Retinal and optic nerve ischemia

Abstract

Purpose of review: This review focuses on aspects of retinal and optic nerve ischemia that may be encountered by neurologists.

Recent findings: Recent guidelines have emphasized the similarities between cerebral and retinal ischemia in terms of etiologic workup, acute management, and subsequent stroke risk. However, although ischemic optic neuropathies reflect optic nerve ischemia, they result from local small vessel disease and are not associated with a higher risk of cerebral infarction. Their management is therefore very different from acute cerebral ischemia. It is essential to rule out giant cell arteritis in all patients with acute retinal or optic nerve ischemia.

Summary: Because the eye is vascularized by branches of the internal carotid artery, retinal ischemic symptoms are common in patients with anterior circulation ischemic strokes. Patients with central retinal artery occlusion, whether permanent or transient (responsible for transient visual loss), need to be evaluated and managed emergently similar to patients with cerebral ischemia, while anterior and posterior ischemic optic neuropathy are more concerning for giant cell arteritis.

Figure 3-1.

Blood supply to the optic nerve. Reprinted with permission from Schuenke M, et al, Thieme. © 2007 Thieme Medical Publishers, Inc.

Figure 3-2.

Acute central retinal artery occlusion in the right eye. The patient lost vision acutely 12 hours prior. The retina is diffusely pale, and the fovea appears red by contrast. The arteries are attenuated. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-3.

Acute superior branch retinal artery occlusion in the left eye. The superior branch of the central retinal artery is occluded, and emboli are seen in the artery (arrows). The ischemic retina appears white because of retinal edema. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-4.

Acute ophthalmic artery occlusion in the left eye. The entire retina is pale because of retinal edema, and there is no cherry red spot because of the associated choroidal ischemia seen in ophthalmic artery occlusion. Mild optic nerve edema is present because of optic nerve ischemia. The arteries are attenuated. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-5.

Asymptomatic cholesterol retinal emboli (arrows) from atheromatous carotid stenosis. Multiple yellow, refractile emboli are seen in branches of the central retinal artery. No associated retinal ischemia is present, and the patient is asymptomatic. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-6.

Platelet-fibrin retinal emboli from aortic arch atheroma. Multiple grayish emboli (arrows) are seen in a few branches of the central retinal artery. The whitish areas in the retina correspond to associated retinal ischemia. Although the patient was not aware of visual loss, a visual field test showed multiple small scotomas corresponding to the areas of ischemic retina. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-7.

Venous stasis retinopathy in a patient with internal carotid occlusion. Multiple dot-blot retinal hemorrhages are present in the midperiphery of the retina. The veins are dilated. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-8.

Ischemic ocular syndrome on the right. The episcleral arteries are dilated and the pupil is spontaneously dilated and unreactive. Visual loss in the eye and pain over the right eye are present. This patient has an ipsilateral carotid artery stenosis and poor collateral circulation. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-9.

Central retinal vein occlusion in the left eye. Occlusion of the central retinal vein results in diffuse dilation of the retinal veins and numerous retinal hemorrhages with retinal edema responsible for visual loss. The disc is swollen and numerous peripapillary hemorrhages are present. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-10.

Nonproliferative severe diabetic retinopathy in the right eye. Long-standing poorly controlled diabetes mellitus produces retinal vascular disease responsible for bilateral diabetic retinopathy. The retina is hypoperfused and the arteries are very attenuated. Retinal hemorrhages and lipid exudates with macular edema are responsible for visual loss. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-11.

Hypertensive retinopathy in the right eye. Stage IV hypertensive retinopathy is bilateral and associates disc edema with attenuated arteries, retinal hemorrhages, and cotton wool spots, as well as diffuse exudates. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-12.

Retinal vasculitis from sarcoidosis. The inflamed arteries are surrounded by whitish sheathing (arrows), and the resultant retinal ischemia produces retinal hemorrhages. This patient has ocular inflammation in the setting of untreated sarcoidosis. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-13.

Radiation retinopathy in a patient who had received brain and eye radiation therapy for CNS lymphoma. Radiation retinopathy is insidious and causes chronic retinal ischemia with attenuated arteries, cotton wool spots, and retinal hemorrhages. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-14.

Bilateral Purtscher disease in a patient with acute pancreatitis. In the left eye, numerous cotton wool spots and large white exudates cover the optic nerve and the retina. This developed in the setting of acute pancreatitis and is consistent with Purtscher disease. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-15.

Left Horner syndrome from a left internal carotid artery dissection. This patient presented with pain over the left eye and had one episode of sudden visual loss in the left eye, lasting a few minutes. A left Horner syndrome is present with mild decreased left palpebral fissure from mild left upper lid ptosis. The left pupil is smaller than the right pupil, and the amount of anisocoria increases in the dark. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-16.

Nonarteritic anterior ischemic optic neuropathy in the right eye. A (right), B (left), Optic nerves 1 week after visual loss in the right eye. The right optic nerve is swollen with a small peripapillary hemorrhage. The left eye has a disc at risk for nonarteritic anterior ischemic optic neuropathy, with a small cup-disc ratio. C (right), D (left), Optic nerves 8 weeks later. In the right eye, the swelling has resolved, and segmental superior optic nerve head pallor is present in the right eye. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-17.

Inferior altitudinal defect in nonarteritic anterior ischemic optic neuropathy in the right eye. Humphrey visual field tests (A, left eye; B, right eye) showing an inferior altitudinal defect (in dark) in the right eye of the same patient in Figure 3-16. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-18.

Left anterior ischemic optic neuropathy in giant cell arteritis. Pallid disc swelling acutely occurs in arteritic anterior ischemic optic neuropathy. The nerve is very pale acutely and cotton wool spots are present. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.

Figure 3-19.

Right branch retinal artery occlusion with anterior ischemic optic neuropathy in giant cell arteritis. This older patient had profound acute visual loss in the right eye and was found to have disc edema suggestive of anterior ischemic optic neuropathy associated with a superior branch retinal artery occlusion in the same eye. The association of anterior ischemic optic neuropathy and branch artery retinal occlusion in the same eye is very suggestive of vasculitis, such as giant cell arteritis. Reprinted with permission from Biousse V, Newman NJ, Thieme. © 2009 Thieme Medical Publishers, Inc.