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K. Hufendiek, T. Finkenzeller, K. Hufendiek, H. Helbig, C. Framme; Acute Visual Loss After Pre-Operative Embolization of an Ethmoidal Metastasis. Invest. Ophthalmol. Vis. Sci. 2009;50(13):374.
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To report a case in which embolization of tumor feeder vessels through the left ophthalmic artery led to occlusion of the central retinal artery along with posterior ciliary arteries and caused an acute permanent visual loss.
A 40-year-old male patient with a history of right nephrectomy for renal cell carcinoma underwent pre-operative radiological embolization of an ethmoidal metastasis after having experienced a life-threatening sinus bleeding. To minimize the risk of a second life-threatening bleeding, pre-operative endovascular application of PVA embolization particles (Contour® 150-250µ, Boston Scientific, MA, USA) was selected to achieve obliteration of the tumor-supplying vessels. The radiological intervention was performed under anticoagulation with Heparin (5000 I.U. initially followed by constant infusion of 500 I.U./h during intervention). During the procedure, repeated microcatheter-probing (Echelon® 14, MTI, MN, USA) of the mandibulovidian, the inferolateral and the ophthalmic artery became necessary to access the tumor-supplying arteries for embolization.An opthalmological examination including visual acuity, slit-lamp examination, funduscopy, fluorescein angiography (FA) and indocyanine green angiography (ICGA) was performed. Macular assessment was performed using stereo funduscopy and OCT.
Pre-operative ophthalmologic evaluation showed no abnormalities and an uncorrected visual acuity of 20/20 on both eyes. At the end of the intervention, the central retinal artery and the posterior ciliary arteries appeared angiographically patent, although reduced blood flow in the ophthalmic artery was evident. On the first day after the embolization procedure, visual acuity of the left eye was hand movement. Further evaluation could not be performed due to the patient's general condition directly after the procedure. On follow up three days later, a complete loss of visual function had occurred on the left eye. Fundoscopic evaluation revealed a cherry-red spot and milky-white edema in the region of the papillo-macular bundle. FA presented a recanalized central retinal artery occlusion, while ICGA showed infarctions of the choroid. OCT showed an increased macular thickness and subretinal fluid.
Radiological intervention via the ophthalmic artery can result in complete loss of vision, even after limited and transient obstruction of the vessel. To our knowledge, the occlusion of the central retinal artery with complete loss of vision has never been reported as a complication after embolization of tumor-supplying branches of the ophthalmic artery.
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