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Show Journal of Clulleal Neuro- ophthalmology 9( 4): 270- 272, 1989. © 1989 Raven Press, Ltd., New York Bilateral Central Retinal Artery Occlusion in Occult Temporal Arteritis Kanwar Mohan, M. S., Amod Gupta, M. S., 1. S. Jain, F. R. C. S., D. O., F. A. M. S., and C. K. Banerjee, M. D. A rare case of bilateral central retinal artery occlusion due to occult temporal arteritis is reported. We stress temporal artery biopsy in every patient with central retinal artery occlusion in old age. Key Words: Central retinal artery occlusion- Temporal arteritis. From the Departments of Ophthalmology ( K, M., A. G., 1.5.).) and Pathology ( CK. B.), Postgraduate Institute of Medical Education and Research, Chandigarh, India. Address correspondence and reprint requests to Dr. Kanwar Mohan at Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India YO Bilateral central retinal artery occlusion is extremely uncommon and accounts for only 4- 7% of all central retinal artery occlusions ( 1,2). Although temporal arteritis is responsible for only 3- 10% of central retinal artery occlusions ( 1- 3), most of the bilateral central retinal artery occlusions in elderly patients are due to temporal arteritis ( 1,4,5). To prevent central retinal artery occlusion in the other eye, a strong suspicion of temporal arteritis must exist. CASE REPORT A 65- year- old man presented to us with sudden loss of vision in the right eye for 2 days, unaccompanied by any significant systemic complaints. On examination, his visual acuity was counting fingers in temporal quadrant in the right eye and left eye vision was 6/ 12. The intraocular pressure was normal and the anterior segment was unremarkable in both eyes. Ophthalmoscopy of the right eye revealed narrowed retinal arteries, marked opacification of the posterior pole, and a cherry- red spot suggestive of central retinal artery occlusion. A triangular area of retina between the macula and optic disk supplied by a cilioretinal artery was normal ( Fig.!, top). Three days later, he reported sudden loss of vision in his left eye preceded by several transient obscurations of vision and was seen in the emergency service after - 7 h. At that time, he had a visual acuity of counting fingers at 1 m in his left eye. Ophthalmoscopy of this eye revealed a picture of central retinal artery occlusion with narrowed retinal arteries, cattle- trucking, opacification of the posterior pole, and a cherry- red spot. There was no cilioretinal artery in this eye. Within eight hours, visual acuity in this eye dropped to perception of light and ophthalmoscopy showed further opacification of the retina ( Fig. 1, bottom). BILATERAL CENTRAL RETINAL ARTERY OCCLUSION 271 FIG. 1. Top: Central retinal artery occlusion and a triangular area of normal retina supplied by a cilioretinal artery in the right eye. Bottom: Central retinal artery occlusion in the left eye. Both eyes were treated with immediate paracentesis and retrobulbar injection of Duvadilan ( isoxsuprine hydrochloride) 10 mg but this did not improve his vision. On investigation, his blood pressure, blood sugar, total and differential leukocyte count, lipid profile, coagulogram, cardiac status, and blood flow in both the carotid arteries on Doppler scan were normal. The erythrocyte sedimental rate done twice was 12 and 10 mm in the 1st hour by the Westergren method. Results of tests for rheumatoid factor, lupus erythematous, and VORL were negative. A chest x- ray film showed unfolding of aorta and an x- ray film of the cervical region showed no calcification in the carotid arteries. Temporal arteries on both sides were palpable, nontender, and pulsatile. Biopsy of the left temporal artery showed an organizing thrombus, focal infiltration of the adventitia and intima by lymphocytes, histiocytes and eosinophils, and fragmentation of the internal elastic lamina diagnostic of temporal arteritis ( Fig. 2). Giant cells were not present. A 60- mg prednisolone tablet once a day was instituted only after the temporal artery biopsy report became available. His vision in the left eye improved to counting fingers close to the face after 2 weeks of systemic corticosteroids, and showed no further improvement. Vision in the right eye did not improve and subsequently he developed optic atrophy and macular degeneration in both eyes. DISCUSSION In temporal arteritis, one eye is usually affected first and the other eye is involved after an interval of days or weeks. In view of a higher incidence of FIG. 2. Inflammatory cells in the adventitia and intima, and fragmentation of the internal elastic lamina ( arrows) of temporal artery ( hematoxylin and eosin x298). I Clin Neuro- ophthalmol, Vol. 9, No. 4, 1989 272 K. MOHAN ET AL. unilateral or bilateral irreversible visual loss in untreated cases and the demonstrated protective action of high- dose corticosteroids, an early diagnosis and prompt treatment of this disorder is of prime importance. In classic temporal arteritis, the presence of signs in the temple, general symptoms, and a raised sedimentation rate help in the diagnosis. However, the occult form of the disease is more common than the classic variety ( 5), and in the former classic symptoms and the temporal artery signs are usually absent but a raised sedimentation rate is a good guide to the diagnosis although not absolute. Isolated cases of normal sedimentation rate in temporal arteritis have been reported ( 3,6,7), although in larger series the incidence of normal sedimentation rate may be as high as ~ 1O% ( 8; J. Smith, unpublished data, 1989). Our patient belongs to the category of occult temporal arteritis. He had no temporal artery signs and symptoms with a persistently normal sedimentation rate, which misled us, and the diagno- , Clin Neuro- crphtllJllmol, Vol. 9, No. 4, 198~ sis was delayed. This case amply illustrates that in unilateral or bilateral central retinal artery occlusion in the elderly, the possibility of temporal arteritis cannot be ruled out and a temporal artery biopsy should become a part of the routine workup even if the sedimentation rate is normal. REFERENCES 1. Karjalainen K. Occlusion of the central retinal artery and retinal branch arterioles. Acta Ophthalmol [ Suppl] 1971; 109: 9. 2. Appen RE, Wray SH, Cogan DG. Central retinal artery occlusion. Am I Ophthalmol 1975; 79: 374. 3. Cullen JF, Coleiro JA. Ophthalmic complications of giant cell arteritis. Surv OphthalmoI1976; 20: 247. 4. Meythaler H. Uber die verschlusse von Blutgefassen der Netzhaut. Klin Monatsbl Augenheilkd 1966; 149: 32. 5. Cullen JF. Occult temporal arteritis-- a common cause of blindness in old age. Br I Ophthalmol 1967; 51: 513. 6. Kansu T, Corbett JJ, Savino P, Schatz N. Giant cell arteritis with normal sedimentation rate. Arch Neural 1977; 34: 624. 7. Healey LA, Wilske KR. Presentation of occult giant cell arteritis. Arthritis Rheum 1980; 23: 641. 8. Whitfield AGW, Bateman M, Cooke TW. Temporal arteritis. Br I Ophthalmol 1963; 47: 555. |
