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Carotid endarterectomy restores decreased vision due to chronic ocular ischemia

  • Original Article - Vascular Neurosurgery - Ischemia
  • Published:
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Abstract

Background

The therapeutic effect of carotid endarterectomy (CEA) on visual disturbance caused by chronic ocular ischemia due to carotid artery stenosis has not been validated. This prospective observational study aims to investigate whether CEA is associated with an increase in ocular blood flow (OBF) and postoperative visual improvement.

Methods

In total, 41 patients with carotid artery stenosis treated by CEA between March 2015 and September 2018 were enrolled in this study. OBF was evaluated by laser speckle flowgraphy, which can measure the mean blur ratio (MBR) which is well correlated to the absolute retinal blood flow. Visual acuity was assessed before and after CEA by subjective improvement and objective visual assessment using CSV-1000, an instrument used to test contrast sensitivity.

Results

OBF increased after CEA on the operated side (mean MBR 33.5 vs 38.2, p < 0.001) but not on the non-operated side (mean MBR 37.8 vs 37.5, p = 0.50). After CEA, 23 patients (56.1%) reported subjective visual improvement on the operated side. The mean CSV-1000 score among the patients with increased OBF after CEA (5.44 vs 5.88, p = 0.04) but not among those without increased OBF (5.48 vs 5.95, p = 0.09). The mean CSV-1000 scores increased significantly after CEA in 18 patients with decreased vision and decreased OBF (4.51 vs 5.37, p < 0.001), but not in the 23 patients without those (6.19 vs 6.31, p = 0.6).

Conclusion

CEA may successfully reverse visual dysfunction caused by chronic ocular ischemia due to carotid artery stenosis by increasing OBF.

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Acknowledgments

The authors thank Dr. Takashi Ueta for his valuable suggestions regarding the ophthalmological evaluation of visual acuity.

Funding

This study was supported by a Young Investigator research fund from Saitama Medical Center.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan

    Shinsuke Yoshida, Soichi Oya, Naoaki Fujisawa, Tsukasa Tsuchiya, Takumi Nakamura, Masahiro Indo, Masaaki Shojima & Toru Matsui

  2. Ophthalmology, Saitama Medical Center, Saitama Medical University, Saitama, Japan

    Hiroto Obata

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  1. Shinsuke Yoshida
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  2. Soichi Oya
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Corresponding author

Correspondence to Soichi Oya.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Saitama Medical Center Institutional Review Board) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Comments

We perform carotid surgery in alignment with clinical trials evidence, primarily to treat TIA or stroke, or in selected cases of asymptomatic stenosis. But experienced carotid surgeons will have likewise seen cases where epiphenomena of improved cognitive function, or improved visual acuity, are reported by the patients as an unanticipated benefit of CEA.

Hence this paper, which is a fascinating and worthwhile prospective study of retinal blood flow and improved vision (subjective and objective), after CEA.

The authors hypothesized that visual function would improve in conjunction with increased ocular blood flow (OBF) after ipsilateral CEA, and that this effect would be most prominent in patients with a history of chronic ocular ischemia (COI). They studied 41 patients with carotid artery stenosis treated by CEA, measured preoperative and postoperative ocular blood flow with laser speckle flowgraphy, and both subjective (by report) and objective (by visual assessment using CSV- 1000), visual improvement in these patients. It is important to note that not all patients had a history of COI.

Their results show, first, that CEA surgery increased ocular blood flow. OBF increased after CEA on the operated side (mean MBR 33.5 vs 38.2, p < 0.001) but not on the non-operated side (mean MBR 37.8 vs 37.5, p = 0.50). In addition, increased flow correlated with subjective and objective visual improvement, although the effect was mainly seen in patients with preoperative visual issues, as follows: after surgery, 56.1% of patients reported subjective visual improvement on the operated side. The mean CSV-1000 scores increased significantly after CEA in 18 patients with decreased preop vision and decreased preop OBF (4.51 vs 5.37, p < 0.001), but not in the 23 patients without those (6.19 vs 6.31, p = 0.6).

I agree with the authors’ conclusion that their study demonstrates increased OBF at the optic disc on the operated side after CEA, and that postoperative rapid visual recovery is correlated with improvement in OBF. It is important to note that therapeutic effect was more prominent among the patients with decreased vision and chronic ocular hypoperfusion than among those with normal visual acuity or normal OBF. Their paper is valuable and insightful as we continually seek reduce stroke risk and improve the lives of patients with progressive occlusive extracranial carotid disease.

Christopher Miranda Loftus.

PA, USA

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This article is part of the Topical Collection on Vascular Neurosurgery - Ischemia

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Yoshida, S., Oya, S., Obata, H. et al. Carotid endarterectomy restores decreased vision due to chronic ocular ischemia. Acta Neurochir 163, 1767–1775 (2021). https://doi.org/10.1007/s00701-020-04603-3

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  • DOI: https://doi.org/10.1007/s00701-020-04603-3

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