Ocular Ischaemic Syndrome

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Ocular Ischaemic Syndrome

• Dr Gulrez Ansari
• Department of Ophthalmology
• Watford General Hospital
• 3rd November 2004

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Ocular Ischaemic Syndrome

• A severe form of chronic ischaemia of both
  anterior and posterior segments of the eye as
  well as other orbital structures supplied by the
  ophthalmic artery.
• Chronic hypoperfusion when carotid artery
  stenosis gt 90
• Usually unilateral
• Age 50-80 yrs
• MaleFemale21

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Symptoms

• Vision loss Sudden (41)
• Gradual (28)
• Transient (15)
• ?Precipitated by exposure to bright lights
  (bright light amaurosis)
• Pain Ocular / Orbital
• Incidental asymptomatic finding

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Signs

• Anterior Segment
• Dilated Episcleral vessels
• Corneal edema
• AC Cells
• Flare (ischemic pseudoinflammatory uveitis)
• Mid-dilated poorly reactive pupil
• Cataract
• Iris atrophy
• Iris neovascularisation angle
  neovascularisation
• Neovasuclar Glaucoma

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Gonioscopy Angle neovascularisation
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Signs

• Posterior Segment
• Disc NVD, Easily inducible retinal artery
  pulsation, AION (rare)
• Vessels Venous dilatation (no tortuosity)
• Periphery Mid peripheral haemorrhages,
  Microaneurysms
• Macular oedema
• Ischaemic changes Retinal arteriolar narrowing,
  retinal capillary non-perfusion

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Retinal Haemorrhages
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Differential Diagnosis

• Other causes of iris neovascularisation
• Proliferative diabetic retinopathy
• Ischaemic CRVO

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Systemic evaluation

• Systemic associations
• Diabetes mellitus (56)
• Hypertension (50-73)
• Ischaemic heart disease (38-48)
• Cerebrovascular disease (27-31)
• Giant cell arteritis (rare)

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Investigations

• FFA
• ?Aid in confirmation of diagnosis,
• ?Demonstrate retinal capillary non-perfusion to
  validate PRP
• Delayed patchy choroidal filling
• ?ed retinal arteriovenous circulation times
• Areas of retinal capillary non-perfusion
• Late leakage from arterioles and veins
• Macular oedema

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FFA
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Visual Fields

• Normal (23)
• Central scotomas (27)
• Nasal defects (23)
• Centrocaecal defects (5)
• Central or temporal islands (22)

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Carotid artery ultrasound

• Carotid occlusion, usually 90 or more
• Colour Doppler Imaging (CDI) of retrobulbar
  circulation
• Reduced peak systolic velocities in ophthalmic
  central retinal arteries
• Conitnuous / intermittent reversal of ophthalmic
  artery blood flow
• Limitation Difficult to reliably reproduce
  orbital blood flow measurements
• ERG
• Diminished b- and a- waves

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Management

• Ophthalmologist
• Physician/Neurologist
• Vascular surgeon

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Ocular treatment

• Anterior segment inflammation
• Topical steroids and cycloplegics
• Ablation of retinal ischaemia
• Early FFA, Only if retinal ischaemia gtgt
  3000-5000 burns of 200-500µm spot size
• Control of IOP Neovascular glaucoma
• ?Medical therapy (topical ß blockers,
  cycloplegics, oral carbonic anhydrase inhibitors)
• ?Surgery (trab with mitomycin C, Tube shunt
  procedure)
• ?Ciliary body ablation (cyclocryotherapy,
  laser cyclophotocoagulation NdYAG / Diode
  laser)

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Medical Treatment

• Full medical and neurological assessment
• Aspirin
• Treatment of hypertension, diabetes
• Stop smoking

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Carotid Surgery

• Of benefit in symptomatic Cerebral ischaemia when
  there is gt70 carotid artery stenosis
• Pts with severe carotid stenosis and a recent
  cerebral rather than ocular event had a greater
  risk of stroke when taking medical treatment
  therefore a greater benefit from surgery
• Impact on visual prognosis unclear (no randomized
  controlled studies)
• In one series 7 improved Vn, 33 no change,
  60 worsened

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Conclusion

• Rare, but severe condition
• Leads to significant visual loss and chronic
  ocular pain
• Iris neovascularisation is an indicator of poor
  visual prognosis
• 5 year mortality rate 40
• Majority of deaths are due to cardiac disease

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THANK YOU