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Disease
- Chronic ocular hypoperfusion
- Cause: marked ipsilateral carotid stenosis (>90%), mostly internal carotid artery, typically due to atherosclerosis, rarely dissection, or giant cell arteritis
Clinical Presentation
- Vision loss over several weeks to months, occasionally sudden or transient (amaurosis fugax)
- Ocular and periocular pain
- Diffuse episcleral injection
- Corneal edema
- Anterior chamber flare with few or no cells (“ischaemic pseudoiritis”)
- Iris atrophy
- Rubeosis iridis
- Retina: venous dilation, narrowing of arterioles, haemorrhages, microaneurysms, papilledema, cotton wool spots, neovascularisation of the disc / elsewhere
- IOP often not elevated due to decreased ciliary body function
Differential Diagnoses
Work-up
- Fluorescein angiography: delayed filling of the choroid and retina, prolonged arteriovenous passage time, diffuse leakage
- Carotid duplex ultrasound: stenosis of the internal carotid artery
Treatment
- Consider reducing intraocular pressure -> to increase perfusion pressure
- Panretinal photocoagulation -> evaluate if rubeosis iridis or retinal neovascularisation is present
- In case of neovascular glaucoma: medical or surgical therapy
- Carotid endarterectomy (not possible with 100% stenosis) -> postoperatively the IOP might be elevated due to increased ciliary body perfusion
- Treatment of cardiovascular risk factors
Sources
- EyeWiki Ocular Ischemic Syndrome
- The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
- Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)