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Combined central retinal artery and vein occlusion secondary to cataract surgery in a patient with persistent hyaloid artery
Oclusión combinada de arteria y vena central de la retina tras cirugía de catarata en paciente con arteria hialoidea persistente
N. Doménech-Aracil
, J. Montero-Hernández, A. Gracia-García, E. Cervera-Taulet
Corresponding author
Servicio Oftalmología, Hospital General Universitario de Valencia, Valencia, Spain
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Palidez del polo posterior con mancha rojo cereza en la fóvea; tortuosidad vascular, edema de papila y hemorragias intrarretinianas en llama en los 4 cuadrantes de la retina. Obstrucción combinada de arteria y vena central de la retina.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Doménech-Aracil, J. Montero-Hernández, A. Gracia-García, E. Cervera-Taulet" "autores" => array:4 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Doménech-Aracil" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Montero-Hernández" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Gracia-García" ] 3 => array:2 [ "nombre" => "E." 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(B) Endoscopic image of microdebridling opening of bullous shell prior to endoscopic DCR. CB BS: bullous shell; CNL: Nasolacrimal duct; Septum: nasal septum; Unc: unciform apophysis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Nogueira, P. Zaragoza, N. Toledano, I. Genol, G. Plaza" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Nogueira" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Zaragoza" ] 2 => array:2 [ "nombre" => "N." "apellidos" => "Toledano" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Genol" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Plaza" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579414000917?idApp=UINPBA00004N" "url" => "/21735794/0000008900000004/v1_201407250030/S2173579414000917/v1_201407250030/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Combined central retinal artery and vein occlusion secondary to cataract surgery in a patient with persistent hyaloid artery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "161" "paginaFinal" => "164" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Doménech-Aracil, J. Montero-Hernández, A. Gracia-García, E. Cervera-Taulet" "autores" => array:4 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Doménech-Aracil" "email" => array:1 [ 0 => "nurife@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Montero-Hernández" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Gracia-García" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Cervera-Taulet" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Oftalmología, Hospital General Universitario de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Oclusión combinada de arteria y vena central de la retina tras cirugía de catarata en paciente con arteria hialoidea persistente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1561 "Ancho" => 898 "Tamanyo" => 164570 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fluorescein angiograph. Repletion defect of retinal vessels in (a) early times and (b) late times.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The hyaloid artery (HA) provides the blood required for the development of the lens and posterior segments in the embryo. It appears around the third week of gestation and reaches the lens during the fourth–fifth week to form the <span class="elsevierStyleItalic">vasculosa lentis</span> tunic. In general, at the time of birth it has regressed. However, infrequently some remains may persist,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> and exceptionally the entire hyaloid artery remains, constituting hyaloid artery persistence (HAP) from the posterior capsule of the lens up to the optic nerve. This paper presents the case of a patient with HAP exhibiting combined obstruction of central retinal vein and artery after lens surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical case</span><p id="par0010" class="elsevierStylePara elsevierViewall">Female, 72, without relevant history, referred for cataract surgery in the right eye (RE). Ophthalmology exploration revealed best corrected visual acuity (MACV) of 20/80 RE. Anterior pole biomicroscopy (APB) revealed corticonuclear ++ cataract and retrocapsular fibrotic tissue without visible flow, indicating the lens posterior capsule with the optic nerve papilla. This finding led the authors to consider a diagnostic of HAP (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Indirect ophthalmoscopy exhibited ocular fundus within normality with the exception of the fibrotic vestige adhered to the papilla.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After receiving an explanation about the biggest risk of surgery and limited benefits due to probable amblyopia secondary to HAP, the patient accepted surgery and signed the appropriate informed consent.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During surgery, at the time of hydrodissection, a sudden recanalization of the hyaloid vestige was observed, with fluid going through the fibrotic tissue in a matter of seconds to recover the morphology of an artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This unexpected development continued with the disruption of the lens posterior capsule. Upon completion of the lens surgery, by means of pars plana vitrectomy the posterior pole was examined for normality, and finally a sulcus lens was implanted (LI61AO model, Bausch & Lomb) using the support of the anterior capsule.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient returned the following day for examination exhibiting significant visual deterioration with BCVA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>20/200. APB revealed a broad anterior chamber, with the lens centered and positioned in sulcus, with intraocular pressure of 14<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg. However, the funduscopic study showed retinal paleness in the posterior pole together with a bright red spot in the fovea suggesting central retinal artery obstruction (CRAO). In addition, venous tortuosity was observed as well as multiple flame-shaped retinal hemorrhages together with vascular arches in the 4 quadrants and the papilla edema, which in turn suggested central retinal vein occlusion (CRVO) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Fluorescein angiography (FA) showed repletion defect in the retinal vessels, both in early and late times (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), thus confirming the suspected diagnostic, i.e., combined occlusion of central retinal vein and artery.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Hemogram analytics and thrombosis study were carried out, in which all parameters were normal.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Very few publications discuss said entity and no explanation has been found in the literature relating said complication with HAP. Accordingly, a hypothesis is proposed to relate both findings. In the fourth week of gestation the HA is formed, with origin in the papilla extending up to the lens posterior capsule to provide irrigation. This process is completed by the sixth week, when the distal portions of the hyaloid vascular system degenerate while the proximal portions persist due to being comprised within the optic nerve and become the central retinal artery and vein.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to the common embryological origin of HA and the central retinal artery (CRA), and considering that in this case the HA only regressed partially, it is proposed that communication between them could persist.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> When the hyaloid vestige was recanalized during hydrodissection, the HA remains were filled up to the proximal end thus producing a sudden disruption of this joining tissue and establishing direct communication between the CRA layers in the fashion of an arterial dissection and giving rise to the formation of a third space which could have caused the collapse of the CRA patency. In turn, the formation of this compartment could have generated a spatial compromise, giving rise to a secondary CRVO.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, the regression of the fetal vascular system is generally completed at birth. HAP is an infrequent finding usually associated with slight amblyopia without further complications. In addition, other associated diseases have been described such as nystagmus, strabismus, cataract, vitreous hemorrhage and retinal detachment among others.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,5</span></a> However, combined central retinal artery and vein occlusion was not described previously and for this reason the authors point out this possible complication so it can be taken into account during lens surgery. In order to predict associated vascular complications, it is recommended firstly to analyze the functionality of the artery and its partial or total regression before surgery by means of FA<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> or ocular ecodoppler, as well as devising special surgical maneuvers such as careful hydrodissection or vitrectomy (as in the described case) prior to lens surgery in order to remove the HAP.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">No conflict of interests has been declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres354624" "titulo" => array:3 [ 0 => "Abstract" 1 => "Case report" 2 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec336021" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres354623" "titulo" => array:3 [ 0 => "Resumen" 1 => "Caso clínico" 2 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec336022" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-04-10" "fechaAceptado" => "2012-09-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec336021" "palabras" => array:5 [ 0 => "Persistent hyaloid artery" 1 => "Cataract surgery" 2 => "Central retinal vein occlusion" 3 => "Central retinal artery occlusion" 4 => "Combined central retinal artery and vein occlusion" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec336022" "palabras" => array:5 [ 0 => "Arteria hialoidea persistente" 1 => "Cirugía de catarata" 2 => "Oclusión arteria central de la retina" 3 => "Oclusión vena central de la retina" 4 => "Oclusión combinada de arteria y vena central de la retina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Case report</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 72-year-old woman referred for cataract surgery in her right eye. Biomicroscopy revealed a retrocapsular fibrotic tissue in communication with the optic nerve, suggesting a persistent hyaloid artery (PAH). A posterior capsule rupture unexpectedly occurred during lens hydrodissection. One day after surgery, fundus examination showed a combined central retinal artery and vein occlusion.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">PAH is uncommon, but its presence may alert us of this possible complication during cataract surgery.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0025">Caso clínico</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mujer de 72 años remitida para cirugía de catarata en su ojo derecho. La biomicroscopía mostró un tejido fibrótico retrocapsular que comunicaba con el nervio óptico, sugestivo de arteria hialoidea persistente (PAH). Durante la hidrodisección se produjo una inesperada disrupción de la cápsula posterior del cristalino. Un día tras la cirugía, el fondo de ojo reveló una oclusión combinada de la arteria y la vena central de la retina.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusión</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La PAH es un hallazgo infrecuente, sin embargo, su presencia debe alertarnos de esta posible complicación durante la cirugía del cristalino.</p>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Doménech-Aracil N, Montero-Hernández J, Gracia-García A, Cervera-Taulet E. Oclusión combinada de arteria y vena central de la retina tras cirugía de catarata en paciente con arteria hialoidea persistente. Arch Soc Esp Oftalmol. 2014;89:161–164.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Presented at the 87th Congress of the Ophthalmology Society of Spain and in Oviedo, September 21–24, 2011.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 816 "Ancho" => 901 "Tamanyo" => 60840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Persistent hyaloid artery, communication between lens posterior capsule and optic nerve papilla.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 859 "Ancho" => 1403 "Tamanyo" => 114298 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hydrodissection. Sequences showing HA recanalization (a–d).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 788 "Ancho" => 901 "Tamanyo" => 114000 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Retinograph. Posterior pole paleness with bright red spots in the fovea: vascular tortuosity, papilla edema and flame-shaped intraretinal hemorrhages in the 4 retina quadrants. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2018 February | 6 | 1 | 7 |
| 2018 January | 5 | 0 | 5 |
| 2017 December | 7 | 0 | 7 |
| 2017 November | 15 | 0 | 15 |
| 2017 October | 14 | 2 | 16 |
| 2017 September | 16 | 4 | 20 |
| 2017 August | 25 | 4 | 29 |
| 2017 July | 20 | 3 | 23 |
| 2017 June | 28 | 8 | 36 |
| 2017 May | 86 | 2 | 88 |
| 2017 April | 34 | 4 | 38 |
| 2017 March | 49 | 18 | 67 |
| 2017 February | 37 | 6 | 43 |
| 2017 January | 28 | 2 | 30 |
| 2016 December | 32 | 5 | 37 |
| 2016 November | 38 | 1 | 39 |
| 2016 October | 37 | 3 | 40 |
| 2016 September | 50 | 2 | 52 |
| 2016 August | 40 | 2 | 42 |
| 2016 July | 37 | 1 | 38 |
| 2016 June | 45 | 5 | 50 |
| 2016 May | 39 | 5 | 44 |
| 2016 April | 52 | 10 | 62 |
| 2016 March | 38 | 6 | 44 |
| 2016 February | 30 | 5 | 35 |
| 2016 January | 22 | 3 | 25 |
| 2015 December | 25 | 8 | 33 |
| 2015 November | 28 | 4 | 32 |
| 2015 October | 25 | 4 | 29 |
| 2015 September | 35 | 3 | 38 |
| 2015 August | 45 | 5 | 50 |
| 2015 July | 44 | 3 | 47 |
| 2015 June | 21 | 3 | 24 |
| 2015 May | 19 | 2 | 21 |
| 2015 April | 23 | 13 | 36 |
| 2015 March | 17 | 5 | 22 |
| 2015 February | 24 | 3 | 27 |
| 2015 January | 24 | 4 | 28 |
| 2014 December | 33 | 8 | 41 |
| 2014 November | 20 | 5 | 25 |
| 2014 October | 43 | 7 | 50 |
| 2014 September | 4 | 2 | 6 |
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