Pearls & oy-sters: ocular ischemic syndrome.

CASE REPORT A 46-year-old man with a 60-packyear smoking history, dyslipidemia, and migraine without aura had a cervical lateral acceleration/deceleration injury due to a motor vehicle accident while driving his car. No neurologic deficits were noticed within the next days. Ten days later, his right eye became gradually red, with ipsilateral lacrimation and ocular pain. Ophthalmoscopic examination showed a right episcleral vascular congestion without pupil abnormalities. Intraocular pressure (IOP) was within normal limits. The patient was diagnosed with uveitis, and topical treatment with dexamethasone and cyclopentolate (a long-acting cycloplegic) was prescribed, with initial improvement of the symptoms. Fifteen days later, the patient started experiencing episodes of right eye amaurosis that lasted for few seconds, triggered by exposure to bright light and postural changes. Initially, these episodes were transient but throughout the next weeks they became increasingly constant. Eventually, the patient developed a severe decrease in visual acuity. Concurrently, the pain reappeared in the right eye, becoming a dull, constant ache, and radiating to the orbit and upper face. The pain worsened in the upright position, and did not improve with topical dexamethasone. Five months after the vehicle accident, the patient presented to our clinic. Ocular movements were normal. Ophthalmoscopic examination revealed corneal edema, episcleral injection, and rubeosis iridis (abnormal neovascularization in the surface of the iris) in the right eye (figure 1A). A right Marcus-Gunn pupil was present. Visual acuity examination was 20/20 in the left eye, but he was only able to count fingers with the right eye. Funduscopy revealed small hemorrhages in the right retina (figure 1B). IOP was increased in the right eye (24 mm Hg) and normal in the left eye (18 mm Hg). The rest of the neurologic examination was unremarkable. Complete blood count and coagulation tests were normal. Duplex carotid ultrasonography revealed occlusion of the initial portion of the right common carotid artery. Peak systolic velocity of the left internal carotid artery was increased (146 cm/s). Right ophthalmic artery flow was reversed and increased (125 cm/s). Transcranial Doppler ultrasound showed a reversed flow in the A1 segment of the right anterior cerebral artery. Right middle cerebral artery flow did not change with Valsalva maneuver. A brain magnetic resonance angiography confirmed the occlusion of the right common carotid artery, showing no other abnormalities. As the carotid occlusion did not fully explain the eye pain and visual loss, and to rule out other causes (i.e., arteriovenous malformations or fistulas), an arterial angiography was performed, which verified the presence of occlusion (figure 2A) and revealed an increased collateral vascularization in the right periocular region (figure 2B); thus the diagnosis of OIS was made. He was prescribed treatment with subcutaneous enoxaparin 120 mg/day, and oral prednisone 30 mg/day with dose reduction by 10 mg per week. He later underwent panretinal photocoagulation. By 6 months, the pain had resolved, and Correspondence & reprint requests to Dr. Palma: [email protected]