Discussion on vascular events (ischaemic & haemorrhagic) that can affect the eye.

1. Vascular Events
@ Ophthalmology
Dr Yong Meng Hsien 2021

2. Vascular Events @ Ophthalmology
Ischaemic (sudden/acute) Haemorrhage
(sudden/acute)
Ischaemic/
Haemorrhage
(gradual/asymptom)
1. CRAO
2. BRAO
3. CLRAO
4. Choroidal ischaemia
5. PION
6. AION
7. Amourosis fugax/ ocular TIA
8. CVA
9. Ischaemic mononeuropathy
10.Mononeuritis multiplex
1. Subconjunctival
2. Hyphaema
3. VH
4. Retinal
5. Subretinal/sub
RPE/choroidal
6. Suprachoroidal
7. Retroorbital
8. Haemorrhagic
CVA
1. Ischaemic retinopathy
(various causes)
2. Cerebral venous
thrombosis (various
location)

3. When to suspect vascular event?

4. Visual complaint

6. Blood supply (artery)
• Carotid/ophthalmic  OIS
• Central retinal arteries  CRAO/BRAO
• Retinal arterioles/capillary  CWS (RNFL infraction) or subtle retinal
depression/atrophy
• Retinal capillary @macula  paracentral acute middle maculopathy
(PAMM)
• Ciliary arteries/PCA – ischaemic ON
• Ciliary arteries /PCA – cilioretinal artery occlusion, choroidal ishaemia
• Visual pathway, cranial nerves
• Look for: involvement of inner vs outer or both retina, OD, ant segment
• Poor vision e.g. NPL  both ciliary + CRA occlusion, or ophthalmic
artery

8. Risk Factors
• Virchow’s triad: hypercoagulability, stasis and endothelial injury
• Atherosclerosis +- aneurysm/dissection
• Age, metabolic diseases, smoking, hemocysteinemia
• Thrombo-embolic event
• Sources (thrombotic): cardiac (calcification), carotid (cholesterol), other
large vessels (platelet-fibrin), CTD/Coagulopathy
• Sources: septic, fat, talc (IVDU), cosmetic filler
• Hypercoagulopathy
• protein C/S/AT III, lupus anticoagulant, anticardioliplin, SLE/APS,
drug/sildenafil
• Hyperviscosity/stasis
• OCP, pregnancy, leukemia/lymphoma
• Inflammatory/vasculitis
• GCA, SLE, RA, Wegener/GPA, PAN, Behcet/uveitis
• Others: Eisenmenger, vasospasm/migraine, radiation, infection
(systemic/local/extension)

9. Ocular

10. Ischaemic Retinopathy- Causes
Bilateral
• Metabolic:
DR > RVO/RAO/OIS
• Blood: SCA/thalassemia,
hyperviscosity
• Paeds: ROP/FEVR
• Inflam/vasculitis
• Abn vessels
• Radiation/trauma/tumour
Unilateral
• Metabolic: OIS/RVO/RAO >
DR (aggravating factor+)
• RD
• Inflam/vasculitis
• Radiation
• Tumour
• Trauma/Purtscher
• Abn vessel:
macroaneurysm,
telangiectasia

11. Ischaemic Retinopathy- Sequelae
• Macular ischaemia
• Macular edema
• NeoV  VH  fibrovascular proliferation  TRD
 combine TRD/RRD
• Rubeosis  NVG (angle open  closure)

12. Ocular Ischaemic Syndrome (OIS)
• Chronic hypoperfusion  gradual onset
• carotid/ophthalmic artery
• Spectrum of severity with collateral from Circle of
Willis
• SSx orbital & ocular (ant & posterior)
• DDx CRVO
• Mx: PRP, stenting, endarterectomy, bypass
• Landmark study: NASCET, CREST

13. Cilio-retinal CLRAO
• CLA < SPCA < OA
• <10% RAO
• a/w CRVO, AION

14. Radiation retinopathy
• Damages the endothelial cells
• safe dose <30 Gray (still +risk)
• Safer with <10 Gray per week in five fractions (2
Gray per session)

15. Proliferative Sickle Cell Retinopathy
Goldberg staging:

16. Optic Disc

18. Giant Cell Arteritis (Horton Disease)
• Systemic inflam necrotizing granulomatous vasculitis
• Arterties  SSx
• Temporal
• Maxillary/Messeter
• Carotid/ICA/ECA
• Post ciliary
• Ophthalmic
• Dx criteria (3/5)
• age >50/new localised headache/temporal art tender or
pulseless/ESR >50/TAB +-skip leison)
• Others Ix: CRP, Platelet
• Rx: steroid +- tocilizumab

19. Intracranial/Visual Pathway/EOM

20. Cerebral Venous Thrombosis
• Location  SSx (general: headache)
• Cavernous sinus
• Lat/transverse: facial pain + 6th CNP Gardenigo
• Sup sagittal (SSS)
• Deep: thalamus/basal ganglia infarct
• Ix: CT/MRI  CTV/MRV  venography
• Rx: cause based (anticoagulant +- Ab), steroid only
if severe non septic CST, IR/endovascular
procedure/canalization

21. CCF
• Def: AV fistula of carotid A & cavernous V
• PathoP: high V pressure & low A perfusion
• Types: direct (intracavernous ICA), indirect (meningeal branch of
ICA/ECA or both)
• Causes: head trauma (75%) & spontaneous
(aneurysm/atherosclerotic/post menopause > direct, HPT >
indirect), congenital
• SSx:
– high V: proptosis (pulsatile), corkscrew episcleral V, IOP, EOM/ptosis
(CN/muscle enlarged), ON, CRVO
– low A: AS ischemia (20%), ischemic retinopathy
•Ix: CT (enlarged SOV/EOM/fat streakiness, cavernous sinus loss of
wedge/bowing) → angio/CTA/MRA/doppler
• Rx:
– observe if no Cx/spontaneous close (less in traumatic CCF)
– catheter embolization (ballon/glue)
– surgical ligation

22. Ocular Movement- Anatomy
Supranuclear
• Cerebral cortex control
– FEF, MT/MST/POT
– + subcortex: basal ganglia (BG), thalamus, and superior colliculus (SC)
• Brainstem
– Reticular formation- mesencephalic/para-pontine/medullary
– + neural integrators
– + tracts (MLF)
– + vestibular-ocular system
• Cerebellum
Infranuclear
• Ocular motor CN (III, IV, and VI)- nuclei & nerve
• NMJ
• EOMs
Supra- VS Infra-nuclear: Symmetrical BE + No diplopia + Normal VOR

24. Parietal Lobe Lesion (Gerstmann’s Syndrome)
• VF: pie in the floor (CL inf quadrantanopia)
• LR disorientation
• Finger agnosia
• Agraphia
• Dyscalculia
• Abn OKN when drum toward lesion

25. Q
• Cilioretinal RAO- related to CRAO or CRVO?
• OIS- similar features with CRVO or CRAO
• What are the risk factors for
• OIS, CRAO/BRAO/CLRAO, PION/AION, CVT, ischeamic
mononeuropathy or mononeuritis multiplex, CVA
• Vichow’s, systemic/local, infective/non
• Ocular presentation of GCA/other vasculitis
• EOM, ON, ocular (OIS/retina)

26. Eye Pressing Procedure in Ophthal
• Ophthalmodynanometer
• Easily collapsed CRA in OIS
• Scleral buckle TRO CRAO
• Ocular massage for CRAO
• Retropulsion for orbital examination
• Ocular massage for glaucoma shunt

27. Haemorrhage

28. Hemorrhage in Ophthal
• Ant chamber bleeding/hyphaema
• Vitreous hemorrhage
• Retinal hemorrhages
• Subretinal hemorrhage
• Orbital hemorrhage

29. Retinal Vessels Changes & Hrge
Vascular changes
• OIS: A narrowed,
microaneurysm; V
dilated but not
tortuous
• RVO: V tortuous
• DR: A microaneurysm,
V beaded not tortuous
Haemorrahages
• OIS: deep, round,
midperiphery
• RVO: flame-shaped
• DR: dot-blot

30. Retinal SSx: Roth spots
What: haemorrhages (round/oval/flame-shaped), with centre white spot
How: blood disorder/bleeding tendency, capillary ischemia, increased
vessel permeability, high venous pressure → retinal capillaries rupture
→ extrusion of whole blood → coagulation cascade → platelet-fibrin
thrombus.
Causes:
* subacute bacterial endocarditis/DIVC/leukaemias (thrombocytopenia)
* anaemia/anoxia/carbon monoxide poisoning/prolonged intubation
(ischemia)
* hypertensive retinopathy/pre-eclampsia/DR/ocular decompression
following trabeculectomy (capillary fragility)
* birth trauma/traumatic deliveries/battered children/shaken baby
syndrome/intracranial haemorrhage/AVM (high venous pressure)

31. CNV Subretinal Haemorrhages
 Degenerative:
 wet ARMD/IPCV, chronic CSCR
 high myopia, angioid streaks
 Traumatic/iatrogenic
 Choroidal rupture, laser
 Inflammation
 POHS, post uveitis (VKH/toxoplasmosis), white dot syndrome
 Dystrophy
 Best’s dz
 Tumour
 Choroidal nevus/hemangioma

32. VH
• Causes x 3
• abn vessels/NeoV
• normal vessels with tear
• breakthrough
• Key
• 2nd eye for DDx
• B scan (RD/tumour/PVD)
• Mx
• observe 3mth  persistent  op
• earlier op: precious eye, RD, uncontrolled VH glaucoma,
un-lasered ischemic retinopathy, paeds with risk of
amblyopia

33. Suprachoroidal hemorrhage
• PathoP: rupture of SCA/LPCA/VV
• Types:
• intraop VS postop/delayed VS traumatic
• limited VS kissing VS expulsive
• arterial VS venous (>limited/>related to hypotony)
• Risk
• ocular: high myope, high IOP, choroidal hemangioma, prev
inflam/uveitis/laser/cryo/trauma, aphakia/post TPPV
• systemic: HPT/atherosclerotic, age, obese/short neck, nervous, anticoagulant/bleeding
d/o
• intraop: large incision/open sky/poor wpund, hypotony/IOP fluctuation/sudden change,
vitreous loss, suture injury to deep scleral/choroidal bv, SB, valsalva
maneuver/cough/strain, tachycardia
• sign of expulsive SCH
• red reflex loss, sudden pain/high IOP, AC shallow, wound gape, prolapsed
iris/lens/vitreous/retina/blood
• Mx- intraop: closure, IOP lowering, AC reform
• Mx- postop: IOP/pain control, sclerotomy (indication/timing/procedure)
• Timing: POD 7-14 days for liquefaction of blood clots (B scan hyper  hypo
reflectivity)
• Cx: VH/RD/angle closure  toxic & ischemic retinopathy, IOP ON damage,
corneal decompensation with blood stain/IOP/shallow AC

34. Retrobulbar Hemorrhage
• orbital apex syndrome + proptosis + high IOP +
conj/eyelid hematoma/edema
• Lateral Canthotomy
– local anaesthesia (1–2 ml lidocaine 2% with
adrenaline) → clamping x 60 sec → scissors cut 1–2
cm horizontal full-thickness
• Lateral Cantholysis (inferior +- superior)
– canthotomy → lower lid retracted downwards →
inferior crus of the lateral canthal tendon transected
– blunt-tipped scissors directed inferiorly and inserted
adjacent and parallel to the lateral orbital rim
between conjunctiva and skin