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ARTICLE
Year : 1969  |  Volume : 17  |  Issue : 6  |  Page : 270-272

Embolism of central retinal artery originating from mitral valves (mitral stenosis)- case report


Department of Ophthalmology, R.N.T. Medical College, Udaipur, India

Date of Web Publication11-Jan-2008

Correspondence Address:
O P Kulshreshtha
Department of Ophthalmology, R.N.T. Medical College, Udaipur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Kulshreshtha O P, Jain M R, Singh M M, Bhargawa S. Embolism of central retinal artery originating from mitral valves (mitral stenosis)- case report. Indian J Ophthalmol 1969;17:270-2

How to cite this URL:
Kulshreshtha O P, Jain M R, Singh M M, Bhargawa S. Embolism of central retinal artery originating from mitral valves (mitral stenosis)- case report. Indian J Ophthalmol [serial online] 1969 [cited 2020 Aug 4];17:270-2. Available from: http://www.ijo.in/text.asp?1969/17/6/270/38554

It is currently presumed that the embolism of Central retinal artery is not so common though embolism of cerebral vessels is not uncommon. This is understandable as an embolus can readily pass from the ascending aorta into the innominate and the left common carotid artery which are con­tinuous with it. The rarity of embol­ism in the central retinal artery is ex­plained on the basis of the fact that these emboli must first pass the per­pendicular ramifications of the artery from the internal carotid and then the perpendicular ramifications of the cen­tral retinal artery from the ophthalmic artery.

A typical case of occlusion of cen­tral retinal artery with embolus from mitral valves in a young female with mitral stenosis is described.


  Case Report Top


Mrs. M., 26 years old Mohammedan widow attended the eye out-door on 3rd August, 1968, with a complaint of sudden loss of vision in the right eye since 8.00 A.M. While washing her clothes, she felt sudden clouding and loss of vision in her right eye leading to complete blindness.

On examination, the right pupil was found to be slightly dilated and slug­gishly reacting to light directly, but reacting briskly consensually. Percep­tion of light was absent. Fundus show­ed typical picture of central artery ob­struction : Optic-disc was pale and showed slight oedema with indistinct margins. Retina was dull, oedematous, pale opaque white in colour showing a characteristic cherry-red spot at the fovea. Larger arteries were reduced to thread like dimensions and small arteries were invisible. Veins showed typical cattle-truck appearance with the blood thrown into columns or beads.

Following treatment was immediate­ly instituted : Ocular massage accom­panied with retrobulbar injection of Atropine 1/100 grain and tablet Ni­cotinic acid 50 mg each, 3 tablets stat. A hot bath was also given. At 12 o'clock, Inj. Duadilan 2 c.c. (isox suprine HCL 5 mg/ml) with 20 c.c. of 5%, glucose slowly was given intravenously followed by tablet Arlidine (nylidrine hydrochloride N.F. 6 mg.) stat and 4 hourly.

At 12.00 P.M. the patient developed perception of light, recognised a few objects dimly around her and even could count fingers in the temporal field at a distance of about 8 inches. At 1.00 P.M. her vision improved to finger counting at 2 meters. On fun­dus examination, the arteries over and near the disc became visible though markedly attenuated. Rest of the pic­ture was the same. At 5.00 P.M. vi­sion was finger counting at 5 meters in the temporal field. Pallor of the disc was as before. Retinal arteries were visible all over the fundus except in the temporal region. Rest of the picture was the same.

With continued administration of retrobulbar injection of Atropine 1/100 gr. twice a day and Nicotinic acid 100 mg. intravenously twice a day along with oral vasodilators (Tab. Arlidine 6 mg. thrice daily) and anticoagulant therapy (Dindivan 50 mg. tablet 8 hourly), the patient's vision improved to 6/12 in the temporal field and hand movement in the central and nasal field. Perimetry was not possible due to lack of fixation. After 6 days since the attack, fundus still showed pallor of the optic disc. The retina on the nasal side of the disc was normal in ap­pearance, colour and reflex. Vessels in the nasal quadrant appeared perfectly normal but the lower temporal ves­sels (arteries) were still attenuated and showed a probable impaction of an embolus two disc diameters away from the disc. Smaller vessels around the macula were visible and instead of cherry-red spot, the macular area showed fine punctate pigmentary spots with an absent foveal reflex. Slight perimacular oedema still persisted.

Ten days later, the examination showed vision of 6/9 with glasses (-0.5 D. Sph) with slight eccenteric fixation. The disc was comparatively less pale and only the lower temporal vessel showed constriction with the lodged embolus. Macular area showed punctate pigment deposits.

General Examination and Investigations

Cardiac examination showed a late diastolic murmur of crescendo charac­ter with presystolic accentuation, sug­gestive of mitral stenosis. Blood pres­sure was 112/80 mm Hg. and electro­cardiogram was normal.

Blood tests were as under :-­

Total lececocytes 7,500 c mm.

Differential: count polymorphs 66%, lymphocytes 32%, monocytes 1%, basophils 1%.

Kahn's Test : Negative.

Coagulation time and clotting time were within normal limits.

No septic focus was present any­where in the body and there was no history of any joint pains or of pro­longed illness.


  Discussion Top


The case is of clinical interest be­cause the effected eye showed typical clinical picture of central retinal arte­rial obstruction due to embolism with clinical evidence of mitral stenosis and presence of impacted embolus in the lower temporal retinal vessel. Em­bolism as a cause of central arterial obstruction is presumed to be uncom­mon though various workers have de­monstrated various embolic agents. von Graefe [3] and Manchot [4] have de­monstrated endocarditis as a cause of retinal embolism. Fat (Fritz and Ho­gan [2] ), Mercury (Vallotton and Stokes [6] ) and Loiasis (Toussaint and Danis [5] ; Corrigan and Hill [1] ) have also been de­monstrated as rare embolic agents. In the case cited above an embolus ori­ginating from the mitral valves was lodged in the central retinal artery pro­bably at the cribriform plate (where there is physiological narrowing) lead­ing to rapid loss of vision. Vasodilator drugs used dislodged the embolus from the central artery but it got finally lodged in the lower temporal branch. Early recovery of vision in the tempo­ral field synchronises immediate re­establishment of blood circulation after the treatment.

Urgency of treatment is imperative. Once total occlusion has been present for some time, there is retinal ischtemia specially to the nerve fibre layers and irrepairable damage is done. Treat­ment consisting of intensive vasodila­tors systemically combined with retro­hulbar injection of atropine, ocular massage and hot bath are essential. Anticoagulant therapy may also be of some value.


  Summary Top


A case of central retinal arterial ob­struction due to embolism arising from mitral valves (mitral stenosis) is re­ported. The diagnosis of embolism was supported by clinical evidence of mit­ral stenosis and ophthalmoscopic evi­dence of impacted embolus in lower temporal retinal artery. The embolus finally got lodged in the inferior tem­poral branch of retinal artery.

Intensive treatment resulted in re­establishment of retinal circulation and considerable improvement in visual acuity.

 
  References Top

1.
Corrigan, M. J.. and Hill, D. W.: Re­tinal Artery Occlusion in Loiasis. Brit. J. Ophth. 52: 477 (1968).  Back to cited text no. 1
    
2.
Fritz. M. H.. and Hogan, M. J.: Fat Embolization involving the human Eye. Amer. J. Ophth., 31: 527 (1948).  Back to cited text no. 2
    
3.
Graefe. A, von: On Embolism of the central retinal Artery as a cause of sudden Blindness (in German) Arch. f. Ophth. 5: 136 (1959).  Back to cited text no. 3
    
4.
Manchot. W. A.: Embolism of Cen­tral Retinal Artery Originating from a endocardial Myxoma. Amer. J. Ophth. 48: 381-385 (1959).  Back to cited text no. 4
    
5.
Toussaint. D.. and Danis. P.: Arch. Ophthal. (Chicago) 74: 470 (1965).  Back to cited text no. 5
    
6.
Vallotton, W. W., and Stokes, H. R.: Mercury_ Embolism of Central Retinal Artery. Amer. J. Ophth. 57: 476 (1964).  Back to cited text no. 6
    




 

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