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Radial optic neurotomy in combined cilioretinal artery and central retinal vein occlusion
  1. S Mennel,
  2. K Droutsas,
  3. C H Meyer,
  4. J C Schmidt,
  5. P Kroll
  1. Department of Ophthalmology, Philipps-University Marburg, Germany
  1. Correspondence to: Stefan Mennel MD, Department of Ophthalmology, Philipps-University Marburg, Robert-Koch-Strasse 4, 35037 Marburg, Germany; stefan.mennellycos.com

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Combined cilioretinal artery and central retinal vein occlusion (CRVO) is a rare clinical finding, first described by Oosterhuis.1 The pathogenesis of this condition is not well established and remains controversial. Most reports postulate that the initial CRVO causes an elevation of the intraluminal capillary pressure and induces a consecutively reduced perfusion pressure at the arterial side. Since the perfusion pressure of the cilioretinal artery is lower than the central artery, it becomes relatively occluded.2–4 Recently Opremcak et al described radial optic neurotomy (RON) involving pars plana vitrectomy (PPV) and radial incision of the optic nerve to treat CRVO.5 We report this new surgical approach in a patient with combined cilioretinal artery occlusion and CRVO.

Case report

A healthy 64 year old woman complained of unilaterally blurred vision for the past 3 days. Her visual acuity (VA) was 20/200 in the right eye (RE) and 20/20 in the left eye (LE). The anterior segment in both eyes was unremarkable on slit lamp examination. Fundus examination RE demonstrated a whitening of the macula corresponding to an area supplied by an cilioretinal artery. The retinal veins were dilated, accompanied by adjacent retinal haemorrhages (fig 1A). The fundus of the left eye appeared normal. Fluorescein angiography (FA) RE revealed a delayed arteriovenous (AV) perfusion time of 13 seconds. Systemic evaluation of the patient did not reveal any general disease. Although treated systemically with corticosteroids6 and low dose heparin for 4 weeks, she developed CRVO with severe disc oedema, extensive dilatation of the retinal veins, radial orientated intraretinal haemorrhages, and cotton wool spots (fig 1B). On FA there was a reduced perfusion time of the cilioretinal artery in addition to the typical signs of CRVO (fig 2A). Based on positive results of RON in CRVO, we offered this treatment to our patient. After she signed an informed consent, RON was performed with two radial cuts at the nasal edge of the optic disc. After 2 days disc oedema was significantly reduced with sharp visible disc margins. Two months postoperatively the retinal haemorrhages, cotton wool spots, and disc oedema resolved and her VA improved to 20/25 RE (fig 1C). FA demonstrated a physiological AV perfusion time of less than 3 seconds and no signs of an occluded cilioretinal artery (fig 2B).

Figure 1

 Colour fundus photography of the right eye. (A) 3 days after decrease of VA. A whitening of the macula corresponding to an area supplied by the cilioretinal artery (white arrow) can be seen. The retinal veins appear dilated and sparse retinal haemorrhages are visible. (B) 1 day preoperatively. The cilioretinal artery appears with reduced diameter (white arrow), typical picture of CRVO with disc oedema without visible disc margin, extensive dilatation of the retinal veins, radial orientated intraretinal haemorrhages, and several cotton wool spots are present. (C)10 weeks postoperatively. The optic disc appear with sharp margin, the diameter of the retinal veins are similar to those of the left eye. Chorioretinal whitening at the 2 and 4 o’clock position at the disc margin indicate the location, direction, and length of the radial cuts by RON (white arrows). Remaining signs of the CRVO, including retinal haemorrhages or macular oedema have vanished. The cilioretinal artery appears with physiological diameter.

Figure 2

 Fluorescein angiography of the right eye. (A) Preoperative, arterial phase (14 seconds after dye injection). A delayed filling of the cilioretinal artery becomes apparent (white arrow). The macular area supplied by the cilioretinal artery appear hypofluorescent as a result of retinal thickening. (B) 10 weeks postoperatively, arterial phase (14 seconds after dye injection). The filling of the cilioretinal artery occurs at 13 seconds and appears similar to the central retinal artery. There are no signs of non-perfused areas or ischaemia.

Comment

Combined cilioretinal artery occlusion and CRVO are discussed as a separate clinical entity in the literature,1–4 and its treatment by RON has not been described. Opremcak et al postulated that a surgical decompression of the optic disc and scleral ring by RON may contribute to an improved venous perfusion in CRVO. Our patient demonstrated additional signs of an arterial occlusion with delayed filling of the cilioretinal artery in the macula, which may induce permanent functional loss. The underlying pathomechanism of CRVO remain unknown, current discussion leans towards an intraluminal occlusion by a thrombus, increased extravasal pressure, or a combination of both as possible causes.7 In addition the therapeutic effect of RON is also questionable. It remains unclear as to whether RON causes a decompression of the optic disc increasing the ocular blood flow or induces the formation of new chorioretinal shunt vessel.8 In our case the goal of RON was to reduce the capillary pressure, therefore increasing the perfusion in the cilioretinal artery and thus improving central vision. Patients with combined occlusive AV disease may benefit from RON by improving their haemodynamic perfusion pressure, retinal anatomy, and consecutive central visual function.

References

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Footnotes

  • Financial support: none.

  • Proprietary interest: none.

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