On OCT, the RNFL in the left eye was thinner than that in the right eye. OCT of the macula showed marked thinning of the inner one-half to two-thirds of the retina superiorly in the left eye. These findings, in addition to the trace RAPD, sectoral optic disc pallor, and retinal arteriolar narrowing of the superior vascular arcade of the left eye, are most consistent with superior branch (perhaps hemiretinal) retinal arteriolar occlusion.
Nonarteritic anterior ischemic optic neuropathy (NAION) typically occurs in patients who have small optic discs with small cups. NAION occurs in the absence of systemic symptoms, and is most commonly seen in patients 50 years and older. Optic disc edema must be present in the acute phase for there to be symptomatic visual loss. In this patient, optic disc cups in both eyes were relatively larger than those typically seen in NAION. In addition, the degree of inner retinal thinning seen on OCT of the macula would not be expected with optic neuropathy. Finally, with an optic neuropathy, one would expect a RAPD larger than that seen in this patient.
Cerebral visual loss from stroke would result in homonymous visual field loss, with the exception of the temporal crescent syndrome (which could result in loss of the temporal visual field between 60° and 90° in the affected eye).
An optic tract syndrome would be associated with a homonymous hemianopia and would not be expected to cause unilateral retinal thinning evident on OCT.
A carotid ultrasound showed 90% occlusion of the left internal carotid artery, which was thought to be a greater percentage than that observed during testing conducted 3 months earlier.
The patient was advised to see a vascular surgeon and a neurologist before deciding on surgical therapy (carotid endarterectomy) or continued medical therapy.
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Cite this: After a Stroke, Decreased Vision for a 73-Year-Old Patient - Medscape - Mar 30, 2017.