VISUAL FLOW study: Ophthalmologic outcomes following carotid aneurysm treatment using a flow-diverter stent covering the origin of the ophthalmic artery in patients under dual antiplatelet therapy with aspirin and ticagrelor

INTRODUCTION: The use of flow-diverting stents (FDS) for intracranial aneurysms has become common practice. This study aimed to evaluate ophthalmologic outcomes following carotid-ophthalmic aneurysm treatment with an FDS covering the origin of the ophthalmic artery in patients receiving aspirin and ticagrelor, through a systematic ophthalmic screening. METHODS: From January 2021 to October 2023, patients treated for carotid-ophthalmic aneurysms with an FDS were prospectively included in our study. All patients underwent a systematic ophthalmologic examination prior to treatment, within 15 days after embolization and 6 months post-embolization. Each patient received dual antiplatelet therapy (DAPT) with aspirin and ticagrelor for 3 months, followed by aspirin alone. RESULTS: A total of 24 patients with 25 aneurysms were included. Median age (IQR) was 55 years and 22 were females. Although all patients were asymptomatic, fundus examination revealed pathological findings on the treated side in 6 patients (25%) within the first 15 days after treatment: cotton wool spots in 5 patients (20%), retinal hemorrhages in 3 patients (12%), and multifocal choroidal ischemia in 1 patient (4%). All abnormalities detected during the postoperative fundus examination had resolved by 6 months. No thromboembolic complications were observed. CONCLUSIONS: Retinal and choroidal changes occurred in 25% of patients treated with an FDS covering the ophthalmic artery in the setting of DAPT. While these changes were asymptomatic and spontaneously resolved, these findings warrant further consideration. Additional studies are needed to clarify the underlying mechanisms.