OSLI Retina

June 2019

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June 2019 · Vol. 50, No. 6 385 ■ C A S E R E P O R T ■ Occurrence of Hemi- Central Retinal Artery Occlusion Following Embolization in a Case of Recurrent Juvenile Nasopharyngeal Angiofibroma Shahnaz Anjum, MBBS; Shreyas Temkar, MD; Rohan Chawla, MD; Gaurav Garg, MD ABSTRACT: Preoperative embolization is currently widely followed in the treatment of juvenile naso- pharyngeal angiofibroma (JNA) to reduce intraop- erative bleeding. However, embolization can result in untoward complications like stroke and blind- ness. The authors present the case of a 14-year-old boy with recurrent JNA who developed hemi-cen- tral retinal artery occlusion after embolization of branches of the external carotid artery. It was man- aged by intraocular pressure reduction and globe massage to dislodge the possible embolus. At 4 weeks' follow-up, there was near complete recov- ery in visual acuity; however, residual hemi-field defect persisted. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:385-387.] INTRODUCTION Selective vascular embolization is currently a standard accepted procedure for the treatment of vari- ous conditions of the head and neck, including an- eurysms, intractable epistaxis, and vascular tumors. Juvenile nasopharyngeal angioma (JNA) is a common benign tumor with a tendency to bleed profusely in- traoperatively. Embolization of the external carotid artery branches before surgical resection in JNA has been shown to reduce intraoperative bleeding and de- crease the chances of recurrence. Potential complica- tions of preoperative embolization include stroke and blindness from occlusion of branches of ophthalmic artery. This report highlights the rare occurrence of hemi-central retinal artery occlusion (hemi-CRAO) following embolization in a case of recurrent JNA. CASE REPORT A 14-year-old boy, a known case of recurrent JNA, presented with a history of repeated episodes of nasal bleeding. He had undergone embolization and endo- scopic tumor resection twice (May 2016 and Febru- ary 2017) in another hospital. Both surgeries were uneventful. He was posted for repeat surgery in our hospital in October 2017 in view of recurrent epistax- is following two previous procedures. Pre-surgical embolization of the branches of right external carotid artery was done with polyvinyl alcohol particles to reduce the tumor vascularity. The patient complained blurring of vision in right eye after embolization pro- cedure was completed. On immediate ophthalmic examination, pupils were found briskly reacting and fundus examination of both eyes was within normal limits. Six hours later, the patient noticed sudden-on- set vision loss in his right eye. On examination, there was a relative afferent pupillary defect and visual acuity (VA) was noted to be 4/60 in the right eye. Fun- dus examination of the right eye showed whitening (edema) of the superior hemiretina, both nasal and temporal to the disc, at the posterior pole and along the superior arcade (Figure 1a). No embolus was iden- tified in any of the retinal vessels. Left eye examina- tion was within normal limits. There was no evidence of any neurological deficits. Based on the clinical ex- amination, a diagnosis of hemi-CRAO was made. He was given immediate globe massage along with oral acetazolamide (Diamox Sequels; Teva Pharmaceu- ticals, Petah Tikva, Israel) and topical antiglaucoma medications to reduce intraocular pressure (IOP). Paracentesis could not be performed, as the child was not cooperative. No improvement in VA was noted. The next day, the patient's vision further deteriorat- ed to 1/60. Visual field charting showed presence of inferior hemifield defect (Figure 1b). The head and From the All India Institute of Medical Sciences, Delhi, India. Originally submitted August 5, 2018. Revision received August 5, 2018. Accepted for publication November 6, 2018. The authors report no relevant financial disclosures. Address correspondence to Gaurav Garg, MD, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi, Delhi 110029, India; email: dr.garg1012@gmail.com. doi: 10.3928/23258160-20190605-07

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