September 14, 2023

Vascular Disorders of the Eye - Clinical Patient Case of the Week

By Andrea Eberly, MD, MS, FAAEM · 2 minute read

Vascular Disorders of the Eye - Clinical Patient Case of the Week

Try this free Eye Vascular Disorders Case Q&A courtesy of Med-Challenger.

This vascular disorders of the eye case comes from our Emergency Medicine review course.

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Try this case and test your knowledge of vascular disorders of the eye.

A 63-year-old male, who recently immigrated from Africa to the USA, presents complaining of an episode of complete, painless blindness in his right eye that lasted for a few seconds.

He is currently asymptomatic and his in-depth eye and neurological exams are normal.

Question:

Which of the following statements is correct?

Answer Options:

The patient is most likely suffering from functional (hysterical) blindness.

Management consists of immediate referral to an ophthalmologist.

This might represent the only warning of an impending, life threatening stroke.

The number one hematological cause of this condition is malaria.

The correct answer is:

This might represent the only warning of an impending, life threatening stroke.

Educational Objective:

Discuss amaurosis fugax as a sign of possibly impending stroke.

Key Point:

This is a classic case of Amaurosis fugax (ocular ischemic syndrome) that is caused by a transient lack of blood flow to the optic nerve (this is basically a transient ischemic attack of the eye). Even though it ultimately is the central retinal artery that does not have sufficient blood flow, the lesion causing the vascular compromise to the retinal artery typically is further proximal, i.e. in the carotid arteries.

Explanation:

Most commonly, amaurosis fugax is due to vascular disease that is triggering thrombi, emboli, and vasospasm. Amaurosis fugax can usually only be diagnosed by history (there will be no physical findings) and might be the only sign of an imminent stroke. It might also be the first sign of an impending giant cell arteritis attack or of an impending sickle cell crisis.

The number one hematological cause (as opposed to vascular cause) of this condition is sickle cell disease (not malaria).

Management includes a complete blood count, an immediate Westergren ESR, possibly a temporal artery biopsy, and carotid as well as cardiac studies. Depending on the findings and on the patient’s past medical history, an immediate referral to a neurologist, cardiologist, vascular surgeon, or internist should be made (not to an ophthalmologist).

Figure:

Eye Vascular Disorders of the Eye Amaurosis Fugax Case

Amaurosis Fugax Retinal Arterial Branch Occlusion by a Cholesterol Embolus (Close View)

This patient has amaurosis fugax due to cholesterol emboli. Note the arterial embolus lodged at an arterial bifurcation over the right upper quadrant of the optic disk in this image. Definite retinal pallor is noted in the left upper quadrant of the image, the area served by the occluded arterial branch.

References:

Guluma K, Lee JE. “Ophthalmology.” (Chapter 361) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 790-819.e3.

Hayreh SS, Zimmerman MB: Amaurosis fugax in ocular vascular occlusive disorders: prevalence and pathogeneses. Retina 34(1):115-122, 2014

Jean E. Klig, “Ophthalmologic Complications of Systemic Disease” Emergency Medicine Clinics of North America - Volume 26, Issue 1 (February 2008)

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Vascular Disorders of the Eye - Clinical Patient Case of the Week