Sudden Painless Loss Of Vision Research Articles

Recurrent stroke in a reproductive age women with patent foramen ovale

BackgroundPatent foramen ovale (PFO) is a known cause of ischemic stroke in young adults and combined oral contraceptives (COCs) are widely used by women of reproductive age. If young women with PFO are taking COCs, they may be subjected to a synergistic increase in the occurrence of stroke, though reports of ischemic stroke in this population are rare. We report a woman of reproductive age who was taking COC suffered repetitive ischemic strokes before a patent foramen ovale (PFO) was detected and closed, which may raise concerns in this field.Case presentationA 31-year-old woman presented to the emergency department with sudden-onset right upper- and lower-limb weakness and dysarthria for 1 hour, whose only risk factor of stroke was oral contraceptive use. On admission, she was alert with left gaze deviation, dysarthria, and right-sided hemiplegia. Her symptoms improved after receiving the revascularization therapy. About 24 hours later, her left eye experienced sudden painless vision loss. Then the PFO with a substantial right-to-left shunt was detected and then she received a trans-catheter closure of the defect. Over 3 months of follow-up, there were no signs of stroke, but visual loss persisted.ConclusionThis case of disabling stroke raises concerns regarding optimal management in primary and secondary prevention of stroke in young women on COCs with additional risk factors of stroke.

Neuromyelitis Optica Spectrum Disorder (Device’s Disease): - A Case Report Of Full Recovery With Corticosteroids, Therapeutic Plasmapheresis And Immunotherapy

Neuromyelitis optica is a severely disabling inflammatory disorder of autoimmune etiology of the central nervous system, mainly affecting the optic nerves and spinal cord. Here, we present a case report of neuromyelitis optica in a 28-year-old Indian woman who presented with sudden painless loss of vision with tingling followed by weakness of all four limbs with bowel involvement that developed over a period of one week, with a significant history of recent vaccination with COVISHIELD (ChAdOx1 nCoV- 19) vaccine . Clinical evaluation showed diminished vision in both eyes, which progressed to loss of power across all major muscle groups in all limbs and bowel involvement. Magnetic resonance imaging of brain with contrast was done which showed T2W/FLAIR hyperintense non enhancing signal in bilateral thalami extending caudally in mid brain on left side and in midline anterior medulla with subtle T2 hyperintense signal in body of corpus callosum, similar foci are seen in bilateral frontoparietal white matter suggestive of ADEM or demyelination. Also T2 hyperintense signal in both optic nerves [left> right] in posterior part of orbit suggestive of optic neuritis. MRI whole spine showed multiple patchy hyperintense signals on T2 and hypointensity on T1 all over cervical and dorsal vertebrae through whole segment in contiguous manner. The patient was immediately started on intravenous methylprednisolone pulse therapy followed by plasmapheresis and immunomodulator therapy. The diagnosis of neuromyelitis optica was later confirmed with strongly positive neuromyelitis optica immunoglobulin G. Since, treatment was started early patient responded very well and made full recovery. Hence, early initiation of aggressive immunosuppressive treatment is essential in such cases.

We Didn’t See That Coming: Right Eye Blindness Post-Cardiac Surgery

Postoperative visual loss (POVL) is a very rare but devastating event that can occur post-cardiac surgery. The most common cause of POVL is vascular occlusion. We present a case of a 39-year-old male with severe mixed aortic valve disease, who had to undergo double valve replacement (mechanical) due to extensive calcification. On postoperative day 7, he complained of sudden painless loss of vision in the right eye. He was diagnosed with right eye central retinal artery occlusion and was discharged home with permanent right eye blindness. Neuro-ophthalmologic complications following non-ocular surgery occur rarely. POVL occurs more likely when there are calcified heart valvular lesions, higher perioperative blood loss, hypotension, low systolic blood pressure, anaemia, hypothermia, prolonged surgery time and age >50 years old. In our case report we have encountered a couple of risk factors for ischaemia which are heavily calcified aortic and mitral valves, lower mean arterial pressure and bypass time >5 hours. Postoperative blindness can be avery serious and devastating problem with no known or established treatment. Stroke is a well-known and established complication of cardiac surgery, but central retinal artery occlusion causing loss of vision is rarely covered and explained.

Combined central retinal vein occlusion and cilioretinal artery occlusion as the initial presentation of frosted branch angiitis: a case report and literature review

PurposeTo report a case of combined central retinal vein occlusion (CRVO) with cilioretinal artery occlusion (CLRAO) that heralded the development of frosted branch angiitis (FBA).Case reportA 25-year-old healthy male presented with sudden painless visual loss in his left eye with a visual acuity (VA) of 20/300. Fundus exam and fluorescein angiography showed signs of combined CRVO and CLRAO. Without treatment, his vision gradually improved until it reached 20/30 within four months. Five months after initial presentation, he returned with severe visual loss (20/400) in the same eye and a clinical picture of severe occlusive periphlebitis resembling a frosted branch angiitis pattern associated with severe macular edema. This was promptly and successfully treated with systemic steroids and immunosuppressive medications.ConclusionCRVO in young population can have an unusual course and one should carefully rule out underlying uveitic etiologies in each visit. Clinical suspicion and close follow‑up are required for early detection and timely management of FBA.

Polymyalgia rheumatica presenting as sternoclavicular arthritis: a case report

BackgroundPolymyalgia rheumatica and giant cell arteritis are systemic inflammatory conditions of the elderly. Polymyalgia rheumatica classically presents as a bilateral proximal muscle pain and stiffness syndrome. Biceps tenosynovitis is the commonest pathology in polymyalgia rheumatica. However according to literature, erosive sternoclavicular arthritis is a rare association of polymyalgia rheumatica. Giant cell arteritis is an inflammatory granulomatous arteritis predominantly involving large cerebral arteries. Thus, its classic clinical presentation includes severe headache with scalp tenderness, jaw claudication, and sudden painless loss of vision. Urological manifestations (prostatic vasculitis and epididymo-orchitis) were seldom reported in giant cell arteritis.Case presentationA 53-year-old Sinhalese man presented with progressive right-sided shoulder joint pain and neck pain associated with constitutional symptoms and episodic generalized headache. Examination revealed restricted movements of the right shoulder joint with nontender pulsatile bilateral temporal arteries. Blood testing showed elevated erythrocyte sedimentation rate and C-reactive protein. Color Doppler ultrasound of the superficial temporal artery revealed “halo sign.” The temporal artery showed infiltration of mononuclear cells in the arterial media and adventitia. Computed tomography revealed right sternoclavicular arthritis with incidental finding of ureteric stricture. The patient was treated with high-dose oral prednisolone, and good clinical and biochemical response was observed during follow-up.ConclusionPolymyalgia rheumatica–giant cell arteritis may rarely present as erosive sternoclavicular arthritis as the initial manifestation, mimicking many rheumatological conditions. Urological involvement such as ureteric strictures may be rare associations of primary systemic vasculitis. A high degree of suspicion combined with targeted investigations would allow early identification the polymyalgia rheumatica–giant cell arteritis syndrome in the presence of atypical manifestations, leading to improved patient outcomes.

A young soldier with Susac syndrome: a case report

BackgroundSusac syndrome is a rare disease with multisystem manifestations. While the exact pathogenesis is not known, it has been proposed to be an autoimmune endotheliopathy affecting the microvasculature of the brain, retina, and inner ear. The disease is characterized by a triad of encephalopathy, vision loss, and hearing loss. However, patients may not have the triad at initial presentation and present with only a single finding.Case presentationA 25-year-old male resident of Panu Akil presented to Combined Military Hospital Lahore with complaints of dizziness and vertigo associated with severe migraine like headaches. He experienced sudden painless loss of vision in his right eye and was admitted to the medical intensive care unit. On examination, he had right-beating nystagmus and diplopia along with scintillating scotoma. After his admission, contrast-enhanced magnetic resonance imaging (MRI) was done which showed numerous enhancing bilateral white matter internal capsule micro-infarcts indicating typical “string of pearls” sign and a snowball lesion on the corpus callosum. His fundus fluorescein angiography (FFA) did not exhibit any branched retinal artery occlusions (BRAO). Fundoscopy showed the presence of drusen spots. His pure tone audiometry was unremarkable. Based on the highly characteristic findings present on the MRI, a diagnosis of Susac syndrome was made. He was started on injection methylprednisolone 1 gm IV in 500 ml normal saline over 1 h once a day for 5 days and then once a week for 8 weeks. He was also started on tablet mycophenolate mofetil 500 mg once daily for 7 days. Patient showed marked clinical improvement afterwards.ConclusionsSusac syndrome is a rare multisystem illness with an often insidious presentation. Patients can be misdiagnosed due to the nonspecific nature of the early complaints present in the disease. High index of suspicion is required for timely diagnosis and adequate management. Although no specific guidelines exist, management consists mainly of immunosuppressants.

Retinal Detachment in Dengue Fever – A Case Report

A 20 years old female came to our hospital with sudden painless loss of vision in her right eye for two days. She was diagnosed with dengue fever two and a half weeks back and was managed conservatively. Ocular examination showed mid-dilated pupils with sub-conjunctival hemorrhage, lens opacity, vitreous hemorrhage and haze, sub-retinal hemorrhage and retinal detachment. Visual acuity in right eye was perception of light only. Ultrasound revealed moderate number of low to moderately reflective vitreous echoes and a highly reflective membrane attached to the disc suggesting retinal detachment. An urgent ophthalmologist opinion was sought followed by pars plana vitrectomy with silicon oil. She was lost to follow up after surgery.

CLINICAL PROFILE OF PATIENTS OF CENTRAL SEROUS CHORIORETINOPATHY PRESENTED TO THE TERTIARY HEALTH CARE CENTRE

Purpose:To study the clinical profile and relationship between time of presentation and visual outcome in patients with central serous chorioretinopathy . Material and Method: Total 100 eyes of 50 patients were selected for the study who presented with complaints of blurring and or sudden painless loss of vision ,out of which 10 eyes of 5 patients were excluded due to corneal opacity, diabetic retinopathy, hypertensive retinopathy ,cataract and retinal detachment, retinitis pigmentosa. Total 90 eyes of 45 patients were included in the study and divided into two groups according to the time of presentation :1) Group 1-Within 15 days of onset of symptoms.2) Group 2 -After 2 months of onset of symptoms. Result:Group 1 patients showed the better visual outcome(BCVA 6/36-6/9) than the group 2 patients(BCVA 6/36-6/24). Conclusion: The time of presentation to the tertiary care centre was the major factors influence the visual outcome in patients with CSR.

Purtscher’s Retinopathy: A Case Report

Purtscher’s retinopathy is a rare microvasculopathy eye disease that causes sudden painless loss of vision after a severe injury but can be associated with nontraumatic etiologies. In this case, a 30-year-old female had noticeable decrease in visual acuity and a central scotoma to her right eye after undergoing ankle surgery

Ipsilateral nonarteritic anterior ischemic optic neuropathy: case report and discussion on pathophysiological mechanisms

We present the case of a 45-year-old male patient with sudden painless visual loss in the left eye (OS), diagnosed as nonarteritic anterior ischemic optic neuropathy (NAION). Three months later, a new superior scotoma, accompanied by an inferior optic disc edema, characterized a recurrent episode of NAION in OS. Ambulatory blood pressure monitoring disclosed arterial hypertension, with no pressure drop during sleep. Optical Coherence Tomography showed optic disc drusen. Ipsilateral recurrence of NAION is a rare event. We believe insufficient relief of the “crowding” effect in predisposed optic discs after a sectoral NAION episode is an important risk factor for ipsilateral recurrences.

Combined therapy with intravitreal aflibercept and subtenon corticosteroids in eyes with severe diabetic papillopathy: two case reports

BackgroundDiabetic papillopathy is a rare diagnosis of exclusion characterized by unilateral or bilateral optic disc edema with variable degrees of visual loss. Although the visual prognosis has been generally reported as favorable, the presence of severe disc edema associated with macular edema prompts the need for treatment. We present a specific and unreported therapeutic approach consisting of intravitreal aflibercept and subtenon triamcinolone acetonide injections in two patients with evidence of diabetic papillopathy and macular edema.Case presentationIn the first case, a 60-year-old Caucasian woman affected by type II diabetes mellitus presented with fundoscopic evidence of sequential bilateral optic disc edema associated with acute severe visual loss in both eyes. The second patient, a diabetic 57-year-old Caucasian male, presented with sudden painless visual loss in his left eye. Multimodal imaging and systemic findings correlated towards an infrequent diagnosis of diabetic papillopathy. In a period of 5–7 weeks after treatment, both patients experienced almost full visual and anatomical recovery. A steady situation was observed at 12 months of follow-up.ConclusionsBoth our cases displayed a severe grade of optic disc edema, which was optimally reversed with intravitreal aflibercept and subtenon triamcinolone acetonide leading to a relatively rapid and safe improvement in visual acuity.

Chemotherapy-Induced Toxic Orbitopathy with Combined Ischemic Optic Neuropathy and Central Artery Occlusion

A 51-year-old man presented with sudden painless vision loss (no light perception) in his left eye 4 weeks after 7 cycles R-CHOEP-14 chemotherapy for T-cell-lymphoma without orbital involvement. Fundoscopy revealed optic disc swelling, whitened retina with a cherry-red spot of the macula, arterial attenuation, peripapillary and central flame-shaped hemorrhages, and venous engorgement (Fig A). Magnetic resonance imaging (MRI) showed diffuse edema of the left retrobulbar tissue (Fig B) and edematous thickening of the left optic nerve (Fig B, C).

Permanent Unilateral Vision Loss From Allergic Fungal Sinusitis.

In the absence of trauma, sudden unilateral painless visual loss is an uncommon condition in the pediatric population requiring emergent medical evaluation. In the acute care setting, clinicians face the challenge of accurately assessing the patient and determining the initial diagnostic workup. A careful history alone helps guide diagnosis with sudden visual loss that is unilateral and persistent. Several neuro-ophthalmological conditions that present with these characteristics include retinal artery or vein occlusion, diseases affecting the cavernous sinus or orbital apex region, and optic neuropathy. Simple eye examination techniques have crucial diagnostic value in helping localize the disease process, determining the level of urgency, and need for timely intervention. Here we present an adolescent patient with nontraumatic, acute unilateral visual loss who had concerning ophthalmological examination findings and was subsequently diagnosed with optic neuropathy secondary to allergic fungal sinusitis.

Psychogenic blindness as a rare cause of presumed vision loss

A 12-year-old girl presented with unilateral, sudden painless loss of vision for the past 2 days. Ocular examination was normal. Optical coherence tomography, visually evoked potential, and magnetic resonance imaging of the brain and orbits were normal. With no organic cause found for vision loss, psychiatrist opinion was sought. After evaluation, she was diagnosed to have psychogenic blindness and treated with psychotherapy. When findings are inconsistent and no organic etiology can be diagnosed for the vision loss, psychogenic blindness is suspected and prompt referral to a psychiatrist is essential for complete recovery.

Serum cortisol and serum testosterone levels in idiopathic central serous chorioretinopathy

Aim: To analyse the serum cortisol and serum testosterone levels in idiopathic central serous chorioretinopathy. Material and methods: The prospective interventional study was conducted in the central laboratory associated with the Department of Ophthalmology, Subharti Medical College, Meerut. A study was conducted in 30 cases of CSR. The patients were divided into two groups i.e. Group A (15 patients with unilateral sudden painless loss of vision of less than one month of duration serving as cases and Group B (15 patients with no signs and symptoms serving as control). Evaluation of Macular thickness was done using OPTOVUE RTvue 100 OCT procedure. After pupil dilation, the patient is seated at the machine, asked to fixate at the internal fixation point and scan is obtained. The macular thickness map was taken to measure the thickness of macula. Fundus Fluorescein Angiography (FFA) was done, if required. Patients of both the groups underwent investigations such as dilated fundus examination, serum cortisol and serum testosterone levels. Results: Mean serum cortisol (μg/dL) among the case group was higher as compared to the control group with statistically significant difference as p

Bilateral retinal hemorrhages and macular edema in a patient with dengue fever associated with cerebral hemorrhage

We report a case of bilateral retinal hemorrhages with macular edema in a patient with dengue fever (DF). This patient also had cerebral hemorrhage. A 17-year-old female presented with sudden painless loss of vision in her both eyes for 2 days associated with redness of eyes. She was diagnosed having DF based on detected dengue immunoglobulin M in her blood sample. Fundus examination of both eyes showed preretinal and intraretinal hemorrhages. Optical coherence tomography showed neurosensory detachment and macular edema. This case report warrants the importance of ocular screening in a patient having systemic complications of DF.

Commentary: COVID-19 disease is more than just a respiratory infection

The coronavirus disease (COVID-19), caused by the novel, highly contagious severe acute respiratory syndrome coronavirus 2, has quickly become a global health emergency. It started with an outbreak of pneumonia causing fever, cough, and shortness of breath. However, the virus has been noted to involve multiple organs and systems. The global research community has made an impressive effort in compiling the various manifestations of the disease in a short time.[1] The infected individuals are predisposed to arterial and venous thromboembolic complications like deep vein thrombosis, pulmonary embolism, myocardial infarction, and stroke. The proposed mechanisms responsible for these thromboembolic events include a transient hypercoagulable state due to systemic inflammation and cytokine storm, postinfectious immune-mediated responses, and direct viral-induced endothelitis.[2] The incidence of thrombotic complications in COVID-19 patients admitted to intensive care unit ranges between 16 to 49%.[1] Acute cardiovascular accident has been reported in 0.5–6.0% of COVID-19 patients.[3] Acharya et al.[4] first reported a central retinal artery occlusion (CRAO) in a case of severe COVID-19 disease. However, recent evidence suggests that arterial thromboembolism can occur in patients with mild disease also. Currently, the incidence is unknown due to possible underreporting of symptoms. Turedi et al. first reported CRAO within a case of moderate COVID-19 disease.[5] Early anticoagulant treatment has been reported to improve the clinical outcome of COVID-19 patients and reduce the risk of thromboembolic events.[1] Interestingly, all the patients that have been reported to develop RAO secondary to COVID-19 were already being treated with anticoagulant therapy. The occurrence of RAO in COVID-19 patients is limited to only case reports. Further studies should be planned to evaluate out the incidence of vascular occlusions in patients suffering and recovered from COVID-19. Such studies can give us insight related to the association of the ocular diseases with the stage and severity of the COVID-19 infection. Our knowledge regarding the pathophysiology and treatment of this disease is still in its preliminary stage. The fast-paced ongoing research will hopefully provide better algorithms for management of this disease and prevention of its complications. Physicians treating COVID-19 patients must be sensitized to seek an urgent retina consultation for patients complaining of symptoms like blurry vision, sudden painless visual loss, or scotomas. We congratulate the authors for reporting the first case of an isolated cilioretinal artery occlusion (CLRAO) associated with paracentral acute middle maculopathy (PAMM) in a patient with moderate COVID-19 disease and no other predisposing diseases. PAMM is reported to be present in 100% of isolated CLRAO due to hypoperfusion of the involved cilioretinal artery.[6] The authors started treating the patient 48 h after the episode and gave 20 sessions (40 h) of hyperbaric oxygen (HBO), which led to resolution of retinal edema after 3 weeks. HBO involves the inhalation of 100% oxygen at pressures greater than 1 atm. The inspired oxygen partial pressure is nearly 203 kPa, which is almost 10 times that of breathing air at normal atmospheric pressure. It is postulated that oxygen at higher pressures diffuses from the choroidal circulation to reach the ischaemic retina and increase the oxygen delivery to the ischemic tissue until spontaneous or assisted reperfusion occurs.[7] However, isolated CLRAO is associated with good prognosis and does not usually require treatment. Retinal edema usually resolves spontaneously within few weeks. The central field defect improves in nearly half of the eyes and remains stable in the other half.[8] HBO is usually reserved for patients presenting with poor vision due to CRAO and BRAO. Also, the maximum benefit of the treatment is expected in case it is started within 6–8 h of the occlusion.[7] The risk-benefit for the application of multiple sessions to gain <1 line of vision during the COVID-19 pandemic should be carefully calculated. Role of corticosteroids in COVID-19 has been evaluated by several studies. The RECOVERY trial was a prospective study where 2104 patients were randomized to dexamethasone 6 mg per day (oral or intravenous) for 10 days and compared to the 4321 patients receiving usual care. They concluded that in patients hospitalized with COVID-19, dexamethasone reduced the 28-day mortality among those receiving invasive mechanical ventilation or oxygen at randomization, but not among patients with mild to moderate COVID-19 disease.[9]

Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION)

We present a non-arteritic anterior ischemic optic neuropathy (NAION) with unknown cause, but good recovery after the management with antiplatelet therapy in a 45-year-old male patient who came to the hospital with complaints of sudden painless loss of vision.

An atypical presentation of ANCA-associated retinal vasculitis in a young Malay woman

We describe a case of antineutrophil cytoplasmic antibody (ANCA)-associated retinal vasculitis in a 21-year-old previously healthy Malay woman, who presented to us with complaints of sudden painless loss of vision in her left eye. Her vision upon presentation was counting fingers and her fundus examination showed retinal vasculitis and ischemic changes. Fundus fluorescein angiography showed leakage from the vasculitic retinal vessels, resulting in macular oedema. All investigations were normal, except that a full blood test showed eosinophilia and an autoimmune screening revealed positive perinuclear staining-ANCA, which led us to diagnose ANCA-associated retinal vasculitis. The patient was comanaged with the rheumatology team. She was started on a high-dose intravenous steroid followed by a tapering dose of an oral steroid. Improvement was noted from the resolution of macular oedema evident on optical coherence tomography of the macula. However, vision remained poor and unchanged.

Atypical central retinal artery occlusion as the first presentation of POEMS syndrome: a case report

BackgroundPOEMS syndrome is a plasma cell disorder, which clinically manifests from paraneoplastic syndrome: polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes. The most common ocular manifestation is optic disc swelling, whereas other ocular manifestations; cystoid macular edema, serous macular detachment, venous sinus thrombosis, infiltrative orbitopathy, uveitis, neovascularization of the disc, peripapillary choroidal neovascularization and optic disc drusen, had also been reported.Case presentationA 52-year-old Thai man presented with 5-day sudden painless visual loss in the left eye. Ocular examination revealed visual acuity of 20/20 and no light perception in the right and left eye, respectively. Right fundoscopic examination was significant for hyperemic generalized optic disc swelling. Left fundoscopic examination revealed opaque and edematous entire retina giving the appearance of central retinal artery occlusion (CRAO) along with pallid “chalky white” optic disc swelling. Fluorescein angiography showed profound leakage of bilateral optic nerve heads and arteriolar filling defect in macular area along with leakage of small retinal arterioles in the left eye. Indocyanine green angiography demonstrated choroidal filling defect in the left eye only. Neuroimaging showed enhancement and luminal narrowing of left internal carotid artery, early subacute watershed infarctions in the left cerebral hemisphere and pachymeningeal enhancement. Cerebrospinal fluid analysis revealed high protein level with normal opening pressure. Intravenous methylprednisolone was initially started without any benefit. After extensive investigations, diagnosis of “POEMS syndrome” was made based on polyneuropathy, elevated lambda light chain level, elevated plasma vascular endothelial growth factor (VEGF), hepatomegaly, spinal sclerotic bone lesions, and thrombocytosis. Furthermore, sural nerve biopsy demonstrated neuropathy and positive VEGF staining. He was treated with eight cycles of bortezomib, cyclophosphamide and dexamethasone (BorCyDex). Polyneuropathy and thrombocytosis had remarkably improved after 2nd cycle, whereas, visual impairment had shown no recovery. Hepatomegaly was significantly reduced after the completion of BorCyDex. Our case eventually received autologous hematopoietic stem cell transplantation with high dose melphalan.ConclusionsTo our knowledge, we illustrated the first patient given CRAO as the first presentation and ocular finding ever reported in POEMS syndrome. Both cerebral and ocular infarctions were presumably the result of VEGF-induced cranial vasculopathy as evidenced by neuroimaging.