Ophthalmic Artery Aneurysm: Potential Culprit of Central Retinal Artery Occlusion
A 59-year-old woman presented to the emergency room with sudden visual loss in the right eye, which had started 15 hours prior. She denied past systemic or ophthalmic history. Her best corrected visual acuities were light perception OD and 20 / 22 OS. Her intraocular pressures were 13 mmHg OD and 12 mmHg OS by Goldmann applanation tonometry. Anterior segment examination was normal, and fundus examination demonstrated a pale retina with typical "cherry red spot" in the right eye. Her blood pressure, glucose, lipid, and coagulation profiles, as well as her erythrocyte sedimentation rate and C-reactive protein were within normal limits. Under the diagnosis of acute non-arteritic CRAO, she was urgently transferred to the neuro-intervention team for intra-arterial thrombolysis. Although there is some debate regarding the efficacy of intra-arterial thrombolysis for treatment of CRAO, her acute onset of symptoms within 15 hours without any systemic risk factors, and her insistence for further intervention encouraged consideration for thrombolysis therapy.\nTransfemoral cerebral angiography demonstrated normal choroidal blush with a patent right ophthalmic artery which was stemming from a 3.7 × 4.5 × 5.2 mm sized aneurysm located at the origin of the ophthalmic artery (). External cerebral artery angiography revealed visualization of distal parts of the ophthalmic artery via the middle meningeal artery. Due to the fear of aneurysm rupture, and as the middle meningeal artery collateral communication was confirmed, the right middle meningeal artery was selected for target vessel instead of ophthalmic artery and 200,000 units of urokinase and 100 grams of tirofiban were hand injected. Procedures were finished without any clinical or angiographic complications. The next day, her visual acuity improved to finger count and the right fundus showed macular edema with improved vascularity. Fluorescein angiography showed normal arteriovenous transit time and full peripheral perfusion (). Spectral-domain optical coherence tomography (SD-OCT; Spectralis OCT, Heidelberg Engineering, Germany) showed increased thickness and reflectivity of the inner retina (). Goldmann visual field test demonstrated typical temporal islands, and electroretinography revealed decreased amplitude of the b-wave in the affected eye. To evaluate other possible systemic causes of the CRAO, ancillary studies including brain magnetic resonance imaging, transcranial Doppler, Holter monitoring, carotid Doppler, and echocardiography were performed and no further abnormalities were found aside from an asymptomatic patent foramen ovale. Definite treatment of the ophthalmic artery aneurysm was not recommended considering the risk of the procedure. After four months, her visual acuities were stationary (hand motion), but SD-OCT showed atrophy of the inner retina ().