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Haj Najeeb B, Gerendas BS, Montuoro A, Simader C, Deák GG, Schmidt-Erfurth UM. A Novel Effect of Microaneurysms and Retinal Cysts on Capillary Perfusion in Diabetic Macular Edema: A Multimodal Imaging Study. J Clin Med 2025; 14:2985. [PMID: 40364016 PMCID: PMC12072257 DOI: 10.3390/jcm14092985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2025] [Revised: 04/14/2025] [Accepted: 04/21/2025] [Indexed: 05/15/2025] Open
Abstract
Background/Objectives: The aim of this study was to investigate the potential contribution of microaneurysms (MAs) and retinal cysts to the pathogenesis of macular non-perfusion in patients with diabetic macular edema (DME) using multimodal imaging. Methods: In this cross-sectional study, 42 eyes with DME were analyzed using color fundus photography, fluorescein angiography (FA) and optical coherence tomography (OCT). Macular non-perfusion within the central 3000 µm was categorized by location and extent into foveal avascular zone enlargement (FAZE), focal non-perfusion (FNP) and diffuse non-perfusion (DNP). A custom-developed software was used to assess the colocalization of retinal cysts on OCT with areas of non-perfusion on the corresponding FA images. Also, the presence of leaky MAs adjacent to retinal cysts on FA was verified. Results: Colocalization between retinal cysts and non-perfusion was observed in 32 of 42 (76%) eyes: 19 of 23 (83%) eyes with FAZE and 13 of 16 (81%) eyes with FAZE+FNP. No cysts colocalization was found in all three eyes (100%) presenting with DNP. None of the eyes presented with FNP alone. In the remaining seven eyes (four eyes with FAZE and three eyes with FAZE+FNP), no colocalization was noticed. At least one leaky MA adjacent to retinal cysts was identified in all eyes presented with colocalization. Conclusions: Retinal cysts may contribute to the development of limited non-perfusion in DME. Leaky MAs appear to be the primary source of cyst formation, which may lead to localized capillary occlusion in the macula.
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Affiliation(s)
- Bilal Haj Najeeb
- Vienna Reading Center, Department of Ophthalmology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Abdelmassih Y, Mauget-Faÿsse M, Seners P, Milea D, Hallali G, Guillaume J, Lecler A, Vignal C, Le Mer Y, Paques M, Bonnin S, Obadia M. Early reperfusion in patients with acute retinal artery occlusion: A multicenter prospective study. Int J Stroke 2025; 20:338-346. [PMID: 39614619 DOI: 10.1177/17474930241306692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2024]
Abstract
BACKGROUND The visual outcome after central retinal artery occlusion (CRAO) is poor, but its relationship with early reperfusion (ER) is poorly known. We evaluated the incidence of ER in acute CRAO or branch retinal artery occlusion (BRAO), and its association with clinical outcome. METHODS In this prospective observational multicenter study, we included patients with acute CRAO or macula-involving BRAO presenting within 24 hours from symptom onset. ER was evaluated within 24 hours after the initial clinical evaluation using indocyanine green angiography (ICGA). The primary outcome was the best-corrected visual acuity (BCVA) at 1 month. RESULTS In all, 70 patients were enrolled, of whom 63 (90%) had CRAO. Median age was 71 years (interquartile range: 67-77), 63% were male, median time from symptom onset to presentation was 5.3 hours (interquartile range: 3.1-15.1), and 17% received intravenous fibrinolysis. ER was identified in 34 patients (49%), of whom 21 (30%) achieved complete reperfusion (100% filling of the 55° ICGA field). Patients with ER were less likely to have hypertension and diabetes mellitus (p < 0.001 and p = 0.046, respectively). At the 1-month follow-up, BCVA was significantly better in ER patients (median BCVA 1.3 logMAR vs 1.7 logMAR, p = 0.001), with greater benefit with complete reperfusion (p for trend < 0.001). ER was also associated with improved visual field and quality of life at the 1-month follow-up (both p < 0.05). CONCLUSION ER occurred in almost 50% of the patients and was associated with improved visual outcomes and quality of life. Therapies that increase ER in CRAO will likely improve clinical outcomes. CLINICAL TRIAL REGISTRATION This study was registered on ClinicalTrials.gov (identifier NCT03049514); https://classic.clinicaltrials.gov/ct2/show/NCT03049514.
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Affiliation(s)
| | | | - Pierre Seners
- Department of Neurology and Stroke Center, Rothschild Foundation Hospital, Paris, France
| | - Dan Milea
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Gabriel Hallali
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Jessica Guillaume
- Department of Clinical Research, Rothschild Foundation Hospital, Paris, France
| | - Augustin Lecler
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Catherine Vignal
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Yannick Le Mer
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Michel Paques
- Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DHOS CIC 503, Paris, France
| | - Sophie Bonnin
- Department of Ophthalmology, Rothschild Foundation Hospital, Paris, France
| | - Michael Obadia
- Department of Neurology and Stroke Center, Rothschild Foundation Hospital, Paris, France
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Yang CC, Weng CC, Chou YB, Huang YM, Hwang DK, Chen SJ, Lin TC. Visual outcomes of central retinal artery occlusion: Exploring treatment strategies beyond the conventional time window. J Stroke Cerebrovasc Dis 2025; 34:108240. [PMID: 39809373 DOI: 10.1016/j.jstrokecerebrovasdis.2025.108240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2024] [Revised: 11/13/2024] [Accepted: 01/11/2025] [Indexed: 01/16/2025] Open
Abstract
BACKGROUNDS/AIMS Central retinal artery occlusion (CRAO) is a vision-devastating emergency. However, widely-acknowledged treatment consensus is lacking and prehospital delays commonly occur. Hence, we aimed to investigate the visual outcomes of conservative treatments (CT), local intra-arterial fibrinolysis (LIF) and hyperbaric oxygen (HBO) therapy for non-arteritic CRAO (NA-CRAO) patients beyond the conventional time window. METHODS This retrospective comparative study included 99 NA-CRAO patients followed up for over 6 months. The subjects were divided into three groups: the CT (50 patients), LIF (10 patients) and HBO group (39 patients). The primary endpoint was the best-corrected visual acuity (BCVA) change at 6 months compared to baseline. The secondary endpoint was the improvement in BCVA at 1 year and final visits. RESULTS No heterogeneity regarding demographics was identified. However, the HBO group had a more extended time-to-treatment period (median 6.0 days) and more advanced-stage CRAO cases (41 % stage III) than the CT (median 4.0 days, 14 % stage III) and LIF (median 0.6 days, 20 % stage III) groups. Despite this, the HBO group exhibited a significantly greater BCVA and a higher proportion of patients achieving significant vision improvement than those in the CT group at 6-, 12-month and final exams (51.3 % vs. 24.0 %, P < 0.05). The LIF appeared to improve outcomes more than CT over time without significance. CONCLUSION Our study provided a concurrent comparison across 3 approaches and demonstrated that HBO therapy beyond the time window remained more effective in improving vision than CT alone for NA-CRAO patients, which had not been proposed by prior studies.
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Affiliation(s)
- Chi-Chun Yang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Chang-Chi Weng
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Yu-Bai Chou
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Yi-Ming Huang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Tai-Chi Lin
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Department of Ophthalmology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China.
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Venkatesh R, Joshi A, Maltsev D, Munk M, Prabhu V, Bavaskar S, Mangla R, Ruamviboonsuk P, Chhablani J. Update on central retinal artery occlusion. Indian J Ophthalmol 2024; 72:945-955. [PMID: 38905460 PMCID: PMC11329807 DOI: 10.4103/ijo.ijo_2826_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/13/2024] [Accepted: 02/13/2024] [Indexed: 06/23/2024] Open
Abstract
The medical condition referred to as "central retinal artery occlusion" (CRAO) was first documented by Albrecht von Graefe in 1859. Subsequently, CRAO has consistently been identified as a serious medical condition that leads to substantial visual impairment. Furthermore, it is correlated with vascular complications that have the potential to affect crucial organs such as the brain and heart. A considerable amount of research has been extensively published on the various aspects of this topic, which is marked by notable debates and misconceptions, especially regarding its management and outcomes. The primary aim of this review article is to analyze the latest developments in the understanding of CRAO, which includes its causes, techniques for retinal imaging, systemic evaluation, and therapeutic strategies, such as vitrectomy. This review article offers readers a comprehensive learning experience to gain knowledge on the fundamental principles and recent advancements in CRAO.
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Affiliation(s)
- Ramesh Venkatesh
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Aishwarya Joshi
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Dmitrii Maltsev
- Department of Ophthalmology, Military Medical Academy, St. Petersburg, Russia
| | - Marion Munk
- Department of Retina, Augenarzt Praxisgemeinschaft Gutblick AG, Pfäffikon, Switerland
- Department of Retina, University Hospital Bern, Inselspital, Bern, Switzerland
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Vishma Prabhu
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Snehal Bavaskar
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Rubble Mangla
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Lak Hok, Thailand
- Center of Excellence for Vitreous and Retinal Disease, Rajavithi Hospital, Bangkok, Thailand
| | - Jay Chhablani
- Department of Medical Retina and Vitreoretinal Surgery, University of Pittsburgh School of Medicine, Pittsburg, PA 15213, USA
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Li X, Chen T, Li Y, Wang C, Wang Y, Wan Y, Yang A, Xiao X. Improved visual outcomes of central retinal artery occlusion with local intra-arterial fibrinolysis beyond the conventional time window. J Thromb Thrombolysis 2024; 57:503-511. [PMID: 38114857 DOI: 10.1007/s11239-023-02927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/21/2023]
Abstract
Local intra-arterial fibrinolysis (LIF) is a promising therapeutic option for CRAO. However, the narrow time window of 6 h has greatly limited the application of LIF. In this study, we explored the efficacy of LIF beyond the conventional time windows and compared the result with conservative therapy. This prospective study included 179 CRAO patients with baseline visual acuity (VA) ≤ 20/400 treated at Renmin Hospital of Wuhan University. The mean time from vision loss to presentation was 5.5 days. 58 patients received conventional standard therapy (CST) alone.121 patients underwent LIF. Main outcome was VA improvement ≥ 0.3 logMAR. Secondary outcome was a favorable VA outcome of 20/200 or better. Logistic regressions were performed to identify predictors of visual improvement. 43% patients in the LIF group experienced VA improvement versus 19% with CST (P = 0.002). LIF was associated with 4.0-fold higher likelihood of visual improvement compared to CST (P = 0.001). Poor baseline VA (light perception or no light perception) and shortened prothrombin time (PT) were associated with greater chance of visual improvement with LIF. However, LIF showed no significant advantage over CST for favorable VA outcomes. No major complications occurred. LIF beyond the therapeutic time window improved vision in functionally blind CRAO patients and showed better efficacy when compared with CST. PT may be a potential predictor of visual outcome after LIF. Our findings could complement existing time-based treatment guidelines and potentially allow for personalized decisions on the use of LIF beyond time windows.
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Affiliation(s)
- Xuejie Li
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China
| | - Ting Chen
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China
| | - Ying Li
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China
| | - Chuansen Wang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China
| | - Yuedan Wang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China
| | - Yuwei Wan
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China
| | - Anhuai Yang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China.
| | - Xuan Xiao
- Department of Ophthalmology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuhan, 430060, Hubei, China.
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Wei J, Zhang L, Wu K, Yu J, Gao F, Cheng J, Zhang T, Zhou X, Zong Y, Huang X, Jiang C. R-(+)-WIN55212-2 protects pericytes from ischemic damage and restores retinal microcirculatory patency after ischemia/reperfusion injury. Biomed Pharmacother 2023; 166:115197. [PMID: 37572634 DOI: 10.1016/j.biopha.2023.115197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Cannabinoids are vasoactive substances that act as key regulators of arterial tone in the blood vessels supplying peripheral tissues and the central nervous system. This study aimed to investigate the potential of R-(+)-WIN55212-2 (WIN), a cannabinoid receptor 1 agonist (CB1), as a treatment for retinal ischemia/reperfusion (I/R) injury. EXPERIMENTAL APPROACH Male Wistar rats were subjected to retinal I/R injury by increasing intraocular pressure in the anterior chamber. The rats were randomly divided into four groups: normal control, I/R, vehicle (pre-treated with dimethyl sulfoxide [DMSO] via intraperitoneal injection), and experimental (pre-treated with WIN at a dose of 1 ml/kg via intraperitoneal injection). The rats were sacrificed at different time points of reperfusion (1 hour, 3 hours, 6 hours, and 1 day) after inducing retinal I/R injury, and their retinas were collected for analysis. Oxygen-glucose deprived/reperfusion (OGD/R) was performed by initially perfusing the retinas with oxygenated artificial cerebrospinal fluid (ACSF), then switching to an OGD solution to simulate ischemia, followed by another perfusion with ACSF. Pericyte contraction and the "no-reflow" phenomenon were observed using infrared differential interference contrast (IR-DIC) microscopy and immunohistochemistry. Western blot, enzyme-linked immunosorbent assay (ELISA), and nitric oxide (NO) detection were used to explore the potential mechanism. KEY RESULTS In both the OGD/R and I/R models, retinal pericytes exhibited persistent contraction even after reperfusion. The ability of WIN to regulate the tone of retinal pericytes and capillaries was specifically blocked by the BKCa inhibitor iberiotoxin (100 nM). WIN demonstrated a protective effect against retinal I/R injury by preserving blood flow in vessels containing pericytes. Pretreatment with WIN alleviated the persistent contraction and apoptosis of retinal pericytes in I/R-induced rats, accompanied by a reduction in intracellular calcium ion (Ca2+) concentration. The expression of CB1 decreased in a time-dependent manner in the I/R group. After I/R injury, endothelium-derived nitric oxide (eNOS) levels were reduced at all time points, which was successfully reversed by WIN therapy except for the 1 day group. Additionally, the downregulation of cyclic guanosine monophosphate (cGMP) and BKCa expression at 3 hours, 6 hours, and 1 day after I/R injury was restored by pretreatment of WIN. CONCLUSIONS & IMPLICATIONS WIN exerted its protective effects on retinal I/R injury by inhibiting the contraction and apoptosis of pericytes through the CB1-eNOS-cGMP-BKCa signaling pathway, thus ameliorated the occlusion of retinal capillaries.
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Affiliation(s)
- Jiaojiao Wei
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Lili Zhang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Kaicheng Wu
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Jian Yu
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Fengjuan Gao
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Jingyi Cheng
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Ting Zhang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
| | - Xujiao Zhou
- Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China.
| | - Yuan Zong
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China.
| | - Xiaojing Huang
- Department of Ophthalmology, Shanghai Pudong New Area Gongli Hospital, Shanghai 200135, People's Republic of China.
| | - Chunhui Jiang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai 200031, People's Republic of China; Eye and ENT Hospital, State Key laboratory of Medical Neurobiology, Institutes of Brain Science and Collaborative Innovation Center for Brain Science, Fudan University, Shanghai 200031, People's Republic of China; Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai 200031, People's Republic of China
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Anayat S, Majid K, Nazir HS, Nizami AA, Mustafa W, Abbasi MSR, Ahsan MN, Jadoon SK, Ullah I, Asghar MS. Meta-Analysis on the Efficacy of High-Dose Statin Loading Before Percutaneous Coronary Intervention in Reducing No-Reflow Phenomenon in Acute Coronary Syndrome. Am J Cardiol 2023; 195:9-16. [PMID: 36989606 DOI: 10.1016/j.amjcard.2023.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 02/15/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
Currently, guidelines recommend the uptake of high-dose statins before and after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome. However, the association of high-dose statins with the incidence of the no-reflow phenomenon remains unclear. This study aimed to review the evidence of preprocedural high-dose statin therapy to reduce no-reflow incidence after PCI. PubMed, Embase, and Google Scholar were searched from inception until May 2022 for studies comparing high-dose statins with low-dose or no statin therapy before PCI. Studies reporting the no-reflow phenomenon were shortlisted. The National Institutes of Health tool for randomized and cohort studies was used to assess the quality of included studies. A random-effects model was used to derive odds ratios (ORs) and their corresponding 95% confidence intervals (CIs). A total of 11 studies were included, with a population of 4,294 patients. The use of high-dose statins before PCI significantly reduced postprocedural no-reflow (OR 0.51, 95% CI 0.35 to 0.74, p = 0.0005, I2 = 32%). A total of 7 studies included patients who underwent PCI without previous use of statins. A significant decrease in overall no-reflow events was observed with high-intensity statin treatment versus low-intensity statin/placebo (OR 0.55, 95% CI 0.34 to 0.88, p = 0.01, I2 = 25%) among patients who were statin naive. Acute high-dose statin therapy before PCI significantly reduces the hazard of post-PCI no-reflow events in patients with acute coronary syndrome. Our results encourage the routine use of statins before PCI.
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Affiliation(s)
| | | | | | - Awais Ahmad Nizami
- Shahida Islam Institute of Cardiology/Shahida Islam Medical College, Lodhran Bahawalpur, Pakistan
| | - Waqar Mustafa
- Abbas Institute of Medical Sciences, Azad Jammu Kashmir Medical College, Muzaffarabad, Pakistan
| | | | - Muhammad Nadeem Ahsan
- Department of Nephrology and Hypertension, Dow University of Health Sciences, Karachi, Pakistan
| | - Sarosh Khan Jadoon
- Sheikh Khalifa Bin Zayed Al Nahyan Hospital/Combined Miltiary Hospital, Muzaffarabad, Pakistan
| | - Irfan Ullah
- Gandhara University Kabir Medical College, Peshawar, Pakistan
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Kang MS, Kwon HJ, Lee JE. Retinal Capillary Reperfusion from Ischemic Retinal Vasculitis in Henoch-Schönlein Purpura: A Case Report. Ocul Immunol Inflamm 2022; 30:2037-2042. [PMID: 34403301 DOI: 10.1080/09273948.2021.1957120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION We present a case of ischemic retinal vasculitis in adult-onset Henoch-Schönlein purpura (HSP) and the first report of capillary reperfusion through regenerative angiogenesis using optical coherence tomography angiography (OCTA). CASE REPORT A 34-year-old male complained of bilateral blurred vision after successive episodes of abdominal pain, purpura, and hematuria. Fundus examination showed perivascular infiltration and phlebitis. Fluorescein angiography and OCTA revealed extensive capillary nonperfusion. Laser photocoagulation was performed on the peripheral nonperfused area. Intravenous methylprednisolone with azathioprine was administered and continuously tapered. With consecutive OCTA follow-up, the capillary nonperfusion of the maculae progressively reperfused. Capillary buds and loops emerged within the nonperfused area, continued to elongate and branch, and finally connected with adjacent preexisting capillaries. CONCLUSIONS Regenerative angiogenesis was the mainstay process for capillary reperfusion in this patient. Systemic steroid therapy might support capillary reperfusion and recover the damaged ischemic maculae from ischemic retinal vasculitis of HSP.
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Affiliation(s)
- Min Seung Kang
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea.,Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Han Jo Kwon
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea.,Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Ji Eun Lee
- Department of Ophthalmology,Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea.,Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, South Korea.,Lee Eye Clinic, Busan, South Korea
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Klefter ON, Hansen MS, Willerslev A, Faber C, Terslev L, Jensen MR, Døhn UM, Wiencke A, Heegaard S, Hamann S. Optical Coherence Tomography of Peripapillary Vessels in Giant Cell Arteritis and Ischaemic Ocular Disease. Neuroophthalmology 2022; 46:383-389. [PMID: 36544584 PMCID: PMC9762795 DOI: 10.1080/01658107.2022.2113901] [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: 05/03/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022] Open
Abstract
With normal retinal blood flow, cross-sectional optical coherence tomography (OCT) of retinal vessels shows a structured intravascular reflectivity profile, resembling a 'figure-of-8'. Altered profiles have been reported in vascular occlusive and haematological diseases. Giant cell arteritis (GCA) can cause visual loss, usually due to anterior ischaemic optic neuropathy (AION) or retinal artery occlusion. Our aim was to extend the assessment of OCT vascular profiles to patients with suspected GCA and to determine if any abnormalities were related to GCA per se or to ischaemic ocular conditions. This nested retrospective study included 61 eyes of 31 patients (13 with GCA). Six eyes had arteritic and seven eyes non-arteritic AION, three eyes had non-arteritic retinal artery occlusion, 11 eyes had other ocular conditions and 34 were unaffected control eyes. For each eye the appearance of structured intravascular profiles on peripapillary OCT was graded as present, partial, absent or uncertain. Non-presence of structured intravascular profiles was more frequent in AION and retinal artery occlusion than in other ocular conditions or unaffected eyes (Fisher's test, p = .0047). Based on follow-up of 25 eyes, reflectivity profiles normalised in three out of four eyes after 85 (35-245) days. Vessel profiles were not associated with GCA (p = .32) and were similar in arteritic and non-arteritic AION (p = .66). In conclusion, absence of structured intravascular reflectivity profiles may be a marker of acute ischaemia in the anterior optic nerve or inner retina. However, it did not seem specific for GCA. The prognostic value warrants further studies.
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Affiliation(s)
- Oliver N. Klefter
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Michael S. Hansen
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Anne Willerslev
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Carsten Faber
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Lene Terslev
- Department of Rheumatology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Mads R. Jensen
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Uffe M. Døhn
- Department of Rheumatology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Anne Wiencke
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - Steffen Heegaard
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
- Eye Pathology Section, Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
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10
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Kang MS, Kim SY, Kwon HJ. Case Report: Recanalization of Branch Retinal Artery Occlusion Due to Microthrombi Following the First Dose of SARS-CoV-2 mRNA Vaccination. Front Pharmacol 2022; 13:845615. [PMID: 35401231 PMCID: PMC8988066 DOI: 10.3389/fphar.2022.845615] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background: We report on a patient with a branch retinal artery occlusion (RAO) and its recanalization based on multimodal retinal and angiographic images after he was administered the first dose of the SARS-CoV-2 mRNA vaccine. Case summary: A 64-year-old man complained of a right, painless, inferior field defect 3 days after the first dose of BNT162b2 vaccination. Fundus examination revealed decolorization of the right upper macula, including microthrombi in the superior proximal branch of the retinal artery. Optical coherence tomography angiography revealed upper macular hypoperfusion. Fluorescein angiography revealed prolonged arteriovenous transit to the macula. After paracentesis with antiplatelet medications, the artery was recanalized as the thrombi dissolved, and the right visual field was recovered. Re-occlusion did not occur during the 3 months after the second mRNA vaccination. Conclusion: Non-embolic thrombotic RAO may develop shortly after the SARS-CoV-2 mRNA vaccine. Ophthalmologists should consider RAO as a possible post-vaccination adverse event. The temporal association between mRNA vaccination and RAO onset with evidence of microthrombi might provide additional clues to elucidate the unpredictive arterial thrombosis following SARS-CoV-2 mRNA vaccination.
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Affiliation(s)
- Min Seung Kang
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Sang Yoon Kim
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Han Jo Kwon
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
- Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
- *Correspondence: Han Jo Kwon,
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11
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Shearer TR, Hwang TS, Steinkamp PN, Azuma M. Segmenting OCT for detecting drug efficacy in CRAO. PLoS One 2020; 15:e0242920. [PMID: 33306701 PMCID: PMC7732080 DOI: 10.1371/journal.pone.0242920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Thinning of the inner layers of the retina occurs in patients with central retinal artery occlusion (CRAO). The mechanism for such thinning may be partially due to proteolysis by a calcium-activated protease called calpain. Calpain inhibitor SNJ-1945 ameliorated the proteolysis in a past series of model experiments. The purposes of the present retrospective study were to: 1) use segmentation analysis of optical coherence tomography (OCT) images to mathematically model the loss of specific retinal layers in CRAO patients, and 2) predict the number of patients and days of observation needed for clinical trials of inhibitors against CRAO. METHODS A retrospective case control study was conducted by computer-aided search for CRAO (ICD10 H43.1) with at least one OCT procedure (CPT: 92134) in the OHSU Epic patient data base. RESULTS After initial swelling, thinning of the inner retinal layers, especially the ganglion cell (GCL) layer followed exponential decay curves. Using sample size statistics and GCL thickness as a marker in a 30-day clinical trial, 19 eyes/group could theoretically detect a 20% beneficial effect of an inhibitor against CRAO. Other markers, such as the whole retinal thickness and combined inner layers could also be used as less-specific markers. CONCLUSIONS Using thickness changes in the GCL layer to monitor the efficacy of potential inhibitors against CRAO is practical in human trials requiring a reasonable number of patients and relatively short trial period. TRANSLATIONAL RELEVANCE Measurement of GCL thickness would be a useful indicator of CRAO progression in a clinical trial of putative inhibitors.
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Affiliation(s)
- Thomas R Shearer
- Department of Integrative Biomedical & Diagnostic Sciences, Oregon Health & Science University, Portland, OR, United States of America
| | - Thomas S Hwang
- Department of Ophthalmology-OHSU, Portland, OR, United States of America
| | - Peter N Steinkamp
- Department of Ophthalmology-OHSU, Portland, OR, United States of America
| | - Mitsuyoshi Azuma
- Senju Laboratory of Ocular Sciences, Portland, OR, United States of America
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12
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Littlewood R, Mollan SP, Pepper IM, Hickman SJ. The Utility of Fundus Fluorescein Angiography in Neuro-Ophthalmology. Neuroophthalmology 2019; 43:217-234. [PMID: 31528186 DOI: 10.1080/01658107.2019.1604764] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022] Open
Abstract
While its use is still widespread within the medical retina field, fundus fluorescein angiography (FFA) is increasingly falling out of favour in the investigation of neuro-ophthalmological disease, with the introduction of new technologies, particularly optical coherence tomography. FFA does, however, provide useful diagnostic and prognostic information in many neuro-ophthalmological diseases including papilloedema, pseudo-papilloedema, optic neuropathies and central retinal artery occlusion to name a few. We aim to summarise the main FFA findings in each of these conditions and highlight where FFA is of most use in providing complementary information to other modes of investigation.
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Affiliation(s)
| | - Susan P Mollan
- Department of Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Irene M Pepper
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon J Hickman
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
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13
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Dammacco R, Procaccio P, Racanelli V, Vacca A, Dammacco F. Ocular Involvement in Systemic Lupus Erythematosus: The Experience of Two Tertiary Referral Centers. Ocul Immunol Inflamm 2018; 26:1154-1165. [DOI: 10.1080/09273948.2018.1501495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Rosanna Dammacco
- Department of Ophthalmology and Neuroscience, University of Bari Medical School, Bari, Italy
| | - Pasquale Procaccio
- Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
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14
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Differentiating Occult Branch Retinal Artery Occlusion from Primary Open-angle Glaucoma. Optom Vis Sci 2018; 95:106-112. [PMID: 29370018 DOI: 10.1097/opx.0000000000001170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SIGNIFICANCE Clinical findings in occult branch retinal artery occlusion (BRAO) can mimic those of primary open-angle glaucoma (POAG). Because management of these conditions substantially differs, accurate diagnosis is crucial. Our comparative analysis indicates that specific macular thickness variables reliably differentiate these conditions and that macular scanning may enhance routine glaucoma evaluation. PURPOSE The aim of this study was to identify clinical factors that reliably and efficiently identify occult BRAO masquerading as POAG. METHODS All subjects had comprehensive eye examinations including measurements of retinal nerve fiber layer and macular thickness (MT) using spectral-domain optical coherence tomography (SD-OCT). All subjects were asymptomatic for previous acute vision loss episodes, had optic nerve appearances suggestive of glaucoma, and exhibited SD-OCT retinal nerve fiber layer thinning with corresponding visual field loss. Macular thickness scans were divided into 64 individual thickness blocks with thin MT blocks defined by the lower 99% confidence interval from a group of normal eyes. We defined BRAO by the presence of regional inner retinal thinning with lack of inner-layer stratification on macular SD-OCT b-scan images that spatially corresponded with arteriolar distribution and visual field loss location. Primary open-angle glaucoma eyes were selected to match the BRAO eyes by age and disease severity. Pairwise and receiver operating characteristic curve analyses were used to compare occult BRAO and POAG eyes. RESULTS Compared with POAG (n = 52), occult BRAO eyes (n = 11) demonstrated lower cup-disc ratio, greater intereye and intraeye (superior vs. inferior) MT asymmetry, and higher frequency of thin MT blocks (<200 μm). Area under the receiver operating characteristic curve (AUC) for differentiating these conditions was highest for intraeye MT asymmetry (AUC = 0.990 [95% confidence interval, 0.925 to 1.000]) and number of thin MT blocks (AUC = 0.993 [95% confidence interval, 0.929 to 1.000]). CONCLUSIONS Macular thickness parameters provided accurate and efficient diagnostic capability in this study. Considering the clinical implications of inaccurate diagnosis, macular scanning may be important in baseline glaucoma evaluation.
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15
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Liu W, Zou Z, Jiang H, Li Q, Guo F, Wang Z, Zhu H. Clinical effect of preoperative high-dose atorvastatin against no-reflow after PCI. Exp Ther Med 2016; 13:97-102. [PMID: 28123475 PMCID: PMC5244837 DOI: 10.3892/etm.2016.3910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/27/2016] [Indexed: 12/13/2022] Open
Abstract
The aim of the present study was to evaluate the use of preoperative high-dose atorvastatin to prevent the no-reflow phenomenon after percutaneous coronary intervention (PCI). A total of 138 patients with ST-segment elevation myocardial infarction, admitted from March 2014 to January 2015, were enrolled and randomly divided into 3 groups of 46 individuals each. The groups included a control group in which patients were not treated with atorvastatin before PCI; a conventional-dose atorvastatin treatment group in which patients received a single dose of 20 mg at bedtime one day prior to PCI; and a high-dose atorvastatin treatment group in which patients were treated with 40 mg divided in two doses the day before PCI. The treatment effects were assessed by re-examining the echocardiography, high-sensitivity C-reactive protein and brain natriuretic peptide (BNP) levels after the PCI. The follow-up examinations included determinations of ultrasound imaging indicators and the contact with patients was maintained for a whole year. The CTFC (frame), pro-BNP, CK-MB peak and WMSI levels of the patients in the high-dose treatment group were significantly lower than those in the conventional dose or the control group. Trombolysis in myocardial infarction ≤2 and myocardial blush grade ≤1 levels were significantly lower than those in the conventional dose group (P=0.01) or those in the control group (P=0.01), although the echocardiographic indicators of the three groups were not significantly different (P<0.05). Nevertheless, it was found that there were significantly fewer adverse cardiovascular events in the high-dose group (P<0.05 in both cases). During the follow-up period, thromboembolism and restenosis were most infrequent in the high-dose atorvastatin group. Based on our findings the oral administration of high-dose atorvastatin before bedtime, one day before the procedure, can effectively prevent no-reflow cases, reduce adverse events and improve the long-term prognosis for acute coronary syndrome patients after PCI.
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Affiliation(s)
- Wenbo Liu
- Yantaishan Hospital, Yantai, Shandong 264001, P.R. China
| | - Zhipeng Zou
- Department of Cardiology, Yeda Hospital of Yantai City, Yantai, Shandong 264001, P.R. China
| | - Haipeng Jiang
- Department of Minimally Invasive Surgery, Yantaishan Hospital, Yantai, Shandong 264001, P.R. China
| | - Qiang Li
- Department of Cardiology, Yantaishan Hospital, Yantai, Shandong 264001, P.R. China
| | - Fangming Guo
- Department of Cardiology, Yantaishan Hospital, Yantai, Shandong 264001, P.R. China
| | - Zhen Wang
- Department of Cardiology, Yantaishan Hospital, Yantai, Shandong 264001, P.R. China
| | - Hongguang Zhu
- Department of Cardiology, Haigang Hospital of Yantai City, Yantai, Shandong 264001, P.R. China
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16
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Wu XJ, Gao F, Liu X, Zhao Q. Observation on therapeutic efficacy of rt-PA intravenous thrombolysis combined with compound anisodine injection on central retinal artery occlusion. Exp Ther Med 2016; 12:2617-2621. [PMID: 27698763 PMCID: PMC5038466 DOI: 10.3892/etm.2016.3681] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 08/22/2016] [Indexed: 01/19/2023] Open
Abstract
The aim of the present study was to observe the clinical efficacy and safety of recombinant tissue plasminogen activator (rt-PA) combined with compound anisodine in treating central retinal artery occlusion (CRAO). Forty-eight patients diagnosed with CRAO were randomly divided into a treatment group (24 cases) and a control group (24 cases). For the control group, nitroglycerin, 654-2, methazolamide, puerarin and compound anisodine were used for the treatment, along with oxygen, massage and other conventional treatments. Besides conventional therapy, the treatment group was also given intravenous rt-PA thrombolysis. Visual acuity, fundus oculi, visual field changes were taken as indicators for efficacy evaluation. It was found that the total effective rate of the control group was 70.83%, while that for the treatment group was 91.67%, and the comparative difference between the two groups was of statistical significance (p<0.05). The visual field defect of the control group after treatment was approximately 74.26±12.91%, and the visual field defect of the treatment group after treatment approximately 35.08±16.33%; thus, the comparative difference was statistically significant (p<0.01). The comparative difference of the original contents of fibrous protein in blood in the treatment group before and after treatment was statistically significant (p<0.01). In conclusion, the result show that intravenous thrombolysis with rt-PA combined with compound anisodine is safe and effective in treating CRAO, which can significantly improve the prognosis of patients.
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Affiliation(s)
- Xiao-Jun Wu
- Department of Ophthalmology, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Feng Gao
- Department of Ophthalmology, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Xu Liu
- Department of Ophthalmology, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Qing Zhao
- Department of Ophthalmology, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
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