American Journal of Neuroradiology 24:1552-1553, September 2003
© 2003 American Society of Neuroradiology
Case Report
INTERVENTIONAL
Glaucoma as a Complication of Superselective Ophthalmic Angiography
Takatoshi Sorimachia,
Jun Maruyab,
Yuka Mizusawac,
Yasushi Itod and
Shigekazu Takeuchid
a Department of Neurosurgery, Nishiogi-chuo Hospital, Tokyo, Japan
b Department of Neurosurgery, Niigata Prefectural Koide Hospital, Niigata, Japan
c Department of Ophthalmology, Niigata Prefectural Koide Hospital, Niigata, Japan
d Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata, Japan
Address correspondence to Dr. Takatoshi Sorimachi, Department of Neurosurgery, Nishiogi-chuo Hospital, 2–5–5, Nishiogi-kita, Suginami-ku, Tokyo, 167-0042, Japan
 |
Abstract
|
|---|
Summary: We report a case of glaucoma that resulted as a complication
of superselective ophthalmic angiography in a 67-year-old man
with a recurrent olfactory groove meningioma. Superselective
angiography in the right ophthalmic artery was performed to
confirm the orifice of the feeding arteries during preoperative
embolization. Immediately after the fourth injection of contrast
medium, the patient suffered from acute angle-closure glaucoma
with elevation of intraocular pressure. Early treatment, including
laser iridotomy, relieved the symptoms completely.
|
Introduction
|
|---|
Recent advances in microcatheter technology have facilitated
superselective ophthalmic angiography for diagnosis and treatment
(
1–
4). We report a case of glaucoma induced by superselective
ophthalmic angiography that improved markedly with early treatment.
As far as we are aware, this is the first report of glaucoma
as a complication of the ophthalmic angiography.
|
Case Report
|
|---|
A 67-year-old male patient presented with progressive mental
disturbance caused by enlargement of an olfactory groove meningioma,
which had been partially removed 5 years earlier. Because of
heavy bleeding during the first surgery, the plan was to perform
embolization preoperatively. The patient had no medical history
of glaucoma, and ophthalmologic examination, including measurement
of intraocular pressure performed the day before embolization,
revealed no ophthalmologic abnormalities. Angiograms revealed
that the tumor was fed by the right ethmoidal and middle meningeal
arteries. First, the right middle meningeal artery was embolized
by using polyvinyl alcohol particles. Next, superselective angiography
of the right ophthalmic artery was performed by injecting 0.3
mL ioxaglic acid (320 mg I/mL), diluted to a 50% concentration
with saline, through a microcatheter (Tracker-18, Target Therapeutics,
Inc., Los Angeles, CA) (
Fig 1). To confirm the orifice of the
posterior ethmoidal artery, angiography was performed several
times at different positions in the ophthalmic artery. Immediately
after the fourth injection of contrast medium, the patient complained
of severe pain in the right eye and right visual loss with corneal
edema and conjunctiva hyperemia. The procedure was discontinued.
CT showed remarkable enhancement in the margin of the right
eyeball by contrast medium administration (
Fig 2). The ophthalmologist
(Y.M.) made the diagnosis of right acute angle-closure glaucoma
with elevation of intraocular pressure (48 mm Hg). Treatment
with glycerol and pilocarpine had no effect on the increased
intraocular pressure. Laser iridotomy performed 12 hours after
the onset of the symptoms promptly relieved the eye pain and
reduced intraocular pressure (20 mm Hg). Vision in the patient’s
right eye completely returned 8 days after the procedure, with
normalization of intraocular pressure (10 mm Hg). The meningioma
was entirely removed surgically 1 month after the embolization.
His mental state improved after the surgery, and he was able
to return to work.
View larger version (170K):
[in this window]
[in a new window]
|
FIG 1. Right ophthalmic angiogram (lateral projection). The anterior ethmoidal (arrow) and posterior ethmoidal arteries (arrowhead) faintly feed the tumor in the olfactory groove.
| |
View larger version (101K):
[in this window]
[in a new window]
|
FIG 2. Axial CT scan obtained before (left) and after (right) ophthalmic angiography. The margin of the right eye is markedly enhanced by contrast medium after angiography.
| |
|
Discussion
|
|---|
Recent advances in microcatheter technology have made catheterization
of the ophthalmic artery and its branches possible. Neurointerventional
techniques have been used for both embolization of hypervascular
lesion fed by the ophthalmic artery (
1,
2) and fibrinolytic
therapy of central retinal artery thrombosis (
3,
4). The efficacy
of preoperative embolization of the posterior ethmoidal artery
via the ophthalmic artery has been reported for hypervascular
meningioma in the olfactory groove (
1,
2). Ischemic retinal
complications may be caused by migration of embolization materials
into the central retinal artery in this procedure (
5). Li et
al reported a case of ocular complication associated with injection
of meglumine sodium diatrizoate into the ophthalmic artery (
6).
One hour after injection, the patient complained of orbital
pain with swelling of the eye and loss of vision, although the
case report did not refer to intraocular pressure. Although
this case might be similar to that of our patient, to our knowledge
there has been no report of glaucoma as a complication of superselective
ophthalmic angiography.
Superselective ophthalmic angiography was thought to induce glaucoma in this case, because ophthalmologic examination the day before the procedure revealed no abnormality and the symptoms occurred in the right eye immediately after superselective angiography in the right ophthalmic artery. The ocular complication appears to be related to the radiographic contrast material, which has direct chemotoxicity as well as high osmolality (584 mOsm/kg H2O) (6). Intraarterial delivery of hyperosmotic agents can lead to disruption of the blood-ocular barriers, consisting of the blood-aqueous barrier and the blood-retinal barrier. The blood-aqueous barrier is formed by an epithelial barrier located in the nonpigmental layer of the ciliary epithelium and in the posterior iridal epithelium. In primates, disruption of the blood-aqueous barriers by Conray-60 produced alterations in the cell morphology and extravasation of Evans blue dye from the vascular space into anterior chamber (7). The pathophysiology of the glaucoma in our case seemed to be osmotic disruption of blood-aqueous barrier by repeated injection of ionic contrast medium into the ophthalmic artery. Pulmonary edema has been shown to depend on dose and rate of contrast medium (8). In cases of superselective ophthalmic angiography, a minimal amount of contrast medium may be recommended to prevent this complication. In rat models, nonionic contrast medium causes fewer, and more transient pulmonary edemas than ionic contrast medium (9). Ionic contrast medium (ioxaglic acid) was used in this case because of its advantage to prevent embolisms; however, nonionic contrast medium might be better for superselective ophthalmic angiography. Early ophthalmologic treatment avoided permanent visual complication. The glaucoma induced by ophthalmic angiography may cause profound, permanent loss of vision. As superselective ophthalmic angiography becomes popular in the future, ionic contrast material should be avoided for ophthalmic artery injections.
|
Conclusion
|
|---|
We have presented a case of acute closure-angle glaucoma as
a complication of superselective ophthalmic angiography. Marked
improvement was achieved by ophthalmologic treatment, including
laser iridotomy. Ionic contrast medium should be avoided for
ophthalmic angiography.
|
References
|
|---|
- Lefkowitz M, Giannotta SL, Hieshima G, et al. Embolization of neurosurgical lesions involving the ophthalmic artery.
Neurosurgery1998; 43
:1298
–1303[Medline]
- Terada T, Kinoshita Y, Yokote H, et al. Preoperative embolization of meningioma fed by ophthalmic branch arteries.
Surg Neurol1996; 45
:161
–166[Medline]
- Tsai FY, Wadley D, Angle JF, et al. Superselective ophthalmic angiography for diagnostic and therapeutic use.
AJNR Am J Neuroradiol1990; 11
:1203
–1204[Medline]
- Vallee JN, Massin P, Aymard A, et al. Superselective ophthalmic arterial fibrinolysis with urokinase for recent severe central retinal venous occlusion: initial experience.
Radiology2000; 216
:47
–53[Abstract/Free Full Text]
- Morgan CM, Schatz H, Vine AK, et al. Ocular complications associated with retrobulbar injections.
Ophthalmology1988; 95
:660
–665[Medline]
- Li V, Turski PA, Levin AB, Weinstein J, et al. Osmotic disruption of the blood-ocular barriers.
AJNR Am J Neuroradiol1987; 8
:347
–348[Medline]
- Cunha-Vax J. The blood-ocular barriers.
Surv Ophthalmol1979; 23
:279
–296[Medline]
- Hayashi H, Kumazaki T, Asano G. Pulmonary edema induced by intravenous administration of contrast media: experimental study in rats.
Radiat Med1994; 12
:47
–52[Medline]
- Mare K, Violante M. Pulmonary edema induced by contrast medium: a comparative investigation in the rat following high intravenous doses of one ionic (diatrizoate) and non-ionic (metrizamide) contrast medium.
Acta Radiol Diagn (Stockholm)1983; 24
:481
–485[Medline]
Received February 16, 2003;
accepted after revision March 6, 2003.
TOP
Abstract
Introduction