|Year : 2022 | Volume
| Issue : 1 | Page : 155-158
Combined branch retinal vein and branch retinal artery occlusion in atrial septal defect
Zhiqin Zuo1, Zhihua Shen2, Xiaoqing Zhou1
1 The Subject of Diagnostics of Traditional Chinese Medicine in Hunan University of Chinese Medicine, Changsha, Hunan, China
2 Ophthalmology of Traditional Chinese Medicine in Hunan University of Chinese Medicine, Changsha, Hunan, China
|Date of Submission||22-Mar-2021|
|Date of Acceptance||27-Aug-2021|
|Date of Web Publication||07-Jan-2022|
Prof. Xiaoqing Zhou
The Subject of Diagnostics of Traditional Chinese Medicine in Hunan University of Chinese Medicine, Changsha, Hunan 410208
Source of Support: None, Conflict of Interest: None
A 30-year-old male patient presented with branch retinal artery occlusion and branch retinal vein occlusion in his right eye. The patient had a history of atrial septal defect (ASD). A cardiology consultation was sought, and the patient was admitted for closure of moderate-grade ASD. Subsequently, his retinal hemorrhage showed improvement. Patients with branch retinal artery occlusion and branch retinal vein occlusion affecting the same retinal quadrant should be examined for heart issues to rule out an atrial septal defect.
Keywords: Atrial septal defect, branch retinal artery occlusion, branch retinal vein occlusion, combined
|How to cite this article:|
Zuo Z, Shen Z, Zhou X. Combined branch retinal vein and branch retinal artery occlusion in atrial septal defect. Indian J Ophthalmol Case Rep 2022;2:155-8
|How to cite this URL:|
Zuo Z, Shen Z, Zhou X. Combined branch retinal vein and branch retinal artery occlusion in atrial septal defect. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 19];2:155-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/155/334952
Atrial septal defect (ASD) is the most common type of congenital heart disease and one of the most commonly recognized congenital cardiac anomalies in the adult population. Patients with ASD or patent foramen ovale have been found to be at increased risk of paradoxical thromboembolism., There are many clinical reports of ASD complicated with cerebral infarction that are thought to be related to cerebral infarction. Retinal microvessels and cerebral microvessels share anatomical characteristics, and ASD combined with retinal vascular obstruction is usually reported after retinal artery occlusion secondary surgery for ASD. We here report a case of combined branch retinal vein occlusion (BRVO) and branch retinal artery occlusion (BRAO) in an ASD patient.
| Case Report|| |
A 30-year-old man presented with a complaint of dark shadows on the nasal side and underneath his right eye and blurred vision over the last 2 days. The patient's visual acuity showed no obvious decrease. There were no flashing lights, deformed shapes, or pain associated with eye movement. The patient said he had experienced no bulging, headaches, nausea, vomiting, or ringing in the ears, and he experienced no little after resting. Two months ago, he had the same symptoms with dark shadows in his right eye; only after several hours would the dark shadow in his field of vision go away. The patient was diagnosed with amaurosis fugax and did not have any further examination.
Upon ocular examination, the patient had a best-corrected distance visual acuity (BCVA) of 20/20 in both eyes. A relative afferent pupillary defect was also noted. Intraocular pressure was at the upper limit of the normal range at 20 mm Hg bilaterally. Funduscopic examination showed optic nerve hyperemia and swelling of the optic nerve, diffused intraretinal hemorrhages around the optic nerve, and dilated and tortuous retinal veins in the right eye [Figure 1]a. The left eye was normal with no damage [Figure 1]b and [Figure 1]c.
|Figure 1: (a) Funduscopic examination showing the optic nerve hyperemia and swelling of the optic nerve, diffused intraretinal hemorrhages around the optic nerve, and dilated and tortuous retinal veins in the right eye. Normal left eye: Fundus color photography (b), Fluorescein angiography (c)|
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Fluorescein angiography showed retinal superior temporal branch artery sparing in early frames [Figure 2]a and obstruction of venous reflux in the later frames [Figure 2]b. The left eye was normal. A diagnosis of branch retinal vein occlusion and branch retinal artery occlusion of the right eye was made. Improved circulation therapy was ineffective. A cardiology consultation was sought. The patient was confirmed to have ASD by echocardiography [Figure 3]a and [Figure 3]b. The patient was admitted for closure of moderate-grade ASD [Figure 3]c. One month later, the patient showed improvement in retinal hemorrhage [Figure 4]a. The tortuosity of the retinal vein gradually improved [Figure 4]b and [Figure 4]c. The defect visual field was also restored [Figure 4]d.
|Figure 2: Fluorescein angiography showing retinal superior temporal branch artery sparing in early frames (a) and retinal venous reflux in the later frames in the right eye (b)|
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|Figure 3: (a) Four-chamber view: continuous interruption of the posterior lower margin of the interventricular septum (19 mm in width). (b) Artery short shaft section: defect color blood flow. (c) Four-chamber view: the occluder was in a good position, and no abnormal blood flow was observed in the atrial septum|
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|Figure 4: (a) After closure, the retinal bleeding was absorbed and the vascular tortuosity improved in the right eye. (b) Fluorescein angiography showing that the filling time of retinal vessels was normal in the right eye. (c) Fluorescein angiography showing that venous return was not delayed in the right eye. (d) There is no obvious visual field defect in the right eye|
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| Discussion|| |
The overall prevalence of ASD has been estimated to be 8.5 per 10,000 adults, which is likely an underestimate considering that some patients remain clinically asymptomatic and have a normal life expectancy. ASDs are classified into four types: ostium secundum, ostium primum, sinus venosus, and unroofed coronary sinus. Sequelae and complications include exercise intolerance, pulmonary vascular disease, right ventricular (RV) dysfunction, paradoxical thromboemboli, and atrial arrhythmias. Paradoxical thromboemboli often cause stroke and cerebral infarction. Retinal microvessels and brain microvessels have similar physiological and pathological characteristics. However, there are few reports about the relationship between atrial septal defect and retinal vascular occlusion. Lyons et al. confirmed that atrial septal defect complicates central retinal artery occlusion.
Retinal vein occlusion with retinal artery occlusion has been reported previously. Among them, central retinal vein combined with central retinal artery occlusion is more common, and combined BRAO and BRVO is exceedingly rare. These patients also had systemic diseases, such as diabetes, dyslipidemia, systemic lupus, and hyperhomocysteinemia. Such patients can have a good visual outcome if recognized early and treated appropriately. Clinically, cerebral infarction with ASD has been reported, but there are few reported cases with retinal vascular occlusion. Most cases of retinal vascular occlusion with ASD are secondary to retinal artery occlusion after ASD closure. After closure, despite regular treatment with aspirin, some patients report acute loss of vision in one eye, called amaurosis fugax, or bilateral blurred vision. Amaurosis fugax can be caused by any of several etiologies, among which are the embolic event in the retinal blood vessels and vasospastic events.,
In this case, the retinal hemorrhage occurred mainly in the optic disc and the retinal vein tortuosity was severe. This finding is consistent with the results of a previous study. After ASD closure, this patient's retinal hemorrhage was gradually absorbed and the retinal vascular tortuousness gradually improved, which also supported the conclusion that branch retinal vein occlusion and branch retinal artery occlusion can have a good prognosis if the primary disease is detected and treated early. It is vital to make systematic observation and follow up, although this patient had no other symptoms, except for retinal vascular occlusion. Thus, we conclude that ASD is the one of the risk factors for retinal vascular occlusion.
| Conclusion|| |
Combined BRAO and BRVO is exceedingly rare and is associated with significant systemic comorbidity. A thorough systemic evaluation and close monitoring for cardiovascular events are critical to all cases of combined occlusion. Combined BRAO and BRVO in ASD can have a good visual outcome if recognized early and treated appropriately.
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
National Natural Science Foundation of China (81804148, 81503619).
Conflicts of interest
There are no conflicts of interest.
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