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Utility of ocular ultrasonography in the thrombolytic therapy for acute central retinal artery occlusion
Utilidad de la ecografía ocular en el tratamiento fibrinolítico de la oclusión de la arteria central de la retina
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Color photograph of the fundus (A). Fluorescein angiography (B). Ocular ultrasound (C).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Central retinal artery occlusion (CRAO) is a severe eye condition in which the blood supply to the retina is interrupted, causing a sudden and painless loss of vision<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. While some patients experience spontaneous visual recovery, more than 80% of affected individuals are left with a final visual acuity of counting fingers or less<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently, as per the American Heart Association/American Stroke Association (AHA/ASA)<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, it is considered a form of acute ischemic stroke. As an ischemic stroke type, acute CRAO can be amenable to treatment with thrombolytic therapy, and indeed, this concept has been applied since the 1960s, initially with streptokinase<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is currently no universally accepted treatment regimen, although various studies and meta-analyses on intravenous or intra-arterial thrombolysis have yielded promising results<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a>. In fact, in a recent survey, over half of neurologists in North American university hospitals offered intravenous alteplase to selected patients with acute CRAO<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. Furthermore, another recent study and meta-analysis found that early administration of intravenous alteplase within the first 4.5 h of symptom onset improved the rate of visual recovery compared to untreated patients and historical controls<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the assessment of patients with CRAO, the fundus examination reveals a lack of perfusion in the retinal arteries, but direct evidence of retrobulbar occlusion of the central retinal artery is scarce<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Conversely, ocular ultrasonography allows for the direct examination of the central retinal artery. Alongside Color Doppler assessment of vascular flow, at times, the B-mode can reveal a hyperechoic structure within the occluded artery, known as the retrobulbar spot sign<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. This sign can help distinguish vasculitic occlusion from embolic occlusion, as it does not occur in vasculitis. On the other hand, the spot sign is only found in a proportion of embolic CRAOs. It has been suggested that it might represent a calcified portion of the embolus, which would also have implications for patient treatment<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Thus, in a prospective study involving 46 CRAO patients, among those undergoing thrombolysis, clinically relevant visual improvement was only found in those without the spot sign<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. Therefore, this finding predicts low rates of spontaneous reperfusion and thrombolytic treatment success.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To clearly illustrate the utility of ultrasonography in such cases, we present here the case of a 72-year-old patient with a history of hypertension and diabetes, who presented with painless vision loss in the left eye and was diagnosed with occlusion of a branch of the retinal artery (BRAR).</p><p id="par0035" class="elsevierStylePara elsevierViewall">An ocular ultrasound was performed, revealing a hyperechoic linear embolus located within the optic nerve/retina disc. Fundoscopy revealed an embolus occluding the inferotemporal arteriole, which was later confirmed by fluorescein angiography of the fundus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was treated conservatively. Further extensive diagnostic studies showed that the cause was a calcific embolus due to a severely calcified aortic valve with severe valvular insufficiency.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Traditionally, direct fundoscopy has been used as the primary diagnostic tool for CRAO. However, many physicians may not reliably visualize ocular abnormalities through fundus examination, making its urgent use often more limited. Additionally, a retrospective study showed that only 11% of CRAO patients exhibit evidence of embolism through fundus visualization<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ocular ultrasonography is gaining prominence and becoming an integral part of evaluating monocular vision loss<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. More commonly, it has been used to assess retinal detachment, vitreous hemorrhage, and posterior vitreous detachment. Ultrasonography can also be used to evaluate CRAO and assess the presence of the spot sign<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,7</span></a>. Its presence or absence can assist in the evaluation and treatment of these patients. Thus, ultrasonography can identify patients with a higher likelihood of benefiting from acute thrombolytic treatment.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We believe, therefore, that ocular ultrasonography should be incorporated into routine clinical practice for assessing patients with suspected CRAO, not only for diagnosis but also to aid in determining whether the patient is a candidate for thrombolysis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">No funding has been received for the preparation of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:1 [ "titulo" => "Bibliografía" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 540 "Ancho" => 1674 "Tamanyo" => 103790 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Calcified embolus occluding the inferotemporal retinal arteriole of the left eye. Color photograph of the fundus (A). Fluorescein angiography (B). Ocular ultrasound (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A review of central retinal artery occlusion: clinical presentation and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.D. Varma" 1 => "S. Cugati" 2 => "A.W. Lee" 3 => "C.S. 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