• Users Online: 331
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 155-158

Combined branch retinal vein and branch retinal artery occlusion in atrial septal defect


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 Submission22-Mar-2021
Date of Acceptance27-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Prof. Xiaoqing Zhou
The Subject of Diagnostics of Traditional Chinese Medicine in Hunan University of Chinese Medicine, Changsha, Hunan 410208
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_476_21

Rights and Permissions
  Abstract 


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 28];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.[1] Patients with ASD or patent foramen ovale have been found to be at increased risk of paradoxical thromboembolism.[2],[3] 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 Top


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)

Click here to view


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)

Click here to view
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

Click here to view
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

Click here to view



  Discussion Top


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.[4] ASDs are classified into four types: ostium secundum, ostium primum, sinus venosus, and unroofed coronary sinus.[5] Sequelae and complications include exercise intolerance, pulmonary vascular disease, right ventricular (RV) dysfunction, paradoxical thromboemboli, and atrial arrhythmias.[4] 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.[6] 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.[7] 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.[7] 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.[8],[9]

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.[10] 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.[7] 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 Top


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.



 
  References Top

1.
Bredy C, Mongeon F-P, Leduc L, Dore A, Khairy P. Pregnancy in adults with repaired/unrepaired atrial septal defect. J Thorac Dis 2018;10(Suppl 24):S2945-52.  Back to cited text no. 1
    
2.
Overell JR, Bone I, Lees KR. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: A meta-analysis of case control studies. Neurology 2000;55:1172-9.  Back to cited text no. 2
    
3.
Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptogenic Stroke Study (PICSS) Investigators. Effect of medical treatment in stroke patients with patent foramen ovale: Patent foramen ovale in cryptogenic stroke study. Circulation 2002;105:2625-31.  Back to cited text no. 3
    
4.
van der Bom T, Bouma BJ, Meijboom FJ, Zwinderman AH, Mulder BJM. The prevalence of adult congenital heart disease, results from a systematic review and evidence based calculation. Am Heart J 2012;164:568-75.  Back to cited text no. 4
    
5.
Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: A report of the American college of cardiology/American heart association task force on practice guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 2008;118:e714-833.  Back to cited text no. 5
    
6.
Lyons LJ, Yarrabolu T, Kuffel RR Jr, Bishop JE. Juvenile central retinal artery occlusion associated with atrial septal defect. J Pediatr Ophthalmol Strabismus 2019;56:e73-5.  Back to cited text no. 6
    
7.
Sengupta S, Pan U. Combined branch retinal vein and branch retinal artery occlusion - Clinical features, systemic associations, and outcomes. Indian J Ophthalmol 2017;65:238-41.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Gautier JC. Amaurosis fugax. N Engl J Med 1993;329:426-8.  Back to cited text no. 8
    
9.
Ehrlich R, Mutzmacher L, Averbuch L, Dotan G, Hirsh R. Do complaints of amaurosis fugax and blurred vision after transcatheter device closure of atrial septal defect indicate microemboli to retinal vessels? J Interv Cardiol 2005;18:21-5.  Back to cited text no. 9
    
10.
Wang H, Chang Y, Zhang F, Yang R, Yan S, Dong J, et al. Clinical features of combined central retinal artery and vein occlusion. J Ophthalmol 2019;2019:7202731.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed142    
    Printed0    
    Emailed0    
    PDF Downloaded10    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]