Diagnostic and Theraputic Challenges

Abstract

A 71-year-old woman noticed a sudden decrease of vision in the right eye. She had been hospitalized 1 week before with a 4-year history of bronchial asthma, erythema, and peripheral neuropathy. Visual acuity in the right eye was light perception with a relative afferent pupillary defect. The optic disk was pale and swollen, and the retina was cloudy and edematous due to a retinal infarction in the superotemporal region ( Fig. 1). Visual acuity in the left eye was 0.7 with a cataract; the left eye was otherwise normal.Fluorescein angiography (Fig. 2) showed a delayed arteriovenous transit time corresponding to the superotemporal retinal infarction and an extensive segmental choroidal perfusion delay clearly demarcated over time (20.26 seconds and later). The largest segment of the choroidal perfusion delay spread vertically across the optic disk and seamlessly connected to the superotemporal wedge-shaped optic disk fluorescent defect. The choroidal perfusion delay also was clearly detected by indocyanine green angiography (Fig. 3). The superotemporal retinal artery arising at the disk margin with pulsatile flow was proved to be a cilioretinal artery, which was also connected to the superotemporal region of the optic disk.This case is presented for discussion concerning diagnoses and management.We asked several experts for their opinion. Dr. Rajiv Anand (Dallas, TX):A 71-year-old woman with a sudden loss of vision in one eye, assumed free of any accompanying pain, is