Retinal ischemic perivascular lesions ( RIPL) represent focal atrophy of the middle retina or inner nuclear layer. These lesions are a legacy of acute medial paracentral maculopathy (MAPM), which is believed to occur due to the preferential susceptibility of the inner nuclear layer, at the level of the deep capillary plexus, to ischemia.
Retinal hypoperfusion may occur secondary to decreased afferent blood flow to the retinal capillary plexus in patients with various disorders, such as low ejection fraction, carotid artery stenosis, thrombus or emboli formation, or vascular stasis, all of which have been reported. associated with MAPM. Therefore, the eye may manifest the earliest evidence of ischemia due to systemic disease at the level of the medial retina, which is extremely sensitive to subtle changes in blood flow.
Although both MAPM and RIPL can be easily visualized in a noninvasive manner, using spectral domain optical coherence tomography (SD‐OCT) scans, only retinal ischemic perivascular lesions (RIPL) are permanent. Hyperreflective MAPM lesions are transient and generally resolve within 6 weeks, but leave a legacy of thinning of the inner nuclear layer, with compensatory expansion of the fiber layer of Henle. Therefore, retinal ischemic perivascular lesions (RIPL) represent an actionable imaging biomarker that can be exploited to detect retinal ischemia.
Optical coherence tomography ( OCT) is a ubiquitous tool with rapid image acquisition. Detection of retinal ischemic perivascular lesions (RIPL) with OCT is a simple process that could have ramifications beyond the ophthalmological clinic. Screening for RIPL may provide an entry point for general medical practice in the management of cardiovascular health and may help identify those who would benefit from additional, targeted diagnostic testing.
Coronary artery disease can coexist with other cardiovascular conditions, which can also cause retinal hypoperfusion.
A common comorbidity is atrial fibrillation, as 17% to 46% of patients with atrial fibrillation also have coronary artery disease. Atrial fibrillation is a heart rhythm disorder and can cause blood stasis and embolus formation. People with atrial fibrillation have a 5-fold increased risk of stroke compared to the general population, a risk that can be mitigated with anticoagulation.
Therefore, early detection of atrial fibrillation is important, before the development of sequelae of the disease. In the present study, we sought to determine whether retinal ischemic perivascular lesions (RIPL) are associated with atrial fibrillation, independently of underlying ischemic heart disease. It is important to identify whether this association exists, as it may help inform clinicians about the appropriate medical evaluation needed for a patient who presents to the ophthalmology clinic and is incidentally found to have RIPL on OCT.
Background
We previously demonstrated that retinal ischemic perivascular lesions (RIPL), which are indicative of medial retinal ischemia , may be a biomarker of ischemic cardiovascular disease. In this study, we sought to determine the relationship between RIPLs and atrial fibrillation, a common source of cardiac embolism.
Methods and Results
In this case-control study , we identified individuals between the ages of 50 and 90 years who had undergone macular spectral domain optical coherence tomography imaging.
Individuals with atrial fibrillation were identified and individuals of the same age and sex from the same group, but without a diagnosis of atrial fibrillation, were selected as controls .
Spectral domain optical coherence tomography scans were reviewed by 3 independent and masked observers for the presence of RIPL. The relationship between RIPL and atrial fibrillation was analyzed using multivariable logistic regression models.
There were 106 and 91 subjects with and without atrial fibrillation, respectively. The percentage of subjects with RIPL was higher in the atrial fibrillation group compared to the control group (57.5% vs. 37.4%; p = 0.005).
After adjusting for age, sex, smoking history, hypertension, diabetes, coronary artery disease, carotid stenosis, stroke, and myocardial infarction, the presence of RIPL was significantly associated with atrial fibrillation, with an odds ratio of 1. 91 (95% CI, 1.01). –3.59).
Conclusions Retinal ischemic perivascular lesions ( RIPL) are significantly associated with atrial fibrillation , regardless of underlying ischemic heart disease or cardiovascular risk factors. This association may inform diagnostic cardiovascular workup for individuals with RIPL detected incidentally on optical coherence tomography of the macula. |
Clinical Perspective
What’s new?
- In this case-control study, the presence of perivascular ischemic lesions in the retina was significantly associated with atrial fibrillation, independent of underlying ischemic heart disease and other cardiovascular risk factors.
What are the clinical implications?
- This may help inform the cardiovascular workup of patients who incidentally have ischemic perivascular lesions in the retina on optical coherence tomography scans.
- Future prospective studies are needed to confirm this association and determine the timing of development of retinal ischemic perivascular lesions in patients with atrial fibrillation.
