Ocular ischemic syndrome

Institute of Clinical Medicine (Hung), College of Medicine, National Cheng Kung University; Department of Ophthalmology (Hung, Chang), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Department of Ophthalmology (Chang), College of Medicine, National Cheng Kung University Tainan, Taiwan • • • Institute of Clinical Medicine (Hung), College of Medicine, National Cheng Kung University; Department of Ophthalmology (Hung, Chang), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University; Department of Ophthalmology (Chang), College of Medicine, National Cheng Kung University Tainan, Taiwan • • • • For correspondence: A 74-year-old man with hypertension and diabetes mellitus presented with a three-month history of intermittent orbital pain and progressive vision loss in his left eye, deteriorating to hand motions. The intraocular pressure was in the normal range at 13 mm Hg. Biomicroscopy showed prominent iris neovasculature ( Clinical images are chosen because they are particularly intriguing, classic or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption. A brief explanation (300 words maximum) of the educational importance of the images with minimal references is required. The patient’s written consent for publication must be obtained before submission. Acknowledgements The authors thank Drs. Chun-I Wu and Cheng-Han Lee (Department ...

Ocular ischemic syndrome (OIS) is characterized by hypoperfusion to the eye due to underlying systemic conditions, most commonly involving carotid artery disease. While this condition can also have sight-threatening ocular sequelae, it can have life-threatening systemic implications since carotid artery disease increases risk for stroke and cerebrovascular accidents. It is for this reason that eyecare providers must be able to quickly recognize OIS signs and symptoms in order to initiate the proper systemic work-up and treatment. 1,2 As always, a thorough medical history and review of systems must be performed. The mean age of patients with OIS, as determined by Mizener et al., is 68 years-old, plus or minus a standard deviation of eight years. The condition is twice as common in men as women. Because patients who suffer from carotid occlusive disease often suffer from multiple comorbidities, it is always important to consider the appropriate differentials if not already diagnosed. According to Meziner et al.’s analysis of patients with OIS, more than 50% were diabetic, more than 50% had hypertension, 40% suffered from coronary artery disease and 30% had a history of stroke or transient ischemic attack. 3 OIS is a rare condition. The proposed incidence is eight cases per million; however, considering underdiagnosis/misdiagnosis of the condition, experts note that this figure could be much greater. 4 OIS retinal appearance can overlap with those of other conditions, such as...

1 reported on the ocular symptoms and signs occurring secondary to severe carotid artery obstructive disease. They called the entity “venous stasis retinopathy” and noted that it occurred in approximately 5% of patients with severe carotid artery insufficiency or thrombosis. Some confusion has since arisen with this term because it has also been used to designate mild central retinal venous obstruction. 2 A number of additional alternative names have been proposed, including ischemic ocular inflammation, 3 ischemic oculopathy, 4 and the ocular ischemic syndrome. 5, 6 Histopathologic examination of eyes with the entity generally does not reveal inflammation, 7, 8 and therefore the descriptive term the present authors and Dr. Larry Magargal have thought preferable is the ocular ischemic syndrome. 5, 6 5 It has been shown that a 90% carotid stenosis reduces the ipsilateral central retinal artery perfusion pressure by about 50%. 10, 11 The obstruction can occur within the common carotid or internal carotid artery. In about 50% of cases, the affected vessel is 100% occluded, while in 10% there is bilateral 100% carotid artery obstruction. 5 5, 12, 13 Rarely, an isolated obstruction of the central retinal artery alone can mimic the dilated retinal veins and retinal hemorrhages seen in eyes with the ocular ischemic syndrome. 14 5 Dissecting aneurysm of the carotid artery has been reported as a cause, 15 as has giant cell arteritis. 16 Hypothetically, entities such as fibromuscula...

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Symptoms of carotid artery disease frequently present to ophthalmologists. Though these may be sight threatening, they may represent the first signs of life threatening carotid artery stenosis. These include cerebral transient ischaemic attacks (TIA), transient monocular blindness (amaurosis fugax), central or branch retinal artery occlusion, hypotensive retinopathy (previously known as “venous stasis retinopathy”), and ocular ischaemic syndrome (OIS). Of these associations with carotid artery disease, OIS presents the most challenging condition for the ophthalmologist with many controversial aspects to its management. OIS is a severe form of chronic ischaemia of both anterior and posterior segments of the eye as well other orbital structures supplied by the ophthalmic artery. It is thought to be due to chronic hypoperfusion when carotid artery stenosis is greater than 90%. OIS is rare; however, ophthalmoscopic features of hypotensive retinopathy have been found in 5%–20% In this article we present an overview and recommendations for best clinical practice for OIS based on an extensive review of recent studies. Clinical findings in OIS SYMPTOMS Clinical presentation may include sudden (41%), gradual (28%), or transient vision loss (15%) or pain, either ocular or orbital (13%). In 20% of cases, the clinical signs of OIS are an incidental, asymptomatic finding. et al, Rarely, vision loss may be precipitated by exposure to bright lights (“bright light amaurosis”) with subject...