Retrograde Flow in the Left Ophthalmic Artery

Transient Left Eye Blindness after Exercise • Xray of the Week

This 73 year old male with a history of transient left eye blindness after exercise had a carotid doppler with evaluation of the ophthalmic arteries. What is the abnormality and what is the anatomic reason?

Fig. 1A: No flow in the left internal carotid artery. Fig. 1B: Antegrade flow in the right ophthalmic artery. Note red color above the baseline in the ophthalmic artery. The pulsed Doppler signal is also above the baseline. Fig. 1C: Retrograde flow in the left ophthalmic artery. Note blue color below the baseline in the ophthalmic artery. The pulsed Doppler signal is also below the baseline.

Fig. 2A. Normal flow direction shown with arrows in the arteries. There is normal antegrade flow in the ophthalmic artery (OA), signified by the red arrow.

Fig. 2B Note the retrograde flow in the ophthalmic artery (OA), signified by the blue arrow. With occlusion of the internal carotid artery (ICA), peri-orbital collaterals from the ECA circulation open up, and flow is restored to the supra-clinoid segment of the ICA.

Key:

CCA: Common carotid artery

ECA: External carotid artery

ICA: Internal carotid artery

FA: Facial artery

AA: Angular artery

STA: Superficial temporal artery

STA (FA): Superficial temporal artery (Frontal artery-branch)

OA: Ophthalmic artery

STA: Supratrochlear artery

Fig. 3. Neovascularization of the iris (NVI), also known as rubeosis iridis, is when small fine, blood vessels (black arrows) develop on the anterior surface of the iris in response to retinal ischemia. These changes most often develop at the pupillary border (yellow arrow). Ophthalmic Image by EyeRounds.org, The University of Iowa is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

Discussion

Retrograde flow in the ophthalmic artery can be seen with ICA occlusion or severe stenosis and may lead to transient orbital ischemia. (1,2,3) Due to the decreased flow to the globe, this may present as transient monocular blindness after exposure to bright light, position-induced visual loss, postprandial transient visual loss, exercise-induced visual loss, or visual loss following facial heating.(1,2,3) Patients with markedly diminished flow to the globe may eventually develop rubeosis iridis (Fig.3) which is defined as neovascularization of the iris in response to retinal ischemia.(3,4) This may in turn lead to the development of neovascular glaucoma. Therefore, these patients should be treated with superficial temporal artery to middle cerebral artery (STA-MCA) bypass to avoid this serious complication.(3)

References:

1. Anupriya Arthur, et al. Ophthalmic masquerades of the atherosclerotic carotids. Indian Journal of Ophthalmology. 2014. Volume 62, Page 472-476

2. Yamamoto K, Mori T, Yasuhara M, et al. Ophthalmic artery blood flow in patients with internal carotid artery occlusion. Br J Ophthalmol. 2004 Apr; 88(4): 505–508. doi: 10.1136/bjo.2003.025809

3. CL Tsai, et al. Reversal of ophthalmic artery flow as a predictor of intracranial hemodynamic compromise: implication for prognosis of severe carotid stenosis. European Journal of Neurology Volume 20, Issue 3, pages 564–570, March 2013

4. Beebe, J and Haugsdal J. Rubeosis iridis or neovascularization of the iris in diabetes. Accessed 11/10/2018. EyeRounds.org. https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/NVI/index.htm

Kevin Rice, MD is the president of Global Radiology CME and serves as the Chief of Staff and Chair of the Radiology Department at Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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