Retinal arterial occlusion and patent foramen ovale: A case study-based review

J Fr Ophtalmol. 2024 Jan;47(1):104021. doi: 10.1016/j.jfo.2023.07.022. Epub 2023 Nov 10.

Abstract

Purpose: To identify all reported cases of retinal artery occlusion (RAO) associated with patent foramen ovale (PFO) in the literature and present a similar case of CRAO from our clinic.

Methods: PubMed database was searched for studies reporting RAO in individuals with PFO. Relevant data were tabulated and reviewed. We estimated each case's Risk of Paradoxical Embolism (RoPE) score.

Results: 23 cases of CRAO (n=10; including ours), BRAO (n=10), and CILRAO (n=3) were reviewed. Most cases were under 50 years of age (78.3%). The reported predisposing factors were: hypertension (26.1%), migraine (17.3%), smoking (13.0%), recent immobilization (13.0%), strenuous exertion (8.7%), pregnancy (8.7%), and diabetes (4.3%). A high RoPE score (≥7; suggestive of paradoxical embolism via PFO) was estimated for 71.4% of patients. In most cases, the neurological and cardiovascular examinations, laboratory studies, and imaging were unremarkable, except for the PFO±atrial septal aneurysm (present in 21.7%). In only 28.6% of cases, transthoracic echocardiography (TTE) (± saline contrast) could visualize the PFO; transesophageal echocardiography (TEE) was necessary to detect the PFO in 71.4%. Approximately one-half of the patients underwent percutaneous closure of the PFO; no complications or subsequent acute ischemic events ensued. The visual prognosis was poorer for CRAO than for BRAO or CILRAO.

Conclusion: Timely diagnosis, acute management, and ensuring urgent initiation of stroke workup in cases with RAO or transient monocular vision loss are crucial. Clues to a possible paradoxical embolism as the cause include the absence of known cardiovascular risk factors, young age, migraine, recent immobility, vigorous exercise, and pregnancy.

Keywords: Accident vasculaire cérébral; Branch retinal artery occlusion; Central retinal artery occlusion; Embolie paradoxale; Foramen ovale perméable; Occlusion de l’artère centrale de la rétine; Paradoxical embolism; Patent foramen ovale; Stroke; occlusion de l’artère rétinienne secondaire.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Adult
  • Embolism, Paradoxical* / diagnosis
  • Embolism, Paradoxical* / epidemiology
  • Embolism, Paradoxical* / etiology
  • Foramen Ovale, Patent* / complications
  • Foramen Ovale, Patent* / diagnosis
  • Foramen Ovale, Patent* / epidemiology
  • Humans
  • Middle Aged
  • Migraine Disorders* / diagnosis
  • Migraine Disorders* / epidemiology
  • Migraine Disorders* / etiology
  • Retinal Artery Occlusion* / diagnosis
  • Retinal Artery Occlusion* / epidemiology
  • Retinal Artery Occlusion* / etiology
  • Stroke* / complications
  • Stroke* / diagnosis