First Author: R.Couceiro PORTUGAL
Co Author(s): C. Loureiro A. Fonseca H. Proença M. Monteiro Grillo 0 0 0 0 0 0 0 0 0
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We aim to describe a clinical case of simultaneous unilateral arterial and venous retinal occlusions. This is an uncommon and alarming situation, with serious effects on visual acuity, demanding a systemic thorough investigation for potencially life-threatening conditions.
Teaching hospital, terciary referral center.
Case report of a 63 year-old male that presented with acute, unilateral and painless vision loss in his right eye for the last 2 hours and no other physical symptoms. He had a history of type 2 diabetes, hypertension, aortic abdominal aneurism surgery at the age of 43 and coronary heart disease, currently under antiaggregation therapy. Complete ophthalmic examination, colour fundus photographs, static perimetry (tG2 program, Octopus®), spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), electrocardiogram (EKG), echocardiogram, carotid ecodoppler and trombophilia screening was obtained.
Baseline best corrected visual acuity (BCVA) was hand motion in the right eye and 20/20 in the left eye. Fundoscopy revealed a pale retina with multiple cholesterol emboli occluding the superior and inferior lateral arterial branches of the right eye. Sparse intrarretinal hemorrhages were seen along the lateral vascular branches. Macular drusen were also evident in the right eye and asteroid hyalosis was present bilaterally. The patient immediately received ocular digital massage and systemic and topical ocular hypothensive therapy. These measures enabled fragmentation and mobilization of emboli, restoring circulation to the macular area and allowing for right central vision recovery. FA confirmed superior branch reperfusion with preserved macular circulation and inferior branch peripheral occlusion, with irreversible retinal ischemia and a corresponding scotoma on static perimetry. FA also showed delayed venous filling. Macular SD-OCT did not show relevant changes. Ethiologic investigation included carotid ecodoppler, which revealed a large right carotid atheromatous plaque, causing a 95% lumen stenosis. Trombophilia screening was positive for antiphospholipidic syndrome (APS) criteria. EKG and echocardiogram were unremarkable. The patient was submitted to carotid endarterectomy and later initiated on oral anticoagulation. At 10 months follow-up he mantained 20/20 right central BCVA and did not report new thrombotic events.
Arterial retinal occlusion has a devastating and irreversible effect in visual acuity unless circulation is quickly restored, which is rarely accomplished since no actual treatment has consistently proved to be effective. The value of mechanical and pharmacological measures undertaken in this case is not completely established, however they seem to have been successful, restoring circulation in a critical time of retinal ischemia and enabling complete central visual acuity recovery. Besides its ocular consequences, arterial retinal occlusion should prompt a thorough systemic investigation that might disclose potencially serious conditions, carotid occlusion being one of them. Moreover, evidence of intrarretinal hemorrhages along the temporal vascular branches and delayed venous filling detected on FA, suggested a simultaneous venous occlusion. Although the patient had multiple cardiovascular risk factors, this suspicion reinforced the need for a persistent systemic evaluation, which allowed for APS diagnosis.