Why you should own a stethoscope – Patent Foramen Ovale in association with Retinal Macroaneurysm
Author: Aadil Hussain (United Kingdom)
Co-authors: Ben Burton
Patent Foramen Ovale (PFO) represents a persistent atrial communication following birth. This opening may be large enough to act as a channel for the flow of thrombi/emboli from venous to arterial circulation. PFO has been associated with cryptogenic stroke, migraine with aura, and decompression sickness. Ophthalmic manifestations have been reported in the literature, including retinal artery occlusions and ischaemic optic neuropathy. We report a case of undiagnosed Patent Foramen Ovale (PFO), identified following presentation with recurrent retinal arterial macroaneurysms.
Care for this patient was provided at James Paget University Hospitals NHS Foundation Trust in Norfolk, United Kingdom.
A 49-year-old fit and well female presented with a 5-day history of floaters in the right eye after referral from General Practitioner. Upon review, V/A was 6/6 in both eyes, and examination of the anterior segment was unremarkable. Fundal examination of the left eye returned normal while the right eye revealed multi-layered retinal haemorrhages along the inferotemporal retinal vascular arcade without macular extension. Ruptured retinal macroaneurysm was suspected. At one month follow up, haemorrhage had resolved, and a thrombosed and involuted saccular retinal macroaneurysm was identified. At this time, she was noted to have some disruption of normal vascular architecture in the superonasal arcade with irregular narrowing. A smaller macroaneurysm was also seen to be developing proximally to the original macroaneurysm on the inferonasal arcade. It was suspected that these appearances may be linked to cardiac emboli. Auscultation of her heart revealed a cardiac murmur. An echocardiogram was arranged, and she was subsequently referred to cardiology for review and further investigations. Transthoracic echocardiogram confirmed diagnosis of PFO.
With 7-day ECG, CT Angiogram and Aortic Arch study returning normal, percutaneous closure of the PFO in the context of an otherwise structurally normal heart has been planned to reduce risk of cryptogenic stroke. Whilst on the waiting list for PFO closure the patient re-presented with sudden onset loss of vision to counting fingers in the right eye. Investigation revealed repeat bleed with large subhyaloid haemorrhage covering the entirety of the macula preventing visualisation of retinal layers. This was treated with YAG laser hyaloidotomy. At 1 week follow up the vision improved to 6/15 with some residual vitreous haemorrhage noted. She remains on the waiting list for percutaneous closure of PFO. Pars plana vitrectomy and retinal laser for the treatment of incomplete clearance of vitreous haemorrhage remain an option for consideration. We postulate that emboli from PFO may play a role in the development of retinal arterial macroaneurysms. Thrombus formation and emboli dislodgment cause focal vessel wall damage, creating a predisposition for macroaneurysm as a compensatory mechanism for abnormal local blood flow and resultant hypoxia. PFO may act as a conduit for the flow of paradoxical emboli into the ophthalmic arterial circulation.
Patent Foramen Ovale (PFO) and associated paradoxical emboli may play a role in the development of retinal arterial macroaneurysms. PFO should be considered as a potential cause in a younger population with lower cardiovascular risk. YAG laser hyaloidotomy proved a successful technique for the rapid treatment of subhyaloid haemorrhage due to ruptured macroaneurysm.
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