Journal of Neuro-Ophthalmology:
Hwang, Gyo Jun MD; Woo, Se Joon MD; Hwang, Jeong-Min MD, PhD; Jung, Cheolkyu MD; Park, Kyu Hyung MD, PhD; Kwon, O-Ki MD, PhD
Departments of Neurosurgery (GJH, O-KK); Ophthalmology (SJW, J-MH, KHP); and Radiology (C-KJ), Seoul National University College 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: firstname.lastname@example.org
A 65-year-old woman who had undergone internal 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 ischemia recurred, angiography revealed worsening stenosis 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 angioplasty in this setting.
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 experienced episodic ipsilateral visual loss despite antiplatelet therapy and who achieved improvement in ischemic manifestations following balloon angioplasty of the ophthalmic artery origin, an intervention not previously reported.
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 cervical 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 ophthalmic artery for bougination, and a fibrinolytic agent (300,000-unit urokinase) was injected into the ophthalmic 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 complained 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 multiple cotton wool patches (Fig. 3A). Fluorescein angiography (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 × 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).
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 following 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 visual function and retinal perfusion. We are unaware of a previous report showing its efficacy in this setting.
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