Download Embolic Central Retinal Artery Occlusion

The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2016
Copyright Ó 2016 Elsevier Inc.
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http://dx.doi.org/10.1016/j.jemermed.2015.12.022
Ultrasound in
Emergency Medicine
EMBOLIC CENTRAL RETINAL ARTERY OCCLUSION DETECTED WITH
POINT-OF-CARE ULTRASONOGRAPHY IN THE EMERGENCY DEPARTMENT
Alessandro Riccardi, MD,* Cristina Siniscalchi, MD,† and Roberto Lerza, MD*
*SC Medicina e Chirurgia d’Accettazione e d’Urgenza-OBI and †SC Oculistica, Ospedale San Paolo, Savona, Italy
Reprint Address: Alessandro Riccardi, MD, SC Medicina e Chirurgia d’Accettazione e d’Urgenza-OBI, Ospedale San Paolo, Via Genova 1,
Savona 17100, Italy
, Keywords—central retinal artery occlusion; emergency
ultrasound; sudden vision loss
, Abstract—Background: Ocular emergencies account
for 2–3% of all emergency department (ED) visits. Sonographic evaluation of the eye offers a very useful diagnostic
tool in the ED. In the ED setting, ocular ultrasound could
identify a retinal detachment, or a massive vitreous hemorrhage, and the training for emergency medicine practitioners is quite easy. Case Report: An 84-year-old woman
presented to our ED with a painless acute vision loss in her
right eye. Immediate bedside emergency ocular ultrasound
was performed, and it showed a retrobulbar hyperechoic
material, suggestive of an embolus within the central retinal
artery. Fluorescein angiography showed limited and sluggish filling of the retinal arteries after injection of fluorescein, and optical coherence tomography demonstrated a
decrease in the reflectivity and thickness of the inner retinal
layers. The final diagnosis was embolic central retinal artery
occlusion (CRAO). Why Should an Emergency Physician Be
Aware of This?: Among the causes of acute loss of vision,
CRAO is associated with systemic vascular disease. The
importance of visible retinal emboli has been well documented due to its association with increase in mortality. A
rapid evaluation of the central retinal artery could be a simple tool to identify an embolus, and this could lead to a rapid
treatment. The evaluation of central retinal artery is a less
defined setting in emergency physician bedside ultrasound,
but the identification of CRAO could lead to a rapid acceleration in diagnosis and treatment of a potentially lifethreatening disease. Ó 2016 Elsevier Inc.
INTRODUCTION
We briefly report a case of embolic central retinal artery
occlusion detected by point-of-care emergency ultrasound. Ocular disease is quite common and could range
from conditions that are not urgent to organ-threatening
disease: in the latter conditions, point-of-care ultrasonography offers a very useful tool to the emergency
physician.
CASE REPORT
An 84-year-old woman presented to our Emergency
Department (ED) with a painless acute vision loss in
her right eye 30 min prior to presentation. She denied
any associated symptoms. Past medical history included
hypertension, treated with ramipril. She denied smoking
or alcohol use. Her vital signs were normal: heart rate
76 beats/min, blood pressure 130/80 mm Hg, temperature
36.8 C, oxygen saturation 98% while breathing room air,
and electrocardiogram was normal, showing a sinus
rhythm. The physical and neurological examinations
were normal, and the temporal artery evaluation was
normal. Ocular examination was remarkable for visual
acuity loss and for absent light reflex in the right eye,
and the inspection showed no external signs of trauma
Patients gave the authors written consent to use the imaging
reproduced in this paper.
RECEIVED: 21 October 2015; FINAL SUBMISSION RECEIVED: 12 December 2015;
ACCEPTED: 21 December 2015
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A. Riccardi et al.
or infection, conjunctivitis, or evidence of corneal abrasion. Extraocular movements were intact.
Immediate point-of-care emergency ocular ultrasound
was performed, with a 10-MHz linear-array ultrasound
probe using a closed-eye technique: the examination
showed no evidence of vitreous hemorrhage or retinal
detachment, but showed a retrobulbar hyperechoic material, suggestive of an embolus within the central retinal
artery (Figure 1), with intact flow in the ophthalmic
branches. The color Doppler and the pulsated Doppler examinations showed no blood flow within the central
retinal artery. The patient received a weight-adjusted
dose of low-weight molecular heparin (LWMH) (enoxaparin 80 mg) and an emergent Ophthalmology consult
was obtained. The eye’s tonometry was normal. Fundoscopic evaluation of the retina showed optic disc pallor,
and a whitish, edematous retina.
The patient, after a careful examination that excluded
other embolization sites and did not detect any clear
embolic source, was discharged with an LWMH (enoxaparin 80 mg/12 h). The next day the patient returned to
the hospital for further examination in the ophthalmology
ward: fluorescein angiography showed limited and sluggish filling of the retinal arteries (Figure 2), and optical
coherence tomography demonstrated a decrease in the
reflectivity and thickness of the inner retinal layers
(Figure 3). No improvement was observed in visual acuity.
The final diagnosis was embolic central retinal artery
occlusion (CRAO).
DISCUSSION
Ocular emergencies account for 2–3% of all ED visits, and
can range from conditions that are not urgent (e.g., simple
conjunctivitis), or painful conditions (e.g., corneal foreign
Figure 1. Point-of-care ultrasound showed a retrobulbar hyperechoic material as indicated by white arrow suggestive of
an embolus within the central retinal artery.
Figure 2. Fluorescein angiography showed limited and sluggish filling of the retinal arteries after injection of fluorescein.
body) to organ-threatening diseases (such as retinal
detachment or central retinal artery occlusion) (1). The
evaluation of ocular emergencies in a busy ED can be difficult for lack of specialized equipment, and a quick ophthalmologic evaluation is not always available (2,3). The
diffusion of point-of-care ultrasound in Emergency Medicine is useful in many settings, and ocular emergencies are
one of the latest additions: sonographic evaluation of the
eye offers a very useful diagnostic tool to emergency
physicians (1,4). Ocular ultrasonography was initially
investigated in clinical settings in the late 1960s and
early 1970s, but the development of modern equipment
spread its use; in ED settings, ocular ultrasound in
patients with monocular loss of vision could identify
with high accuracy a retinal detachment, or massive
vitreous hemorrhage, and the training for emergency
medicine practitioners is quite easy, as compared with
other settings: the eye is a perfect target for ultrasound,
because it is fluid-filled within hyperechoic structures.
Ocular ultrasound performed by a well-trained emergency
physician could rapidly identify patients with acute visual
change to refer them for appropriate ophthalmology evaluation (1). Among other causes of acute loss of vision,
CRAO is associated with systemic vascular disease, and
the causes include embolism, thrombosis, vasculitis, arterial spasm, arterial dissection, and hypertensive arteriolar
necrosis (5). The importance of visible retinal emboli has
been well documented due to its association with increase
in mortality (2). Furthermore, the identification of an
Emergency Ultrasound in Embolic Retinal Artery Occlusion
3
Figure 3. Optical coherence tomography demonstrated a decrease in the reflectivity and thickness of the inner retinal layers.
embolization is important because it requires a thorough
evaluation for the source of embolic material (3). As reported by Foroozan et al., ocular ultrasound could identify
emboli in the central retinal artery as a cause of CRAO (6).
The detection of hyperechoic material in the retrobulbar
circulation quickly differentiates embolic disease from
other causes of CRAO, and the identification of an embolic
cause of CRAO is critical also for prevention of embolism
in other areas (3–5). To the best of our knowledge, this is
the first documentation of embolic CRAO detected by
emergency ultrasound performed by an emergency
physician. Although there is no good therapy for retinal
artery thrombosis, a quick identification of an embolic
retinal artery occlusion may lead to invasive treatment in
selected cases, as reported in some anecdotal reporting in
the literature (7–9). Also, once an embolic cause for a
CRAO is recognized, any efforts can be directed toward
identifying a source of the embolus (2). Furthermore, the
identification of emboli excludes other important causes
of CRAO, such as giant cell arteritis, and this could spare
patients high-dose corticosteroids and invasive procedures,
such as temporal artery biopsies (2,6). Point-of-care emergency ultrasound is a well-demonstrated useful tool to
evaluate acute change in vision (1). In our case, the
point-of-care ultrasound didn’t change the patient’s
outcome, but in selected patients the rapid detection of
an embolic CRAO could change the management and
could lead to an invasive and appropriate treatment. Evaluation of the central retinal artery is a less defined setting in
emergency point-of-care ultrasound, but the rapid identification of an image, such as that reported in Figure 1, could
lead to an acceleration in the diagnosis and treatment of a
potentially life-threatening disease.
WHY SHOULD AN EMERGENCY PHYSICIAN BE
AWARE OF THIS?
Our case report is important because an immediate identification of embolic CRAO is essential: an emergency
point-of-care ocular ultrasound, usually oriented toward
a search for retinal detachment, could also identify an
embolic CRAO and could lead to an acceleration in diagnosis and treatment of a potentially life-threatening
disease.
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