Sequential bilateral retinal artery occlusion

Abstract

An 86 year old woman experienced a sequential bilateral loss of vision over a period of less than 24 hours. Clinical findings and complementary studies suggested a bilateral atherogenic embolic event. Initially, she presented a superior branch retinal artery occlusion in her right eye followed by a central retinal artery occlusion with cilioretinal artery sparing in her left eye. Some conservative maneuvers performed did not improve visual acuity in the left eye. Supra-aortic Doppler ultrasonography revealed mild right internal carotid artery stenosis and moderate left internal carotid artery stenosis with a small, smooth, and homogeneous plaque. The transthoracic echocardiography showed a severe calcification of the mitral valve with a mild-moderate rim of stenosis. Central retinal artery occlusion and branch retinal artery occlusion are characterized by painless monocular loss of vision. Clinical approach and management attempt to treat the acute event, find the source of the vascular occlusion, and prevent further vascular events from occurring. Giant cell arteritis is a potentially treatable cause of central retinal artery occlusion and should be excluded in every single patient over 50 years old.

Keywords: Hollenhorst plaque; branch retinal artery occlusion; central retinal artery occlusion; loss of vision.

Figure 1

(A and B) Fundus photographs show superior temporal branch retinal artery occlusion in the OD and central retinal artery occlusion with cilioretinal artery sparing in the OS. (A) Morphological appearance suggests a Hollenhorst plaque at the first bifurcation of the temporal superior arterial vessel (black arrow). (B) A cherry-red spot can be seen against the pale retina. Attenuation and “boxcarring” of the blood column in the involved region were observed in OU. After the second bifurcation of the superior temporal retinal vessel, a small embolus (or fragment of the first one) is observed (a′). Abbreviations: OD, oculus dexter (right eye); OS, oculus sinister (left eye); OU, oculi uterque (both eyes).

Figure 2

Spectral domain optical coherence tomography of the macula in the OS reveals a hyperreflective image corresponding to intracellular edema of the internal layers of the retina (366±38 μm of foveal thickness), more prominent in the nasal quadrants. Abbreviations: OS, oculus sinister (left eye); ILM, internal limiting membrane; RPE, retinal pigment epithelium.

Figure 3

Fluorescein angiography (A and B) shows slowed filling of the superior temporal arterial branch in the OD and branches of the central retinal artery in the OS. The optic disk became pale in OU (a′ and b′) 3 months after bilateral retinal artery occlusion. The OD presented a pale aspect of the optic disk in the upper and temporal quadrants (a′), and the OS showed diffuse atrophy (b′). Abbreviations: OD, oculus dexter (right eye); OS, oculus sinister (left eye); OU, oculi uterque (both eyes).