Download Case Report Central Retinal Artery Occlusion

Case Report
Central Retinal Artery Occlusion- A rare complication of oral contraceptive pills
Nidhi Pancholi*, Reema Rawal** Lalit Prabha Gupta
Resident Doctor, Dept. of Obs.&Gynec.,*, Assoc. Professor, Dept. of Ophthalmology,**, Sr. Medical Officer,
Smt. NHL Municipal Medical College, Ahmedabad.
ABSTRACT
Aim: To propose a hypothesis of causal
association between central retinal artery
occlusion (CRAO) and oral contraceptive pills
(OCP)
Case Summary:
A case report-A 22 yr old, female presented with
sudden painless loss of vision in OS [Right Eye]
for 1 day. VA [Visual Activity] in OS was PL
PR [Perception of Light and Projection of Rays]
Faulty with RAPD [Relative Afferent Papillary
Defect] with normal for fifteen minutes, given
five hundred mg of acetazolamide orally stat, 0.4
ml of anterior chamber paracentesis done, 5400
IU LMW [Low Molecular Weight] heparin given
SC[Subcutaneous] with carbogen inhalation.
Retrospectively she was on oral contraceptives
(Mala D) for 1 month. She was not hypertensive
or diabetic with normal blood, coagulation
profile & carotid Doppler. She was evaluated by
an intern to find the cause of coagulation
disorder and was found to be normal. On first
day FFA [Fundus Florescien Angiography]
showed no blockage with normal cilioretinal
artery perfusion established. Visual fields after
one week showed central tubular vision and
OCT [Ocular Coherent Tomography] showed
normal fovea. After 2 weeks vision was 20/80
with persistent RAPD papilla macular bundle
being perfused.
Key words:
OC Pills, CRAO [Central retinal Artery
Occlusion], Arterial occlusion, Mala D,
Thromboembolic event, cilio retinal artery
occlusion, sudden severe vision loss
INTRODUCTION
Central Retinal Artery Occlusion (CRAO) has
one of the most dramatic presentations with
rapid sudden and profound loss of vision, most
of the time irreversible and strong association
with life threatening systemic disorders. CRAO
usually occurs in patients above the age of fifty
years, males being affected twice as frequently
as females. CRAO commonly occurs due to
embolisation (from myocardial infarct, sub acute
bacterial endocarditis, vasoobliteration as seen in
arteritis,
scleroderma,
dermatomyositis,
Takayasu’s disease tuberculous and syphilitic
arteritis) or from pressure outside the arterial
wall e.g.: during increased intra ocular pressure
(acute congestive glaucoma, retinal detachment
surgery) orbital floor fracture or retro bulbar
haemorrhage. Increased blood viscosity may
occasionally precipitate vascular occlusion as in
childhood
leukemia,
polycythemia
and
dysproteinemias.
The role of oral contraceptives (OCs) is assumed
from observation of a few cases, and is rare in
women under the age of 40 years. The vascular
effects may include venous or arterial occlusion
of retina, isolated retinal bleeding, retinal
oedema, vascular pseudopapillitis or visual
problems resulting from transient cerebral
ischemic attacks and ophthalmic migraine1.
Macular edema has been very rarely seen (rare to
establish a causal relationship). Animal
experiments show increased permeability to lens
and vascular dilation. Post marketing experience
has included very rare reports of eye
inflammation including iritis and uveitis.
Manufacturers of oral contraceptive products
have reported that some patients develop
changes in contact lens tolerance.
An American study recently found 82 cases
among ten to fifteen million OC Pill users1. The
incidence of ocular complication from birth
control pills is estimated to be 1 in 2, 30,0002.
Ocular
problems
like
migraine,
thromboembolism or pseudo tumors can be the
presenting symptoms of side effect of OCPills3,4.
Acute
maculoneuroretinopathy5,
macular
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NHL Journal of Medical Sciences/July 2013/Vol.2/Issue 2
hemorrhage, central retinal vein occlusion,
central retinal artery occlusion and perivasculitis
have been reported. Most of these are seen in
patients taking OC Pills for long time. 2 cases of
young woman who had taken birth control pills
and in whom arterial vascular occlusion of retina
developed was reported by Leff et al2. Giromi et
al6 published a case report a central retinal artery
occlusion in a young woman after ten days of
drospirenone containing oral contraceptive. Perry
HD et al. showed cilioretinal artery occlusion
associated with oral contraceptives7. Stowe et al.
first time showed CRAO in association with OC
Pills8,9. We report a case of CRAO in a young
woman who was on contraceptive for 1 month.
CASE REPORT:
A 22 year old female presented to us with a
history of sudden, profound, painless loss of
vision in the left eye for 24 hours. She was on
oral contraceptives ‘Mala D’ for 1 month. She
had a history of menorrhagia for which she was
put on OCP by a gynecologist. Her right eye was
normal. The left eye anterior segment was
normal except for afferent papillary defect and
vision was perception of light only. Fundus
showed right normal eye and left eye mild
neuroretinitis and cherry red spot at the macula
suggestive of central retinal artery occlusion.
She was immediately given a vigorous digital
massage for fifteen minutes, five hundred mg of
diamox orally, anterior chamber 0.4 ml
paracentesis done, five thousand four hundred IU
LMW heparin was given subcutaneously and
carbogen breathing was started under the
observation of an internist.
A thorough systemic examination revealed no
abnormality. She was non hypertensive and
nondiabetic. The blood examination showed a
platelet of 3, 20,000/cmm. Bleeding, clotting and
prothrombin time were within normal limits;
total proteins 6.3 g/dl, albumin 3.1 g/dl; lipid
profile and renal test were normal. LE [Lupus
Erythematous Cells] cell and ANA [Antinuclear
Antibody] were negative. She had normal
Hemoglobin electrophoresis, chest X ray and
echocardiogram. Blood pressure, carotid
ultrasonography,
complete
blood
count,
erythrocyte sedimentation rate, fasting lipids and
glucose, auto antibody screen including anti
cardiolipin antibody, protein C and S level,
factor V Leiden and blood homocysteine level
were normal. She had severe anemia with Hb of
3.5 gm percent but she had no history of
breathlessness or fatigue.
She was given packed cell volume to treat her
anemia and stopped OC Pills and given an intra
vitreal triamcinolone injection to treat the retinal
oedema and started multivitamins.
On first post treatment day, fundus examination
revealed CRAO, with sparing of central cilio
retinal artery. Fundus fluorescence angiography
revealed a normal angiogram with normal arm to
choroid time, normal filling of arteries and veins
with normal cilio retinal artery perfusion. There
was no cart boxing of blood and the arteries were
not attenuated. No visible vascular block was
identified. This was probably due to dislodging
of the embolus due to the treatment given the day
before. Carotid Doppler of the ICA [Internal
Carotid Artery] revealed no abnormalities.
Visual acuity was 20/200p.
A 2 week follow up of the patient revealed the
patient had Relative Afferent Pupillary Defect in
the left eye but the vision restored to 20/80.
Fundus showed resolving retinal edema at
posterior pole with papilla macular bundle being
perfused and pink color of retina being restored
to some extent with disc pallor. OCT showed
normal macula. Visual fields were done and it
showed tunnel vision supporting the diagnosis.
DISCUSSION
Females on OC Pills are prone to
thromboembolic event, more common in the
venous than in the arterial system10.
Concentration of the estrogen content has a role
to play11,12,13. Ethinyl estradiol more than fifty
microgram increases the risk. Anemia, smoking,
impaired glucose tolerance, hypertension, history
of vascular problems and visual problems
increase the risk.
Any patient regardless of age receiving OC Pills
should be assessed thoroughly for vascular
abnormality, lipid profile. The dispensing of oral
contraceptive pills over the counter should be
NHL Journal of Medical Sciences/July 2013/Vol.2/Issue 2
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controlled. Close follow up of woman taking oral
contraceptive pills be done.
REFERENCES
1 Villate-catheloneau B. The eye and hormones: vascular
disorders associated with combined oral contraceptives
and pregnancy. Contracept Fertil Sex (Paris). 1985 Jan; 13
(1 Suppl): 147-52.
2 Leff S P, Side effect of oral contraceptives: occlusion of
branch artery of retina.Bull Sinai Hosp Detroit. 1976
Oct;24(4):227-9.
3 Varga M. Recent experiences on ophthalmologic
complications of oral contraceptives. Ann Ophthalmol
1976; 925-34.
4 Glacet-Bernard A, Kuhn D, Soubrane G. Ocular
complications of hormonal treatments: oral contraception
and menopausal hormonal replacement therapy.
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5 Rush JA. Acute macular neuroretinopathy. Am J
Ophthalmol 1977; 83:490-94.
6 Girolami A, Vettore S, Tezza F, Girolami B. Retinal
central artery occlusion in a young woman after ten days
of a drospirenone-containing oral contraceptive. Thromb
Haemost. 2007 Aug; 98(2):473-4.
7 Perry HD, Mallen EJ. Cilioretinal artery occlusion
associated with oral contraceptives. Am J Ophthalmol
1977; 84:56-58.
8 Stowe GC-3d, Zakov ZN, Albert DM, CRAO associated
with oral contraceptives. Am J Ophthalmol 1978; 86:798801.
9 Mehta C. Central Retinal Artery Occlusion and Oral
Contraceptives. Indian J Ophthalmol. 1999 Mar: 47(1):356.
10 Asensio Sanchez VM, Perez Flandez FJ, Bartolome
Aragon A, Gil Fernandez E. Ophthalmologic vascular
occlusions and oral contraceptives. Arch Soc Esp
Oftalmol. 2002 Mar; 77(3):163-6.
11 Satoskar
K.
Bandarkar’s
Pharmacology
and
Pharmacotherapeutics. XII ed. Bombay. Popular
Prakashan Pvt. Ltd; 1991. Part II. P 843.
12 .Practice Of Fertility Control, S. K. Chaudhari, VII ed.
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13 .Clinical Gynecologic Endocrinology and Infertility, VIII
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