The patient had dilated and tortuous veins and several intraretinal hemorrhages, consistent with a central retinal vein occlusion (CRVO). There was also superotemporal whitening inner edema found on OCT, consistent with a branch retinal artery occlusion. The fluorescein angiogram showed early superotemporal arterial filling followed by more complete filling 13 seconds later. The paradox of a superotemporal artery occlusion in a patient with early superotemporal arterial filling on fluorescein angiography can be explained by a cilioretinal artery occlusion that has recanalized. In fact, clinical examination confirmed the presence of a superotemporal cilioretinal artery. The mechanism of this patient’s condition was likely a central retinal vein occlusion causing swelling of the optic nerve, which compressed a cilioretinal artery. As the CRVO spontaneously resolved, the disc swelling diminished and the cilioretinal artery reopened. Unfortunately, there had been permanent visual loss, and the final visual acuity was 20/300 in the left eye. OCT 2 weeks later showed significant reduction of the edema of the inner retinal layers.
After presenting to our practice, we arranged for an emergent stroke work-up. MRI of the brain was unremarkable. CT angiography with contrast of the head did not reveal any stenotic lesions, and CT angiography with contrast of the neck was unremarkable. Trans-esophageal echography was remarkable for mild atheromatous disease of the descending thoracic aorta with mildly increased intimal thickness.
The following tests were normal and/or unremarkable: CBC, lipid panel, PT, PTT, thrombin time, Factor X, protein S free Ag, Factor VIII:C, diluted Russell viper venom, TTI inhibition, anticardiolipin Ab IgG and IgM, antithrombin III activity, protein C clot activity, beta 2 glycoprotein IgG and IgM, homocysteine level, G20210A variant of prothrombin/factor II gene, and Factor V Leiden mutation. Central vein occlusions in young adults is uncommon, and it is appropriate to evaluate for a hypercoagulable state, blood dyscrasias, and other conditions that predispose to thrombosis. Often, no clear cause is found when there is a CRVO in a young adult patient.
The patient was prescribed a daily baby aspirin and has been stable subsequent to the initial event.