Discuss systemic disease control with patients to prevent fatalities

NEW YORK – Common systemic diseases can result in serious ocular consequences, providing the optometrist an opportunity to query patients on overall health and reduce the risk of mortality, according to a presenter here at Vision Expo East.

Vincent Young, MD, illustrated the importance of primary care by sharing a case of a patient with ocular ischemic syndrome.

The 80-year-old patient presented with gradual vision loss, a painful brow and a red right eye, Young said. The patient had a history of stroke, myocardial infarction and hypertension.

An afferent pupillary defect was present in the right eye, along with mild corneal edema. The anterior chamber had cells and flare, and the iris was neovascularized, which Young said was the eye’s reaction to insufficient circulation to the tissue.

“The retina will develop this neovascular change and then subsequently affect the iris, but it can happen in reverse if this person is growing new blood vessels in response to poor circulation,” Young said. “These new blood vessels are bad; they’re fragile, they break, they can cause scarring. This person will have a severe case of glaucoma.”

A unilateral occurrence, such as in this patient, is a red flag, Young said.

“There’s probably some carotid disease leading to poor circulation on that side,” he said. “This person probably has ocular ischemic syndrome.”

Other signs in such a patient include occasional amaurosis fugax attacks, Young said. Check their pulse and carotid arteries; listen for bruits (wheezing, whistling).

“Look for corneal edema and a lower pressure, because with reduced blood flow to the ciliary body, they won’t make aqueous as effectively, and the pressure will be lower,” he said. “They commonly have anterior chamber reaction; it has to do with new blood vessels growing and being incompetent.”

Posterior segment findings include narrowed retinal vessels to the point where blood is not traveling through them, Young said.

“They looked whitened,” he said. “They’re midperipheral hemorrhages. If someone has diabetic retinopathy, dot and blot hemorrhages are common. But if someone has them outside the arcade vessels, that’s diagnostic of ocular ischemic syndrome.”

The work-up should look for vascular problems, he said. Order an MRA and ERG, but “carotid angiography is probably the definitive test,” Young said.

One treatment is carotid endarterectomy, according to Young.

“It’s a dangerous procedure. There needs to be significant perfusion deficits on both sides to generate a need for the procedure,” he said.

The condition has a significant 5-year mortality rate, Young said.

“Forty percent of people with this will die within 5 years,” he said. “They will die due to cardiac disease or stroke, and sometimes cancers. The cancer growth is contributed to by atherosclerotic changes taking place.”

Young said a conversation regarding prevention needs to take place early, before complications can occur. Urge patients to manage their hypertension and cardiac diseases. – by Nancy Hemphill, ELS