SAEM Clinical Images Series: My Mom Could Not See
An 87-year-old female with a history of hypertension, hyperlipidemia, chronic kidney disease stage IIIB, type 2 diabetes mellitus, and schizophrenia presented for evaluation due to sudden visual loss in her right eye, which began 12 hours before she arrived at the emergency department. She has experienced a sudden loss of vision in her right eye for more than six hours. She reports no eye pain or redness, nor has she experienced any flashing lights. Additionally, there have been no symptoms of numbness, tingling, headache, double vision, facial droop, slurred speech, temporal tenderness, jaw claudication, or localized weakness/numbness. Over the past one to two months, the patient has lost 30 pounds and has noted increasing weakness over the last several weeks.
Vitals: BP 136/46; Temp 97.2°F; HR 54; RR 16; SpO2 96% RA
Constitutional: Alert but doses off frequently, no acute distress, appeared weak.
Neuro: No facial droop, no tongue deviation, no dysarthria, strength 4+/5 throughout, normal finger to nose
HEENT: Normocephalic/atraumatic. No mass palpable. Conjunctiva normal on both eyes. EOMI. Decreased right eye light flex compared to the left eye, visual acuity on the left side can count fingers on the right side only seeing a light. No orbital swelling. Normal ear canal bilaterally, normal TM both sides. Septum midline. Oropharynx is clear and moist and mucous membranes are normal. No lymphadenopathy, no bruit.
CV: Regular rate and rhythm with normal S1 and S2, no murmurs.
MSK: Moves all extremities, no deformity, normal muscle tone.
Skin: Warm and dry. No skin rash.
CBC: WBC 9
Hgb: 8.8
Hct: 29.5
Plt: 394
CMP: Na 137, K 4.7, Cl 101, CO2 25, BUN 25, Cr 1.56
PT: 14.2
INR: 1.1
The fundoscopy of the right eye reveals a Central Retinal Artery Occlusion (CRAO), characterized by a pale retina with a cherry-red macula and “box-carring” of the blood vessels.
The potential causes of CRAO in elderly patients include Giant Cell Arteritis (GCA), atherosclerosis, or embolism. It is advisable to measure inflammatory markers, such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), particularly in patients over the age of 50. Despite the absence of temporal tenderness and jaw claudication, this patient’s non-specific systemic symptoms like weight loss and weakness, combined with elevated ESR (105) and CRP (6.8), heighten the suspicion of GCA as the etiology of the CRAO. Consultations with ophthalmology and rheumatology are warranted. Administering high-dose pulse steroids is crucial for preventing further complications, such as CRAO in the left eye. Additionally, evaluating non-arteritic causes of CRAO, including carotid artery imaging and echocardiography, should also be considered.
Take-Home Points
- With acute painless vision loss, fundoscopy can aid in determining the differential diagnosis and further workup.
- In CRAO, remember arteritic and non-arteritic causes.
- Age cut off in CRAO will help to guide further work up.
- Diagnosis and management of Central Retina Artery Occlusion. (2017). American Academy of Ophtalmology Eyenet magazine. [Online] Available at: https://www.aao.org/eyenet/ article/diagnosis-and-management-of-crao [Accessed 22 Dec 2023]
- Guluma K, Lee JE. Ophtalmology. Rosen’s Emergency Medicine: Concepts and Clinical Practice 10th-ed. Edited by Ron Walls. Elsevier. 2023. 57, 750-780.e4