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Home , Amaurosis fugax, Hyphema

Br J Ophthalmol: first published as 10.1136/bjo.69.9.688 on 1 September 1985. Downloaded from

British Journal of , 1985, 69, 688-690

Transient monocular obscuration-? : a case report

GREGORY S KOSMORSKY,' STEVEN I ROSENFELD,'AND RONALD M BURDE'2 From the 'Departments of Ophthalmology and and 2Neurological Surgery, Washington University School ofMedicine, St Louis, Missouri, USA

SUMMARY A 73-year-old white man with pseudophakia experienced repeated bouts of transient visual loss associated with erythropsia and colour desaturation. A diagnosis of atheromatous carotid vascular disease was considered, prompting carotid , during which time the patient experienced transient aphasia. Subsequent examination during an episode of visual loss showed that a spontaneous anterior chamber haemorrhage was the cause of the visual complaints.

The complaint of transient bouts of monocular visual bifurcation was normal, there was only moderate copyright. loss in an older person suggests the presence of narrowing of the siphon, and no ulceration was seen. atheromatous disease of the carotid arteries and the During the carotid angiography, after repositioning necessity for neuroradiological examination. The the catheter in the aortic arch, the patient noted he symptoms during an attack of transient monocular was unable to talk for a short time, and several visual loss may suggest various diagnoses and obviate minutes of aphasia followed. After this episode the need for such studies, with their inherent risk. a computerised axial tomogram was normal. The A patient with complaints of recurrent bouts of patient was treated with dipyridamole (Persantine)

transient monocular visual loss and suffering from and without any alteration in his symptoms. http://bjo.bmj.com/ temporary speech arrest followed by mild aphasia Elucidation of the patient's history revealed that subsequent to carotid angiography is the subject of the episode of so-called monocular visual loss con- this report. sisted of a sensation of 'foggy vision' associated with erythropsia (seeing red) and colour desaturation, Case report especially for the colour red. He specifically denied total blackouts or a curtain. These episodes initially A 73-year-old white man began experiencing bouts of lasted 15-20 minutes and occurred once a month, but transient visual blurring affecting the right eye eight by the time of his referral his longest episode had on September 29, 2021 by guest. Protected months before his initial examination. During these lasted seven hours and the frequency had increased eight months repeated examinations by his ophthal- to three to four bouts per week. The episodes were mologist while the patient was asymptomatic failed to sudden in onset and unassociated with any neuro- reveal any ocular pathology. He was referred to an logical symptoms such as weakness, numbness, internist and then to a neurologist for evaluation of dysarthria, , headache, or orbital pain. No 'amaurosis fugax.' Venous subtraction angiography precipitating events could be identified. According to revealed irregularities in the area of the left carotid his medical history he had had an intracapsular bifurcation. Subsequent carotid angiography showed extraction with fixation implant in ulceration and mild of the left internal the left eye in 1973, and a similar procedure had been carotid artery at the bifurcation and a 50% stenosis of performed in the right eye in 1980, both without the carotid siphon on the left side. The right carotid complications. Topical 2% pilocarpine had been used intermittently to stabilise the lens in his right Correspondence to Ronald M Burde, MD, Department of eye. He also had a history of hypertension for 10 Ophthalmology-Box 8096, 660 South Euclid Avenue, St Louis, years, treated with chlorothiazide (Diuril), and MO 63110, USA. arthritis occasionally treated with aspirin. 688 Br J Ophthalmol: first published as 10.1136/bjo.69.9.688 on 1 September 1985. Downloaded from

Transientmonocularobscuration 689

Examination at the time ofreferral showed a visual amaurosis fugax. To our knowledge, the complaint of acuity of20/20 in the right eye and 20/15 in the left eye erythropsia has not been reported with amaurosis at distance. His right was 3 mm, square (from fugax, and it should suggest either intraocular an iris fixation implant), and non-reactive. The left haemorrhage or bleaching of the aphakic or pseudo- pupil was 4 mm and minimally reactive. The results of phakic after exposure to bright sunlight. In tests of function, brightness and colour addition, most patients with occlusive carotid disease comparison, and American Optical colour plates and amaurosis fugax experience other concomitant were equal and normal bilaterally. Amsler grid transient neurological symptoms, though a small testing revealed no defects. Slit lamp examination percentage will have only visual complaints. Thus, showed well healed anterior segments on both sides. the lack of associated neurological symptoms in our The intraocular lens implants did not come close to patient suggests, but is not diagnostic of, a normal any angle structures, and the foot processes were not carotid circulation. The history is thus. the key to associated with any iris or pupillary lesions. Applana- suspecting the diagnosis of an anterior chamber tion pressures were 18 mmHg in the right eye and haemorrhage. Most often when the patient is 21 mmHg in the left. testing by kinetic asymptomatic the ophthalmological examination will perimetry was normal. Gonioscopy performed at this be entirely normal. In fact the anterior chamber may time revealed an abnormal sheath of vessels near the clear within hours of a symptomatic haemorrhage.2 iridectomy in the superior angle of the right eye. Therefore the clinician needs a high index of Ophthalmodynamometry was 60 mmHg in both suspicion of the possibility of a transient anterior eyes. chamber haemorrhage. The patient was subsequently seen again during an The causes of spontaneous anterior chamber attack of blurred vision. Examination then revealed haemorrhages are numerous (Table 1). Such diffuse anterior chamber haze secondary to a con- haemorrhages may be seen as a late of siderable number of erythrocytes in the aqueous, cataract surgery due to ruptured incisional vessels,34 which were also found to be layered on the corneal iris or angle neovascularisation, peripupillary micro- endothelium. In addition gonioscopy performed then angiomas, disorders, or anticoagulation copyright. showed blood streaming from the previously noted medication.5 In addition the implantation of an vessels in the superior chamber angle and a micro- intraocular lens compounds the problem depending scopic hyphaema in the inferior angle. The patient on the type of lens used. For example, the - refused because ofa possible -hyphaema (UGH) syndrome67 may be allergy to contrast material. produced by rigid anterior chamber lenses. Peri-

Discussion Table 1 Causes ofspontaneous anteriorchamber haemorrhages http://bjo.bmj.com/ The classic features of amaurosis fugax include sudden painless visual loss in one eye which lasts from Vascular anomalies of the iris 30 seconds to 15 minutes (usually 2 to 3 minutes) and " 12 then vision returns.' The visual loss may be total or Sturge-Weber syndrome'3 Microhaemangiomas partial, often being described as a 'shade effect' Diffuse haemangiomatosis ofchildhood'4 marked by a sharp horizontal border involving the Neoplasms

upper or lower hemifield. The implication of this type on September 29, 2021 by guest. Protected of monocular visual disturbance is that of ipsilateral '3 Diseases of the blood or vessels carotid atherosclerotic disease with or without Leukaemia'3 ulceration, producing either a cholesterol plaque or a '3 fibrin embolus which lodges in the central Scurvy'3 retinal artery or one ofits main branches. Thus, when Lymphomall '6 the clinician hears that a patient has had bouts of Severe iritis'3 16 transient monocular visual loss, he often immediately Fibrovascular membranes begins an investigation of the carotid system, includ- '6 ing angiography with all of its attendant risks. Occult trauma or delayed after trauma16 Hydro-ophthalmos'7 Our patient described the sudden onset ofpainless, Malignant '3 recurrent monocular visual disturbance which con- Histiocytosis X"' sisted of erythropsia, colour desaturation, and a Postsclerotomy with cautery'9 fogginess of his vision. The duration of symptoms Postcataract surgery bridging wound vessels3; irritative phenomenon with neovascular tufts associated with intraocular ranged from 15 minutes to seven hours. These lenses9 20 symptoms are in sharp contrast to those of classic Br J Ophthalmol: first published as 10.1136/bjo.69.9.688 on 1 September 1985. Downloaded from

690 Gregory S Kosmorsky, Steven IRosenfeld, and Ronald M Burde pupillary iris erosion associated with either pupillary 5 Jaffe NS. Cataract surgery and its complications. 2nd ed. St Louis: Mosby, 1976: 321-4. plane or posterior chamber lenses may produce 6 Ellingson FT. The uveitis-glaucoma- syndrome similar clinical findings."' associated with the Mark VIII anterior chamber lens implant. J In our case an abnormal tuft of vessels was noted Am Intraocul Implant Soc 1978; 4: 50-3. near the iridectomy at the time of initial examination, 7 Keates RH, Ehrlich DR. 'Lenses of chance.' Complications of anterior chamber implants. Ophthalmology (Rochester) 1978; and this proved to be the site of haemorrhage when 85:408-14. the patient was examined during a bout of visual 8 Lieppman ME. Intermittent visual 'white out.' A new intra- blurring. The cause of the neovascular tuft of vessels ocular lens complication. Ophthalmology (Rochester) 1982; 89: in this location is not clear. If the diagnosis of 109-12. 9 Magargal LE, Goldberg RE, Uram M, Gonder JR, Brown GC. spontaneous intraocular haemorrhage had been Recurrent microhyphema in the pseudophakic eye. made earlier, angiography with its associated risks Ophthalmology (Rochester) 1983; 90: 1231-4. might have been obviated. The clinician should be 10 Nicholson DH. Occult iris erosion: a treatable cause of recurrent aware of the possibility of spontaneous anterior hyphema in iris-supported intraocular lenses. Ophthalmology (Rochester) 1982; 89: 113-9. chamber haemorrhage as a cause of transient 11 Cobb B, Shilling JS, Chisholm IH. Vascular tufts at the pupillary monocular visual disturbance. Erythropsia should margin in myotonic dystrophy. Am J Ophthalmol 1970; 69: arouse the suspicion of intraocular haemorrhage. 573-82. Ophthalmological examination, preferably while the 12 Stein LZ, Cross HE, Crebo AR. Abnormal iris vasculature in myotonic dystrophy. An anterior segment angiographic study. patient has symptoms, may be diagnostic and obviate Arch Neurol 1978; 35: 224-7. the need for invasive and potentially dangerous 13 Doggart JH. Spontaneous hyphema. XVI Concilium studies. Ophthalmologicum 1950; 1: 450-5. 14 Naidoff MA, Kenyon KR, Green WR. Iris hemangioma and abnormal retinal vasculature in a case of diffuse congenital This work was supported in part by an unrestricted grant from hemangiomatosis. Am J Ophthalmol 1971; 72: 633-44. Research To Prevent Blindness, Inc., New York, New York 15 Guzak SV. Lymphoma as a cause ofhyphema. Arch Ophthalmol (Department of Ophthalmology, Washington University). 1970; 84:229-31. 16 Howard GM. Spontaneous hyphema in infancy and childhood. References Arch Ophthalmol 1962; 68: 615-20. copyright. 17 D'Ermo F. Remarks on spontaneous hemorrhages in the 1 Walsh FB, Hoyt WF. Clinical neuro-ophthalmology. Baltimore: anterior chamber of hydro-ophthalmic eyes, also in relation to Williams and Wilkins, 1969: 2: 1806. surgical indications. Boll Oculist 1957; 36: 401-8. 2 Rosen E, Lyons D. Microhemangiomas at the pupillary border 18 Rupp RH, Holloman KR. Histiocytosis X affecting the uveal demonstrated by fluorescein photography. Am J Ophthalmol tract. Arch Ophthalmol 1970; 84: 468-70. 1969; 67: 846-53. 19 Harris LS, Galin MA. Delayed spontaneous hyphema following 3 Swan KC. Hyphema due to wound vascularization after cataract successful sclerotomy with cautery in three patients. Am J extraction. Arch Ophthalmol 1973; 89: 87-90. Ophthalmol 1971; 72: 458-9. 4 Watzke RC. from vascularization of the 20 Russell RWR, Page NGR. Critical perfusion of and retina.

cataract incision. Ophthalmology (Rochester) 1980; 87: 19-23. Brain 1983; 106:419-34. http://bjo.bmj.com/ on September 29, 2021 by guest. Protected