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Iatrogenic central retinal artery embolization: a complication of cardiac catheterization
Insights
A reusable cardiac catheter fragment caused a retinal artery blockage in a myocardial infarction patient. This preventable event led to severe vision loss, highlighting risks of improper medical equipment sterilization.
Area of Science:
- Cardiology
- Ophthalmology
- Medical Device Safety
Background:
- A 57-year-old male patient with a history of myocardial infarction underwent cardiac catheterization.
- The procedure utilized a cardiac catheter that was previously re-autoclaved despite being intended for single use.
Observation:
- During the procedure, a small fragment of the reused catheter dislodged.
- This fragment traveled through the vasculature while a metallic guide-wire was being used.
Findings:
- The dislodged catheter fragment became lodged in the central retinal artery of the patient's right eye.
- Ophthalmoscopic examination revealed the fragment at the optic nerve head, obstructing blood flow.
Implications:
- The event resulted in the patient's right eye having only light perception vision.
- This case underscores the critical importance of adhering to single-use protocols for medical devices to prevent catastrophic complications.
Abstract:
A 57-year-old man with a myocardial infarction was subjected to cardiac catheterization as a follow-up study for his heart problem. The catheter, made for one time use only, was reautoclaved and used sometime before catheterizing this man. A small fragment of this catheter dislodged while guiding the parent catheter into coronary vessels with a metallic guide-wire. The fragment traveled getting lodged in the central retinal artery of the right eye leaving the eye with only light perception vision. The catheter fragment could be seen in the central retinal artery at the optic nerve head.