History of present illness
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A 29-year-old female patient presented with a 5-month history of progressive loss of vision in both eyes.
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She also reported red eyes and a foreign body sensation.
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She had no history of previous ophthalmological disorders.
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In the last 2 years, she had been under treatment for vertigo with cinnarizine (antihistamine).
Ocular examination
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Best-corrected visual acuity was 20/1200 in the right eye (OD) and 20/80 in the left eye (OS).
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Her intraocular pressures were 10 mm Hg OD and 8 mm Hg OS.
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Anterior segment examination revealed an afferent pupil defect OD and iris neovascularization OS.
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Dilated fundus examination ( Fig. 48.1 A, B)
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Right eye showed disc congestion with surrounding arteriovenous anastomoses, aneurysmal dilatation, distention and tortuosity of central blood vessels, and flame-shaped hemorrhages.
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Left eye showed increased ramifications and capillarity and white patches.
Fig. 48.1
(A) Fundus photograph of the right eye (OD) showing disc edema, peripapillary arteriovenous anastomoses, tortuous vessels, aneurismal dilatation, beading of vessels, increased ramifications and capillarity, and flame-shaped hemorrhages inferiorly. (B) Fundus photograph of the left eye (OS) showing neovascularization, microaneurysms, and retinal nerve fiber layer infarcts. (C) Fluorescein angiography (FA) OD showing arteriovenous shunts and marked neovascularizations. (D) FA OS showing leakage of fluorescein dye.
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Imaging
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Fluorescein angiography (FA) ( Fig. 48.1 C, D)
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Prolonged arm-to-retina circulation time of 17 seconds
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Delayed arteriovenous filling time of 30 seconds
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Reduced choroidal circulation
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Arteriovenous anastomosis
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Questions to ask: What would you do next?
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Medical history
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Systemic examination
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Check systemic blood pressure
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Decreased brachial artery pulse
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Systemic blood pressure in upper extremities not evaluable
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Systemic blood pressure in lower limbs: right, 130/90 mm Hg; left, 135/90 mm Hg
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Referral to specialist
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Blood testing
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The erythrocyte sedimentation rate was high: 41.
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Blood chemistry was normal; anti–double-stranded DNA, anticardiolipin antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, fluorescent treponemal antibody absorption, and tuberculosis were negative.
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Differential diagnosis
Assessment
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Proliferative retinopathies (e.g., diabetes, hypertension)
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Systemic granulomatosis and autoimmune diseases
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Inflammatory aortitis
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Eosinophilic granulomatosis with polyangiitis
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Cerebral aneurysms
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Syphilis
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Fibromuscular dysplasia
Computed tomography angiography (CTA)/magnetic resonance angiography (MRA)
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CTA ( Fig. 48.2 )
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Narrowed lumens of brachiocephalic artery, left common carotid artery, and left subclavian artery
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