Retinal Artery Occlusion – November 2016

November 2016

Case Presentation

A 37 year old previously followed at Illinois Retina Associates for lattice degeneration presented with abrupt loss of vision on the left eye. It was described as flashes and floaters followed by a veil over her entire visual field about one (1) hour prior to arrival.

Further History

The patient had a history of hypertension not currently requiring medication and seasonal allergies. Her only medication was an oral contraceptive.

Examination

VA

  • 20/25 OD
  • Hand Motion OS

Pressures were 14 mmHg (OD) and 16 mmHg (OS)

Pupils were equal and reactive with an RAPD OS.

The anterior segments were unremarkable.

The right eye posterior segment exam showed stable lattice degeneration in the right eye. The left eye also had stable lattice degeneration and was initially unremarkable. However, on repeat exam about 30 minutes later subtle whitening of the macula with a cherry red spot was appreciated (Figure 1).

Figure1
Figure 1

Imaging

Angiography revealed extremely delayed filling in the left eye (Figures 2 & 3)

Figure1
Figure 2
Figure1
Figure 3

Differential Diagnosis

Differential diagnosis for central retinal artery occlusion includes Susac syndrome, giant cell arteritis, artherosclerotic disease, cardiac disease, coagulopathy, collagen vascular disease, arterial loops, migraine, hypotension and trauma.

Treatment

The patient was sent to the emergency department for supplemental oxygen therapy and was found to have elevated blood pressure of 205/129.

She was diagnosed with a central retinal artery occlusion secondary to malignant hypertension.

Follow-Up

Two weeks later vision was 20/25 in both eyes. The cherry red spot had resolved and only a few cotton wool spots remained.

Discussion

Central retinal artery occlusions are most common in those in their 6th decade of life. Men are more often affected than women. Acutely, patients notice a severe decrease in vision. At presentation they may appear normal or have a cherry red spot in the middle of the fundus. A cilioretinal artery may perfuse the fovea in 15% of patients. Such patients have an 80% chance of returning to 20/50 vision or better. Those without cilioretinal perfusion of their fovea have a much more guarded visual prognosis.

Many treatment shave been purposed includeing: breathing an increased concentration of carbon dioxide, an increased concentration of oxygen (including trials of hyperbaric oxygen), lowering the intraocular pressure via paracentesis or pharmacologically to nudge the obstruction further down the arterial tree, and using intraarterial TPA to dissolve the clot. None of these has been established as a standard of care.

It is important to realize that there is a high rate of stroke after retinal artery occlusion with a 15 times increase in stroke rate in the first 30 days after onset. Thus, these patients need a full workup with their primary care physicians to minimize stroke risks. Some even advocate sending these patients to emergent stroke centers for acute management of risk.

References

Atebara NH, Brown GC, Cater J. Efficacy of anterior chamber paracentesis and Carbogen in treating nonarteritic central retinal arterial occlusion. AM J Ophthalmol 1995; 102:2029-2034.

Brown GC, Margargal LE. Central retinal obstruction and visual acuity. Ophthalmology 1982;89:14-19.

Recchia FM, Brown GC. Systemic disorders associated with retinal vascular occlusion. Curr Opin Ophthalmol 2000;11:462-467

Sang Jun Park, Nam-Kyong Choi, Bo Ram Yang, Kyu Hyung Park, Joongyub Lee, Sun-Young Jung, Se Joon Woo. Risk and Risk Periods for Stroke and Acute Myocardial Infarction in Patients with Central Retinal Artery Occlusion, Ophthalmology 2015;122:11