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Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 445-447

Central retinal artery occlusion secondary to patent foramen ovale: A case report

Department of Ophthalmology, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China

Date of Submission12-Apr-2022
Date of Acceptance28-Dec-2022
Date of Web Publication28-Apr-2023

Correspondence Address:
Zhongxia Cheng
Department of Ophthalmology, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu
People's Republic of China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_916_22

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A 50-year-old male presented to the emergency ophthalmological service with amaurosis fugax in his right eye. A patent foramen ovale (PFO) was confirmed using transthoracic echocardiography. The patient underwent a PFO closure surgery. Postoperative transesophageal echocardiography revealed no obvious residual shunts. There was no recurrence of amaurosis fugax in the right eye during the follow-up period of more than two years. A PFO with ophthalmic and visual sequelae is an important emerging association. Such cases benefit from early referral to a cardiology specialist. Prompt diagnosis and treatment will help avoid unnecessary ocular or nonocular embolic events.

Keywords: Central retinal artery occlusion, patent foramen ovale, transesophageal echocardiography

How to cite this article:
Xiu L, Cheng Z, Li H. Central retinal artery occlusion secondary to patent foramen ovale: A case report. Indian J Ophthalmol Case Rep 2023;3:445-7

How to cite this URL:
Xiu L, Cheng Z, Li H. Central retinal artery occlusion secondary to patent foramen ovale: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:445-7. Available from: https://www.ijoreports.in/text.asp?2023/3/2/445/375228

Central retinal artery occlusion (CRAO) is similar to an ischemic stroke, usually presenting with sudden, severe, and painless loss of vision,[1] whose main causes are heart disease and carotid atherosclerosis.[2] An impermanent embolic episode may cause reversible visual loss, also known as amaurosis fugax.[3] Patent foramen ovale (PFO), a type of congenital cardiac anomaly, may be the source of paradoxical embolic events, although the majority of patients follow an uneventful clinical course.[4] CRAO secondary to PFO is a paradoxical thromboembolic event, which is exceptionally unusual because the source of thrombus formation requires extensive investigation. Herein, we report a case of PFO-related CRAO.

  Case Report Top

A 50-year-old man with a history of hypertension and hyperlipidemia received emergency ophthalmic services for amaurosis fugax in his right eye. Upon immediate ocular examination, the best-corrected visual acuity was hand motion and 20/20 in the right and left eyes, respectively. The pupil of the right eye was moderately dilated and a relative afferent pupillary defect was detected. Fundus examination showed thin and straight retinal arteries with arteriovenous pressure traces [Figure 1]. A fluorescein filling delay was detected in the right eye through fundus fluorescein angiography. The background fluorescein was visible in the retina at angiography 10.4 s [Figure 2]a, arterial front-peak began to appear at angiography 14.2 s [Figure 2]b, the venous laminar flow was visible at angiography 48.9 s [Figure 2]c, and the retinal blood vessels were completely filled at angiography 1 min and 21.2 s [Figure 2]d. The patient was diagnosed with CRAO. Symptomatic treatments such as oxygen inhalation and intraocular pressure reduction were administered immediately.
Figure 1: The color fundus photo

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Figure 2: The results of fundus fluorescein angiography (FFA) (a) the background fluorescein at angiography 10.4 s; (b) the arterial front-peak at angiography 14.2 s; (c) the venous laminar flow at angiography 48.9 s; (d) the complete filling of retinal blood vessels at angiography 1 min and 21.2 s

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There was a significant improvement in visual acuity in the right eye after approximately 30 min. Ocular examinations were repeated. The best-corrected visual acuity was 20/25 in the right eye, and pupil size was normal. Relative afferent pupillary defects were negative. In the last two months, the patient's right eye had repeated episodes of amaurosis fugax, usually after bathing, urinating, and defecating. The duration of the onset of these symptoms gradually increased but resolved spontaneously, and the patient showed no obvious abnormalities when he came to the hospital. He denied other systemic symptoms, and his blood pressure and lipids were well controlled with enalapril maleate and atorvastatin.

The patient completed relevant examinations including neurology, cardiology, and hematology. Biochemical investigations and routine hematological were unremarkable, barring the slightly elevated total cholesterol and triglyceride levels up to 5.46 and 1.92 mmol/L, respectively. Coagulation parameters and inflammatory markers were within normal ranges. Further examinations for autoimmune and thrombophilic disorders yielded negative results. Digital subtraction angiography and cervical vascular color Doppler ultrasound were also negative.

Transesophageal echocardiography (TEE) also eliminated the possibility of an embolic event originating from a cardiac valvular defect. Surprisingly, right heart contrast echocardiography revealed right-to-left shunts at atrial levels I and II in the resting state and after the Valsalva maneuver, respectively [Figure 3]a. All of these suggested PFO because the Valsalva maneuver transiently increased the pressure in the right atrium, resulting in the entry of saline microbubbles into the left atrium through the foramen ovale. After the administration of oral rivaroxaban for anticoagulation and oral diltiazem, symptoms were not relieved, and repeated episodes of amaurosis fugax in the right eye still occurred. The patient subsequently underwent PFO closure surgery at the cardiology department. Postoperative TEE showed no obvious residual shunts [Figure 3]b. Moreover, there was no recurrence of amaurosis fugax in his right eye during the follow-up period of more than two years.
Figure 3: The TEE imaging (a) TEE imaging before surgery; (b) TEE imaging after surgery

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  Discussion Top

The foramen ovale is a physiological channel in the embryonic stage of the atrial septum that is usually closed during the first year after birth. However, as a common congenital atrial septal defect, PFO has an incidence of 20–34% in the adult population.[5] In general, PFO is benign and asymptomatic. Most patients with sporadic PFO and no other systemic problems do not require treatment. Medication or surgery may be required when related to other unexplained ophthalmic or neurological events. Occasionally, they cause systemic embolism that can lead to ischemic events, such as cryptogenic strokes, in the eyes and brain. Ocular diseases caused by PFO include retinal artery occlusion (RAO) and optic neuropathy.[6]

Although generally uncommon, PFO should be considered as a possible cause of RAO. To date, RAO associated with PFO is rare and only a handful of cases have been reported.[7],[8] Chatziralli et al.[9] reported a 35-year-old man with branch retinal artery occlusion (BRAO) and concomitant PFO, who was first diagnosed with BRAO. Recently, Sabanis et al.[10] described a CRAO in a 62-year-old male with PFO, who maintained the central vision and remained symptomless during follow-up after oral anticoagulant administration. In our case, the patient was found to have a PFO after a complete systemic examination. After surgical closure of the foramen ovale, symptoms of amaurosis fugax in the right eye disappeared. Furthermore, occlusion of the central retinal artery in the patient's right eye is believed to be caused by the PFO. A case of PFO causing repeated occlusion of the central retinal artery without treatment and recanalization within a short period of time has not been reported.

  Conclusion Top

Ophthalmologists should consider PFO in patients diagnosed with RAO. PFO is an important emerging condition associated with ophthalmic and visual sequelae. Such cases benefit from an early referral to a cardiology specialist. Prompt diagnosis and treatment will help avoid unnecessary ocular or nonocular embolic events in the future.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Schorr ME, Rossi KC, Stein LK, Park BL, Tuhrim S, Dhamoon MS. Characteristics and outcomes of retinal artery occlusion: Nationally representative data. Stroke 2020;51:800-7.  Back to cited text no. 1
Varma DD, Cugati S, Lee AW, Chen CS. A review of central retinal artery occlusion: Clinical presentation and management. Eye (Lond) 2013;27:688-97.  Back to cited text no. 2
Hayreh SS, Zimmerman MB. Amaurosis fugax in ocular vascular occlusive disorders: Prevalence and pathogeneses. Retina 2014;34:115-22.  Back to cited text no. 3
Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: An autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17-20.  Back to cited text no. 4
Calvert PA, Rana BS, Kydd AC and Shapiro LM. Patent foramen ovale: Anatomy, outcomes, and closure. Nat Rev Cardiol 2011;8:148-60.  Back to cited text no. 5
Clifford L, Sievers R, Salmon A and Newsom RS. Central retinal artery occlusion: Association with patent foramen ovale. Eye (Lond) 2006;20:736-8.  Back to cited text no. 6
Ballerini L, Cifarelli A, Ammirati A, Gimigliano F. Patent foramen ovale and cryptogenic stroke: A clinical review. J Cardiovasc Med 2007;8:34-8.  Back to cited text no. 7
Shoeibi N, Poorzand H, Abrishami M. Branch retinal artery occlusion in a patient with patent foramen ovale. J Ophthalmic Vis Res 2013;8:58-61.  Back to cited text no. 8
  [Full text]  
Chatziralli IP, Parikakis EA, Mitropoulos PG. Undiagnosed patent foramen ovale as a rare cause for branch retinal artery occlusion. Eur J Ophthalmol 2015;25:88-90.  Back to cited text no. 9
Sabanis N, Zagkotsis G, Krikos V D, Paschou E, Tapanlis E. Central retinal artery occlusion secondary to patent foramen ovale: The unexpected journey of a paradoxical embolus. Cureus 2020; 2:e9496.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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