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Chirurgi R, Duvvi A, Hussain B, Li L, Singh J, Nigussie AH, Hashmi A, Roffe E, Jauhal S, Fasazadeh M, Kalantari H, Hassen GW. Monocular Painless Vision Loss in the Emergency Department: Multipurpose Utility of Point-of-Care Ultrasound. J Emerg Med 2024; 66:192-196. [PMID: 38278678 DOI: 10.1016/j.jemermed.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/04/2023] [Accepted: 10/01/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Eye-related symptoms are a common presentation in the emergency department (ED). The cases range from simple viral conjunctivitis to trauma-related eye injuries. One pathological condition that could lead to vision loss is retinal artery occlusion (RAO). Evaluating a patient with an eye symptom requires thorough eye examination and advanced imaging in certain instances. Consultation with an ophthalmologist is also necessary for cases that require treatment recommendations and further testing. In the ED, point-of-care ultrasound (POCUS) is a commonly used diagnostic tool that can be used for ocular examination. CASE REPORT We reported a case of a 60-year-old man who presented with painless partial right-eye vision loss. POCUS showed decreased flow in the right central retinal artery with an area of the pale retina seen on the image from the retinal camera, suggesting a possible branch RAO. Further examination with POCUS showed plaque formation at the carotid bifurcation, a potential cause of the patient's symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians and other providers should be encouraged to use POCUS to diagnose eye symptoms accurately and promptly. Abnormal findings will prompt immediate specialty consult and early appropriate management. Our case and other reported cases highlight POCUS's reliability and rapid diagnostic ability.
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Affiliation(s)
- Roger Chirurgi
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Anisha Duvvi
- Albert Einstein College of Medicine, Bronx, New York
| | - Bisma Hussain
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Lucy Li
- Department of Ophthalmology, New York Medical College, Metropolitan Hospital Center, New York, NY
| | - Jaspreet Singh
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Abaynesh Haftu Nigussie
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Ahmed Hashmi
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Estrella Roffe
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Sonja Jauhal
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Misagh Fasazadeh
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Hossein Kalantari
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
| | - Getaw Worku Hassen
- Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York
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Shen Z, Zhang S, Yu W, Yue M, Hong C. Optical Coherence Tomography Angiography: Revolutionizing Clinical Diagnostics and Treatment in Central Nervous System Disease. Aging Dis 2024:AD.2024.0112. [PMID: 38300645 DOI: 10.14336/ad.2024.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/12/2024] [Indexed: 02/02/2024] Open
Abstract
Optical coherence tomography angiography (OCTA), as a new generation of non-invasive and efficient fundus imaging technology, can provide non-invasive assessment of vascular lesions in the retina and choroid. In terms of anatomy and development, the retina is referred to as an extension of the central nervous system (CNS). CNS diseases are closely related to changes in fundus structure and blood vessels, and direct visualization of fundus structure and blood vessels provides an effective "window" for CNS research. This has important practical significance for identifying the characteristic changes of various CNS diseases on OCTA in the future, and plays a key role in promoting early screening, diagnosis, and monitoring of disease progression in CNS diseases. This article reviews relevant fundus studies by comparing and summarizing the unique advantages and existing limitations of OCTA in various CNS disease patients, in order to demonstrate the clinical significance of OCTA in the diagnosis and treatment of CNS diseases.
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Affiliation(s)
- Zeqi Shen
- Postgraduate training base Alliance of Wenzhou Medical University (Affiliated People's Hospital), Hangzhou, Zhejiang, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Weitao Yu
- The Second School of Clinical Medicine, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Mengmeng Yue
- Postgraduate training base Alliance of Wenzhou Medical University (Affiliated People's Hospital), Hangzhou, Zhejiang, China
| | - Chaoyang Hong
- Center for Rehabilitation Medicine, Department of Ophthalmology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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Podraza K, Bangera N, Feliz A, Charles A. Reduction in retinal microvascular perfusion during migraine attacks. Headache 2024; 64:16-36. [PMID: 38031892 DOI: 10.1111/head.14654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To determine if there are changes in structure and function of the retinal vasculature during and between migraine attacks using optical coherence tomography angiography (OCTA). BACKGROUND Migraine attacks commonly include visual symptoms, but the potential role of the retina in these symptoms is not well understood. OCTA is a rapid, non-invasive imaging technique that is used to visualize the retinal microvasculature with high spatial resolution in a clinical setting. In this study we used OCTA to quantify different features of the retinal vasculature in patients with migraine during and between attacks, as well as in healthy controls (HCs). METHODS We performed a prospective cohort study of 37 patients with migraine with aura (MA) (median [interquartile range, IQR] age of 37 [14] years, 86% female) and 30 with migraine without aura (MO) (median [IQR] age of 37 [17] years, 77% female) and 20 HCs (median [IQR] age of 35 [7] years, 50% female). Macular OCTA scans were obtained for all participants for the interictal analysis. In 12 MA and eight MO, scans were captured both during and outside of migraine attacks and five HCs had initial and repeat scans. In addition to analyzing the morphology of the foveal avascular zone, we calculated the vessel flux index (VFI), which is an indicator of retinal perfusion and conventional metrics (such as vessel area density) in the foveal and parafoveal regions. RESULTS There was a significant difference in the parafoveal VFI in the ictal state between the groups (p = 0.009). During migraine attacks there was a significant reduction in the parafoveal region VFI in MA (-7%, 95% confidence interval [CI] -10% to -4%; p = 0.006) and MO (-7%, 95% CI -10% to -3%; p = 0.016) from their interictal baseline as compared to the change between repeat scans in HCs (2%, 95% CI -3% to 7%). Interictally, there was a mean (standard deviation [SD]) 13% (10%) (p = 0.003) lower blood perfusion in the MA group as compared to the MO group in the foveal region (mean [SD] 0.093 [0.023] vs. 0.107 [0.021], p = 0.003). Interictal analysis also revealed higher circularity in the superficial foveal avascular zone in the MA group compared with the MO group (mean [SD] 0.686 [0.088] vs. 0.629 [0.120], p = 0.004). In addition, interictal analysis of the patients with MA or MO and unilateral headache showed increased retinal vascular parameters consistent with greater perfusion in the eye ipsilateral to the side of the pain as compared with the contralateral eye. CONCLUSIONS These results indicate that perfusion is reduced in MA and MO in the parafoveal retina during the ictal period. Interictally, the foveal retina in MA has reduced perfusion when compared to the foveal retina in MO. Patients with unilateral headache showed interictal asymmetry of retinal perfusion between eyes. These results indicate that changes in retinal perfusion could be a part of migraine pathophysiology, and that distinct retinal vascular signatures identified with OCTA could represent biomarkers for migraine.
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Affiliation(s)
- Katherine Podraza
- Department of Neurology, University of California, Los Angeles, California, USA
- Hartford Healthcare Headache Center, Mystic, Connecticut, USA
| | - Nitin Bangera
- Department of Neurology, University of California, Los Angeles, California, USA
- Center for Advanced Diagnostics, Evaluation and Therapeutics (CADET NM Inc.), Albuquerque, New Mexico, USA
| | - Akira Feliz
- Department of Neurology, University of California, Los Angeles, California, USA
| | - Andrew Charles
- Department of Neurology, University of California, Los Angeles, California, USA
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Liu Z, Jie C, Wang J, Hou X, Zhang W, Wang J, Deng Y, Li Y. Retina and microvascular alterations in migraine: a systemic review and meta-analysis. Front Neurol 2023; 14:1241778. [PMID: 37840933 PMCID: PMC10568463 DOI: 10.3389/fneur.2023.1241778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Objective This study aimed to evaluate the retina and microvascular alterations with optical coherence tomography (OCT) or optical coherence tomography angiography (OCTA) in patients with migraine with aura (MA) and migraine without aura (MO). Methods PubMed, Embase, and Cochrane Library databases were searched to find relevant literature on patients with MA or MO using OCT/OCTA devices. The eligible data were analyzed by Stata Software (version 15.0). Results There were 16 studies identified, involving 379 eyes with MA, 583 eyes with MO, and 658 eyes of healthy controls. The thickness of the peripapillary retinal nerve fiber layer (pRNFL) of patients with MA decreased significantly in most regions. The foveal avascular zone (FAZ) area and perimeter in MA patients significantly enlarged, while the perfusion density (PD) in the macular deep capillary plexus (mDCP) significantly decreased in the whole image and its subregions except for the fovea, with the PD in radial peripapillary capillary (RPC) decreasing inside the disk. Patients with MO demonstrated a significantly decreased thickness of pRNFL in most regions, and the FAZ parameters were significantly enlarged. No statistical significance was observed in the retina and microvascular features of patients with MA and MO. Conclusion The eyes affected by MA and MO demonstrated significantly reduced thickness of pRNFL and enlarged FAZ. Patients with MA showed retinal microvascular impairments, including a decreased PD in mDCP. The OCT and OCTA could detect membrane morphology and circulation status in migraine and might provide the basis for the diagnosis and follow-up of patients with migraine. Systematic review registration https://www.crd.york.ac.uk/prospero/, CRD42023397653.
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Affiliation(s)
| | - Chuanhong Jie
- Eye Hospital China Academy of Chinese Medical Sciences, Beijing, China
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Ke W, Yu N, Liu X, Gu Y, Qin Q, Ye Z, Li Y, Wang K, Chen M. Analysis of macular microvasculature with optical coherence tomography angiography for migraine: A systematic review and meta-analysis. Front Neurol 2022; 13:1001304. [PMID: 36313505 PMCID: PMC9606770 DOI: 10.3389/fneur.2022.1001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to evaluate the features of macular microvasculature with optical coherence tomography angiography (OCTA) among migraine patients. Methods We systematically searched PubMed, Web of Science, Embase, and Cochrane Library for studies that evaluated the macular microvasculature of migraine patients. The weighted mean differences (WMDs) of the foveal avascular zone (FAZ), foveal superficial capillary plexus (SCP) vessel density (VD), parafoveal SCP VD, foveal deep capillary plexus (DCP) VD, and parafoveal DCP VD with 95% confidence intervals (CIs) among migraine with aura (MA) group, migraine without aura (MO) group, and healthy controls (HC) group were analyzed using a random-effect model. P < 0.05 was considered significant in statistical analyses. Publication bias was assessed using funnel plots and statistical tests (Egger's test and Begg's test). Results Nine studies covering 675 individuals were enrolled in this meta-analysis ultimately. The FAZ of MA patients was not significantly different from HC (WMD = 0.04, 95% CI −0.00 to 0.09). However, the FAZ of MA was significantly larger than that of HC after correction of publication bias by trim and fill method (WMD = 1.03, 95% CI 0.99 to 1.08). The FAZ of MO patients was similar to that of HC (WMD = 0.03, 95% CI −0.00 to 0.07), while smaller than that of MA patients (WMD = 0.05, 95% CI 0.01 to 0.09). VD of the SCP, either in the foveal or parafoveal area, was not significantly different among the three groups. As for DCP, VD in MA patients was lower when compared with HC in the parafovea (WMD = −1.20, 95% CI −1.88 to −0.51). Conclusions We found that there was a larger FAZ in MA compared with HC after adjusting for publication bias. The FAZ in MO was not significantly different from that in HC, but significantly lower than that in MA. There was no significant difference in either foveal or parafoveal VD of SCP among MA, MO, and HC participants, while the parafoveal VD of the DCP in MA was lower than that of the HC.
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Affiliation(s)
- Weishaer Ke
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Naiji Yu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Xin Liu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Yuxiang Gu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Qiyu Qin
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Zifan Ye
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Yuhang Li
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
| | - Kaijun Wang
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
- *Correspondence: Kaijun Wang
| | - Min Chen
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Ophthalmology, Hangzhou, China
- Min Chen
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