Abstract
Purpose
To describe a case of central retinal vein occlusion (CRVO) in a young adult found to have elevated homocysteine after bariatric surgery and to review risk factors for CRVO in younger patients.
Observations
An 18-year-old female presented with a CRVO and severe cystoid macular edema (CME). She was normotensive, not on medications, and without known heritable hypercoagulable disease. Her medical history was notable for bariatric surgery and subsequently she was found to have nutritional deficiency, anemia, and elevated homocysteine. Her elevated homocysteine may have induced a hypercoaguable state that predisposed her to developing a CRVO. Treatment with bevacizumab dramatically improved her macular edema and visual acuity. Nutritional supplementation was initiated.
Conclusions
Elevated homocysteine in the setting of nutritional deficiency from prior bariatric surgery may cause a hypercoaguable state and is a potential risk factor for CRVO.
Importance
With the increasing prevalence of obesity and bariatric surgery, it is important to consider associated nutrient deficiency as a potential cause of induced hypercoagulability and increased risk for CRVO. Identification of these at-risk patients is especially important given this condition is easily treatable and may be present in younger individuals. To the best of our knowledge, this is the first reported case of a CRVO with elevated homocysteine in the setting of nutrient deficiencies from laparoscopic sleeve gastrectomy.
1
Introduction
Central retinal vein occlusions (CRVOs) are relatively rare in patients under the age of 55 years or those who lack classic risk factors including hypertension, hyperlipidemia, and ocular hypertension or glaucoma. Risk factors for CRVOs in younger adults include autoimmune conditions such as Behçet syndrome, sarcoidosis and granulomatosis with polyangiitis; inherited hypercoagulable states including factor V Leiden, Protein C and S deficiency, and antithrombin deficiency; and acquired hypercoagulable states, including lupus anticoagulant and homocystinuria. Elevated homocysteine (HCY) can induce a prothrombotic state. , Hyperhomocysteinemia is a rare inherited condition in which there are elevated levels of homocysteine and can be associated with cardiovascular disease and other systemic findings such as ectopia lentis. The prevalence of a genetic defect leading to hyperhomocysteinemia is roughly 5 % while secondary causes are far more common. For example, HCY can be elevated as a result of nutrient deficiencies and has been strongly linked with bariatric surgeries.
With the increasing prevalence of obesity and the decreasing average age of bariatric surgery patients, physicians must consider bariatric surgery-induced nutritional deficiency as potential risk factor for CRVO. Our case describes a young female without known hypercoagulable risk factors and not on medications who presented with a severe ischemic CRVO. She was subsequently found to have had a history of laparoscopic sleeve gastrectomy (LSG) one year prior and secondary anemia with elevated homocysteine levels. To the best of our knowledge, this is the first known reported case of a CRVO with elevated homocysteine in the setting of nutrient deficiencies from LSG.
2
Case report
An 18-year-old female presented to the retina clinic with decreased vision in her left eye for 5 days duration. She denied any systemic or topical medications. Review of systems was only notable for fatigue. Vital signs were normal. Visual acuity in her right eye (OD) was 20/20 and her left eye (OS) was 20/200. Intraocular pressure (IOP) was 14 mmHg OD and 15 mmHg OS. Here ocular examination showed normal anterior segments in both eyes and normal posterior segment OD. The fundoscopic examination OS revealed venous tortuosity, diffuse intraretinal hemorrhages, cotton wool spots, and significant cystoid macular edema ( Fig. 1 ). Optical coherence tomography (OCT) and fluorescein angiography (FA) ( Figs. 2 and 3 ) confirmed the presence of cystoid macular edema and associated features consistent with a severe, ischemic CRVO. Additional medical and surgical history was obtained, revealing a prior history of cholecystectomy, appendectomy, and tonsillectomy. She was not on oral contraceptives or any other medications. However, her records from an outside hospital revealed a history of bariatric surgery the year prior with a laparoscopic sleeve gastrectomy (LSG). She had a history of poor follow-up and noncompliance with her medications and supplements. She was previously closely followed and treated by a team of physicians at an outside hospital for chronic multifactorial anemia intermittently requiring blood transfusions, attributed to nutrient deficiencies in the setting of recent bariatric surgery. She had been evaluated by gastroenterology with an unremarkable endoscopy and was lost to general medical follow-up thereafter.
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