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CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 50-52

Bilateral central retinal artery occlusion in a case of eclampsia


Department of Ophthalmology, Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication19-Feb-2019

Correspondence Address:
Dr. Y D Shilpa
Department of Ophthalmology, Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru - 560 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/erj.erj_8_18

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  Abstract 


A 19-year-old primigravida admitted in eclampsia ward noticed sudden loss vision in both the eyes. On the same day, she underwent emergency cesarean section due to her deteriorating systemic condition. After her general condition improved, loss of vision in both the eyes continued. On ocular examination, she had bilateral central retinal artery occlusion (CRAO). This is the second case of bilateral CRAO in eclampsia reported in the English literature till date. In our case, the hematological changes occurring in pregnancy and pregnancy-induced hypertension could have caused CRAO in both the eyes.

Keywords: Bilateral central retinal artery occlusion, eclampsia, fundus


How to cite this article:
Shilpa Y D, Kalpana B N, Devaru S. Bilateral central retinal artery occlusion in a case of eclampsia. Egypt Retina J 2018;5:50-2

How to cite this URL:
Shilpa Y D, Kalpana B N, Devaru S. Bilateral central retinal artery occlusion in a case of eclampsia. Egypt Retina J [serial online] 2018 [cited 2019 Dec 8];5:50-2. Available from: http://www.egyptretinaj.com/text.asp?2018/5/2/50/252542




  Introduction Top


The incidence of bilateral central retinal artery occlusion (CRAO) in young is very rare. Here, we present a case of bilateral CRAO in eclampsia patient.


  Case Report Top


A 19 year primigravida with 32 weeks of gestation, acute raise in blood pressure (BP), and the onset of seizures was admitted to eclampsia ward. Previously, the patient was diagnosed to have pregnancy-induced hypertension and was on treatment for hypertension from 28 weeks of pregnancy. She had a history of seizures and loss of consciousness at 32 weeks and was referred to the tertiary care center. She was referred to an ophthalmologist for a reduced vision for the past 2 days. Her ocular examination revealed serous macular elevation with hypertensive retinopathy in both eyes with the vision of counting fingers 5 m at the bedside. Next day morning, she developed sudden onset of loss of vision in both eyes, with uncontrolled raise in BP of 180/120 mmHg. She was diagnosed to have acute kidney injury since her renal function parameters were deteriorating and had reduced urine output. She was taken up for the emergency cesarean section. She delivered a 1.9 kg healthy baby. After her general condition improved, she continued to have loss of vision in both the eyes. Her blood reports were according to [Table 1].
Table 1: Reports of blood investigation

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On ocular examination, vision in both eyes was the perception of light, and direct light reflex had relative afferent pupillary defect. On fundus examination in both the eyes, media was clear, disc margins were well defined with 0.2 cup to disc ratio, there was whitening of posterior pole with cherry-red spot and few superficial retinal hemorrhages in the macula, blood columns in veins and arteries appeared normal, peripheral retina was normal [Figure 1]. Time-domain optical coherence tomography (OCT) was done. Macular OCT showed increased thickness and reflectivity of the sensory retina due to inner retinal layer edema. There is a hyporeflective band between sensory retina and retinal pigment epithelium, and there is decreased reflectivity of outer retinal layers and retinal pigment epithelium-choriocapillary layer [Figure 2].
Figure 1: Fundus images of the right eye and left eye

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Figure 2: Optical coherence tomography of the right eye and left eye

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Diagnosis of bilateral CRAO was done. Ocular massage with three mirror gonio mirror was given. Oral acetazolamide 500 mg was given. Paracentesis was deferred since the visual loss was for more than 5 days. Her vision did not improve any further.

Cardiac evaluation was done. Electrocardiography and echocardiogram reports were within normal limits.


  Discussion Top


After literature search, we found that there are some cases with bilateral CRAO due to different systemic causes. Few of them are given in [Table 2].
Table 2: CRAO in various systemic conditions

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After literature search, we found that CRAO presenting bilaterally and simultaneously was noted in <30 years of the age group in two cases of head trauma and one case of preeclampsia. Kirfan and Arunachalam in 2016 have reported bilateral CRAO in eclampsia patient.[1] To the best of our knowledge, this is the second case of bilateral CRAO in eclampsia reported in the English literature in eclampsia patients.

In 1859, Van Graefe first described CRAO as an embolic event to the central retinal artery in a patient with endocarditis.[2] The incidence of CRAO is 1 in 100,000 population.[2] Bilateral CRAO is observed in 1%–2% of CRAO cases.[3] In young patients emboli due to cardiac cause may lead to this entity,[4] Patients with CRAO present with painless persistent loss of vision anterior segment evaluation is usually normal except for afferent papillary defect.[3]

Preeclampsia is associated with microvascular fibrin deposition.[5] It is associated with activation of coagulation system with thrombocytopenia. Preeclampsia is associated with activation of coagulation system with thrombocytopenia. There is increased platelet activation. Hypercoagulability is accentuated.[6] These factors could be the cause for multiple emboli and hence vascular occlusions. In this case, the lady was a healthy female with no known systemic complications previously. There was no history of diabetes mellitus or hypertension before conception. There was no history of using oral contraceptives previously. In this case, the hematological changes occurring in eclampsia could have been the cause for CRAO in both the eyes simultaneously.

Visual symptoms are reported in 25% of patients with severe eclampsia and 50% eclampsia. Permanent visual symptoms are reported in 1%–3% of cases due to cortical blindness, acute ischemic optic neuropathy, or serous retinal detachment.[7] Previous studies have reported branch retinal artery occlusion[8],[9] and CRAO[10] in pregnancy. The incidence of bilateral CRAO is very rare. After literature search to the best of our knowledge, this is the second reported case of bilateral CRAO in the English literature.

Acknowledgment

The authors would like to thank the Department of Obstetrics and Gynecology, Bangalore Medical College and Research Institute, Bengaluru.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.[14]

Financial support and sponsorship

Nil.



 
  References Top

1.
Kirfan G, Arunachalam M. Bilateral central retinal artery occlusion in pregnant women with severe preeclampsia post caesarian section delivery. Am J Respir Crit Care Med 2016;193:A6931.  Back to cited text no. 1
    
2.
Varma DD, Cugati S, Lee AW, Chen CS. A review of central retinal artery occlusion: Clinical presentation and management. Eye (Lond) 2013;27:688-97.  Back to cited text no. 2
    
3.
Ghose S, Subhabrata P. Bilateral central retinal arterial obstruction following head trauma: A very rare case report. Indian J Ophthalmol 2011;59:66-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Narang S, Kochhar S, Gupta S, Gupta H, Bansal R, Sood S, et al. Bilateral simultaneous central retinal artery occlusion following head injury. Int Ophthalmol 2007;27:387-90.  Back to cited text no. 4
    
5.
Pinheiro Mde B, Junqueira DR, Coelho FF, Freitas LG, Carvalho MG, Gomes KB, et al. D-dimer in preeclampsia: Systematic review and meta-analysis. Clin Chim Acta 2012;414:166-70.  Back to cited text no. 5
    
6.
Lindheimer MD, Taler SJ, Cunningham FG. Hypertension in pregnancy. J Am Soc Hypertens 2008;2:484-94.  Back to cited text no. 6
    
7.
Abu Samra K. The eye and visual system in the preeclampsia/eclampsia syndrome: What to expect? Saudi J Ophthalmol 2013;27:51-3.  Back to cited text no. 7
    
8.
Kurtz WS, Glueck CJ, Hutchins RK, Sisk RA, Wang P. Retinal artery and vein thrombotic occlusion during pregnancy: Markers for familial thrombophilia and adverse pregnancy outcomes. Clin Ophthalmol 2016;10:935-8.  Back to cited text no. 8
    
9.
Chung YR, Kim JB, Lee K, Lew HM. Retinal artery occlusion in a healthy pregnant patient. Korean J Ophthalmol 2008;22:70-1.  Back to cited text no. 9
    
10.
Shilpa YD, Kalpana BN. Ocular coherence tomography and demographic profile in Central retinal artery occlusion: A South Indian study. Egypt Retina J 2015;3:10-4.  Back to cited text no. 10
  [Full text]  
11.
Weissman HM, Biousse V, Schechter MC, Del Rio C, Yeh S. Bilateral central retinal artery occlusion associated with herpes simplex virus-associated acute retinal necrosis and meningitis: Case report and literature review. Ophthalmic Surg Lasers Imaging Retina 2015;46:279-83.  Back to cited text no. 11
    
12.
Wong SC, Boyce RL, Dowd TC, Fordham JN. Bilateral central retinal artery occlusion in wegener's granulomatosis and alpha(1) antitrypsin deficiency. Br J Ophthalmol 2002;86:476.  Back to cited text no. 12
    
13.
Lee AY, Zhang Q, Baughman DM, Mudumbai R, Wang RK, Lee CS, et al. Evaluation of bilateral central retinal artery occlusions with optical coherence tomography-based microangiography: A case report. J Med Case Rep 2016;10:307.  Back to cited text no. 13
    
14.
Rezaei L, Ghambari H. Bilateral central retinal artery occlusion after opium consumption. J Biol Todays World 2014;3:201-5.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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