Fundus signs in temporal arteritis.

Abstract

SUMMARY A patient with temporal arteritis developed a variety of ischaemic lesions in the eyes. Infarction of the inner retina and optic nerve head was delineated on presentation by white swelling in the retinal nerve fibre layer. The role of interrupted axoplasmic transport in the production of this sign is discussed. Outer retinal infarction was also noted on presentation and subsequently gave rise to striking pigmented scars.Temporal arteritis often presents with visual loss, and necropsy examination in such cases shows widespread disease of the ophthalmic artery and the extraocular course of its ciliary and retinal branches (Henkind et al., 1970). The medial and lateral posterior ciliary arteries supply the optic nerve head, the outer retina, and, in 20 to 50% of individuals, a variable area of inner retina contiguous with the optic disc (Hayreh, 1969); the central retinal artery supplies the remainder of the inner retina.We present a patient with a unique combination of fundus signs resulting from arteritic obstruction of the blood supply to each of the above arterial territories. The clinical findings are correlated with recent experimental work on the pathophysiology of ischaemic fundus lesions. Case reportA 75-year-old woman presented with a 2-week history of 'misty' vision in each eye. She had suffered weight loss, bitemporal headaches, jaw claudication, and aching limbs during the previous 3 months.On examination vision in each eye was found to be reduced to perception of hand movements only. Pupil reactions were sluggish, and there was a left relative afferent pupillary defect. Examination of the right fundus revealed pallor and swelling of the optic disc and mild translucent swelling of the temporal parapapillary retina (Fig. 1) At first sight the left eye showed a similar ophthalmoscopic picture, with pale swelling of the nasal part of the optic disc and a row of fluffy white cotton-wool spots crossing the papillomacular bundle (Fig. 2). However, there was no cilioretinal arteriolar supply to this eye, and the temporal parapapillary retina was normal in appearance. The remainder of the fundus showed diffuse translucent swelling of the inner retina sparing the fovea, and a band of opacity of the outer retina was noted in the macula (Fig. 2). The central arterioles were attenuated, and the venous blood was markedly deoxygenated.Fluorescein fundus angiography on the right showed satisfactory filling of the central retinal artery but slow filling of the choroid, optic nerve head, and cilioretinal arterioles. In the left eye markedly impaired perfusion was evident in the territories of supply of both the posterior ciliary arteries and the central retinal artery. Both optic discs showed excessive dye leakage in the late pictures. The right eye had a normal electroretinogram (ERG) and electro-oculogram (EOG), but there were minimal electroretinal responses from the left eye.The patient appeared to be indifferent to her loss of sight. No other abnormality was found on general examination. The erythrocyte se...

Visual improvement with corticosteroid therapy in giant cell arteritis. Report of a large study and review of literature

“…Some of these are based on retrospective reviews of varying numbers of patients seen in the authors' clinics (Whitfield et al 1953;Meadows 1954;Bennett 1956;Parsons-Smith 1959;Russell 1959;Norn 1966;Cohen 1973;Graham et al 1981;Bengtsson & Malmvall 1982;Aiello et al 1993;Liu et al 1994;Kupersmith et al 1999). Others are derived from observation of only one or two cases (Caccamise 1956;Cullen 1963;Friedman 1965;Schneider et al 1971;McLeod et al 1978;Model 1978;Lipton et al 1985;Rosenfeld et al 1986;Diamond 1991;Clearkin & Caballero 1992;Matzkin et al 1992;Postel & Pollock 1993;Thystrup et al 1994;Kattah et al 1999). The incidence of improvement in visual acuity (VA) with corticosteroid therapy reported in the larger retrospective series varies widely, as does the extent of improvement, from only minor to dramatic.…”

Evidence for an enduring ischaemic penumbra following central retinal artery occlusion, with implications for fibrinolytic therapy

“…Whether such pan-retinal hypoperfusion reflects incomplete obstruction of the CRA lumen, or exaggerated proximal collateral flow, is impossible to determine. Both possibilities are embraced by use of the term "partial" CRAO McLeod et al, 1978;Brown et al, 1985;Gass, 1987). Global retinal ischaemia (or "panretinal hypoperfusion") is corroborated by the severe haemoglobin oxygen desaturation or "cyanosis" seen in the main tributaries of the central retinal vein McLeod, 2005McLeod, , 2012Schmidt and McLeod, 2007).…”

“…Aetiopathologic factors underlying "partial" CRAO include embolism, cranial arteritis, sickle cell disease and systemic hypertension, the latter in the absence of associated (bilateral) hypertensive retinopathy McLeod et al, 1978;Fine et al, 2000). In such eyes, the inner retina typically reperfuses after several days whereupon visual function will often improve markedly, sometimes to "normal" visual acuity and a "full" visual field albeit usually with a persistent RAPD and subsequent development of some degree of optic atrophy (Wise et al, 1971;Oji and McLeod, 1978;Kurimoto et al, 2011).…”

Obstructed Axoplasmic Transport in Purtscher’s Traumatic Retinopathy

“…in the proximal side of a retinal infarct, while distal deposits arise from the blockade of retrograde transport. This mechanism seems to apply to a series of clinical condi tions in which cotton-wool spots are part of the ophthalmoscopic picture [13,14].…”