David Cartwright’s case has been selected for our Clinical Case of the Month! David is a 4th year optometry student at State University of New York College of Optometry. Here’s the case:
Age/Sex/Race
78 yo white male
Chief Complaint
He complained of complete vision loss OD following a “stroke” that occurred 6 weeks prior. His scheduled appointment was for a 3 month IOP check for monitoring mild stage normal tension glaucoma.
Medical History/medications
The patient reported a right-sided “stroke” six weeks prior that resulted in vision loss to the right eye. He reported being hospitalized for five days, and at that time an emergent carotid endarterectomy 
was performed on the right side. A stent was placed in the right carotid at that time. He reported imaging studies indicated the right carotid was 70% stenosed and was told the left carotid was “good.”
The patient also reported a history of several “mini-strokes” eight weeks prior that resulted in gait and balance difficulties requiring him to need the assistance of a walker. He reported bumping into things on his right side. At the end of his five-day hospitalization he was placed in a nursing home rehabilitation facility where he has been since. He will be discharged from rehab in 4 days.
He was being followed by a vascular surgeon who had started him on coumadin following the carotid surgery. He also has a history of hypertension for which he was taking metoprolol and amlodipine. He was taking atorvastatin for hyperlipidemia. He also had a history of sleep apnea and wore a CPAP (Continuous Positive Airway Pressure) during sleep.
No known drug allergies.
Ocular History
The patient has a history of mild stage normal tension glaucoma and is taking latanoprost 0.005% 1 gtt QHS OU. Despite his hospitalization and placement in rehab, he reports good compliance with drops.
From his last visit:
- Refractive error: a myope with -1.50D of astigmatism OD and -2.50 of astigmatism OS
- Visual fields: essentially full OU
- Thin corneas
- Stable and symmetric optic nerve heads: OD 0.65/0.65, OS 0.45/0.45, with intact, healthy rim tissues OU
- Macula: parafoveal hard drusen superior to the macula OD, macular mottling OS
Family History
No known family history of any eye diseases.
Diagnosis and initial plan of action
When the patient initially reported vision loss in the right eye my immediate reaction was to downplay the degree of visual decline. I thought he was exaggerating the amount of vision loss. When he told me his recent medical history regarding the stroke and specifically his need for an emergent carotid endarterectomy, it made more sense to me that he would have complete vision loss. My next thought was of a possible retinal vascular occlusion. My initial plan was to check his visual acuity and dilate.
Applicable Testing & Results of Testing
Distance visual acuity:
OD minimal LP
OS 20/30-2
Confrontation fields: FTFC OS ONLY
Pupils:
OD 4-2, 2 consensual stimulation only
OS 4-2, 2 direct stimulation only
[+]RIGHT RAPD GR 3
Slit lamp examination:
Lids / Adnexa: CLEAR OU
Conjunctiva / Sclera: TEMP pingueculae OU
Cornea: arcus OU
Iris: FLAT/INTACT OU, (-)NVI OD
Anterior Chamber: Open by Von Herrick Evaluation OU
(-) Cells & Flare OU
Lens: OD (tr inf spoke (tr) )
OS (tr inf spole (large central vacuole) tr PSC)
IOP : OD 15 mmHg & OS 15mmHg @2:05pm
Vitreous: OU ant syneresis
Dilated fundus exam
C/D: OD 0.75 round, moderate ONH pallor, (-)NVD, (-)hemes
OS 0.5 round, healthy rim, (-)NVD, (-)hemes
Vasculature: OD attenuated arteries and veins
OS venous engorgement sup and inf
Macula: OD 2DD ring of RETINAL edema with central “cherry red spot”, few scattered hard drusen superiorly,
OS clear
Peripheral retina: OD ST chorioretinal atrophy at the ora
OS flat and intact 360, no holes, tears or anomalies
Fundus Photos were taken OU — see below
Differential Diagnosis
1. A textbook CRAO given the patient’s history and the appearance of the fundus. The retinae OU were scrutinized for plaques and additional occlusions without any evidence of such.
2. Ophthalmic artery occlusion – usually has no cherry-red spot and the entire retina is whitened.
3. Commotio retinae – whitening of retina secondary to edema following blunt trauma, pt had no recent history of trauma.
Assessment and Plan
ASSESSMENT:
1. OD Central Retinal Artery Occlusion with Resultant Light Perception Vision
- Pt 6 weeks S/P emergent RIGHT carotid endarterectomy with stenting
- Pt being followed by vascular surgeon with next appointment in 2 weeks
- (+)associated RAPD OD
- Fundus photos taken today
- OS venous engorgement noted today
- LEFT carotid doppler “good” per pt wife
2. Mild Normotensive Glaucoma OU with Acceptable IOP
- Moderate/large optic nerve cupping OD>OS with increased cupping noted today OD
- H/o thin corneas
- H/o full fields
3. OS Mixed Cataract with Associated Mild Decrease In Vision
- No improvement with refraction
PLAN:
1. RTC 6 weeks to monitor for neovascularization of the disc. The patient and his wife were educated on importance of continued monitoring of carotid arteries for possible re-stenosis. Pt ed on full time use of specs for protection given monocular status.
2. Continue latanoprost 1gtt qPM OU. RTC 3 mos for IOP check and HVF OS only.
3. Pt edu on slight decrease in vision. Pt ed on low vision services. Pt declines at this time
RTC 6 wks for fundus evaluation for disc neovascularizino check OD.
RTC 3 mos for IOP check and visual field OS only.
