The central retinal artery occlusion in the right eye followed by a branch retinal artery occlusion in the left eye four days later
A 65-year-old woman was admitted to our clinic with complaints of sudden, painless, decrease in vision, and sectoral visual field defect in the left eye for the past 3 days. On examination, the corrected visual acuity by the Snellen chart was 20/40 OS and 20/20 OD. Intra-ocular pressures were 13 mm Hg bilaterally. A relative afferent pupillary defect was observed in the left eye. External and slit lamp examinations were unremarkable in both eyes. Fundus examination of the left eye showed a patchy area of partially faded retinal whitening in the inferotemporal quadrant of the macula, just encroaching into the fovea. There was an emboli at the disc margin within the inferotemporal artery []. Fluorescein angiogram of the left eye showed a delay in arterial filling in the affected vessels [] and late leakage from the embolus site [Fig. and ]. Confrontation visual field revealed a loss of superior visual field in the left eye. She had a history of uncontrolled hyper-tension and hypercholesterolemia. She had no history of amaurosis fugax, diabetes mellitus, coronary artery disease, or stroke. A fundus examination of the right eye showed an emboli and segmentation in the inferotemporal artery. Due to these findings, cardiology consultation, carotid Doppler ultrasound, echocardiography and blood tests were requested from the patient. Four days after the initial examination, she was presented to our clinic again with a history of sudden loss of vision in her right eye for the last 4 h. Visual acuity in the right eye was reduced to perception of light only. The right eye fundus examination demonstrated a diffuse disc pallor, severe attenuation of retinal arteries, retinal edema, and a “cherry-red spot” appearance on the macula []. The red-free photograph greatly accentuates the retinal whitening surrounding the macula and with segmentation of blood columns in inferotemporal retinal artery because of the multiple emboli plaques []. She was immediately given a vigorous digital ocular massage, breathing carbogen (95% oxygen, 5% carbon dioxide), started on intra-venous mannitol and systemic carbonic anhydrase inhibitor. Unfortunately, visual acuity in the right eye was not changed after the treatment. In the cardiovascular evaluation, there was a fibro-fatty plaque in the right internal carotid artery at carotid Doppler ultrasonography. There were also calcified mitral and aortic valves in the echocardiography. Serum cholesterol level was 231 mg/dL and serum low-density lipoprotein level was 166 mg/dL. Prothrombin time and partial thromboplastin time were in the normal range. An urgent erythrocyte sedimentation rate, C-reactive protein, and complete blood count were normal. The patient's blood pressure was measured at 170/100 mm Hg. One month after the admission, visual acuity did not change in either eye. There was no iris neovascularization in both the eyes. However, there was a neovascularization of optic disc in the right eye. Optical coherence tomography (OCT) revealed diffuse thickening of the inner retinal layers. Increased reflectivity was noted in the inner retinal layers from the surface of the retina to the photoreceptor layers. Colored fundus photographs and OCT images in the 1st month are shown in .