Central retinal artery occlusion as a result of symptomatic patent foramen ovale

Abstract

Objective: The objective of this case report is to highlight the importance of patent foramen ovale (PFO) as a potential cause of central retinal artery occlusion (CRAO). Methods: A teenage girl presented with a sudden painless onset of vision loss in the right eye, which was accompanied by frontal headaches and vertigo. The patient was referred to the Ophthalmology Department, where subsequent examination revealed a best corrected visual acuity of 20/ 400 and a positive relative afferent pupillary defect (RAPD) in the right eye. Fundoscopy and optical coherence tomography confirmed the diagnosis of central retinal artery occlusion following which investigations to rule out hematologic, vascular, and cardiac causes were performed. Results: Transoesophageal echocardiography revealed PFO as the cause of this cryptogenic stroke. All the necessary blood testing work was performed (complete blood counts, erythrocyte sedimentation rate, C-reactive protein, lipid profile, homocysteine levels, prothrombin time, activated partial thromboplastin time, international normalized ratio, liver, renal and thyroid function tests, antinuclear antibodies, anti-smooth muscle antibodies, anti-mitochondrial antibodies, p-ANCA, c-ANCA, anti-cardiolipin antibodies, protein C, Protein S, activated protein C resistance, anti-thrombin III, VDRL, antibodies for viral retinitis, angiotensin converting enzyme, Mantoux test, detailed urine and electrolyte reports). Transoesophageal echocardiography revealed right to left shunt. Conclusions: This case along with other reported evidence in literature support the strong connection between PFO and CRAO. Closure of symptomatic PFO may result in prevention of severe visual loss. Abbreviations: CRAO = central retinal artery occlusion, PFO = patent foramen ovale, RAPD = relative afferent pupillary defect, BCVA = best corrected visual acuity, OCT = Optical coherence tomography, IOP = Intraocular pressures, TTE = transthoracic echocardiography, HM = hand motion, TEE = transesophageal echocardiogram.

Keywords: central retinal artery occlusion; patent foramen ovale; transesophageal echocardiography.

Fig. 1

OCT scan of the right eye shows hyperreflectivity of inner retinal layers

Fig. 2

Colored fundus picture of the right eye showing cherry red spot