Neuroophthalmic outcomes following carotid intervention for ocular symptoms.

Introduction: The long term neuroophthalmic outcomes following carotid intervention in patients presenting with pre-operative visual symptoms vary widely based on the underlying etiology of retinal ischemia and are not well understood.

Methods: We performed a retrospective review of consecutive patients presenting with retinal ischemia who subsequently underwent carotid intervention from January 2018 to December 2022. Patients were classified into three groups [Group I: Amaurosis fugax (AF)/ vascular transient monocular vision loss (TMVL), Group II: Ocular Ischemic Syndrome (OIS) and Group III: Central/Branch Retinal Artery Occlusion (C/BRAO)]. Clinical details and the nature of visual symptoms were recorded. Outcomes analyzed were ipsilateral symptom recurrence, visual improvement, stroke rate and survival.

Results: There were 90 patients included in this study (70 male, 75+ 9 years); 31 patients (34%) in Group I (AF), 7 patients (8%) in Group II(OIS), and 52 patients (58%) in Group III (C/BRAO). Atherosclerotic risk factors were similar across groups with similar preoperative antiplatelet and statin use. Interventions performed were carotid endarterectomy in 64 (71%), transfemoral carotid artery stenting in 21 (23%), transcarotid artery revascularization in 4 (4%) and carotid artery bypass in one patient (1%). Median follow-up was 38.5 months (range 0- 207 months). There was no recurrence of transient or permanent retinal ischemic events in any patient in the Group I. In Group II, 5 of 7 patients presenting with transient symptoms of OIS showed resolution of symptoms and ocular signs. Two patients presenting with permanent vision loss in Group II had no improvement but no worsening symptoms, and visual decline was reported in two patients in Group III. Ipsilateral stroke rate was 2% at 5 years for the entire group. Survival was 93% and 82% at 1 and 5 years, with no difference between groups (p<0.05) There was 1 post-operative death from ischemic stroke secondary to stent thrombosis within 30 days (Group III), with no long-term mortality from cerebrovascular disease in the rest of the cohort.

Conclusions: Neuro-ophthalmic outcomes following carotid intervention for visual symptoms is favorable with low symptomatic recurrence following both carotid endarterectomy and carotid artery stenting. Intervention for OIS when detected early (with transient symptoms) is associated with resolution of symptoms and prevention of permanent visual loss.