An 80-year-old man comes to the emergency department due to sudden loss of vision in his left eye that occurred on waking this morning. He has no associated pain. Past medical history is notable for hypertension. Current medications include ramipril and chlorthalidone. He has smoked half a pack of cigarettes a day for the past 60 years. His temperature is 36.8 C (98.4 F), blood pressure is 140/90 mm Hg, pulse is 86/min, and respirations are 14/min. Examination of the right eye shows no abnormalities. Funduscopic examination of the left eye reveals swelling of the optic disk, retinal hemorrhages, dilated and tortuous veins, and cotton wool spots. Which of the following is the most likely diagnosis?

Question

An 80-year-old man comes to the emergency department due to sudden loss of vision in his left eye that occurred on waking this morning.  He has no associated pain.  Past medical history is notable for hypertension.  Current medications include ramipril and chlorthalidone.  He has smoked half a pack of cigarettes a day for the past 60 years.  His temperature is 36.8 C (98.4 F), blood pressure is 140/90 mm Hg, pulse is 86/min, and respirations are 14/min.  Examination of the right eye shows no abnormalities.  Funduscopic examination of the left eye reveals swelling of the optic disk, retinal hemorrhages, dilated and tortuous veins, and cotton wool spots.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d543_f438_bc81_133c113eb631_MD0003_00 This patient with acute, unilateral, painless loss of vision has findings suggestive of central retinal vein occlusion (CRVO). The characteristic changes on funduscopic examination are sometimes referred to as the "blood and thunder" appearance, and include optic disk swelling, retinal hemorrhages, dilated veins, and cotton wool spots. CRVO should be considered in the differential diagnosis for acute or subacute monocular loss of vision, but it is typically not quite as acute as the vision loss seen in patients with central retinal artery occlusion. CRVO is caused by thrombosis of the central retinal vein and is most common in patients with coagulopathy, hyperviscosity, chronic glaucoma, and atherosclerotic risk factors (eg, age, diabetes, hypertension). The diagnosis can be confirmed with fluorescein angiography. Patients with no significant macular edema or neovascularization are often managed conservatively with close observation. Significant macular edema can be treated with intravitreal injection of vascular endothelial growth factor inhibitors. No treatment is particularly effective, but some patients may have partial recovery of vision within the first 3 months. (Choice A) Acute angle-closure glaucoma presents with acute onset of severe eye pain and blurred vision associated with nausea and vomiting. Examination shows a red eye with a steamy cornea and moderately dilated pupil that is non-reactive to light. Acute angle-closure glaucoma (Choice B) Patients with anterior uveitis may have vision loss, but the affected eye is usually red and painful. anterior uveitis (Choice C) Amaurosis fugax is usually caused by atheroemboli from the carotid arteries and causes temporary vision loss as opposed to the persistent vision loss seen in this patient. Swelling of the optic disc may be seen in some cases, but retinal hemorrhage is more consistent with CRVO. (Choice E) Optic neuritis is characterized by acute unilateral loss of vision, severe pain, and an afferent pupillary defect. It most commonly occurs in women age <50 and is often an initial presentation of multiple sclerosis. Educational objective: Central retinal vein occlusion presents with acute or subacute painless monocular visual loss. Funduscopic examination shows a "blood and thunder" appearance consisting of optic disk swelling, retinal hemorrhages, dilated veins, and cotton wool spots. References: Risk factors for central and branch retinal vein occlusion: a meta-analysis of published clinical data. (http://www.ncbi.nlm.nih.gov/pubmed/25009743)

An 80-Year-Old Man Comes to the Emergency Department Due to Sudden