Extracranial to Intracranial Artery Bypass as Successful Treatment of Medically-intractable Eye Pain Due to Ocular Ischemic Syndrome in Absence of Stroke

Introduction: In the post EC-IC bypass trial era, controversy for the utility of EC-IC bypass in carotid occlusive disease is ever present. It remains important to identify the correct subsets of individuals who may still benefit from this technique. Extracranial to intracranial (EC-IC) bypass with superficial temporal to middle cerebral artery (STA-MCA) anastomosis has been shown to be helpful in management of ischemic ocular sequalae from carotid occlusive disease such as venous stasis retinopathy and neovascular glaucoma in the setting of stroke.

Methods: We performed an STA-MCA bypass for the treatment of medically refractory ischemic eye pain in a patient devoid of stroke symptoms.

Results: A 64-year-old male who presented with progressive medically refractory right eye pain and declining vision diagnosed with neovascular glaucoma in the setting of ocular ischemic syndrome with an ipsilateral cervical ICA occlusion. He was without any other focal neurological deficit and had no history of transient ischemic attack (TIA) or stroke. The patient had initially been treated with oral timolol and acetazolamide, but had persistently elevated intraocular pressures (IOP) above 30 torr and worsening eye pain and vision acuity in the right eye. The patient underwent right-sided STA-MCA bypass. Within 24 hours of surgery he had complete resolution of eye pain. His IOP was measured post operatively to be 15 torr. At follow-up, he showed improvement in visual acuity and durable resolution of his eye pain.

Conclusion : STA-MCA bypass is a safe and effective treatment for medically-refractory ischemic eye pain and should be considered as a treatment option even in the absence of neurological carotid occlusive sequalae.