A Woman with Unilateral Sudden Painless Vision Loss
Article Outline
A 46-year-old woman presented to the emergency department with a sudden onset of blurry vision in her left eye that started 1 week ago and remained persistent. At evaluation, her visual acuity was 20/40 in the left eye and 20/20 in the right eye. A bedside ophthalmoscopic examination was performed and she was referred to ophthalmology for fluorescein angiography and further care.
Diagnosis
Left central retinal vein occlusion
Patients with central retinal vein occlusion typically present with sudden painless vision loss. Ophthalmoscopic findings include optic disc edema, retinal hemorrhages, cotton-wool spots, and dilated tortuous retinal veins (Figure 1, Figure 2). Retinal vein occlusions occur in 1% to 2% of patients older than 40 years, with branch vein occlusions being 4 times as common as central vein occlusions.1, 2 Risk factors include hypertension, diabetes, dyslipidemia, smoking, renal disease, and glaucoma.3, 4 Visual acuity at presentation is the strongest predictor of final visual outcome. One study found that 65% of central retinal vein occlusion patients presenting with visual acuity of 20/40 maintained 20/40 or better, and less than 1% presenting with worse than 20/200 ever achieved 20/40.5
Figure 1.
Right ophthalmoscopic view with normal optic disc, well-perfused retina, and normal vessels.
Figure 2.
Left ophthalmoscopic view with optic disc edema (large white arrow), retinal hemorrhages (thin black arrows), cotton-wool spots (thin white arrows), and dilated, tortuous retinal veins (large black arrows).
The emergency physician's responsibilities include recognizing the entity and ensuring urgent ophthalmologic evaluation. Fluorescein angiography can be performed to assess the degree of macular edema and perfusion (Figure 3, Figure 4). Treatment options include laser photocoagulation, chorioretinal venous anastomosis, and intravitreal glucocorticoids or anti–vascular endothelial growth factor agents. Although central retinal vein occlusion is not an independent risk factor for cardiovascular mortality, it is considered end-organ damage, and patients should undergo cardiovascular disease risk management interventions.6, 7
Figure 3.
Fluorescein angiography of the right fundus, with uniform retina perfusion and well-defined vessels without evidence of vascular leakage.
Figure 4.
Fluorescein angiography of the left fundus with areas of nonperfusion (white arrows) and vascular congestion and leakage (black arrow).
Used with permission of Yang Wang, MD, Emergency Services, David Grant Medical Center, Travis Air Force Base, CA.
References
- The epidemiology of retinal vein occlusion: the Beaver Dam Eye Study. Trans Am Ophthalmol Soc. 2000;98:133–141discussion 141-133
- The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Europe, Asia, and Australia. Ophthalmology. 2010;117:313–319e1
- Cardiovascular risk factors for retinal vein occlusion and arteriolar emboli: the Atherosclerosis Risk in Communities & Cardiovascular Health studies. Ophthalmology. 2005;112:540–547
- . Prevalence and associations of retinal vein occlusion in Australia (The Blue Mountains Eye Study). Arch Ophthalmol. 1996;114:1243–1247
- . Natural history and clinical management of central retinal vein occlusion. Arch Ophthalmol. 1997;115:486–491
- Retinal vein occlusion and vascular mortality: pooled data analysis of 2 population-based cohorts. Ophthalmology. 2007;114:520–524
- . Hypertensive retinopathy. N Engl J Med. 2004;351:2310–2317
For the diagnosis and teaching points, see page 430.
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PII: S0196-0644(11)00351-9
doi:10.1016/j.annemergmed.2011.03.058
© 2011 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
