Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Combined Occlusion of the Central Retinal Artery and Vein in a Pediatric Patient Secondary to Infective Endocarditis

Combined Occlusion of the Central Retinal Artery and Vein in a Pediatric Patient Secondary to... A 14-YEAR-OLD girl had experienced general fatigue, weight loss, and fever for 3 months when she developed sudden unilateral visual loss. Visual acuity in the right eye was no light sense. Ophthalmologic examination revealed a combined occlusion of the central retinal artery and vein on the first day (Figure 1 and Figure 2) and flame-shaped retinal hemorrhage on the second day (Figure 3). She was diagnosed as having infective endocarditis (IE) with group D streptococcus. Congenital atrial septal defect and mitral valve insufficiency were also found, which probably caused IE and subsequent ophthalmic events. Despite treatment with fibrinolysis (urokinase and low molecular dextran; Otsuka Pharmaceutical Co Ltd, Tokyo, Japan), her visual acuity improved only to hand movement with resolution of the cherry red spot. Two weeks after the first ophthalmologic examination, she underwent mitral valve replacement and surgery to close the atrial septal defect. After 10 years of follow-up, her visual acuity in the right eye has remained hand movement. No iris neovascularization has developed. Figure 1. View LargeDownload Combined occlusion of central retinal artery and vein of the right eye seen on the first day. A gray-white retina with a cherry red spot, a blot hemorrhage, segmented vessels, and optic disc edema are found. Retinal veins are engorged. Figure 2. View LargeDownload Fluorescein angiogram of the right eye on the first day of visual loss reveals nonperfusion of retinal circulation. Ciliary artery remains unobstructed. Figure 3. View LargeDownload Right eye of the patient on the third day. A gray-white retina is seen with flame-shaped hemorrhage adjacent to the retinal vessels, mainly in the posterior pole. Retinal arteries are recanalized, and retinal veins are still engorged. Comment This patient's ophthalmic features were compatible with combined occlusion of the central retinal artery and vein, a rare clinical finding, especially in young patients. Previously reported risk factors are inflammatory, coagulopathic, and tumorous systemic diseases.1-3 In this case, the vessels were occluded and the retina was ischemic on the first day. The pathogenesis was assumed to be a disruption of arterial blood flow into the retina by infectious emboli that caused stagnation of capillary blood flow and venous thrombus. Immunocomplex vasculitis secondary to IE4 probably also existed. To our knowledge, this is the first case in a pediatric patient of combined occlusion of retinal artery and vein secondary to IE. Ophthalmologists should be aware that thorough investigation of even young patients with retinal vascular disease is necessary to rule out underlying severe systemic disorders. Corresponding author: Hiromu K. Mishima, MD, PhD, Department of Ophthalmology, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan (e-mail: hkmishi@hiroshima-u.ac.jp). References 1. Richards RD Simultaneous occlusion of the central retinal artery and vein. Trans Am Ophthalmol Soc. 1979;77191- 209Google Scholar 2. Schwartz SGMcPherson ARMieler WFSessoms SLMoake JLHolz ER Bilateral combined occlusion of the central retinal artery and vein secondary to thrombotic thrombocytopenic purpura. Arch Ophthalmol. 2000;1181304- 1305Google ScholarCrossref 3. Saatci AODuzovali OOzbek Z et al. Combined central artery and vein occlusion in a child with systemic non-Hodgkin's lymphoma. Int Ophthalmol. 1998-99;22125- 127Google ScholarCrossref 4. Gold DH Endocarditis. Gold DHWeingeist TAeds. The Eye in Systemic Disease. Philadelphia, Pa JB Lippincott Co1990;3- 5Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Ophthalmology American Medical Association

Combined Occlusion of the Central Retinal Artery and Vein in a Pediatric Patient Secondary to Infective Endocarditis

Loading next page...
 
/lp/american-medical-association/combined-occlusion-of-the-central-retinal-artery-and-vein-in-a-BT7YX50jrp
Publisher
American Medical Association
Copyright
Copyright © 2001 American Medical Association. All Rights Reserved.
ISSN
0003-9950
eISSN
1538-3687
DOI
10.1001/archopht.119.12.1868
Publisher site
See Article on Publisher Site

Abstract

A 14-YEAR-OLD girl had experienced general fatigue, weight loss, and fever for 3 months when she developed sudden unilateral visual loss. Visual acuity in the right eye was no light sense. Ophthalmologic examination revealed a combined occlusion of the central retinal artery and vein on the first day (Figure 1 and Figure 2) and flame-shaped retinal hemorrhage on the second day (Figure 3). She was diagnosed as having infective endocarditis (IE) with group D streptococcus. Congenital atrial septal defect and mitral valve insufficiency were also found, which probably caused IE and subsequent ophthalmic events. Despite treatment with fibrinolysis (urokinase and low molecular dextran; Otsuka Pharmaceutical Co Ltd, Tokyo, Japan), her visual acuity improved only to hand movement with resolution of the cherry red spot. Two weeks after the first ophthalmologic examination, she underwent mitral valve replacement and surgery to close the atrial septal defect. After 10 years of follow-up, her visual acuity in the right eye has remained hand movement. No iris neovascularization has developed. Figure 1. View LargeDownload Combined occlusion of central retinal artery and vein of the right eye seen on the first day. A gray-white retina with a cherry red spot, a blot hemorrhage, segmented vessels, and optic disc edema are found. Retinal veins are engorged. Figure 2. View LargeDownload Fluorescein angiogram of the right eye on the first day of visual loss reveals nonperfusion of retinal circulation. Ciliary artery remains unobstructed. Figure 3. View LargeDownload Right eye of the patient on the third day. A gray-white retina is seen with flame-shaped hemorrhage adjacent to the retinal vessels, mainly in the posterior pole. Retinal arteries are recanalized, and retinal veins are still engorged. Comment This patient's ophthalmic features were compatible with combined occlusion of the central retinal artery and vein, a rare clinical finding, especially in young patients. Previously reported risk factors are inflammatory, coagulopathic, and tumorous systemic diseases.1-3 In this case, the vessels were occluded and the retina was ischemic on the first day. The pathogenesis was assumed to be a disruption of arterial blood flow into the retina by infectious emboli that caused stagnation of capillary blood flow and venous thrombus. Immunocomplex vasculitis secondary to IE4 probably also existed. To our knowledge, this is the first case in a pediatric patient of combined occlusion of retinal artery and vein secondary to IE. Ophthalmologists should be aware that thorough investigation of even young patients with retinal vascular disease is necessary to rule out underlying severe systemic disorders. Corresponding author: Hiromu K. Mishima, MD, PhD, Department of Ophthalmology, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan (e-mail: hkmishi@hiroshima-u.ac.jp). References 1. Richards RD Simultaneous occlusion of the central retinal artery and vein. Trans Am Ophthalmol Soc. 1979;77191- 209Google Scholar 2. Schwartz SGMcPherson ARMieler WFSessoms SLMoake JLHolz ER Bilateral combined occlusion of the central retinal artery and vein secondary to thrombotic thrombocytopenic purpura. Arch Ophthalmol. 2000;1181304- 1305Google ScholarCrossref 3. Saatci AODuzovali OOzbek Z et al. Combined central artery and vein occlusion in a child with systemic non-Hodgkin's lymphoma. Int Ophthalmol. 1998-99;22125- 127Google ScholarCrossref 4. Gold DH Endocarditis. Gold DHWeingeist TAeds. The Eye in Systemic Disease. Philadelphia, Pa JB Lippincott Co1990;3- 5Google Scholar

Journal

Archives of OphthalmologyAmerican Medical Association

Published: Dec 1, 2001

Keywords: bacterial endocarditis,pediatrics,central retinal artery

References