Perioperative Retinal Artery Occlusion

Abstract

Purpose To study the incidence and risk factors for retinal artery occlusion (RAO) in cardiac surgery. Design Retrospective study using the National Inpatient Sample (NIS). Methods The NIS was searched for cardiac surgery. Retinal artery occlusion was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Postulated risk factors based on literature review were included in multivariate logistic models. Main Outcome Measures Diagnosis of RAO. Results A total of 5 872 833 cardiac operative procedures were estimated in the United States from 1998 to 2013, with 4564 RAO cases (95% confidence interval [95% CI], 4282–4869). Nationally estimated RAO incidence was 7.77/10 000 cardiac operative procedures from 1998 to 2013 (95% CI, 7.29–8.29). Associated with increased RAO were giant cell arteritis (odds ratio [OR], 7.73; CI, 2.78–21.52; P < 0.001), transient cerebral ischemia (OR, 7.67; CI, 5.31–11.07; P < 0.001), carotid artery stenosis (OR, 7.52; CI, 6.22–9.09; P < 0.001), embolic stroke (OR, 4.43; CI, 3.05–6.42; P < 0.001), hypercoagulability (OR, 2.90; CI, 1.56–5.39; P < 0.001), myxoma (OR, 2.43; CI, 1.39–4.26; P = 0.002), diabetes mellitus (DM) with ophthalmic complications (OR, 1.89; CI, 1.10–3.24; P = 0.02), and aortic insufficiency (OR, 1.85; CI, 1.26–2.71; P = 0.002). Perioperative bleeding, aortic and mitral valve surgery, and septal surgery increased the odds of RAO. Negatively associated with RAO were female gender (OR, 0.77; CI, 0.66–0.89; P < 0.001), thrombocytopenia (OR, 0.79; CI, 0.62–1.00; P = 0.049), acute coronary syndrome (OR, 0.72; CI, 0.58–0.89; P = 0.003), atrial fibrillation (OR, 0.82; CI, 0.70–0.95; P = 0.01), congestive heart failure (OR, 0.73; CI, 0.60–0.88; P < 0.001), DM 2 (OR, 0.74; CI, 0.61–0.89; P = 0.001), and smoking (OR, 0.82; CI, 0.70–0.97; P = 0.02). Conclusions Risk factors for RAO in cardiac surgery include giant cell arteritis, carotid stenosis, stroke, hypercoagulable state, and DM with ophthalmic complications; associated with lower risk were female gender, thrombocytopenia, acute coronary syndrome, atrial fibrillation, congestive heart failure, DM 2, and smoking. Surgery in which the heart was opened (e.g., septal repair) versus surgery in which it was not (e.g., CABG) and perioperative bleeding increased the risk of RAO.

Perioperative Retinal Artery Occlusion: Incidence and Risk Factors in Spinal Fusion Surgery From the US National Inpatient Sample 1998–2013

“…The association between DR and RAO in spinal fusion surgery is new and builds on our report of association between DR and RAO in cardiac surgery. 2 DR is characterized by loss of retinal capillary pericytes, increased retinal vascular permeability, neovascularization secondary to chronic hypoxia, and eventually degeneration of retinal neurons. 36 The increased risk of RAO in patients with DR may be due to susceptibility of the retinal vasculature 37,38 to systemic alterations during complex spine surgery, including blood loss, hypotension, and systemic inflammation.…”

“…1 The three primary causes of POVL are ischemic optic neuropathy (ION), cortical blindness, and retinal artery occlusion (RAO). 2 Although perioperative ION is classically associated with spinal fusion surgery, and perioperative RAO with cardiac surgery, 2 presumably related to embolism, a minority of those with POVL have RAO in spinal fusion surgery. Better understanding of these less common events remains significant since U.S. spinal fusion volume is the highest in the world, 3 and the impact of RAO on a patient's life is considerable, with disability from what is often irreversible visual loss.…”

“…It is inversely associated with acute coronary syndrome, atrial fibrillation, congestive heart failure, diabetes without ophthalmic complications and smoking. 2 A unique postulated cause of RAO in spine surgery is eye compression related to prone positioning, evident when signs and symptoms such as eye pain, ophthalmoplegia, and bruising are also present. 13 In a study of visual loss in spine surgery from the American Society of Anesthesiologists Postoperative Visual Loss Registry, of 10 patients with RAO, 3 had no reported signs of eye compression.…”

Homocysteine in retinal artery occlusive disease: A meta-analysis of cohort studies

“…Thrombophilia is a complex hypercoagulable state that increases the risk of thrombosis. It plays a significant pathoetiologic role in the development of RAO, which is associated with stroke, coronary artery disease, atrial fibrillation, and carotid stenosis 35 . The risk factors of thrombophilia include hyperlipidemia, arteriosclerosis, homocysteine and so on 36 , 37 .…”

Central Retinal Artery Occlusion with Sparing of Cilioretinal Artery Post Pulmonary Artery Stenting

“…Retinal emboli and retinal artery occlusions are known to occur following greater arterial circulation procedures, including left ventricular assisted device surgery, coronary artery bypass graft surgery, carotid endarterectomy, and carotid artery stenting [ 1 - 2 ]. Pulmonary artery stenting is a rare procedure that may lead to central retinal artery occlusion.…”