IDENTIFICATION OF ANASTOMOSIS BETWEEN THE CENTRAL RETINAL ARTERY AND THE CENTRAL RETINAL VEIN IN A CASE OF CENTRAL RETINAL VEIN OCCLUSION DUE TO ARTERIOVENOUS MALFORMATION Joe¨l Hanhart, MD,* Marc Labetoulle, MD, PHD,† Fre´de´ric Azan, MD,‡ Jose´-Alain Sahel, MD,*§ Michel Paques, MD, PHD*§
Purpose: To report the identification of an arteriovenous anastomosis over the optic nerve head in a case of arteriovenous malformation. Case Report: Dynamic scanning laser angiography was performed in a 12 year old girl with a severe arteriovenous malformation complicated by central retinal vein occlusion. Results: The presence of an arteriovenous anastomosis between the central retinal artery and vein was identified. This anastomosis later regressed completely. Conclusions: An arteriovenous anastomosis between central vessels within the optic nerve may be a cause of central retinal vein occlusion. Spontaneous regression of the anastomoses may lead to improvement of fundus features. RETINAL CASES & BRIEF REPORTS 2:322–324, 2008
From the Ophthalmology Departments of the *Fondation Ophtalmologique A. de Rothschild, the †Hopital de Biceˆtre, the ‡Hotel–Dieu, Assistance Publique– Hopitaux de Paris, and §Centre d’ Investigation Clinique 503, INSERM, Paris, France.
personal or family history of thrombosis. She denied a history of head trauma. She had been treated elsewhere for vitreous hemorrhage by pars plana vitrectomy, endophotocoagulation, and triamcinolone acetonide injection. At the time of the first examination in our department, visual acuity was 20/20 in the right eye and finger counting in the left eye. Intraocular pressure was 12 mmHg in both eyes. Fundus examination revealed normal findings for the right eye and evidence of chronic CRVO in the left eye that was associated with disseminated laser scars and central macular fibrosis. An enlarged central retinal artery, a vascular loop (Fig. 1, left), and multiple vessels directed toward a peripheral arteriovenous anastomosis (Fig. 1, right) led to a presumed diagnosis of arteriovenous malformation. Early-phase frames of high-speed indocyanine green angiography with a scanning laser ophthalmoscope showed early filling of the vascular loop over the optic nerve head, suggesting it was an arteriovenous anastomosis between the central retinal artery and the central retinal vein (Fig. 2 and video). Doppler pulsed echography did not demonstrate increased flow velocity in the affected optic nerve as compared with the other side. Medical workup, including brain magnetic resonance imaging with angiography, did not reveal any associated lesions. Examination 3 months later showed improvement of fundus features together with disappearance of the arteriovenous anastomosis (Fig. 3). Visual acuity remained counting fingers.
W
e describe a case of central retinal vein occlusion (CRVO) associated with an arteriovenous malformation in a 12-year-old girl in whom highspeed videoangiography identified the presence of an arteriovenous anastomosis between the central retinal artery and the central retinal vein. Case Report
A 12-year-old girl was referred to us with an 8-month history of CRVO in the left eye. She was otherwise healthy and had no The authors have no proprietary interest related to this report. Reprint requests: Michel Paques, MD, PhD, Department of Ophthalmology, Fondation Ophtalmologique A. de Rothschild, 25 rue Manin, 75019 Paris, France; e-mail: [email protected]
322
323
CRVO IN ARTERIOVENOUS MALFORMATION
Fig. 1. Left, Central retinal vein occlusion at presentation (visual acuity, counting fingers). Note the enlarged central retinal artery and vascular loop (arrow). Right, Dilated vessels are directed toward a peripheral anastomosis (not shown).
Fig. 2. Indocyanine green angiographic frame captures from a high-speed scanning laser ophthalmoscope showing early filling of the arteriovenous shunt. Left, The dye fills the emergence of the central retinal artery and the anastomosis (arrowhead), which is presumably connected to the central retinal vein. Middle, Frame captured 0.3 second after the first-order branches of the central retinal artery (arrows) are filled. Right, Late-phase frame.
Discussion
Fig. 3. Indocyanine angiography of the disk 3 months later showing complete regression of the anastomosis (compare with Fig. 2, right).
Although most retinal arteriovenous malformations are clinically silent,1 they may be associated with some complications, such as CRVO. Nine cases of CRVO related to arteriovenous malformations have been reported previously.2– 4 The mechanism of CRVO in these case has been suggested to be a combination of compression of the central retinal vein by the enlarged central retinal artery, endothelial damage from flow turbulences, and possibly a direct anastomosis between the central retinal artery and the central retinal vein. However, to our knowledge, no direct evidence of such an anastomosis has been reported. In the current case, we identified an anastomosis between the central retinal artery and the central retinal vein by dynamic angiography, underlining the interest of high-speed angiography for detection of such lesions. During follow-up, regression of the central and peripheral arteriovenous anastomosis led to
RETINAL CASES & BRIEF REPORTSℜ
324
improvement of fundus features, although the macular damage prevented visual improvement. Factors underlying the progression and/or regression of arteriovenous malformations are unknown. In future cases, identification of arteriovenous anastomoses may allow specific surgical interventions aimed at occluding them to improve venous outflow.
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2008
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VOLUME 2
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NUMBER 4
arteriovenous malformation, scanning laser ophthalmoscope angiography, arteriovenous malformation. References 1. 2.
Videosequence
3.
Early-phase frames of indocyanine angiography with a scanning laser ophthalmoscope demonstrate early filling of the arteriovenous anastomosis. Key words: central retinal vein occlusion, retinal
4.
Zografos L. Tumeurs Intraoculaires. Paris, France: Masson; 2002:635–640. Schatz H, Chang LF, Ober RR, et al. Central retinal vein occlusion associated with retinal arteriovenous malformation. Ophthalmology 1993;100:24–30. Hardy TG, O’Day J. Retinal arteriovenous malformation with fluctuating vision and ischemic central retinal vein occlusion and its sequelae: 25-year follow-up of a case. J Neuroophthalmol 1998;18:233–236. Khairallah M, Allagui M, Chachia N. Communication arte´rioveineuse re´tinienne conge´nitale et occlusion de la veine centrale de la re´tine. J Fr Ophtalmol 1993;16:117–121.
Purpose: To report the identification of an arteriovenous anastomosis over the optic nerve head in a case of arteriovenous malformation. Case Report: Dynamic scanning laser angiography was performed in a 12 year old girl with a severe arteriovenous malformation complicated by central retinal vein occlusion. Results: The presence of an arteriovenous anastomosis between the central retinal artery and vein was identified. This anastomosis later regressed completely. Conclusions: An arteriovenous anastomosis between central vessels within the optic nerve may be a cause of central retinal vein occlusion. Spontaneous regression of the anastomoses may lead to improvement of fundus features. RETINAL CASES & BRIEF REPORTS 2:322–324, 2008
From the Ophthalmology Departments of the *Fondation Ophtalmologique A. de Rothschild, the †Hopital de Biceˆtre, the ‡Hotel–Dieu, Assistance Publique– Hopitaux de Paris, and §Centre d’ Investigation Clinique 503, INSERM, Paris, France.
personal or family history of thrombosis. She denied a history of head trauma. She had been treated elsewhere for vitreous hemorrhage by pars plana vitrectomy, endophotocoagulation, and triamcinolone acetonide injection. At the time of the first examination in our department, visual acuity was 20/20 in the right eye and finger counting in the left eye. Intraocular pressure was 12 mmHg in both eyes. Fundus examination revealed normal findings for the right eye and evidence of chronic CRVO in the left eye that was associated with disseminated laser scars and central macular fibrosis. An enlarged central retinal artery, a vascular loop (Fig. 1, left), and multiple vessels directed toward a peripheral arteriovenous anastomosis (Fig. 1, right) led to a presumed diagnosis of arteriovenous malformation. Early-phase frames of high-speed indocyanine green angiography with a scanning laser ophthalmoscope showed early filling of the vascular loop over the optic nerve head, suggesting it was an arteriovenous anastomosis between the central retinal artery and the central retinal vein (Fig. 2 and video). Doppler pulsed echography did not demonstrate increased flow velocity in the affected optic nerve as compared with the other side. Medical workup, including brain magnetic resonance imaging with angiography, did not reveal any associated lesions. Examination 3 months later showed improvement of fundus features together with disappearance of the arteriovenous anastomosis (Fig. 3). Visual acuity remained counting fingers.
W
e describe a case of central retinal vein occlusion (CRVO) associated with an arteriovenous malformation in a 12-year-old girl in whom highspeed videoangiography identified the presence of an arteriovenous anastomosis between the central retinal artery and the central retinal vein. Case Report
A 12-year-old girl was referred to us with an 8-month history of CRVO in the left eye. She was otherwise healthy and had no The authors have no proprietary interest related to this report. Reprint requests: Michel Paques, MD, PhD, Department of Ophthalmology, Fondation Ophtalmologique A. de Rothschild, 25 rue Manin, 75019 Paris, France; e-mail: [email protected]
322
323
CRVO IN ARTERIOVENOUS MALFORMATION
Fig. 1. Left, Central retinal vein occlusion at presentation (visual acuity, counting fingers). Note the enlarged central retinal artery and vascular loop (arrow). Right, Dilated vessels are directed toward a peripheral anastomosis (not shown).
Fig. 2. Indocyanine green angiographic frame captures from a high-speed scanning laser ophthalmoscope showing early filling of the arteriovenous shunt. Left, The dye fills the emergence of the central retinal artery and the anastomosis (arrowhead), which is presumably connected to the central retinal vein. Middle, Frame captured 0.3 second after the first-order branches of the central retinal artery (arrows) are filled. Right, Late-phase frame.
Discussion
Fig. 3. Indocyanine angiography of the disk 3 months later showing complete regression of the anastomosis (compare with Fig. 2, right).
Although most retinal arteriovenous malformations are clinically silent,1 they may be associated with some complications, such as CRVO. Nine cases of CRVO related to arteriovenous malformations have been reported previously.2– 4 The mechanism of CRVO in these case has been suggested to be a combination of compression of the central retinal vein by the enlarged central retinal artery, endothelial damage from flow turbulences, and possibly a direct anastomosis between the central retinal artery and the central retinal vein. However, to our knowledge, no direct evidence of such an anastomosis has been reported. In the current case, we identified an anastomosis between the central retinal artery and the central retinal vein by dynamic angiography, underlining the interest of high-speed angiography for detection of such lesions. During follow-up, regression of the central and peripheral arteriovenous anastomosis led to
RETINAL CASES & BRIEF REPORTSℜ
324
improvement of fundus features, although the macular damage prevented visual improvement. Factors underlying the progression and/or regression of arteriovenous malformations are unknown. In future cases, identification of arteriovenous anastomoses may allow specific surgical interventions aimed at occluding them to improve venous outflow.
●
2008
●
VOLUME 2
●
NUMBER 4
arteriovenous malformation, scanning laser ophthalmoscope angiography, arteriovenous malformation. References 1. 2.
Videosequence
3.
Early-phase frames of indocyanine angiography with a scanning laser ophthalmoscope demonstrate early filling of the arteriovenous anastomosis. Key words: central retinal vein occlusion, retinal
4.
Zografos L. Tumeurs Intraoculaires. Paris, France: Masson; 2002:635–640. Schatz H, Chang LF, Ober RR, et al. Central retinal vein occlusion associated with retinal arteriovenous malformation. Ophthalmology 1993;100:24–30. Hardy TG, O’Day J. Retinal arteriovenous malformation with fluctuating vision and ischemic central retinal vein occlusion and its sequelae: 25-year follow-up of a case. J Neuroophthalmol 1998;18:233–236. Khairallah M, Allagui M, Chachia N. Communication arte´rioveineuse re´tinienne conge´nitale et occlusion de la veine centrale de la re´tine. J Fr Ophtalmol 1993;16:117–121.
