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ARTICLE
Year : 1956  |  Volume : 4  |  Issue : 3  |  Page : 53-58

Angiography - An aid in the diagnosis of ophthalmic conditions


Ophthalmic Dept., King Edward Memorial Hospital, Bombay, India

Date of Web Publication10-May-2008

Correspondence Address:
S N Sutaria
Ophthalmic Dept., King Edward Memorial Hospital, Bombay
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Sutaria S N. Angiography - An aid in the diagnosis of ophthalmic conditions. Indian J Ophthalmol 1956;4:53-8

How to cite this URL:
Sutaria S N. Angiography - An aid in the diagnosis of ophthalmic conditions. Indian J Ophthalmol [serial online] 1956 [cited 2020 Aug 6];4:53-8. Available from: http://www.ijo.in/text.asp?1956/4/3/53/40748

Cerebral angiography has today become part of the routine Neuro-radiological examination of intracranial conditions. It is the purpose of this paper to show how helpful this procedure can also be in the diagnosis of ophthalmic conditions - those that are primarily ophthalmic conditions and those with ocular signs where damage is to the optic nerve or brain.

A radio-opaque organic iodine compound is injected into the internal carotid artery and as it travels up the vessel into the brain pictures are taken at rapid intervals to trace the course of the dye through the arteries, capillaries and veins. It is the arerial phase which is usually of the greatest value.

I shall show you first a normal carotid angiogram. [Figure - 1]. Then follow the angiograms of cases which came to the Ophthalmic Department, with various ocular manifestations such as proptosis, ptosis and paresis.

The first case is that of a young man of 20 years who came with a gradually increasing proptosis of the L.E. Vision had dropped to hand-movements. The proptosis was of 15 mm., non-reducible, non-pulsatile, and had come up in eight months' time. A soft ill-defined mass was palpable behind the eye, which had good movements, and brisk pupillary reactions. He had a cataract in that eye. The fundus was not visible and the field could not be taken. The other eye was normal.

Skiagrams in this case showed an enlarged optic foramen on the same side.

Angiography showed a raising of the left ant. cerebral artery upwards and a bowing of the internal carotid which was pushed backwards. [Figure - 2].

On operation, a glioma of the left optic nerve was removed.

The next case is that of a 50 year old woman who came with (1) Pain on the left side of head and face for 12 years, (2) Inability to move the left eye - 1 year, (3) Blindness in the left eye for six months.

The left eye showed on examination a proptosis and a ptosis with a total ophthalmoplegia. There was no perception of light and the fundus showed the picture of a primary type of optic atrophy.

The right eye was normal, with a vision of 6/15.

The left carotid angiogram shows on antero-posterior view (a) A displacement to the right of the anterior cerebral artery. (b) A displacement to the right and upwards of the middle cerebral artery. [Figure - 3].

The lateral view shows: (a) A stretching forwards and upward dislocation of the carotid siphon. (b) The middle cerebral group shows a marked upward bowing. [Figure - 4].

The findings are those of a large space occupying lesion in the region of the left temporal lobe.

On operation - a large blood vascular tumour was found along the left Meckel's cave with branches of the fifth nerve below it.

The third case is of a 60 year old farmer who had a proptosis of the left eye for six months and a large temporal swelling on the left side which was gradually increasing.

Ophthalmic examination showed:­

(1) Normal right eye with normal vision and fundus.

(2) Blind left eye with marked proptosis and a left total exophthalmic ophthalmoplegia.

(3) Left fundus showed markedly engorged and tortuous veins with a papill­oedema.

Left carotid angiography showed in the antero-posterior view a slight displacement of the internal carotid medially. The lateral view shows a shift of the anterior cerebral artery upwards and posteriorly, indicating a space occupying subfrontal lesion on the left side. [Figure - 5],[Figure - 6].

On operation a malignant chordoma was discovered eroding the roof of the orbit. the lateral orbit wall and the middle cranial fossa.

My fourth case, a man of 25 years had had an increasing proptosis of the right eye for 2˝ years. diminished vision in the right eye for 1 year with pain on moving the eye.

Examination showed right-sided exophthalmos with engorgement and promi­nence of the veins of the upper lid and conjunctival vessels. A bruit was heard over the temporal and frontal regions. No tumour mass could be felt in the orbit.

Right carotid angiography showed no localising signs of the cerebral vessels but revealed an intra-orbital retro-ocular mass with a vascular sheath of its own.

A diagnosis of meningioma of the optic nerve was made on operation. [Figure - 7].

The next patient was a 17 year old student with a bulging left eye for 3 months and a gradual loss of vision in that eye.

Examination showed

(1) Right eye: Entirely normal with vision 6/6.

(2) Left Eye: Vision finger counting from 31 m.

(3) Proptosis of left eye which was pulsatile on pressure and a bruit was heard over it.

(4) Movements and papillary reactions were normal.

(5) Biomicroscopy showed a marked dilatation of the sub-conjunctival and episcleral vessels which were extremely tortuous and corkscrew like.

(6) Fundus of the left eye showed a hyperaemic disc and tortuosity of the blood vessels. The colour of the arteries was much darker than in the right eye.

A left carotid arteriogram showed the presence of an aneurysm of the left ophthalmic artery and its continuation as the lacrymal artery. [Figure - 8].

The next case is a most interesting one. The patient. a clerk of 36 years had no ophthalmic complaints at all. He had a headache for 5 months which had started with a bout of vomiting for a few days. However a routine ophthalmologi­cal examination was carried out and revealed : -

(1) Corrected vision of 6/9 in B.E. with normal movements and pupillary reactions.

(2) Both fundi showed papilloedema.

(3) Contractions of the peripheral fields of both eyes with enlarged blind spots as tested on Goldman's perimeter with object sizes 2/2 and 2/1.

Neurological examination was entirely negative.

Right carotid angiography although it did not reveal any localising pattern of the cerebral vessels, showed in the lateral view, a much wider sweep of the anterior cerebral artery than usual. The middle cerebral group ran diagonally backwards and upwards. [Figure - 9]. These findings are diognostic of a hydrocephalus.

Subsequent ventriculograms showed in the postero anterior view marked dila­tation of both lateral ventricles. [Figure - 10]. The lateral view showed no filling of the III ventricles, aqueduct or IV ventricle.

On operation, a colloid cyst of the III ventricle was landed upon and was removed in toto.

The next patient, a woman of 32 years had pain in the neck and stiffness of the right side of the body for 4 weeks, with occasional vomiting and loss of appetite.

For 2 weeks she had diminished vision and giddiness and a right convergent squint.

Examination showed:­

(1) Ptosis of both upper lids, marked more on the left side.

(2) Paralysis of right external rectus muscle: all the other movements were normal.

(3) There was severe papilloedema in both eyes.

The general condition of the patient did not allow a further examination in detail.

Right carotid angiography in her case showed on the right side (1) pushing backwards of the carotid siphon. (2) bowing and backward displacement of the anterior cerebral artery. (3) The ophthalmic artery is pushed down. The findings are those of a subfrontal space occupying lesion near or in the midline. [Figure - 11].

On operation an olfactory groove meningioma was encountered with olfactory tracts under it. but not involving the optic tracts or nerves.

The last case is that of a 33 year old man who had

(1) A central corneal opacity in the right eye with a vision of finger counting at 1 m.

(2) Paresis of the III and IV cranial nerves and none of the VI nerve.

(3) Ptosis of the right eye which disappeared on right lateral gaze and also on attempt at fixation with right eye.

(4) His left eye, both fields and fundi were normal.

(5) There was trigeminal involvement with­

(a) Right-sided jaw deviation

(b) Impaired sensation right side of face

(c) Loss of right corneal reflex.

A right carotid angiogram shows an aneurysm of the right internal carotid artery in the cavernous sinus. [Figure - 12].


  Conclusions Top


In my series of eight cases, the first five were of proptosis. It was angiography, in these cases that enabled us to diagnose cases 2 and 3 as those of proptosis due to intracranial pathology and cases I and 4 as proptosis due to lesions behind the eye and within the orbit. In the fifth case it provided the diagnosis itself - that of the ophthalmic artery aneurysm.

In cases 6 and 7, ptosis and ocular motor paresis were the chief clinical fea­tures. Here also angiography showed one case to be due to a tumour in the region of the temporal lobe. and in the second it again provided the diagnosis, namely aneurysm of the internal carotid artery.

The last case was the one with the III ventricular tumour. Although the patient had no ophthalmic complaints a routine examination revealed perimetric defects and an angiogram was therefore taken. This showed the signs of a hydro­cephalus. Ventriculography subsequently revealed obstruction in the region of the foramen of Monroe and III ventricle.

In our opinion, performed by the percutaneous method of injection, and with the use of radio-opaque dyes of the Diodone group which are now used extensively in intravenous urography, cerebral angiography via the internal carotid artery is a relatively safe procedure free of hazards. Its wider use is advocated among the diagnostic investigations used in ophthalmology, particularly when vision and field defects and fundus examinations prove to be of little localising value.


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12]



 

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