors present a patient with unilateral decreased vision due to branch retinal artery occlusion soon after a routine nasal surgery. METHODS: Clinical report. RESULT: A 32-year-old female patient admitted to the author' clinic with the complaints of decreased visual acuity in the left eye. She stated that she had undergone rhinoplasty operation 1 week ago and vision loss started immediately after the surgery.In the ophthalmological examination, the best corrected visual acuity with Snellen chart was 1.0 in the right eye and 0.3 in the left eye. In the fundoscopic examination of left eye there was a pale area in the inferior part of the macula. Fundus fluorescein angiography showed no evidence of nonperfusion in the right and left eyes and vascular structure was normal. On the optic coherence tomography, hyperreflectivity and increased thickness were observed in the inner retinal layers of the left eye. In the visual field test, there was a loss of the visual field which corresponds to the pale area on the left eye. Hyperbaric oxygen therapy was recommended. The ophthalmologic examination carried out 2 months later revealed a best corrected visual acuity of the left eye 0.9. In the fundoscopy pale area was regressed in the left eye. Fundus fluorescein angiography showed a good perfusion. There was a little progression in the visual field test. CONCLUSION: Direct mechanical trauma and vasoplastic/embolic vascular events are thought to be possible mechanisms. The authors think in this case, there was a retrograde flow of agents used during the surgery through ophthalmic artery to retinal arteries and vasospasm by epinephrin worsened the situation. Although rare retinal artery occlusion may develop after rhinoplasty, vision loss as a result of a surgery, if done for aesthetic purposes is not acceptable.

Acute bilateral retinal artery occlusion causing sudden blindness in 25-year-old patient.

A 25-year-old male patient presented to the emergency department with the chief complaint of sudden blindness and was found to have suffered bilateral central retinal artery occlusion (CRAO). This process is most commonly the result of a thrombus or embolus that occludes the retinal artery, and normally presents in a single eye in patients older than 65 who are predisposed to vascular disease. Diagnosis relies most heavily upon funduscopic exam. Potential treatments involve ocular massage, acetazolamide, anterior chamber paracentesis and systemic or local fibrinolysis. Despite these interventions vision is often significantly and permanently impaired. This case underscores the importance of the emergency physician's ability to promptly perform and interpret the funduscopic exam in order to diagnose and evaluate CRAO.

Current treatment of central retinal artery occlusion: a national survey.

BACKGROUND: Central retinal artery occlusion (CRAO) is an ophthalmological emergency, the retinal analog of a stroke. To date there is no consensus or national guidelines on how this disorder should be managed. As academic neurologists and ophthalmologists treat CRAO frequently, we set out to understand how these clinicians approach patients with CRAO with a national survey. METHODS: We identified university-associated teaching hospitals offering vascular neurology, neuro-ophthalmology and/or retina fellowships in the US and asked the directors of the programs to respond to questions in an open response format to profile the acute management of CRAO at their institution. RESULTS: We found remarkable heterogeneity in the approach to acute treatment of patients with CRAO among the 45 institutions that responded to the survey. Only 20% had a formal policy, guideline or white paper to standardize the approach to treatment. The primary treating physician was an ophthalmologist, neurologist, or neuro-ophthalmologist 44, 27, and 4% of the time, respectively; 24% were co-managed acutely by neurology and ophthalmology. Intravenous fibrinolysis was offered to selected patients in 53% of institutions, and was the preferred initial treatment in 36%. When the acute treatment team involved a vascular neurologist, fibrinolysis was more likely to be considered a first-line treatment (p < 0.05). Anterior chamber paracentesis, ocular massage and hyperbaric oxygen therapy were offered 42, 66 and 7% of the time, respectively, while 9% of institutions offered no treatment. Anterior chamber paracentesis was more likely to be offered at programs where neurologists were not involved in treating CRAOs (p < 0.001). At 35% of institutions, patients with acute CRAO were not routinely referred to a general emergency room for initial evaluation and treatment. Carotid imaging was routinely obtained by 89% of programs, magnetic resonance imaging of the brain by 69%, echocardiogram by 62%, laboratory screening for an inflammatory state by 27% and retinal angiography by 30%. The thoroughness of vascular risk factors' screening was greater in programs that routinely referred acute CRAO cases to the emergency department. CONCLUSIONS: This survey shows that there is significant variability in treatment practices for acute CRAO in the US. Because of the high cerebrovascular and cardiovascular risk reported in this population of patients, it is notable that the approach to risk factor screening is also highly variable and many programs do not routinely refer patients to an emergency department for urgent evaluation. Finally, there appears to be equipoise among treatment teams regarding the efficacy of systemic fibrinolysis, as 53% of programs report a willingness to treat at least some patients with this modality.

The efficacy of hyperbaric oxygen therapy in the treatment of central retinal artery occlusion.

Central retinal artery occlusion (CRAO) is an ophthalmological emergency. Various treatment modalities have been tried, but none have shown to alter natural history of the disease. Hyperoxia can restore retinal oxygenation, and favourable results were obtained with hyperbaric oxygen therapy (HBOT). We report two patients with sudden visual loss due to CRAO treated with HBOT. Case 1: a 61-year-old female, presented with CRAO in her left eye(OS). She was submitted to eight sessions of HBOT(2.4atmosphere absolute (ATA)). BCVA(Best corrected visual acuity) improved from counting fingers (CF) to 1.0 and fluorescein angiography (FA) showed a normalisation. Vascular study showed a value of 8.8% for HbA1c and ventricular extrasystoles. Case 2: a 69-year-old male presented with CRAO in his OS. Nine sessions of HBOT(2.4 ATA) were performed. Best corrected visual acuity (BCVA)improved from CF to 0.8 and the FA was normalised. Vascular study revealed an atheromatous carotid disease, and cardiac pathology. HBOT seems to be beneficial on the recovery of vision following CRAO.

Transient central retinal artery occlusion and contralateral amaurosis after retrobulbar anesthetic injection.

A transient, ipsilateral central retinal artery occlusion and contralateral amaurosis developed following retrobulbar injection of 2% lidocaine and 0.75% bupivacaine. A computerized tomography scan obtained 1 1/2 hours following the injection demonstrated an air bubble within the ipsilateral optic nerve sheath. This case further supports the view that intranerve sheath injection can cause these two complications associated with retrobulbar anesthesia.