Grand Rounds Stuck in the wrong place CC Sudden vision loss OD HPI 66 yo WM with a complex traumatic dural arteriovenous fistula status post prior motor vehicle accident who underwent repeat embolization with Onyx Ophthalmology was paged to the PACU for sudden vision loss of the ri ID: 775402
Download Presentation The PPT/PDF document " Patrick Burchell, PGY-2 June 15, 2016" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Patrick Burchell, PGY-2June 15, 2016
Grand Rounds
Stuck in the wrong place
Slide2CC:Sudden vision loss ODHPI:66 yo WM with a complex traumatic dural arteriovenous fistula status post prior motor vehicle accident, who underwent repeat embolization with Onyx. Ophthalmology was paged to the PACU for sudden vision loss of the right eye upon awakening.
Patient Presentation
Slide3Non-adhesive liquid embolic agentEthylene vinyl alcohol (EVOH) Dimethyl sulfoxide (DMSO) Tantalum powder Solidifies from outside to inside5 minutesProlonged injection times compared to N-butyl cyanoacrylate glue
What is Onyx?
Slide4Past Ocular Hx:Nuclear Sclerosis OU Past Medical Hx:Traumatic dural arteriovenous malformation (DAVF), carotid stenosis, hyperlipidemia, hypertension, GERD, seasonal allergiesPast Surgical Hx:Embolization of DAVF X 3, exploratory laparotomy, left knee repair, right maxilla repair
History (
Hx
)
Slide5Fam Hx:Aneurysm (sister)Meds:Amlodipine-benzapril 10 mg, Aspirin 325 mg, Pantoprazole 40 mg, Rosuvastatin 20 mgAllergies: NKDASocial Hx:Previous smoker (35 pack years)ROS:+ decreased vision OD; denied pain, flashes, floaters
History (
Hx
)
Slide6ODOSVA (N sc)Light Perception20/70Pupils5→4mm (sluggish)3+ RAPD OD4→3mmIOP14 mmHg15 mmHgEOMfullfullCVFfull
External Exam
Slide7Anterior Segment Exam
PLE
OD
OS
External/Lids
WNL
WNL
Conj
/Sclera
WNL
WNL
Cornea
Clear
Clear
Ant Chamber
Formed
Formed
Iris
WNL
WNL
Lens
Nuclear Sclerosis
Nuclear Sclerosis
Slide8Posterior Segment Exam
FundusODOSOptic NervePallorPink and sharpMaculaCherry red spot, with retinal whitening in the posterior poleWNLVesselsArteries attenuatedWNLPeripheryWNLWNL
Slide9Cerebral Angiography
Sagittal view of Left Internal Carotid Artery (LICA)
Ophthalmic Artery
Sagittal view of Right Internal Carotid Artery
(RICA); bone window
Ophthalmic Artery
Onyx
Slide10Cerebral Angiography
Late phase sagittal view of RICA
No choroidal Blush
Late phase sagittal view of LICA
Choroidal Blush
Slide11Post-operative CT
Onyx
Axial bone window
Slide1266 yo WM with LP OD and a central retinal artery occlusion status post embolization of a DAVF with Onyx.PlanNo intervention due to the nature of the occlusionNo reversal agent available for OnyxFollow up in Retina Clinic
Assessment/Plan
Slide131 week follow up
OD
OS
Slide14SD-OCT
Slide15Epidemiology1.9 per 100,000 peopleRisk FactorsMale (1.5X)Increased ageHypertensionDiabetesCarotid artery diseaseSmoking
Central Retinal Artery Occlusion
Slide16Sudden, painless loss of vision, 1 eyeAfferent pupillary defectFundus appearance Retinal whiteningCherry red spotArterial attenuationHollenhorst plaquesIrreversible damage begins after 97 minutes in primate model5
Presentation
Slide17Most often due to embolization or thrombosis at the lamina cribosa5% due to vasculitic cause like Giant Cell Arteritis66-80% will have final VA 20/400 or worseNo treatments currently with good evidence of efficacyIntraocular pressure lowering/vasodilationThrombolysis
Causes and Treatment
Slide18Retrospective case series of 44 patients
Most common injection site was the Glabella (59%)
Autologous fat was more likely to cause diffuse occlusion (86%)
27/44 (61%) had final VA of NLP
Slide19Glabella
https://
plasticsurgerykey.com
/glabellar-flaps-in-nasal-reconstruction/
Slide20Most often due to embolization, but can also be vasculiticEvaluate for stroke and other cardiovascular risk factorsCheck ESR, CRP, plateletsNo great treatments at this time Botox your glabella, no filler!
Conclusions
Slide21Dr. SigfordDr. MugavinDr. Piri
Acknowledgements
Slide22Leavitt JA, Larson TA, Hodge DO, Gullerud RE. The incidence of central retinal artery occlusion in Olmsted County, Minnesota.Am J Ophthalmol. 2011 Nov; 152(5):820-3.e2.Mehta N, Marco RD, Goldhardt R, Modi Y. Central Retinal Artery Occlusion: Acute Management and Treatment. Current ophthalmology reports. 2017;5(2):149-159. doi:10.1007/s40135-017-0135-2.Sadeh-Gonike Y, Magand N, Armoiry X, et al. Transarterial Onyx Embolization of Intracranial Dural Fistulas: A Prospective Cohort, Systematic Review, and Meta-Analysis, Neurosurgery, Volume 82, Issue 6, 1 June 2018, Pages 854–863Park KH, Kim YK, Woo SJ, et al. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: a national survey by the Korean Retina Society. JAMA Ophthalmology. 2014 Jun;132(6):714-23.Hayreh SS, Zimmerman MB, Kimura A, Sanon A. Central retinal artery occlusion. Retinal survival time. Experimental eye research. 2004 March; 78(3): 723-36Retina and Vitreous, AAO, BCSC Section 12, 2017-2018 (132-135).
References
Slide234 clinical entitiesNon-arteritic permanent CRAOAmaurosis fugaxNon-arteritic with cilioretinal sparingArteritic CRAO