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Correspondence to Author: Hamad A.Madi.MD ,Ahmad K.Darwazah.MD , Younis Yasseen.MD. 

Department of Cardiothoracic Surgery, Palestine Medical Complex, Ramallah, West Bank, Palestine.

DOI: 10.52338/aots.2026.5747

Abstract:

Background:Central retinal artery occlusion (CRAO) is an ophthalmic emergency most commonly related to carotid atherosclerosis or cardiac embolism in younger patients. Calcific aortic valve disease is an uncommon source of retinal emboli and rarely presents first as CRAO.
Case Presentation: A 30-year-old man with a 7.5 pack-year smoking history presented with sudden, painless, complete left monocular vision loss. Ophthalmic assessment including fundus exam and fluorescein angiography confirmed left central retinal artery occlusion with preserved cilioretinal artery perfusion. Two weeks earlier he had transient chest pain. Cardiac examination revealed a harsh grade III/IV systolic ejection murmur radiating to the carotids. ECG showed sinus rhythm with LV hypertrophy and anterior ST elevation. Transthoracic echocardiography demonstrated moderate–severe aortic stenosis (mean gradient ~40 mmHg), markedly calcified valve with poorly visualized cusps, concentric LV hypertrophy and preserved LVEF (60%). CT chest showed ascending aortic dilation (4.3 cm). Coronary angiography revealed ostial right coronary artery stenosis; cerebral CT and brain MRI/MRA showed no intracranial arterial occlusion. The patient underwent urgent surgical aortic valve replacement; intraoperative inspection revealed a severely stenotic bicuspid aortic valve with large friable calcific vegetations at the fused raphe. A mechanical prosthesis was implanted without complication. Postoperative recovery was uneventful; no further systemic embolic events occurred. Visual prognosis remained limited.
Discussion: This case highlights an unusual presentation of calcific bicuspid aortic valve disease in a young adult, manifesting as CRAO. Retinal calcium microemboli may be clinically apparent due to the retina’s end-arterial circulation. Identification of a cardiac source—particularly heavily calcified aortic valve—is critical because embolic events may recur and can be bilateral. Urgent cardiac evaluation and consideration of valve replacement are warranted even when conventional hemodynamic indications are borderline, given the embolic risk.
Conclusion: CRAO can be the initial manifestation of calcific aortic stenosis. In young patients with retinal artery occlusion, prompt cardiac assessment for valvular calcification (including echocardiography and, where indicated, catheterization) should be undertaken. Urgent valve replacement should be considered to prevent recurrent systemic embolization.

Keywords:Central retinal artery occlusion; retinal embolus; calcific aortic stenosis; bicuspid aortic valve; valve replacement; calcium embolus.

Citation:

Dr.Hamad A.Madi.MD, Retinal Artery Embolization: A Rare Presentation Of Calcific Bicuspid Aortic Valve Stenosis. Annals of Thoracic Surgery 2026.