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Title: Ocular Ischemic Syndrome: A case report and review of ocular and systemic manifestations Category: Ocular Disease Authors: Raneat Cohen, O.D. Rebecca Diller, O.D., F.A.A.O Abstract: A 72 year-old male complains of painful vision loss in left eye. Vision is NLP, an APD is present and optic nerve is edematous. Intraocular pressures are elevated and retina is pale with sclerotic vessels. I. Case History A 72 year-old Caucasion male complains of “sudden” painful loss of vision in the left eye. Ocular history is remarkable for a probable ischemic left CN VI palsy, elevated optic nerves previously attributed to optic disc drusen, bilateral Hollenhorst plaques, and mild hypertensive retinopathy OS. Medical history is remarkable for hypertension, coronary artery disease, hyperlipidemia, and prior cerebrovascular accident. The patient reports that he recently started acetaminophen with codeine for left periorbital pain. Other medications include aspirin, lisinopril, simvistatin, carvedilol, and amlodipine besylate. II. Pertinent Findings Vision in the left eye is reduced to NLP (previous visual acuities are 20/30 OD and 20/70 OS). The pupil is non-reactive and a reverse afferent pupillary defect is present. Slit lamp exam reveals moderate peri-limbal injection, extensive rubeosis iridis, and mild anterior chamber reaction in the left. No angle structures are visible with gonioscopy. Intraocular pressures are 12mmHg OD and 22mmHg OS. The left retina is pale with sclerotic vessels and the optic nerve is pale and edematous. No retinal hemorrhages are present. The right fundus is unremarkable. Carotid doppler shows complete stenosis of the left internal carotid artery (70% noted one year prior) and 80% stenosis of the right (unremarkable one year prior). Cardiology and vascular surgery are consulted. III. Differential Diagnosis The primary diagnosis is end-stage ocular ischemic syndrome with secondary neovascular glaucoma. At various stages of the disease, OIS can resemble other vascular occlusive conditions such as a central retinal artery occlusion, ophthalmic artery occlusion, and central retinal vein occlusion (Table 1). IV. Diagnosis and Discussion Ocular ischemic syndrome (OIS) is a chronic condition which most often results from carotid stenosis greater than 90%. This leads to vascular hypoperfusion, hypoxia and ocular ischemia. Patients typically present with unilateral, painful, gradual loss of vision. Visual prognosis is generally poor for these patients especially in the presence of iris neovascularization. The 5-year mortality rate in patients with OIS is 40%, with cardiovascular disease being the leading cause of death. Therefore , it is important to identify both systemic and ocular manifestations of carotid disease (Table 2), in order to allow for timely and appropriate management of the condition. This case is unique both in its presentation and clinical findings. The patient's complaint of acute vision loss is unusual. This could possibly be explained by an acute embolic event or possibly a discovery phenomenon as record review indicates gradual loss of vision over several years. The patient was only experiencing mild pain at the time of examination but it must be noted that he had self initiated acetaminophen with codeine for periorbital pain several weeks prior. Although retinopathy in the form of midperipheral hemorrhages is often associated with OIS, retinopathy was no longer present in this patient due to the advanced stage and chronic nature of his condition. V. Treatment, management Treatment of OIS is often unsuccessful in restoring perfusion or preventing progression of the condition. Panretinal photocoagulation in the presence of neovascularization is controversial as to whether or not it poses additional benefit. According to research, panretinal photocoagulation does little to improve visual acuity, however, can minimize the progression of neovascularization. Palliative care is often implemented. Cycloablation and even enucleation may be indicated in severe cases. Evaluation by a neurovascular surgeon is often urgent and the risks and benefits of surgical and medical treatment options must be thoroughly explored. Topical combination dorzolamide/timolol BID, prednisolone acetate QID and 5% homatropine BID were initiated OS for patient comfort. A cardiac consult was ordered to assess the benefits of open carotid endarterectomy versus a stent of the right internal carotid artery. No medical intervention was indicated for the left internal carotid artery. VI. Conclusion Ocular ischemic syndrome can present with variable clinical findings and symptomatology, and can therefore be diagnostically challenging for the clinician. This case highlights an advanced presentation of this condition. Prognosis for these patients is poor, even post systemic intervention. Table 1: Review of Differential Diagnosis Signs Ocular ischemic syndrome Central Retinal Artery Occlusion Ophthalmic artery occlusion Central retinal vein occlusion +/- Afferent pupillary defect (depends on asymmetry) Dilated retinal veins, not tortuous +/- Cherry red spot Arterial attenuation Retinal ischemia Assymetric retinopathy Mid-peripheral hemorrhages Symptoms Gradual, monocular loss of vision Periorbital pain +/- Amaurosis fugax Afferent pupillary defect +/- Cherry red spot Arterial attenuation Segmentation of blood column +/- embolus Retinal ischemia Normal choroidal perfusion on angiography Afferent pupillary defect +/- Cherry red spot (less common than CRAO) Arterial attenuation Segmentation of blood column No embolus visible Retinal ischemia +/- Afferent pupillary defect (ishchemic/nonischemic) Diffuse retinal hemorrhages Dilated and tortuous retinal veins Disc edema Neovascularization (disc, retina, or iris) Sudden, monocular loss of vision Usually upon awakening +/- Amaurosis fugax Vision range between count fingers and hand motion (unlikely NLP) Sudden, monocular loss of vision Usually upon awakening +/- Amaurosis fugax Vision generally NLP (worse than CRAO) Sudden, monocular loss of vision Vision generally 20/400 or worse if ischemic; 20/400 or better if nonischemic Table 2: Carotid Occlusive Disease: Systemic and Ocular Manifestations Systemic Manifestations Ocular Manifestations Transient ischemic attacks Transient visual loss Difficulty with speech Ocular ischemic syndrome – corneal edema, anterior uveitis, engorged episcleral Limb weakness contrallaterally vessels, orbital pain, iris Sensory disturbances contralaterally neovascularization Difficulty with spatial orientation Retinal pathology- hollenhorst plaque, Headaches, often severe cotton wool spot, asymmetric retinopathy, dilated retinal veins, optic nerve pallor, Patient may be asymptomatic cherry red spot, irregular vessel caliber, retinal ischemia, sclerotic blood vessels References: Kunimoto D, Kanitkar K, Makar M. The Wills Eye Manual. Fourth edition. 2004, Philadelphia: Lippincott Williams and Wilkins. Onf T, Paine M, O’Day J. Retinal manifestations of ophthalmic artery hypoperfusion. Clinical and Experimental Ophthalmology 2002; 30: 284-291 Sanborn G, Magargal L. Arterial Obstructive Disease of the Eye. [cited 08/07/2008]; Available from: file://x:\pages\v3\v3c014.html. Marks E, Adamczyk D, Thomann K. Primary Eyecare in Systemic Disease. 1995, Norwalk: Appleton and Lange. Conflict of interest/acknowledgement of grant support: None Contact Information: Raneat Cohen, O.D. Dayton VA Medical Center 4100 West Third Street Dayton, OH 45428 [email protected]