Utility of ocular ultrasonography in the thrombolytic therapy for acute central retinal artery occlusion

Castilla-Guerra, Luis; Gómez-Escobar, Antonio; Morillo-Sánchez, María José; Fernandez-Moreno, Maria del Carmen

doi:10.1016/j.rceng.2023.09.001

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Color photograph of the fundus (A). Fluorescein angiography (B). Ocular ultrasound (C)." ] ] ] "textoCompleto" => "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">1</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">1</a>.Currently, as per the American Heart Association/American Stroke Association (AHA/ASA)<a class="elsevierStyleCrossRef" href="#bib0010">2</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">3</a>.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">1–4</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">5</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">4</a>.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">1</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">3</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">6</a>.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">3</a>. Therefore, this finding predicts low rates of spontaneous reperfusion and thrombolytic treatment success.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).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>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>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.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">7</a>.Ocular ultrasonography is gaining prominence and becoming an integral part of evaluating monocular vision loss<a class="elsevierStyleCrossRef" href="#bib0040">8</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">3,5,7</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.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.Conflict of interestThe authors declare no conflicts of interest.FundingNo funding has been received for the preparation of this manuscript." 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Lorenz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Stroke" "fecha" => "2015" "volumen" => "46" "paginaInicial" => "2322" "paginaFinal" => "2324" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intravenous fibrinolysis for central retinal artery occlusion: a cohort study and updated patient-level meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Mac Grory" 1 => "A. Nackenoff" 2 => "S. Poli" 3 => "M.S. Spitzer" 4 => "M. Nedelmann" 5 => "B. 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Vol. 223. Issue 9.

Pages 582-583 (November 2023)

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Si es usted socio de FESEMI siga los siguientes pasos:

Diríjase desde aquí a la web de la >>>FESEMI<<< e inicie sesión mediante el formulario que se encuentra en la barra superior, pulsando sobre el candado.