Empty vessel in central retinal artery occlusion: A sign denovo

Ashok Kanakamedla; Anurag Shandil; Sriram Simakurthy; Vinaya K Konana; Jayamadhury Gudimetla; R Madhu Kumar

doi:10.4103/ijo.IJO_2018_20

CASE REPORT

Year : 2021 | Volume : 1 | Issue : 2 | Page : 335-336

Empty vessel in central retinal artery occlusion: A sign denovo

Ashok Kanakamedla, Anurag Shandil, Sriram Simakurthy, Vinaya K Konana, Jayamadhury Gudimetla, R Madhu Kumar
Department of Vitreo-Retina, Sankara Eye Hospital, Guntur, Andhra Pradesh, India

Date of Submission	20-Jun-2020
Date of Acceptance	04-Dec-2020
Date of Web Publication	01-Apr-2021

Correspondence Address:
Dr. Anurag Shandil
Department of Vitreo-retina, Sankara Eye Hospital, Guntur - 522 509, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2018_20

Abstract

A 16-year-old female presented with a sudden onset painless diminution of vision in the right eye. Fundus examination showed retinal whitening at the posterior pole with a cherry red appearance of fovea suggestive of CRAO. Swept-source Optical coherence tomography (SS-OCT) showed increased thickness, hyperreflective inner retina, and an empty vessel. Optical coherence tomography angiography (OCT-A) confirmed the absence of perfusion in the vessel. After intervention, reperfusion in the vessel was appreciated both on SS-OCT and OCT-A. We report a novel finding of detection of empty vessels on SS-OCT in a case of central retinal artery occlusion (CRAO).

Keywords: CRAO, empty vessel, optical coherence tomography, OCTA

How to cite this article:
Kanakamedla A, Shandil A, Simakurthy S, Konana VK, Gudimetla J, Kumar R M. Empty vessel in central retinal artery occlusion: A sign denovo. Indian J Ophthalmol Case Rep 2021;1:335-6

How to cite this URL:
Kanakamedla A, Shandil A, Simakurthy S, Konana VK, Gudimetla J, Kumar R M. Empty vessel in central retinal artery occlusion: A sign denovo. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2023 Mar 29];1:335-6. Available from: https://www.ijoreports.in/text.asp?2021/1/2/335/312350

Central retinal artery occlusion (CRAO) is a rare sight-threatening condition affecting 1 in 100,000 people.^[1] It presents with sudden onset, severe vision loss and prognosis is usually poor with irreversible damage occurring within 240 min of occlusive event.^[2] The diagnosis of CRAO is made on medical history and clinical examination. Fluorescein angiography (FA) supplements the diagnosis and helps in the follow-up evaluation to check for reperfusion in the occluded vessels. Optical coherence tomography (OCT) and Optical coherence tomography angiography (OCT-A) help in noninvasive layer-by-layer assessment of retinal morphology and vasculature.

In this case report, we demonstrate identification of an empty vessel on SS-OCT in CRAO, which has not been described so far.

Case Report

A 16-year-old female presented with sudden onset painless diminution of vision in her right eye for the last 24 h. At presentation, her best-corrected visual acuity (BCVA) was perception of light in the right eye and 20/20 in the left eye. She had a relative afferent pupillary defect in her right eye. The anterior segment was within normal limits in the left eye. The intraocular pressure was 12 mm Hg in the right and 14 mm Hg in the left eye. In the right eye, fundus examination showed macular whitening sparing a small segment in the papillomacular bundle and a cherry red spot. A greyish-white embolus was seen in the superotemporal artery. Inferior to the fovea an empty vessel was seen embedded in the oedematous retina [Figure 1]a. Left eye fundus was normal on examination.

Figure 1: (a). Colour fundus photograph of the right eye showing cherry red spot, superotemporal embolus (black arrow) and inferiorly an empty vessel (white arrow). (b). SS-OCT showing macular thickening with heaping up at the centre, an empty vessel (white arrow) and a normal vessel (black arrow)

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At initial presentation, her arterial blood pressure was 120/80 mm Hg. There was no relevant medical history of coagulopathies or autoimmune disorders. Colour fundus photography, SS-OCT, and OCT-A were performed by DRI Triton^® (Topcon Corporation, Tokyo, Japan). SS-OCT via macula demonstrated thickening and hyperreflectivity of the inner retina except sparing of small area just temporal to the disc, corresponding to the cilioretinal artery perfusion. The center of the macula appears heaped up due to swollen retinal layers. A hyperreflective foci was noted at the center of fovea at the level of retinal pigment epithelium and choroid [Figure 1]b. SS-OCT imaging showed an empty vessel as a vertically oval cyst-like structure in the inner retina with hyperreflective borders, a hyporeflective lumen along with back shadowing [Figure 1]b.

OCT-A of the right eye demonstrated an absence of blood flow in the superficial retinal plexus slab, except in a wedge-shaped area temporal to the optic disc. The perfusion was decreased in the deep retinal plexus slab and in the outer retinal slab.

Ocular massage and anterior chamber paracentesis were done to reduce intra-ocular pressure. Systemic workup revealed a left atrial myxoma with multisite cerebral infarcts. Patient was taken up for thrombolysis and surgical resection of myxoma by a cardio-thoracic vascular surgeon.

At 1-month post-thrombolysis, color fundus photograph showed a decrease in the retinal whitening, the embolus in the superotemporal artery had dislodged and the empty vessel noted inferiorly at first visit could be traced now filled with blood [Figure 2]a. Reperfusion could be appreciated both on SS-OCT and OCT angiography [Figure 2]b, [Figure 2]c, [Figure 2]d. Vision improved to counting fingers close to face.

Figure 2: One month follow up (a). Colour fundus photograph showing reperfused vessel (white arrow) and dislodged embolus superotemporally (black arrow). (b). SS-OCT showing the vessel to be reperfused (white arrow). (c). OCTA of the right eye inferior to fovea (6 × 6 mm) superficial retinal plexus slab demonstrating reflow through the affected vessel (white arrow). (d). Colour coded image of the right eye OCTA (6 × 6 mm) showing flow in the vessel (white arrow)

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Discussion

In acute CRAO, due to ischemic insult, there is retinal edema and opacification, cattle trucking of blood vessels, arteriolar attenuation, and optic disc edema.^[3] The decreased capillary blood flow leads to axoplasmic stasis, intracellular edema, and ischemic necrosis of the inner retinal layers^[4] seen as retinal edema and hyperreflectivity of inner retinal layers on OCT imaging.^[5]

In our case, the inferotemporal vessel could be barely traced in the oedematous retina. However, via OCT the vessel can be traced as a vertically oval cavity situated in inner retina, sized more than 30 microns^[6] with hyperreflective upper and lower borders, minimal back shadowing and a hyporeflective lumen. Considering hyperreflective upper and lower border, the vessel is identified as an arteriole, supported by study done by Y ouyang et al.^[7] The hyporeflective lumen signifies that the vessel is empty. At 1-month follow-up on SS-OCT scan over the same vessel, lumen of the vessel has become hyperreflective signifying blood column in the vessel. On OCTA perfusion can be seen in the superficial slab as reappearance of hyperreflective blood column along the vessel and in the macular area.

By performing serial OCT/OCTA over the vessel, reperfusion can be established, avoiding the need of FFA. Even if OCTA does not detect perfusion due to sluggish blood flow in the vessel, with combined use of OCT and OCTA imaging we can detect whether the vessel is empty or filled without the need of invasive techniques like FFA. The ease, repeatability, faster, and non-invasive nature of the examinations (OCT & OCTA) justifies their use as the primary means of diagnosis apart from patient's clinical history and fundus examination.

Conclusion

In this case report, we demonstrate the concept of identifying an empty vessel in CRAO by non-invasive imaging tools such as OCT and OCTA, which has not been described so far. To conclude, OCT and OCTA are very useful modalities for assessment of CRAO, sequential follow-up and patient-counseling.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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