Case Studies

Case 5: Sudden painless visual loss

A 36-year-old general practitioner (GP) was seen in eye casualty with sudden, unilateral, painless visual loss. She blamed stress as she was still recovering mentally from her fourth miscarriage in 2 years. Her VA was 6/9, she had no relative afferent pupillary defect and dilated fundoscopy revealed widespread haemorrhages in all quadrants, but no cotton wool spots.

• 1. What is the most likely differential diagnosis?

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  Correct answer: Non-ischaemic central retinal vein occlusion (CVOS) is most likely, due to the haemorrhages in all four quadrants.

• 2. Why could this have happened to this young woman?

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  Correct answer: Due to the recurrent miscarriages, one must consider anti-phospholipid syndrome as an underlying cause. Hence, request lupus anticoagulant and anti-cardiolipin antibodies.

After you explained the diagnosis, she wanted an FFA and laser treatment today.

• 3. Why is this not the correct management regime? Is there any evidence that you could quote?

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  Correct answer: The CVOS study showed that macular grid laser did not improve vision in patients with macular oedema secondary to CRVO.

Three months later in clinic, her VA was 6/18, her intraocular pressure was 14 and there was no evidence of rubeotic vessels. OCT revealed macular oedema. She had been reading around the subject and was reluctant to have monthly injections.

• 4. Is there anything else you can offer her to improve her vision? Is this an established mode of treatment?

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  Correct answer: The only licensed agent in the United Kingdom currently for macular oedema secondary to vein occlusion is the dexamethasone implant. The GENEVA study randomised patients into either sham or implants, and the percentage of eyes with at least 15-letter improvement after 60 days was 29% (versus 11% in the sham group).

• 5. Is there any other medication you could prescribe in the long term?

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  Correct answer: Aspirin.

Five years later she comes back with ischaemic changes in the posterior pole. She also has rubeotic glaucoma and no visual potential.

• 6. Are there any maintenance medications she can have to keep her eye comfortable?

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  Correct answer: Atropine and maxidex for that eye only.