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PHOTO ESSAY
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 209-210

Retinal ischemia in carotid artery stenosis


Shroff Eye Centre, New Delhi, India

Date of Submission15-Jun-2022
Date of Acceptance07-Oct-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Sandeep Kumar
Shroff Eye Centre, A-9, Kailash Colony, New Delhi - 110 048
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1445_22

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  Abstract 


Keywords: Carotid artery stenosis, neovascular glaucoma, retinal ischemia


How to cite this article:
Shroff D, Kumar S, Gupta C, Astir S. Retinal ischemia in carotid artery stenosis. Indian J Ophthalmol Case Rep 2023;3:209-10

How to cite this URL:
Shroff D, Kumar S, Gupta C, Astir S. Retinal ischemia in carotid artery stenosis. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:209-10. Available from: https://www.ijoreports.in/text.asp?2023/3/1/209/368144



Retinal vasculature is the only vessel system visible directly in a living subject. Being connected directly to cerebral blood vasculature, it sometimes can predict the pathological cerebral ischemic events. Unilateral retinal ischemia warrants a detailed systemic workup to rule out the factors that would in turn lead to cerebrovascular accidents. Our patient had severe unilateral retinal ischemia, which on detailed workup revealed significant stenosis of the carotid artery. The case highlights the presentation and early detection of carotid artery stenosis by a multidisciplinary approach to retinal ischemia.

A 65-year-old hypertensive and type 2 diabetic male with chronic kidney disease presented in our clinic with painful loss of vision in his left eye for 3 weeks. There was a history of a transient ischemic attack 3 months back. On presentation, best corrected visual acuity (BCVA) was 6/6 N6 and counting finger 1 m in OD and OS, respectively. Intraocular pressure was 16 and 48 mmHg. Slit-lamp examination of OS showed episcleral congestion, hazy cornea due to edema, neovascularization of iris, and lenticular opacity with nuclear sclerosis grade 3. On fundus examination, OS showed scattered dot blot hemorrhage in mid periphery with optic disk cupping of 0.9 along with pallor. A fundus fluorescein angiography was avoided as the serum creatinine level was 3.56 (0.7–1.3 mg/dl). A 12 × 12 mm swept-source optical coherence angiography (SS-OCTA) using Plex Elite 9000 (Carl Zeiss Meditec Inc) revealed significant areas of capillary nonperfusion along with the formation of collateral (1B) at the macula. No macular edema or neovascularization was noted. In view of unilateral and asymmetric presentation, a carotid Doppler was advised, which revealed a mixed density plaque in the left carotid bulb with approximately 80% stenosis and peak systolic velocity 235 cm/s, while the corresponding right side was having 20% narrowing. The patient was started on anti-glaucoma medications. Anti-vascular endothelial growth factor (Anti-VEGF) injection was delivered through intravitreal route, and the patient was urgently referred to a vascular surgeon for an endarterectomy procedure.


  Discussion Top


Impaired ocular arterial supply can lead to generalized ocular ischemia. Sometimes, neovascularization of iris may be the only sign associated with carotid artery stenosis.[1] Seen in males over 50 years, it is associated with a poor visual outcome even after medical and surgical interventions. It is linked to underlying arteriosclerosis and is bilateral in 15%–20% of cases. The OCTA image [Figure 1] shows a comparative view of retina in carotid artery stenosis [Figure 1]b with the normal [Figure 1]a fellow eye. OD with minimal carotid stenosis shows an orderly retinal microvasculature on 12 × 12 scan, whereas extensive loss of vessels can be appreciated as ischemic zones in OS. A high index of suspicion in unilateral ischemic retina with pain and low visual acuity is imperative as it can be the only presenting sign. Early diagnosis and intervention can avert mortality due to cerebrovascular accidents[1],[2] and prevent potential blindness.
Figure 1: Retinal ischemia in carotid artery stenosis on SS-OCTA. (a) Wide-field montage of the right eye of a 65-year-old male showing well-defined capillary network and clear delineation of the foveal avascular zone (green arrowhead). (b) Left eye showing extensive wipe out of retinal microvasculature and capillary nonperfusion (white cross) along with the formation of collateral (yellow arrow) at the macula. SS-OCTA: swept-source optical coherence angiography

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The case emphasizes the necessity of detecting significant carotid artery stenosis early, as it can lead to cerebrovascular accidents if left untreated. Our patient had eye symptoms, but we were able to rule out a life-threatening situation and prevent probable morbidity.

Author contribution and consent

We were all involved in the care or decisions about the care of the patient. We were all involved in writing the manuscript, and all of us approved the final manuscript. Written consent for publication was obtained from the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chen CS, Varma D, Lee A. Arterial occlusions to the eye: From retinal emboli to ocular ischemic syndrome. Asia Pac J Ophthalmol (Phila) 2020;9:349-57.  Back to cited text no. 1
    
2.
Wong CL, Ang M, Tan ACS. Clinical applications of optical coherence angiography imaging in ocular vascular diseases. Appl Sci 2019;9:2577.  Back to cited text no. 2
    


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