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Cardiovascular disease and the eyeLeo Semes, ODProfessor, OptometryUAB, Birmingham, AL1Case Report75 WMReports the followingAt church last week it looked like I was seeing through cracked glass.

What additional information do you want from this history?

2Cracked glass vision in a 75 WMHas it happened before / since?

How long did it last?

Was it one eye or both? Which one?

Did you experience any other symptoms?

One episode

About 20 min

Left eye only

None; what might you expect?3Cracked glass vision in a 75 WMWhat testing would you do?VAAnterior segment evaluationTonometryFundus evaluation

Results: All unremarkable for age4Cracked glass vision in a 75 WMWhat could be the cause?Local (vitreous traction)

VascularRetinal vasculatureOphthalmic arteryCarotid arteryVertebral basilar

Other?5How would you manage this patient?Further testing?Carotid auscultationOphthalmodynamometryAdditional carotid evaluationGeneral physical / vascular assessment

Results:6Blood supply to the eye

academic.sun.ac.za/neurology/lectures/eyes98/sld030.htmBlood supply to the eyeBranches of CA: a = internal carotid arteryb = vertebral arteryc = basilar arteryd = ophthalmic arterye = anterior cerebral arteryf = middle cerebral arteryg = posterior cerebral artery.

8Blood supply to the eye

Ophthalmic Artery Usually arises intradurally (80-90%), below anterior clinoid process.

Supplies globe, orbit, frontal scalp, the frontal and ethmoidal sinuses.

Ophthalmic artery branches anastamose with maxillary artery branches - potential for collateral flow in cases of proximal carotid occlusion.

9Cracked glass vision in a 75 WMOutcomesCarotid Doppler performedDemonstrated > 90% blockage on left sidePatient recommended for L carotid endarterectomy Successfully performed X 2 days

Patient survived an additional 7 years (succumbing to emphysema)

10Next CaseFloaters and sparkles 63 W/MWhen I was grilling on July 4, I noticed sparks and floaters in my left eye.

I thought it was time for a CL check, so I came in to see youSudden onsetNo other symptoms

63 W/M with sparklersVA 20/20 in each eyeAnterior segment evaluation unremarkable for ageDFE . . . (OS)

07/ 24/ 2007

07/ 24/ 2007

08/14/ 2007

OutcomesSent to Internist for evaluationComplained of dizziness to InternistCarotid Doppler performedSufficient blockage to recommend carotid endarterectomyDone within 3 weeks of visit to UABSOSuccessful procedure

Lets back up . . .08/14/ 2007Other adverse outcomes of interrupted blood supply to the eyeCentral / branch retinal artery occlusion

Ischemic optic neuropathy

Local arterial obstructionPartial, with hemi-field defect; total = sudden painless loss of vision (permanent)Review - Retinal EmboliEmboli are blood clots or clumps of cholesterol and fatty material that break off from atherosclerotic plaques.

When emboli lodge in blood vessels in or close to the eye, the eye's blood supply can be suddenly blocked.

Emboli most often come from arteries in the chest or neck, but they can also come from the heart.

Retinal EmboliEmboli are a common cause of sudden but temporary vision loss; they can also cause permanent vision loss. Vision loss from emboli is sometimes described as a slow dimming of light or as a window shade being pulled down or up over the eye.

When emboli travel to the brain and the eye at the same time, vision loss may be accompanied by loss of speech or weakness in an arm and leg. If these symptoms last more than a day, they indicate that the person has had a stroke.

Diagnosis of the source of retinal emboli is done using ultrasonography or magnetic resonance angiography. Echocardiography and recordings of heart rhythm may be performed to determine if the person is at risk for further emboli.

Retinal EmboliTreatment may involve surgery (carotid endarterectomy) if test results show that the emboli may have come from the arteries in the neck and if the arteries are significantly narrowed.

Otherwise, aspirin or other anticoagulants (sometimes called blood thinners) are used. Warfarin is given if test results show that emboli may have come from the heart. Treatment of atherosclerosis is important as well.

Ischemic optic neuropathy

Review - Ischemic Optic NeuropathyIschemic optic neuropathy is a sudden painless loss of vision in one eye from insufficient blood flow to the optic nerve.

The cause is unknown. Atherosclerosis, diabetes, and high blood pressure may increase the risk of developing ischemic optic neuropathy. Temporal arteritis is a treatable form of ischemic optic neuropathy.

Review - Ischemic Optic NeuropathySome people have pain or discomfort around the eye. An eye doctor diagnoses the condition by examining the eye.

No proven treatments are available for most forms of ischemic optic neuropathy.

For some people, vision improves without treatment. Only a small percentage of people experience the same symptoms in the other eye.

Control of risk factors for atherosclerosis may help prevent ischemic optic neuropathy.

This may be related to Sleep Apnea Syndrome (SAS)

Review - Ischemic Optic NeuropathyPeople with optic neuropathy due to temporal arteritis experience vision loss, which may be sudden in one eye.

They may also experience headache, scalp tenderness at the temple, fever, and jaw pain when chewing. A doctor diagnoses the condition by examining the eye, performing blood tests, and performing a biopsy of the temporal artery.

Treatment involves use of corticosteroids, mainly to prevent occurrence of disease in the other eye, but also to reduce risk of further vision loss in the affected eye.