Radial optic neurotomy in combined cilioretinal artery and central retinal vein occlusion

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Abstract
A healthy 64 year old woman complained of unilaterally blurred vision for the past 3 days. Her visual acuity (VA) was 20/200 in the right eye (RE) and 20/20 in the left eye (LE). The anterior segment in both eyes was unremarkable on slit lamp examination. Fundus examination RE demonstrated a whitening of the macula corresponding to an area supplied by an cilioretinal artery. The retinal veins were dilated, accompanied by adjacent retinal haemorrhages (fig 1A). The fundus of the left eye appeared normal. Fluorescein angiography (FA) RE revealed a delayed arteriovenous (AV) perfusion time of 13 seconds. Systemic evaluation of the patient did not reveal any general disease. Although treated systemically with corticosteroids6 and low dose heparin for 4 weeks, she developed CRVO with severe disc oedema, extensive dilatation of the retinal veins, radial orientated intraretinal haemorrhages, and cotton wool spots (fig 1B). On FA there was a reduced perfusion time of the cilioretinal artery in addition to the typical signs of CRVO (fig 2A). Based on positive results of RON in CRVO, we offered this treatment to our patient. After she signed an informed consent, RON was performed with two radial cuts at the nasal edge of the optic disc. After 2 days disc oedema was significantly reduced with sharp visible disc margins. Two months postoperatively the retinal haemorrhages, cotton wool spots, and disc oedema resolved and her VA improved to 20/25 RE (fig 1C). FA demonstrated a physiological AV perfusion time of less than 3 seconds and no signs of an occluded cilioretinal artery (fig 2B).