Case Report
Transient Non-Inflammatory
Vascular Sheathing in Combined CRVO and Cilioretinal Artery
Imran Akram
Pak J Ophthalmol 2018, Vol. 34, No. 2
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See
end of article for authors
affiliations …..……………………….. Correspondence
to: Imran
Akram Consultant
Ophthalmic & Vitreoretinal Surgeon St
Helens Hospital, UK Email:imranakram2020@gmail.com |
To describe a case of evanescent sheathing of retinal vessels in
a case of combined occlusion of the central retinal vein and Cilioretinal
artery. The sheathing was non-inflammatory and resolved spontaneously after a
few days. This was accompanied by significant visual improvement. No active
treatment was offered to this patient. Even though transient vessel sheathing
has been previously reported in retinal vein occlusion this is the first
published report of transient vessel sheathing in association with combined
central retinal vein and Cilioretinal artery occlusion. Key words: Transient sheathing, Central retinal vein
occlusion, Cilioretinal artery. |
Central
retinal vein occlusion associated with Cilioretinal artery occlusion is well
documented1,2. It can
occur even in the absence of reported systemic pathology3 although
most patients do have associated comorbidity4,5.
CASE REPORT
A 54-year-old Caucasian man presented to our unit with a 24-hour
history of painless visual loss in his right eye. He was a non-smoker, had no
medical history of note .Visual acuity was count fingers in the right eye, and
6/6 unaided left eye. Right eye showed a significant relative pupillary defect (RAPD++).
Anterior segment was quiet. Fundus
examination (Fig. 1) showed a hyperaemic swollen disc, dilated tortuous veins
accompanied by blot haemorrhages in all quadrants. The veins in all quadrants
demonstrated segmental sheathing. Some medium sized arterioles also
demonstrated focal sheathing. There was no vitreous activity. There was a
creamy pallor all over the posterior pole extending from temporal to the disc
and involving the macula. OCT scan (Fig. 1) showed macular SRF and hyper-reflectivity
of the inner retina consistent with cloudy swelling. The left eye was entirely
normal on examination. Fluorescein angiography showed delayed filling and late
venous leakage. There was no significant capillary closure. No macular edema
was seen on FFA. The choroid showed poor filling throughout the angiogram.
These findings supported a diagnosis of non-ischaemic CRVO combined
with Cilioretinal artery occlusion. However, the presence of venous sheathing
was at the time considered by us to represent inflammatory activity. We
therefore organised several tests including FBC, ESR, Urine complete, Glucose,
CRP, angiotensin converting enzyme levels, serology for toxoplasmosis, syphilis,
Varicella, CMV and Mantoux test. He also underwent X-ray chest. All these tests
were reported as normal. He had no systemic features suggestive of Bechet’s
disease. Carotid Doppler scanning showed no narrowing. His blood pressure in
clinic was noted to be 188/95 and his general practitioner was informed about
this.
Fig. 1: Colour fundus photo of Right eye at
presentation. Note the vascular sheathing. OCT scan shows inner retinal
hyper-reflectivity.
Fig. 2: Colour fundus photo of Right eye at 4 weeks. Spontaneous
resolution of vascular sheathing and tortuosity is seen. OCT scan appears
almost normal.
The patient was commenced on
aspirin 75 mg daily and no other treatment was given. He was reviewed in clinic
2 weeks later. By then the VA had spontaneously improved to 6/24 and there was
considerable reduction in the retinal haemorrhages and vascular tortuosity.
Furthermore, the previously observed vascular sheathing had completely
resolved. Two weeks later VA had improved to 6/18 and OCT scan showed no
retinal swelling (Fig. 2). We continued to monitor him in clinic. FFA was
repeated which showed normal retinal and choroidal filling. 6 months later VA
had improved to 6/12.
DISCUSSION
The interesting aspects of this case are the transient nature of
the non-inflammatory vascular sheathing, and the spontaneous visual improvement
without any active treatment.
Transient non-inflammatory venous sheathing has been reported
before. One report describes this phenomena following trauma6. In the context of retinal
vein occlusions, there is a report of four cases. Lightman, Foss et al7
described cases of retinal vein occlusion that demonstrated transient vessel
wall sheathing which then resolved spontaneously. However, this is the first
published report of this phenomenon seen in the setting of combined
non-ischaemic CRVO and Cilioretinal artery occlusion. The reason for the
sheathing is unknown.
The occlusion of the
Cilioretinal artery in this situation is considered a secondary occurrence
following the initial CRVO. It is thought to be due to increased hydrostatic
pressure within the lamina cribrosa, which then leads to a hemodynamic
stagnation within the Cilioretinal artery8.
Spontaneous visual improvement following combined CRVO and Cilioretinal artery
occlusion has been well described by Hayreh in his extensive paper9. It is thought to be due
to the mostly extradural course adopted by the Cilioretinal artery, which
protects it to some extent from the increased hemodynamic pressure in the
lamina cribrosa.
Financial
Support
Nil.
Conflict
of Interest
There is no conflict of interest.
Author’s
Affiliation
Dr. Imran Akram, MBBS, FRCS, FRCOphth
Consultant ophthalmic & vitreoretinal surgeon
Role of
Authors
Dr. Imran Akram
Sole author. Treating physician. Preparing of manuscript.
Literature search. Corresponding author.
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