A 65-year-old woman comes to the emergency department with acute loss of vision in her right eye. Three hours ago, she was watching television when she suddenly noticed the vision in her right eye become cloudy and then go completely black. She has no headache, eye pain, double vision, dysarthria, dysphasia, muscle weakness, or numbness. Past medical history includes type 2 diabetes mellitus and hypertension. Her medications include lisinopril and metformin. She has a 40-pack-year smoking history.
Vital signs are within normal limits. Visual acuity is 20/40 in the left eye and there is no light perception in the right eye. There is a relative afferent pupillary defect on the right. Ocular motility is normal on cardinal signs of gaze testing. The remainder of the physical examination is within normal limits.
Funduscopic examination is shown in the image below.

Which of the following is the most likely diagnosis for this patient's acute vision loss?

Question

A 65-year-old woman comes to the emergency department with acute loss of vision in her right eye.  Three hours ago, she was watching television when she suddenly noticed the vision in her right eye become cloudy and then go completely black.  She has no headache, eye pain, double vision, dysarthria, dysphasia, muscle weakness, or numbness.  Past medical history includes type 2 diabetes mellitus and hypertension.  Her medications include lisinopril and metformin.  She has a 40-pack-year smoking history.
Vital signs are within normal limits.  Visual acuity is 20/40 in the left eye and there is no light perception in the right eye.  There is a relative afferent pupillary defect on the right.  Ocular motility is normal on cardinal signs of gaze testing.  The remainder of the physical examination is within normal limits.
Funduscopic examination is shown in the image below.

Which of the following is the most likely diagnosis for this patient's acute vision loss?

Quizplus · Accepted Answer

11ec193a_967e_9bda_853d_5d406cc3f993_MD0002_00 Central retinal artery occlusion (CRAO) is a rare condition (<0.01% of the population) that usually affects patients age >60 with hypertension, diabetes, and history of cigarette smoking. CRAO is most commonly due to carotid artery atherosclerosis as the central retinal artery is a branch of the ophthalmic artery, which arises from the internal carotid artery. Other etiologies include cardiac embolism, small-vessel disease (eg, hypertension, diabetes), and vasculitis. Patients typically present with acute, painless, and severe vision loss in one eye. There is generally a complete or relative afferent pupillary defect. Funduscopic examination usually shows diffuse ischemic retinal whitening and cherry red spots. Diagnosis includes laboratory studies to exclude giant cell arteritis (erythrocyte sedimentation rate, C-reactive protein), carotid artery imaging, and cardiac evaluation in patients with suspected embolic source. retinal whitening and cherry red spots Irreversible retinal damage can occur within 90-100 minutes of CRAO. As a result, patients require urgent ophthalmology consultation and measures to lower intraocular pressure (eg, ocular massage, anterior chamber paracentesis, intravenous acetazolamide or mannitol). Intra-arterial thrombolysis is still experimental but is performed at some treatment centers. Long-term management includes atherosclerosis risk factor modification (lipid-reducing and antiplatelet agents) and prevention of recurrent vascular events. Prognosis is poor in patients initially presenting with severe vision loss. (Choice A) Patients with acute angle-closure glaucoma typically present with vision loss, severe eye pain, headache, nausea, and vomiting. They may also report seeing light halos. Examination shows conjunctival redness and a poorly reactive, dilated pupil. acute angle-closure glaucoma (Choice C) Nonarteritic anterior ischemic optic neuropathy presents with painless vision loss in one eye, usually on awakening, in individuals age >50. Visual examination shows afferent pupillary defect, and funduscopy shows optic nerve head swelling or papilledema. Cherry red spots are not seen. Nonarteritic anterior ischemic optic neuropathy (Choice D) Optic neuritis is an inflammatory demyelination of the optic nerve that typically affects patients age <50 and can be the presenting symptom of multiple sclerosis. Patients present with acute or subacute painful loss of vision in one eye, color desaturation, headache, pain with eye movement, and afferent pupillary defect. Funduscopic examination may be normal or show papilledema. Optic neuritis (Choice E) Retinal detachment presents with vision loss (peripheral followed by central) and photopsia with showers of floaters. It is usually associated with trauma, previous eye surgery, aging, and severe myopia. Educational objective: Central retinal artery occlusion presents with acute, painless, severe vision loss in one eye and relative afferent pupillary defect. Funduscopy shows diffuse ischemic retinal whitening and cherry red macula. Treatment includes urgent ophthalmology consultation and measures to lower intraocular pressure (eg, ocular massage, anterior chamber paracentesis, intravenous acetazolamide or mannitol). __________ References: Treatment options for central retinal artery occlusion. (http://www.ncbi.nlm.nih.gov/pubmed/23070637) Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/20609991)

A 65-Year-Old Woman Comes to the Emergency Department with Acute