Arterial Occlusive Event

A 73-year-old woman presented for evaluation because of a sudden severe but painless loss of vision in her left eye 2 days earlier. Her medications included ramipril, 2.5 mg/d; aspirin, 81 mg bid; and a multivitamin.

The patient's initial visual acuity was 20/20 in the right eye and light projection in the left eye. She had a left afferent pupillary defect. Results of the funduscopic examination of the right eye were unremarkable. The fundus of the left eye showed a foveal cherry-red spot; retinal whitening and opacification surrounding the fovea; and retinal arterial thinning with segmentation, or "boxcarring." Her seated blood pressure was 200/82 mm Hg in the right arm and 192/80 mm Hg in the left.

This patient had experienced an arterial occlusive event, probably of the central retinal artery in the left eye. This neuroretinal ischemic disorder is often associated with conditions that lead to embolus formation but is also seen in patients with coagulopathies, collagen vascular and inflammatory disorders, and vasculitides and in patients with systemic abnormalities such as untreated or undertreated hypertensionand diabetes.

There is no effective treatment for patients who present several hours or days after onset. In acute presentations, ocular massage, rebreathing in a paper bag, or anterior chamber paracentesis may be tried. Systemic conditions must be identified and treated. This patient was referred to her internist for further evaluation.