Surgical mobilization of an arterial embolus on a cilioretinal artery occlusion

Author: Víctor Lázaro-Rodríguez (Spain)

Co-authors: Maximiliano Olivera, Jéssica Botella, Sònia Viver, Jeroni Nadal

Purpose

To describe an effective surgical approach for the management of cilioretinal artery occlusion. Cilioretinal artery occlusion has been found to comprise about 5% of retinal arterial occlusions. Isolated cilioretinal artery occlusion is very unlikely but it produces significant central vision impairment and central visual field loss with good peripheral vision. Therapeutic options for these patients are scarce. The most common therapeutic attitude is observation. We describe an effective technique to perform surgical direct mechanical mobilization of an arterial embolus on a cilioretinal artery occlusion without inducing intraocular hypotony.

Setting/Venue

Retina and Vitreous Unit, Barraquer Ophthalmology Centre, Barcelona.

Methods

An 80-year-old male was referred to our retina department three hours after a sudden vision loss in his left eye (LE). As medical history, he presented dyslipidemia, atherosclerosis and cardiac arrhythmia. Ophthalmological examination revealed a BCVA of 20/30 in the RE and 20/60 in the LE. Left eye fundus exam showed a well-limited white colored area surrounding the cilioretinal artery in the papillomacular bundle corresponding to nerve fiber layer infarction. Fluorescein angiography (FA) demonstrated a blockage defect over the edematous area in the papilomacullar bundle surrounding the cilioretinal artery with a slow filling. In late stages, an embolus was identified by a characteristic hyperfluorescent staining pattern in a bifurcation of the cilioretinal artery, near the optic nerve head. Optical coherence tomography angiography (OCT-A) revealed a non-perfusion area coincident with previous observations. A 23-G pars plana vitrectomy assisted with two soft tip cannulas was performed. One cannula pressed the cilioretinal artery branch directed towards the macula, distal to the location of the embolus, while the other cannula was used to gently swipe over the cilioretinal artery proximal to the occlusion. Anatomical and functional outcomes were evaluated by fundus examination, fluorescein angiography, Goldmann visual field and best-corrected visual acuity.

Results

It was possible to mobilize the embolus by mechanical displacement with 23-G soft-tip cannulas and disintegrate it, preventing the passage towards the branch directed to the macula. Intrasurgical restoration of retinal circulation was confirmed by fluorescein angiogram after the surgery. The patient recovered his previous documented best corrected visual acuity (20/35) and visual field.

Conlusions

Pars plana vitrectomy followed by direct vascular manipulation could lead to embolus mobilization after several attempts. The present surgical technique should be considered as a new possibility of achieving a permanent solution in the occlusion of cilioretinal artery or any other retinal arterial occlusion.

Financial Disclosure

None