HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vallée, J.-N. Articles by Merland, J.-J. Search for Related Content PubMed PubMed Citation Articles by Vallée, J.-N. Articles by Merland, J.-J.

Combined Central Retinal Arterial and Venous Obstruction: Emergency Ophthalmic Arterial Fibrinolysis¹

¹ From the Departments of Neuroradiology and Therapeutic Angiography (J.N.V., A.A., J.J.M.) and Ophthalmology (M.P., P.M., P.Y.S., A.G.), Hôpital Lariboisière, University of Paris, France; and Department of Biostatistics and Medical Informatics, University of Lyon, France (P.A.). Received February 7, 2001; revision requested March 26; final revision received August 23; accepted September 14. Address correspondence to J.N.V., Federation of Neuroradiology, Charcot Diagnostic and Interventional Neuroradiology Service, Groupe Hospitalo-Universitaire Pitié-Salpétrière, 43-87 boulevard de l’Hôpital, 75651 Paris Cedex 13, France (e-mail: jean-noel.vallee@psl.ap-hop-paris.fr).

View larger version (57K): [in a new window]   Figure 1. Routine investigation for systemic diseases.

View larger version (207K): [in a new window]   Figure 2. A 1.8-F flow-guide microcatheter. An S shape is given to the tip of the microcatheter, by using steam, in accordance with the geometry of the carotid arterial siphon and ophthalmic arterial ostium. This allows effective catheterization of the ophthalmic artery ostium and optimal stability of the microcatheter tip inside the ostium of the ophthalmic artery.

View larger version (132K): [in a new window]   Figure 3. Anteroposterior superselective ophthalmic arteriogram obtained before perfusion of urokinase shows the tip of the microcatheter (arrow) in the ostium of the ophthalmic artery and choroidal blush (arrowheads).

View larger version (165K): [in a new window]   Figure 4a. Patient 11. Preoperative features. (a) Slit-lamp biomicroscopic image of fundus shows moderate dilatation and a tortuous venous network (black arrow), few retinal hemorrhages (white arrows), and ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was counting fingers at 3 feet (91 cm). (b) Fluorescein angiogram depicts the fundus in the retinal arterial phase. Retinal arterial filling is delayed, and filling is not complete (arrows) 20 seconds after emergence of dye in the retinal arteries at the optic disk. This finding indicates severe impairment of the retinal arterial supply. There is no visible intraarterial embolus. (c) Fluorescein angiogram depicts the fundus in the retinal arteriovenous phase. The arteriovenous transit time, from emergence of dye in the retinal arteries to the appearance of venous laminar flow (arrow) at the optic disk, is prolonged to 31 seconds (normal, 2 seconds). There is no capillary occlusion at the posterior pole. The venous network is delayed and is filled completely only after 60 seconds (normal, 15 seconds).

View larger version (165K): [in a new window]   Figure 4b. Patient 11. Preoperative features. (a) Slit-lamp biomicroscopic image of fundus shows moderate dilatation and a tortuous venous network (black arrow), few retinal hemorrhages (white arrows), and ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was counting fingers at 3 feet (91 cm). (b) Fluorescein angiogram depicts the fundus in the retinal arterial phase. Retinal arterial filling is delayed, and filling is not complete (arrows) 20 seconds after emergence of dye in the retinal arteries at the optic disk. This finding indicates severe impairment of the retinal arterial supply. There is no visible intraarterial embolus. (c) Fluorescein angiogram depicts the fundus in the retinal arteriovenous phase. The arteriovenous transit time, from emergence of dye in the retinal arteries to the appearance of venous laminar flow (arrow) at the optic disk, is prolonged to 31 seconds (normal, 2 seconds). There is no capillary occlusion at the posterior pole. The venous network is delayed and is filled completely only after 60 seconds (normal, 15 seconds).

View larger version (173K): [in a new window]   Figure 4c. Patient 11. Preoperative features. (a) Slit-lamp biomicroscopic image of fundus shows moderate dilatation and a tortuous venous network (black arrow), few retinal hemorrhages (white arrows), and ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was counting fingers at 3 feet (91 cm). (b) Fluorescein angiogram depicts the fundus in the retinal arterial phase. Retinal arterial filling is delayed, and filling is not complete (arrows) 20 seconds after emergence of dye in the retinal arteries at the optic disk. This finding indicates severe impairment of the retinal arterial supply. There is no visible intraarterial embolus. (c) Fluorescein angiogram depicts the fundus in the retinal arteriovenous phase. The arteriovenous transit time, from emergence of dye in the retinal arteries to the appearance of venous laminar flow (arrow) at the optic disk, is prolonged to 31 seconds (normal, 2 seconds). There is no capillary occlusion at the posterior pole. The venous network is delayed and is filled completely only after 60 seconds (normal, 15 seconds).

View larger version (158K): [in a new window]   Figure 5a. Patient 11. Postoperative features. (a) Fundus photograph obtained 24 hours after fibrinolysis shows a slight transient increase of retinal hemorrhages (arrows) without clinical consequences. (b, c) Fluorescein angiograms of the fundus were obtained 24 hours after fibrinolysis with urokinase. Visual acuity improved to 20/20. (b) Retinal arterial phase: Retinal arterial filling (arrows) is beginning shortly after choroidal filling. (c) Retinal arteriovenous phase: Arteriovenous transit time returns to normal at 2 seconds as shown by the early appearance of venous laminar flow (arrow) at the optic disk, which indicates normalization of retinal circulation time. Complete venous filling takes 12 seconds. Visual acuity was 20/20. (d) Slit-lamp biomicroscopic image depicting the fundus at 1 month after fibrinolysis shows normalization of the venous caliber (large arrows) and disappearance of retinal hemorrhages (small arrows) and of the ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was 20/20.

View larger version (128K): [in a new window]   Figure 5b. Patient 11. Postoperative features. (a) Fundus photograph obtained 24 hours after fibrinolysis shows a slight transient increase of retinal hemorrhages (arrows) without clinical consequences. (b, c) Fluorescein angiograms of the fundus were obtained 24 hours after fibrinolysis with urokinase. Visual acuity improved to 20/20. (b) Retinal arterial phase: Retinal arterial filling (arrows) is beginning shortly after choroidal filling. (c) Retinal arteriovenous phase: Arteriovenous transit time returns to normal at 2 seconds as shown by the early appearance of venous laminar flow (arrow) at the optic disk, which indicates normalization of retinal circulation time. Complete venous filling takes 12 seconds. Visual acuity was 20/20. (d) Slit-lamp biomicroscopic image depicting the fundus at 1 month after fibrinolysis shows normalization of the venous caliber (large arrows) and disappearance of retinal hemorrhages (small arrows) and of the ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was 20/20.

View larger version (142K): [in a new window]   Figure 5c. Patient 11. Postoperative features. (a) Fundus photograph obtained 24 hours after fibrinolysis shows a slight transient increase of retinal hemorrhages (arrows) without clinical consequences. (b, c) Fluorescein angiograms of the fundus were obtained 24 hours after fibrinolysis with urokinase. Visual acuity improved to 20/20. (b) Retinal arterial phase: Retinal arterial filling (arrows) is beginning shortly after choroidal filling. (c) Retinal arteriovenous phase: Arteriovenous transit time returns to normal at 2 seconds as shown by the early appearance of venous laminar flow (arrow) at the optic disk, which indicates normalization of retinal circulation time. Complete venous filling takes 12 seconds. Visual acuity was 20/20. (d) Slit-lamp biomicroscopic image depicting the fundus at 1 month after fibrinolysis shows normalization of the venous caliber (large arrows) and disappearance of retinal hemorrhages (small arrows) and of the ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was 20/20.

View larger version (162K): [in a new window]   Figure 5d. Patient 11. Postoperative features. (a) Fundus photograph obtained 24 hours after fibrinolysis shows a slight transient increase of retinal hemorrhages (arrows) without clinical consequences. (b, c) Fluorescein angiograms of the fundus were obtained 24 hours after fibrinolysis with urokinase. Visual acuity improved to 20/20. (b) Retinal arterial phase: Retinal arterial filling (arrows) is beginning shortly after choroidal filling. (c) Retinal arteriovenous phase: Arteriovenous transit time returns to normal at 2 seconds as shown by the early appearance of venous laminar flow (arrow) at the optic disk, which indicates normalization of retinal circulation time. Complete venous filling takes 12 seconds. Visual acuity was 20/20. (d) Slit-lamp biomicroscopic image depicting the fundus at 1 month after fibrinolysis shows normalization of the venous caliber (large arrows) and disappearance of retinal hemorrhages (small arrows) and of the ischemic whitening of the retinal posterior pole (arrowheads). Visual acuity was 20/20.

View larger version (22K): [in a new window]   Figure 6a. Line graphs depict the mean evolutionary trends for vision and retinal perfusion in 11 patients with combined CRAO and CRVO. Error bars indicate 95% CIs. (a) Improvement in mean visual acuity was significant within 24-48 hours after fibrinolysis (P = .009), increased until 1 month after (P = .006), and then remained stable throughout the mean 3.5-year follow-up (P > .10). The graph shows a significant linear (P = .046 at 1 year) and quadratic (P = .009 at 1 year) trend over time. (b) Improvement in mean retinal perfusion was significant (P = .002) within 24-48 hours after fibrinolysis and at 1 (P < .001), 6 (P < .001), and 12 (P = .001) months after. The graph shows a significant linear and quadratic trend over time (P < .001 at 1 year).

View larger version (20K): [in a new window]   Figure 6b. Line graphs depict the mean evolutionary trends for vision and retinal perfusion in 11 patients with combined CRAO and CRVO. Error bars indicate 95% CIs. (a) Improvement in mean visual acuity was significant within 24-48 hours after fibrinolysis (P = .009), increased until 1 month after (P = .006), and then remained stable throughout the mean 3.5-year follow-up (P > .10). The graph shows a significant linear (P = .046 at 1 year) and quadratic (P = .009 at 1 year) trend over time. (b) Improvement in mean retinal perfusion was significant (P = .002) within 24-48 hours after fibrinolysis and at 1 (P < .001), 6 (P < .001), and 12 (P = .001) months after. The graph shows a significant linear and quadratic trend over time (P < .001 at 1 year).