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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 921-922

Ophthalmic manifestations and outcome in Takayasu arteritis: An interventional case report


Department of Ophthalmology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission02-Apr-2022
Date of Acceptance11-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Shalini Singh
110, New Colony, Krishna Bihari Nagar, Fatehpur, Uttar Pradesh - 212 601
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_850_22

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  Abstract 


A patient with Takayasu arteritis (TA) with marked ischemia of the retina and choroid underwent successful treatment with stent implantation. The left common carotid artery was markedly narrowed. However, the left subclavian artery showed narrowing at its ostium and proximal segment with narrowing at the origin of the left vertebral artery. The patient underwent left subclavian balloon angioplasty with left vertebral artery stenting. This led to drastic resolution of micro-aneurysms and improvement of vision. Stenting for hypo-perfusion of ophthalmic circulation in cases of TA has rarely been reported, and to our knowledge, this is the rare case report of improved clinical and visual outcome following stent placement.

Keywords: Intervention, ophthalmic manifestation, Takayasu arteritis


How to cite this article:
Singh S, Goyal JL. Ophthalmic manifestations and outcome in Takayasu arteritis: An interventional case report. Indian J Ophthalmol Case Rep 2022;2:921-2

How to cite this URL:
Singh S, Goyal JL. Ophthalmic manifestations and outcome in Takayasu arteritis: An interventional case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:921-2. Available from: https://www.ijoreports.in/text.asp?2022/2/4/921/358191



Takayasu arteritis (TA) is an idiopathic, chronic granulomatous vasculitis predominantly affecting the aorta and its major branches. This large-vessel vasculitis largely affects young women, presenting initially with non-specific symptoms such as fever, malaise, headache, and arthralgias.[1] This initial phase of active inflammation is progressively replaced with the fibrotic phase which involves myofibroblast proliferation and arterial re-modeling resulting in characteristic symptoms of arterial occlusion, vascular pain, and aneurysm formation in the later stages of the disease.[1],[2] Visual symptoms may result from occlusion or stenosis of the carotid, vertebral, or ophthalmic arteries.[3],[4] Cerebral hypo-perfusion because of involvement of the major arch branches may lead to transient ischaemic attacks, seizures, or syncope.[5],[6]

The mainstay of medical treatment involves immunosuppression (high-dose corticosteroids and newer immunosuppressive agents). Medical management is however not much effective in the later fibrotic stages of the disease. Surgical intervention in the form of bypass grafting or percutaneous angioplasty with stenting plays a role in the re-vascularization of the obliterated and stenotic vessels.[7] Till date, improvement of vision in TA following endovascular re-vascularization has been very infrequently reported in the literature. We report a case of TA with retino-choroidal and optic nerve hypo-perfusion which improved following stenting of the subclavian artery.


  Case Report Top


A 15-year-old female patient of TA was referred to our neuro-ophthalmology clinic with complaints of diminution of vision in both eyes for 2–3 months.

On examination, there was no light perception in the right eye, and the left eye had a visual acuity of finger counting at 3 meters. There was ciliary congestion, iris, and angle neo-vascularization with complete opacification of the lens in the right eye, whereas the left eye had normal anterior segment findings. There was no reaction to light and near in the right eye, whereas the pupillary reaction in the left eye was sluggish.

Posterior segment findings in the right eye were not visible because of the opacification of the lens. The B scan of the right eye was normal. There was mild disc pallor in the left eye along with dot and blot hemorrhages and multiple micro-aneurysms over the mid-peripheral retina [Figure 1]. Dilatation and tortuosity of blood vessels, arteriovenous anastomosis, and venous beading were also noted. The macula, however, was normal. The intra-ocular pressures recorded were 7 mm and 11 mm of Hg in the right and left eyes, respectively. Fluorescein angiography was performed. There was an increase in arm-retina time (24 seconds) with marked ischemia of the retina and choroid at the posterior pole and the mid-peripheral and peripheral retina in the left eye. Hyper-fluorescent spots of micro-aneurysms, staining of blood vessels along with extensive capillary drop-out areas, and arteriovenous anastomosis were also noted.
Figure 1: Pre-interventional fundus photograph with multiple dot blot hemorrhages and micro-aneurysms, dilated vessels, and soft exudate in the superonasal part of the disc. Fluorescein angiography suggestive of marked ischemia of the retina and choroid in the left eye

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Computed tomography (CT) angiography demonstrated circumferential wall thickening with luminal narrowing in all major branches of the arch of the aorta starting from their origin.

Digital subtraction angiography (DSA) showed a diffuse high-grade narrowing of the brachiocephalic trunk, proximal right common carotid artery, and right subclavian artery along with the proximal part of the right vertebral artery. The left common carotid artery was markedly narrowed. The left subclavian artery showed narrowing at its ostium and proximal segment with narrowing at the origin of the left vertebral artery. Bilateral posterior cerebral arteries were normal with prominent bilateral posterior communicating arteries.

Hence, on the basis of clinical examination and investigations, ocular ischemic syndrome in the right eye was determined and type 2 TA retinopathy in the left eye was made.

The patient underwent left subclavian balloon angioplasty with left vertebral artery stenting [Figure 2]. Post-procedural color Doppler scan showed a patent left vertebral artery with the in-stent flow and distal flow.
Figure 2: Left subclavian balloon angioplasty with left vertebral artery stenting

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On a follow-up visit, the patient showed improvement in vision in the left eye to 6/18. The fundus examination showed the disappearance of the micro-aneurysms and dilation of blood vessels [Figure 3]. Repeat fluorescein angiography showed good perfusion of the choroid and retina.
Figure 3: Post-interventional fundus examination showing disappearance of the micro-aneurysms and dilation of blood vessels. Fluorescein angiography showing good perfusion of the choroid and retina

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  Discussion Top


Endovascular procedures for re-vascularization are a safer and lesser invasive surgical alternative compared to bypass grafting in the amelioration of symptoms in the occlusive stage of TA.[7] A recent case series reported three cases, who underwent endovascular re-vascularization procedures resulting in visual improvement.[7] They also highlighted the need for earlier detection of the disease, that is, before developing complete vascular occlusion for better effectivity. Dogra et al.[8] in their retrospective study of five patients also highlighted the effectiveness of percutaneous endovascular stenting in the reversal of retinopathy associated with TA and also re-iterated the need for early initiation of endovascular re-vascularization for better visual outcomes. An earlier report of a 37-year-old female of TA with retinopathy and diminution of vision also documented an improvement in symptoms after percutaneous angioplasty and stenting.[9],[10],[11]

In our case, angioplasty with stenting of the subclavian and vertebral artery probably improved the blood flow in the internal carotid artery through the circle of Willis, which resulted in the re-perfusion of the retina and choroid as seen on fluorescein angiography leading to improvement of vision.


  Conclusion Top


Although the effectiveness of endovascular procedures in amelioration of visual symptoms in TA has not been documented adequately in the literature, our report re-establishes its role in the management of ophthalmic manifestations of TA.

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.
Pallangyo P, Epafra E, Nicholaus P, Lyimo F, Kazahura P, Janabi M. Bilateral ocular ischemia-induced blindness as a presenting manifestation of Takayasu arteritis: A case report. J Med Case Rep 2017;11:153.  Back to cited text no. 1
    
2.
Mason JC. Surgical intervention and its role in Takayasu arteritis. Best Pract Res Clin Rheumatol 2018;32:112-4.  Back to cited text no. 2
    
3.
Peter J, David S, Danda D, Peter JV, Horo S, Joseph G. Ocular manifestations of Takayasu arteritis: A cross-sectional study. Retina 2011;31:1170-8.  Back to cited text no. 3
    
4.
Biousse V, Newman N. Retinal and optic nerve ischemia. Continuum (Minneap Minn) 2014;20:838-56.  Back to cited text no. 4
    
5.
Duarte MM, Geraldes R, Sosua R, Alarcao J, Costa J. Stroke and transient ischemic attack in Takayasu's arteritis: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2015;25:781-91.  Back to cited text no. 5
    
6.
Bond KM, Nasr D, Lehman V, Lanzino G, Cloft HJ, Brinjikji W. Intracranial and extracranial neurovascular manifestations of Takayasu arteritis. AJNR Am J Neuroradiol 2017;38:766-72.  Back to cited text no. 6
    
7.
Tyagi S, Sarkar PG, Gupta MD, Mp G, Bansal A. Restoration of vision by endovascular revascularization in Takayasu arteritis: A case series. J Cardiol Cases 2018;18:123-7.  Back to cited text no. 7
    
8.
Dogra M, Kumar A, Bajpai P, Gupta V, Bansal R, Dogra MR, et al. Outcome of endovascular procedures on ocular findings in Takayasu arteritis. Retina 2019;39:1142-8.  Back to cited text no. 8
    
9.
Peter J, Joseph G, David S, Danda D. Regression of Takayasu retinopathy after revascularization of occluded branches of the aortic arch by percutaneous angioplasty. Retin Cases Brief Rep 2013;7:262-6.  Back to cited text no. 9
    
10.
Goldman DR, Prasad PS, Schwartz SD. Dramatic resolution of extreme ocular ischemia in a case of Takayasu's arteritis. Ophthalmic Surg Lasers Imaging Retina 2013;44:198-200.  Back to cited text no. 10
    
11.
Zeng Y, Duan J, Ge G, Zhang M. Therapeutic management of ocular ischemia in takayasu's arteritis: A case-based systematic review. Front Immunol 2022;12:791278.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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