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Ala‐Kauhaluoma M, Nuotio K, Ijäs P, Koskinen SM, Vikatmaa P, Silvennoinen H, Relander K, Lindsberg PJ, Soinne L, Summanen PA. Ocular signs of carotid stenosis in ipsi- and contralateral eyes before and after carotid endarterectomy: a prospective study. Acta Ophthalmol 2022; 100:e1015-e1023. [PMID: 34633762 DOI: 10.1111/aos.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/26/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We describe hypoperfusion-related and embolic ocular signs of carotid stenosis (CS) before and six months after carotid endarterectomy (CEA) in a CS population. METHODS We enrolled prospectively 70 CEA patients (81% male, mean age 69) and 41 non-medicated control subjects (76%, 68), from March 2015 to December 2018, assessing intraocular pressure (IOP), best-corrected visual acuity (BCVA) in logMAR units and performing a bio-microscopy examination. RESULTS Main index symptoms included amaurosis fugax (Afx) (29, 41%) and hemispheric TIA (17, 24%), and 17 (24%) were asymptomatic. Of the 70, 17 patients (24%, 95% CI 16-36) showed ocular signs of CS. Of four embolic (Hollenhorst plaques) findings, one small macular plaque disappeared postoperatively. Four had hypoperfusion, that is ocular ischaemic syndrome (OIS), requiring panretinal photocoagulation: one for multiple mid-peripheral haemorrhages, two for iris neovascularization and one for neovascular glaucoma (NVG); only the NVG proved irreversible. Nine (de novo in three) showed mild OIS, that is only few mid-peripheral haemorrhages, ranging pre- /postoperatively in ipsilateral eyes from one to eleven (median two)/ one to two (median one), and in contralateral eyes from three to nine (median five)/ one to six (median three). Pre- and postoperative median BCVA was 0 or better, and mean IOP was normal, except in the NVG patient. Temporary visual impairment from 0 to 0.3 occurred in one eye soon after CEA due to ocular hyperperfusion causing macular oedema. CONCLUSIONS Ocular signs of CS are common in CEA patients, ranging from few mid-peripheral haemorrhages to irreversible NVG. Clinicians should be aware of these signs in detecting CS.
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Affiliation(s)
- Marianne Ala‐Kauhaluoma
- Department of Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Krista Nuotio
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Petra Ijäs
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Suvi Maaria Koskinen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
- Department of Radiology HUS Diagnostic Center University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Pirkka Vikatmaa
- Department of Vascular surgery University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Heli Silvennoinen
- Department of Radiology HUS Diagnostic Center University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kristiina Relander
- Department of Neuropsychology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Perttu J. Lindsberg
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Lauri Soinne
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Paula A. Summanen
- Department of Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki Finland
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Obadia M, Lamirel C, Meseguer E, Seners P, Zuber K, Rosenheim M, Yavchitz A, Bidot S, Hage R, Sabben C, Savatovsky J, Lavallée PC, Gout O, Vignal C, Amarenco P. Vascular origin in acute transient visual disturbance: A prospective study. Eur J Neurol 2021; 28:4098-4108. [PMID: 34411384 DOI: 10.1111/ene.15074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to validate a clinical score of vascular origin in patients with acute transient visual disturbances (TVDs) without diplopia. METHODS We conducted a prospective study in an ophthalmology emergency department and a transient ischemic attack (TIA) clinic. Patients underwent clinical evaluation including a tailored questionnaire, brain, vascular, and ophthalmologic investigations, and 3-month follow-up. TVDs were classified according to vascular or nonvascular origin by three independent experts based on all clinical, cerebrovascular, and ophthalmologic investigations, but blind to the questionnaire results. A clinical score was derived based on clinical variables independently associated with a vascular origin, and was externally validated in an independent cohort. RESULTS An ischemic origin of TVD was found in 45% (67/149) of patients in the derivation cohort. Age and six questions were independently associated with an ischemic origin. A nine-point score (≥70 years old = 2; monocular visual loss = 2; black or white vision = 1; single episode = 1; lack of headache = 2; diffuse, constricted, altitudinal, or lateralized visual loss pattern on drawings = 1) showed good discriminative power in identifying ischemic origin (c-statistic = 0.82) and was replicated in the validation cohort (n = 130, 25% of ischemic origin, c-statistic = 0.75). With a score ≥ 4, sensitivity was 85% (95% confidence interval = 68-95) and specificity was 52% (95% confidence interval = 41-62). In both cohorts, ophthalmologic evaluation found a vascular cause in 4% and was noncontributive in 85%. After 3 months, no patients had a stroke, TIA, or retinal infarct. CONCLUSIONS Our score may assist in predicting a vascular origin of TVD. Ophthalmologic evaluation, when not readily available, should not delay the neurovascular evaluation.
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Affiliation(s)
- Michael Obadia
- Department of Neurology and Stroke Center, Rothschild Foundation Hospital, Paris, France
| | - Cedric Lamirel
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Elena Meseguer
- Neurology and Stroke Center, Public Assistance Hospitals of Paris, SOS-TIA Clinic, Bichat Hospital, University of Paris, Paris, France
| | - Pierre Seners
- Department of Neurology and Stroke Center, Rothschild Foundation Hospital, Paris, France
| | - Kevin Zuber
- Department of Clinical Research, Rothschild Foundation Hospital, Paris, France
| | - Michel Rosenheim
- Department of Clinical Research, Rothschild Foundation Hospital, Paris, France
| | - Amelie Yavchitz
- Department of Clinical Research, Rothschild Foundation Hospital, Paris, France
| | - Samuel Bidot
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Rabih Hage
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Candice Sabben
- Department of Neurology and Stroke Center, Rothschild Foundation Hospital, Paris, France
| | - Julien Savatovsky
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Philippa C Lavallée
- Neurology and Stroke Center, Public Assistance Hospitals of Paris, SOS-TIA Clinic, Bichat Hospital, University of Paris, Paris, France
| | - Olivier Gout
- Department of Neurology and Stroke Center, Rothschild Foundation Hospital, Paris, France
| | - Catherine Vignal
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Pierre Amarenco
- Neurology and Stroke Center, Public Assistance Hospitals of Paris, SOS-TIA Clinic, Bichat Hospital, University of Paris, Paris, France
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Kvickström P, Lindblom B, Bergström G, Zetterberg M. Amaurosis fugax: risk factors and prevalence of significant carotid stenosis. Clin Ophthalmol 2016; 10:2165-2170. [PMID: 27826182 PMCID: PMC5096748 DOI: 10.2147/opth.s115656] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study was to describe clinical characteristics and prevalence of carotid stenosis in patients with amaurosis fugax (AF). Method Patients diagnosed with AF and subjected to carotid ultrasound in 2004–2010 in Sahlgrenska University Hospital, Gothenburg (n=302), were included, and data were retrospectively collected from medical records. Results The prevalence of significant carotid stenosis was 18.9%, and 14.2% of the subjects were subjected to carotid endarterectomy. Significant associations with risk of having ≥70% stenosis were male sex (adjusted odds ratio [aOR]: 2.62; 95% confidence interval [CI]: 1.26–5.46), current smoking (aOR: 6.26; 95% CI: 2.62–14.93), diabetes (aOR: 3.68; 95% CI: 1.37–9.90) and previous vasculitis (aOR: 10.78; 95% CI: 1.36–85.5). A majority of the patients (81.4%) was seen by an ophthalmologist prior to the first ultrasound. Only 1.7% of the patients exhibited retinal artery emboli at examination. Conclusion The prevalence of carotid stenosis among patients with AF is higher than has previously been demonstrated in stroke patients. An association with previously reported vascular risk factors and with vasculitis is seen in this patient group. Ocular findings are scarce.
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Affiliation(s)
| | - Bertil Lindblom
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at University of Gothenburg; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
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Abstract
Transient vision loss may indicate underlying vascular disease, including carotid occlusion and thromboembolism, or it may have a more benign etiology, such as migraine or vasospasm. This review focuses on the differential diagnosis and workup of patients presenting with transient vision loss, focusing on several key areas: the relationship to thromboembolic vascular disease, hypercoagulable testing, retinal migraine, and bilateral vision loss. The objective is to provide the ophthalmologist with information on how to best manage these patients. Thromboembolic etiologies for transient vision loss are sometimes managed with medications, but when carotid surgery is indicated, earlier intervention may prevent future stroke. This need for early treatment places the ophthalmologist in the important role of expediting the management process. Hospital admission is recommended in patients presenting with transient symptoms within 72 hours who meet certain high-risk criteria. When the cause is giant cell arteritis, ocular ischemic syndrome, or a cardioembolic source, early management of the underlying condition is equally important. For nonthromboembolic causes of transient vision loss such as retinal migraine or retinal vasospasm, the ophthalmologist can provide reassurance as well as potentially give medications to decrease the frequency of vision loss episodes.
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Affiliation(s)
- John H Pula
- Department of Neurology, NorthShore University HealthSystem, Evanston IL, USA
| | - Katherine Kwan
- Department of ophthalmology, NorthShore University HealthSystem, Evanston IL, USA
| | - Carlen A Yuen
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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Abstract
There are a number of autoimmune disorders which can affect visual function. There are a very large number of mechanisms in the visual pathway which could potentially be the targets of autoimmune attack. In practice it is the retina and the anterior visual pathway (optic nerve and chiasm) that are recognised as being affected in autoimmune disorders. Multiple Sclerosis is one of the commonest causes of visual loss in young adults because of the frequency of attacks of optic neuritis in that condition, however the basis of the inflammation in Multiple Sclerosis and the confirmation of autoimmunity is lacking. The immune process is known to be highly unusual in that it is not systemic and confined to the CNS compartment. Previously an enigmatic partner to Multiple Sclerosis, Neuromyelitis Optica is now established to be autoimmune and two antibodies - to Aquaporin4 and to Myelin Oligodendrocyte Glycoprotein - have been implicated in the pathogenesis. The term Chronic Relapsing Inflammatory Optic Neuropathy is applied to those cases of optic neuritis which require long term immunosuppression and hence are presumed to be autoimmune but where no autoimmune pathogenesis has been confirmed. Optic neuritis occurring post-infection and post vaccination and conditions such as Systemic Lupus Erythematosus and various vasculitides may cause direct autoimmune attack to visual structures or indirect damage through occlusive vasculopathy. Chronic granulomatous disorders such as Sarcoidosis affect vision commonly by a variety of mechanisms, whether and how these are placed in the autoimmune panoply is unknown. As far as the retina is concerned Cancer Associated Retinopathy and Melanoma Associated Retinopathy are well characterised clinically but a candidate autoantibody (recoverin) is only described in the former disorder. Other, usually monophasic, focal retinal inflammatory disorders (Idiopathic Big Blind Spot Syndrome, Acute Zonal Occult Outer Retinopathy and Acute Macular Neuroretinitis) are of obscure pathogenesis but an autoimmune disorder of the post-infectious type is plausible. Visual loss in autoimmunity is an expanding field: the most significant advances in research have resulted from taking a well characterised phenotype and making educated guesses at the possible molecular targets of autoimmune attack.
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Affiliation(s)
- Axel Petzold
- The Dutch Expert Center for Neuro-ophthalmology, VU University Medical Center, Amsterdam, The Netherlands and Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Sui Wong
- Moorfields Eye Hospital and St. Thomas' Hospital, London, UK
| | - Gordon T Plant
- Moorfields Eye Hospital, The National Hospital for Neurology and Neurosurgery and St. Thomas' Hospital, London, UK.
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Lawlor M, Perry R, Hunt BJ, Plant GT. Strokes and vision: The management of ischemic arterial disease affecting the retina and occipital lobe. Surv Ophthalmol 2015; 60:296-309. [DOI: 10.1016/j.survophthal.2014.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 12/10/2014] [Accepted: 12/16/2014] [Indexed: 11/16/2022]
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