Chronic ocular ischemia and carotid vascular disease.

Abstract

Venous stasis retinopathy and ischemic oculopathy are ocular manifestations of ischemia in the distribution of the carotid artery. While not as common as transient monocular blindness or retinal arterial emboli, they are readily recognizable and indicate the presence of severe, often bilateral, carotid occlusive disease. Patterns of occlusion vary but usually include complete occlusion of at least one common or internal carotid artery, often accompanied by occlusion or narrowing in the opposite carotid system. The ocular findings in venous stasis retinopathy and ischemic oculopathy indicate ongoing ocular ischemia and may progress to intractable neovascular glaucoma. Therapy, individualized for the specific pattern of occlusive changes, may be directed toward prevention of stroke or may be indicated primarily for the reversal of ocular ischemia and prevention of blindness secondary to neovascular glaucoma.

Venous Stasis Retinopathy in Symptomatic Carotid Artery Occlusion

“…This patient illustrates the diagnostic dilemma of distinction of VSR and mild diabetic retinopathy, particularly in diabetic patients with carotid artery occlusive disease. 2,5 Because patients without VSR at study entry were not followed up by ophthalmologic examination in the absence of new symptoms, we may have missed the development of subclinical retinal ischemic changes. Furthermore, treatment with EC/IC bypass surgery and endarterectomy in patients with severe stenosis of the contralateral carotid artery may have affected the course of VSR in some patients.…”

“…5 Patients were diagnosed with VSR if they had Ն1 of the following early retinal signs ipsilateral to the symptomatic CAO: midperipheral microaneurysms; multiple small dot-and-blot intraretinal hemorrhages or nerve fiber layer splinter hemorrhages; or dilatation, irregularity of caliber, or tortuosity of veins for which no other cause was apparent. Signs of more advanced chronic ocular ischemia were neovascularization of the optic disc, retina, or iris (rubeosis iridis), with or without uveitis, or neovascular glaucoma in the absence of any other cause.…”

“…[1][2][3][4] The chronic form of ocular ischemia is explained by a chronic low perfusion pressure that causes diffuse retinal ischemia, reflected by an increase in circulation time, which initially results in dilatation, irregularity of caliber, and tortuosity of retinal veins. 5 Ophthalmoscopy may also show midperipheral microaneurysms, small dot-and-blot intraretinal hemorrhages, or nerve fiber layer splinter hemorrhages. 1,5 This early stage of chronic ocular ischemia, often referred to as venous stasis retinopathy (VSR), may remain completely asymptomatic.…”

“…5 Ophthalmoscopy may also show midperipheral microaneurysms, small dot-and-blot intraretinal hemorrhages, or nerve fiber layer splinter hemorrhages. 1,5 This early stage of chronic ocular ischemia, often referred to as venous stasis retinopathy (VSR), may remain completely asymptomatic. Progression of the disease may lead to the clinical syndrome of chronic ocular ischemia with progressive visual loss through cotton wool spots; edema of the optic disc and macula; neovascularization of the optic disc, retina, and iris; and finally an uveitislike syndrome and neovascular glaucoma.…”

Management of carotid artery occlusion.

“…Although the clinical symptomatology accompanying ICA occlusion may be quite diverse and nonspecific, certain clinical presentations are more often associated with this condition: watershed infarctions of different types, 20 orthostatic cerebral ischemia, 21 and ischemic oculopathy. 22 …”