Amalric sign: An augur of ophthalmic artery occlusion

Abstract

A 75-year-old man presented to us with sudden onset of profound vision loss in his right eye and was identified as suffering from an ophthalmic artery occlusion. Apart from the retinal whitening and box-carring of the retinal arteries, there were characteristic triangular patches of retinal whitening in the midperipheral temporal fundus indicating a previous lateral posterior choroidal artery occlusion. The patient was a chronic smoker and had dyslipidemia. The carotid Doppler study showed complete occlusion of the internal carotid artery. The presence of these triangular patches of retinal whitening or amalric sign can therefore herald a more proximal vessel occlusion. Hence such patients require evaluation on an emergency basis. The characteristic features of the patches on fluorescein angiography and indocyanine green angiography are discussed here.

Figure 1

Fundus picture of the right eye showing box-carring of the retinal arteries, banking of the veins, and retinal whitening of the posterior pole with few cotton wool spots

Figure 2

Inferior quadrant of the fundus showing triangular patches of retinal whitening

Figure 3

Prominent triangular patches of retinal whitening with base toward the equator and pointing toward posterior pole

Figure 4

Fluorescein angiography image at 2 min highlighting the hyperfluorescent triangular lesions. Note the delayed filling of the cilioretinal artery and the proximal part of the central retinal artery

Figure 5

Late frames showing increased hyperfluorescence and leakage at the triangular patches

Figure 6

The fluorescein angiography and the indocyanine green images taken simultaneously. Note the absence of these patches on the indocyanine green image

Figure 7

Optical coherence tomography image of the right eye macula showing hyperreflective inner retinal layers and the characteristic band of hyporeflectivity