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Ocular massage can help treat central retinal artery occlusion
When faced with an embolism factor, ocular massage proved to be a successful treatment in rare cases.
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FREIBURG, Germany - Retinal artery obstructions can occur from a number of different sources, namely, vaso-obliteration, embolization, raised intraocular pressure, decreased or increased systemic blood pressure and arterial spasms. Central retinal artery occlusion (CRAO) is believed to be due to an embolus originating from a stenotic internal carotid artery, from plaques within the aortic arch or from a diseased heart. It can also form from arterial hypertension, arterial spasm from a migraine, spasm due to carotid artery disease, a subinitimal hemorrhage or a dissecting aneurysm of the central retinal artery.
However, Dieter Schmidt, MD, published a case study in the European Journal of Medical Research that suggests a new reason for CRAO and a positive prognosis and treatment.
The study involved a 50-year-old male patient who presented at the University Eye Hospital in Freiburg, Germany with a sudden compete loss of vision in his left eye about 20 minutes after waking up one morning in August 1999.
The case study
In 1996, the man had a stroke involving the left cerebral hemisphere with transient paresis of the right arm and aphasia. Since his stroke, he has been treated with phenprocoumon every day. In May 1999, the patient reported several episodes of amaurosis fugax occurring over a period of 18 days. The phenprocoumon was discontinued by the family physician, and one tablet per day of clopidogrel was prescribed.
The patient had been a smoker for 30 years, with a slightly more than a half-a-pack-a-day habit, but he gave up smoking in 1998. He was never diagnosed as hypertensive but hypercholesterolemia was known to have been present for several years.
Roughly 3 hours after the onset of the blindness, the patient was tested to show 20/20 vision in his right eye, but perceived no light from any direction except almost non-existent reaction from light from above. There was almost no light reaction by the pupil.
Dr. Schmidt noted in his article that the fundus of the right eye was normal, but the left eye revealed distinct edema of the central retina. A cherry red spot on the macula was also present. The retinal arteries showed an interrupted blood column, and there was a complete breakdown of the circulation in all blood vessels.
The report stated that the papilla was completely pale, thus indicating that an infarction of the optic nerve head also was present. It was assumed that multiple obstructions of vessels by several emboli in the retinal and ciliary circulation had occurred.
Intravenous fluorescein angiography only showed the dye located in the small nasal superior retinal artery. The choroid also revealed a distinct hypofluoresence, mainly in the central area of the fundus and in the surrounding areas, partly adjacent to the macula and showing the spotted areas of the essential regions of the choroid.
On the Goldmann perimeter visual field, the right eye was normal, but the left eye could not detect any visual field, even against a dark background.
CRAO therapy
To combat the effects of the sudden blindness, Dr. Schmidt performed an ocular massage using the Goldmann contact glass. He pushed for 1 or 2 seconds, several times, on the left eyeball. He noted that after a few minutes, the pale color of the optic nerve had changed to pink and the vessels of the papilla became increasingly filled with blood.
"After 15 minutes, the patient noticed a slight recovery of his vision and told us that the blurred contours of objects were reappearing," according to the study. Dr. Schmidt also wrote that the fundus showed complete restoration of the circulation in all the retinal blood vessels, although the central retinal edema remained unchanged.
The visual acuity increased to 1/20 during eccentric fixation in the temporal periphery. The same morning, the left eye showed it could see test points in the mid-periphery, though a large central scotoma was present.
During the afternoon of the same day, isovolemic hemodilution was administered in the afternoon. The hematocrit was lowered to 41.3% to 33.6% within a few days.
Curious aftereffects
On the next morning following the initial bout of blindness, another intravenous fluorescein angiogram was performed and showed that there was no delay in filling the retinal vessels with dye. But Dr. Schmidt said he was surprised to see that embolic clots, or boluses, appeared in the arteries of the papilla moving with the velocity of the blood flow through the retinal vessels to reach the periphery of the retina within several seconds and then immediately disappeared.
Clots appeared in other areas of the retina as well, but also quickly moved away.
During the patient's last angiogram on the afternoon of the second day, Dr. Schmidt noted no boluses flowing in the retinal vessels. However, the choroid still showed impaired perfusion, mainly in the center of the fundus, but much less than compared to the angiogram taken before the massage, and the fundus showed a marked improvement.
The treatment of isovolemic hemodilution and heparin was continued, but no further visual improvement occurred during 1-week follow-up. On 2 days during the week, the patient noticed recurrences of blindness confirmed by the ophthalmoscopic evidence of an interrupted blood column, mainly in the inferior temporal artery, and a decrease of the blood flow velocity during heparin therapy when walking.
To combat the reoccurrence of the blindness, the patient laid down, and the massage was repeated many times - Once by the doctor and several times by the patient himself by pressing down on his closed eyelid and sharply releasing the pressure.
After the heparin treatment, phenprocoumon was introduced along with a daily dosage of 100 mg of aspirin.
A new conclusion for CRAO
Dr. Schmidt said he believes that because it is known that fluorescein molecules become attached to the surface of erythrocytes as well as binding to albumin, "we assume that a hyperflourescent bolus represents an accumulation of red blood cells."
"We suggest therefore that, in addition to cholesterol and calcareous emboli, conglomerations of blood cells may, in rare situations, also cause a transient obstruction of the blood flow, mainly in the arteries with circumscribed narrowing of the caliber, if the vessel wall is covered with atherosclerotic plaques."
Dr. Schmidt also noticed that the transient blindness of the eye in his patient only occurred when the patient was standing up and never when he was lying down. He believes that posture plays a role in the vision loss because a recovery of vision occurred as soon as the patient lay down and was treated with ocular massage.
"We, therefore, tell all of our patients who have an impairment of retinal arterial blood flow to lie down on their backs and keep their heads down in order to avoid orthostatically decreasing the retinal flow," Dr. Schmidt said.
The patient in his case study is believed to be the first suffering a non-inflammatory CRAO that showed a distinct increase in visual function following ocular massage.
For Your Information:Reference:
- Dieter Schmidt, MD, can be reached at Univ.-Augenklinik, Killianstr, 5, D-79106 Freiburg, Germany; (49) 0-761-270-4001; fax: (49) 0-761-270-4104. Dr. Schmidt does not have a direct financial interest in any product mentioned in this article, nor Is he a paid consultant for any company mentioned.
- Schmidt D. Ocular massage in a case of central retinal artery occlusion - the successful treatment of a hitherto undescribed type of embolism. Eur J Med Res. 2000;5:157-164.