Central Retinal Artery Occlusion- A rare complication of oral contraceptive pills

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Case Report

Central Retinal Artery Occlusion- A rare complication of oral contraceptive pills

Nidhi Pancholi*, Reema Rawal** Lalit Prabha Gupta

Resident Doctor, Dept. of Obs.&Gynec.,*, Assoc. Professor, Dept. of Ophthalmology,**, Sr. Medical Officer, Smt. NHL Municipal Medical College, Ahmedabad.

ABSTRACT

Aim: To propose a hypothesis of causal association between central retinal artery occlusion (CRAO) and oral contraceptive pills (OCP)

Case Summary:

A case report-A 22 yr old, female presented with sudden painless loss of vision in OS [Right Eye] for 1 day. VA [Visual Activity] in OS was PL PR [Perception of Light and Projection of Rays] Faulty with RAPD [Relative Afferent Papillary Defect] with normal for fifteen minutes, given five hundred mg of acetazolamide orally stat, 0.4 ml of anterior chamber paracentesis done, 5400 IU LMW [Low Molecular Weight] heparin given SC[Subcutaneous] with carbogen inhalation. Retrospectively she was on oral contraceptives (Mala D) for 1 month. She was not hypertensive or diabetic with normal blood, coagulation profile & carotid Doppler. She was evaluated by an intern to find the cause of coagulation disorder and was found to be normal. On first day FFA [Fundus Florescien Angiography] showed no blockage with normal cilioretinal artery perfusion established. Visual fields after one week showed central tubular vision and OCT [Ocular Coherent Tomography] showed normal fovea. After 2 weeks vision was 20/80 with persistent RAPD papilla macular bundle being perfused.

Key words:

OC Pills, CRAO [Central retinal Artery Occlusion], Arterial occlusion, Mala D, Thromboembolic event, cilio retinal artery occlusion, sudden severe vision loss

INTRODUCTION

Central Retinal Artery Occlusion (CRAO) has one of the most dramatic presentations with rapid sudden and profound loss of vision, most of the time irreversible and strong association

with life threatening systemic disorders. CRAO usually occurs in patients above the age of fifty years, males being affected twice as frequently as females. CRAO commonly occurs due to embolisation (from myocardial infarct, sub acute bacterial endocarditis, vasoobliteration as seen in arteritis, scleroderma, dermatomyositis, Takayasu’s disease tuberculous and syphilitic arteritis) or from pressure outside the arterial wall e.g.: during increased intra ocular pressure (acute congestive glaucoma, retinal detachment surgery) orbital floor fracture or retro bulbar haemorrhage. Increased blood viscosity may occasionally precipitate vascular occlusion as in childhood leukemia, polycythemia and dysproteinemias.

The role of oral contraceptives (OCs) is assumed from observation of a few cases, and is rare in women under the age of 40 years. The vascular effects may include venous or arterial occlusion of retina, isolated retinal bleeding, retinal oedema, vascular pseudopapillitis or visual problems resulting from transient cerebral ischemic attacks and ophthalmic migraine1. Macular edema has been very rarely seen (rare to establish a causal relationship). Animal experiments show increased permeability to lens and vascular dilation. Post marketing experience has included very rare reports of eye inflammation including iritis and uveitis. Manufacturers of oral contraceptive products have reported that some patients develop changes in contact lens tolerance.

An American study recently found 82 cases among ten to fifteen million OC Pill users1. The incidence of ocular complication from birth control pills is estimated to be 1 in 2, 30,0002.

Ocular problems like migraine,

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central retinal artery occlusion and perivasculitis have been reported. Most of these are seen in patients taking OC Pills for long time. 2 cases of young woman who had taken birth control pills and in whom arterial vascular occlusion of retina developed was reported by Leff et al2. Giromi et al6 published a case report a central retinal artery occlusion in a young woman after ten days of drospirenone containing oral contraceptive. Perry HD et al. showed cilioretinal artery occlusion associated with oral contraceptives7. Stowe et al. first time showed CRAO in association with OC Pills8,9. We report a case of CRAO in a young woman who was on contraceptive for 1 month.

CASE REPORT:

A 22 year old female presented to us with a history of sudden, profound, painless loss of vision in the left eye for 24 hours. She was on oral contraceptives ‘Mala D’ for 1 month. She had a history of menorrhagia for which she was put on OCP by a gynecologist. Her right eye was normal. The left eye anterior segment was normal except for afferent papillary defect and vision was perception of light only. Fundus showed right normal eye and left eye mild neuroretinitis and cherry red spot at the macula suggestive of central retinal artery occlusion. She was immediately given a vigorous digital massage for fifteen minutes, five hundred mg of diamox orally, anterior chamber 0.4 ml paracentesis done, five thousand four hundred IU LMW heparin was given subcutaneously and carbogen breathing was started under the observation of an internist.

A thorough systemic examination revealed no abnormality. She was non hypertensive and nondiabetic. The blood examination showed a platelet of 3, 20,000/cmm. Bleeding, clotting and prothrombin time were within normal limits; total proteins 6.3 g/dl, albumin 3.1 g/dl; lipid profile and renal test were normal. LE [Lupus Erythematous Cells] cell and ANA [Antinuclear Antibody] were negative. She had normal Hemoglobin electrophoresis, chest X ray and echocardiogram. Blood pressure, carotid ultrasonography, complete blood count, erythrocyte sedimentation rate, fasting lipids and

glucose, auto antibody screen including anti cardiolipin antibody, protein C and S level, factor V Leiden and blood homocysteine level were normal. She had severe anemia with Hb of 3.5 gm percent but she had no history of breathlessness or fatigue.

She was given packed cell volume to treat her anemia and stopped OC Pills and given an intra vitreal triamcinolone injection to treat the retinal oedema and started multivitamins.

On first post treatment day, fundus examination revealed CRAO, with sparing of central cilio retinal artery. Fundus fluorescence angiography revealed a normal angiogram with normal arm to choroid time, normal filling of arteries and veins with normal cilio retinal artery perfusion. There was no cart boxing of blood and the arteries were not attenuated. No visible vascular block was identified. This was probably due to dislodging of the embolus due to the treatment given the day before. Carotid Doppler of the ICA [Internal Carotid Artery] revealed no abnormalities. Visual acuity was 20/200p.

A 2 week follow up of the patient revealed the patient had Relative Afferent Pupillary Defect in the left eye but the vision restored to 20/80. Fundus showed resolving retinal edema at posterior pole with papilla macular bundle being perfused and pink color of retina being restored to some extent with disc pallor. OCT showed normal macula. Visual fields were done and it showed tunnel vision supporting the diagnosis.

DISCUSSION

Females on OC Pills are prone to thromboembolic event, more common in the venous than in the arterial system10. Concentration of the estrogen content has a role to play11,12,13. Ethinyl estradiol more than fifty microgram increases the risk. Anemia, smoking, impaired glucose tolerance, hypertension, history of vascular problems and visual problems increase the risk.

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contraceptive pills be done.

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