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  Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 26  |  Issue : 4  |  Page : 240-242  

Cilioretinal artery branch avulsion secondary to surgical embolectomy: Management and outcome


1 Retina Department and Ophthalmology Service, Clinica David; Department of Ophthalmology, School of Medicine, Michoacan University, Morelia, Michoacan, Mexico
2 Department of Subspecialties, Retina Service, Association to Prevent Blindness in Mexico; Department of Ophthalmology, School of Medicine, Tecnologico de Monterrey, Mexico City, Mexico
3 Department of Subspecialties, Retina Service, Association to Prevent Blindness in Mexico, Mexico City, Mexico

Date of Submission07-Feb-2018
Date of Acceptance24-Sep-2019
Date of Web Publication29-Jan-2020

Correspondence Address:
Dr. Sergio E Hernandez-Da Mota
Department of Retina, Clinica David, Ophthalmology Service, Blvd., Garcia de Leon 598-2, Colonia Nueva Chapultepec, CP 58280, Morelia, Michoacan
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.MEAJO_36_18

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   Abstract 


We report the trans-operative approach and short-term outcome of a patient who suffered a traumatic avulsion of the cilioretinal artery branch during the surgical management of a cilioretinal arterial branch occlusion (CRABO) with intraocular embolectomy. A patient with acute CRABO underwent a pars plana vitrectomy with in situ embolectomy. The blocked artery was incised using 25 gauge vertical scissors, and embolus manipulation was done using microsurgical forceps. During embolus extraction, the occluded cilioretinal artery and its branch were inadvertently avulsed and torn with subsequent intense bleeding. Laser and endodiathermy were used for acute hemostasis. The maneuvers created an unintended retinochoroidal anastomosis. Visual field improvement was noted 3 months after the surgery. In the event of a complicated surgical embolectomy with the avulsion of the artery, the formation of a retinochoroidal anastomosis and reperfusion of the occluded may occur along with the improvement of visual fields in some cases.

Keywords: Cilioretinal arterial branch occlusion, embolectomy, retinochoroidal anastomosis, surgical complications, vitrectomy


How to cite this article:
Hernandez-Da Mota SE, Garcia-Aguirre G, Velez-Montoya R. Cilioretinal artery branch avulsion secondary to surgical embolectomy: Management and outcome. Middle East Afr J Ophthalmol 2019;26:240-2

How to cite this URL:
Hernandez-Da Mota SE, Garcia-Aguirre G, Velez-Montoya R. Cilioretinal artery branch avulsion secondary to surgical embolectomy: Management and outcome. Middle East Afr J Ophthalmol [serial online] 2019 [cited 2020 Jul 3];26:240-2. Available from: http://www.meajo.org/text.asp?2019/26/4/240/277266




   Introduction Top


Cliioretinal arterial branch occlusion (CRABO) is an uncommon clinical entity that accounts for <10% of all arterial occlusions.[1]

Surgical embolectomy is proposed as a feasible alternative to medical therapy for CRABO due to the lack of an adequate medical treatment.[2],[3],[4],[5] The purpose of this case report is to describe the trans-operative management and short-term outcome of a complicated case of surgical embolectomy in a patient with acute cilioretinal artery occlusion.


   Case Report Top


A65-year-old male patient has been presented for consultation referring a sudden decrease of vision of about 7 days in his left eye. Best-corrected visual acuity was 20/20 in his right eye and 5/400 in his left eye. A Hollenhorst plaque was detected at fundus examination of the affected eye, obstructing the arterial flow of a branch of the cilioretinal artery with superior foveal involvement. Preoperative fluorescein angiography findings, as well as a central and temporal scotoma involving fixation in the 30-2 visual fields, are shown in [Figure 1].
Figure 1: Preoperative clinical image of the Hollenhorst plaque (white dotted circle) (a) obstructing the flow of a superior subsidiary branch of the cilioretinal artery of the left eye (b). Visual field shows a central and temporal scotoma (c)

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After discussing several therapeutic alternatives, and obtaining an informed consent the patient opted for a surgical embolectomy. A three-port 23-Ga pars plana vitrectomy was performed with separation of the posterior hyaloid. Brilliant blue G was then injected to stain the internal limiting membrane (ILM) which was peeled off from the area surrounding the occlusion site. Once all vitreous and ILM were removed from the embolus site, 25-gauge vertical scissors were used to perform a longitudinal incision in the artery at the occlusion site. During this part of the procedure, the infusion pressure was temporarily elevated to approximately 60 mmHg to minimize the risk of bleeding. Intraocular 25 Ga end-gripping forceps were then used to grasp and remove the exposed embolus. When removing the second and most proximal portion of the embolus, the cilioretinal artery and its occluded branch became ruptured. There was accompanying massive bleeding. Surgical maneuvers were then performed to try to control the bleeding including injection of perfluorocarbon fluids. Endodiathermy and laser therapy were then applied directly and adjacent to the artery. SF6 at a 10% concentration gas was used as an internal tamponade.

Three months after surgery, visual field testing showed that although the central scotoma enlarged nasally, best-corrected visual acuity was 20/400, and the temporal scotoma improved. Fluorescein angiography showed a reestablished flow of the occluded artery. This restored flow was not apparently continuous with the flow of the cilioretinal artery [Figure 2] which led us to believe that a retinochoroidal anastomosis had formed. Enface optical coherence tomography imaging at the level of the choroidal Haller's and Sattler's layer also showed the confluence of the previously obstructed site with choroidal vessel network. This image might indicate also the presence of the retinochoroidal anastomosis [Figure 3].
Figure 2: Postoperative images 3 months after complicated embolectomy of the left eye. A chorioretinal scar is seen at the obstruction site (a). Fluorescein angiography shows a reestablished arterial flow of the formally obstructed arterial branch that seems to come not from the cilioretinal artery but directly from the choroidal circulation (white arrow) (b). Temporal scotoma improved in the postoperative visual field testing (c)

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Figure 3: En face image at the obstruction site. The formerly obstructed subsidiary branch of the cilioretinal artery (white dotted line) seems to converge with a choroidal vessel (red line) of the Haller's and Sattler's layer (white arrows), suggesting the formation of a retinochoroidal anastomosis

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The surgical technique is provided in video format [Video, Supplemental Content 1].


   Discussion Top


We describe a complicated case of surgical embolectomy in a patient with CRABO.

This is a controversial surgical technique that may be of limited benefit in cases of retinal artery occlusions. Given the acute ischemic insult of artery occlusions, prompt reperfusion is thought to be crucial to maximize visual benefit.[1],[2],[3],[4],[5],[6] Although mostly safe, noninvasive treatment options have been found to be somewhat inefficacious.[1] More invasive options, which include intra-arterial tissue plasminogen activator, offer no substantial benefit with some adverse events.[1] Transluminal Nd: YAG laser therapy has been used to photodisrupt obstructive emboli with promising visual outcomes, but significant vitreous hemorrhage and collateral tissue damage are some reported complications.[6]

Peyman successfully performed the first surgical embolectomy in 1990.[2] Since then, a total of 13 case reports of surgical embolectomy have been published, with reperfusion of the occluded artery and visual acuity improvement achieved in most of them.[2],[3],[4],[5]

Our patient referred 7 days of decreased vision, and there was a rupture of the obstructed vessels during the surgical procedure. Nonetheless, the artery flow was reestablished, and visual field testing suggested that the temporal scotoma improved.

Based on experimental models of central retinal artery occlusion (CRAO) in rhesus monkeys, the retina suffers no damage up to 97 min after an acute CRAO, but after 4 h, the retina suffers massive and irreversible damage. Therefore, no treatment instituted after 4 h from the onset of the arterial occlusion can logically restore any vision in the setting of complete obstruction. In addition, this model showed that the more protracted the ischemia, the longer the time to recovery.

Humans rarely have a complete obstruction, unlike the animal model, and although treatment for CRAO has been recommended within 24 h of symptom onset, there might be some cases where this therapeutic window could be longer.[1]

Another point worth mentioning is the fact that very profuse bleeding was present after the rupture of the arterial vessels when trying to remove part of the embolus. An iatrogenic retinal tear formed adjacent to the obstruction site. One of the maneuvers performed to control the bleeding was the application of laser therapy. Thermal laser injury to the retinal tissue might have contributed to the nasal enlargement of the central scotoma seen 3 months postoperatively. Laser therapy also probably induced the formation of a retinochoroidal anastomosis which led to the reperfusion of the occluded artery and improvement of the temporal scotoma.

One of the most commonly reported complications of embolectomy is vitreous hemorrhage that occurs in almost 30% of patients who undergo this surgical technique.[2],[3],[4],[5] García-Arumí et al.,[3] reported that reperfusion was not achieved in one of the patients of their series.

Several authors have reported that treatment with a laser might induce the formation of retinochoroidal anastomosis in vein occlusions with an improvement of the perfusion status of the retina.[7] It is debatable if the absence of laser treatment would have had a better campimetric outcome in our patient. Reanastomosis of the ruptured arterial vessels at the occlusion site might have taken longer to be formed, and ischemic damage of the retina would have been more significant.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Patel PS, Sadda SR. Retinal artery occlusions. In: Wilkinson CP, Hinton DR, Sadda SR, Wiedemann P, editors. Ryanxs Retina. Philadelphia, PA: ElSevier; 2018. p. 1136-50.  Back to cited text no. 1
    
2.
Peyman GA, Gremillion CM Jr. Surgical removal of a branch retinal artery embolus: A case report. Int Ophthalmol 1990;14:295-8.  Back to cited text no. 2
    
3.
García-Arumí J, Martinez-Castillo V, Boixadera A, Fonollosa A, Corcostegui B. Surgical embolus removal in retinal artery occlusion. Br J Ophthalmol 2006;90:1252-5.  Back to cited text no. 3
    
4.
Ramchandran RS, Fekrat S. Embolectomy for branch retinal arterial occlusion. Retin Cases Brief Rep 2010;4:116-9.  Back to cited text no. 4
    
5.
Almeida DR, Mammo Z, Chin EK, Mahajan VB. Surgical embolectomy for fovea-threatening acute retinal artery occlusion. Retin Cases Brief Rep 2016;10:331-3.  Back to cited text no. 5
    
6.
Hsu TK, Chen SJ, Lei J, Wu Z, Lin CC, Chen MM, et al. Embolus-induced branch retinal artery occlusion with a presenting best-corrected visual acuity of 6/12 and visual field defect: Yag embolectomy safely restores arteriolar perfusion and/or visual function. Retin Cases Brief Rep 2013;7:210-6.  Back to cited text no. 6
    
7.
Browning DJ. Fundus photographic, fluorescein angiographic, and indocyanine green angiographic signs in successful laser chorioretinal venous anastomosis for central retinal vein occlusion. Ophthalmology 1999;106:2261-8.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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