eMedicine Specialties > Ophthalmology > Hematologic & Cardiovascular Disorders

Ocular Ischemic Syndrome: Differential Diagnoses & Workup

Author: Igal Leibovitch, MD, Oculoplastic and Orbital Devision, Department of Ophthalmology, Tel-Aviv Medical Center, Tel-Aviv, Israel
Coauthor(s): Diego Calonje, MD, Consulting Staff, Department of Ophthalmology, Private Practice; Sherif M El-Harazi, MD, MPH, Consulting Staff, Department of Ophthalmology, Sherif El-Harazi, MD
Contributor Information and Disclosures

Updated: May 13, 2009

Differential Diagnoses

Central Retinal Vein Occlusion
Giant Cell Arteritis
Retinopathy, Diabetic, Background
Retinopathy, Diabetic, Proliferative

Other Problems to Be Considered

Aortic arch disease

Workup

Laboratory Studies

  • Although there are no specific blood tests that are required in the workup of ocular ischemic syndrome (OIS), it is essential to evaluate the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels in patients with suspected giant cell arteritis.14,15

Imaging Studies

  • Fluorescein angiography: Intravenous fluorescein angiographic studies showed the following features in eyes with OIS: prolonged arm-to-choroid and arm-to-retina circulation times, delayed or patchy choroidal filling, increased retinal arteriovenous transit time, staining of the retinal vessels, and retinal capillary nonperfusion.1
  • Color Doppler imaging: This noninvasive imaging quantitates hemodynamic characteristics of the retrobulbar circulation in OIS. It shows reduced peak systolic velocity and increased vascular resistance in ocular end arteries, such as the central retinal and posterior ciliary arteries. It may also show reversal ophthalmic artery blood flow.16,17,18
  • Magnetic resonance angiography (MRA): MRA is a noninvasive technology for the evaluation of arterial vessels. This test can provide accurate anatomical details about intracranial vessels. This imaging modality is still not available in many medical centers, and it is expensive.
  • Carotid angiography: Carotid angiography is an essential study for assessing the risk of stroke and for deciding the appropriate treatment of extracranial carotid artery stenosis.1

Other Tests

  • Electroretinography: Electroretinography in OIS shows a reduction or absence of both a-waves and b-waves. The a-wave corresponds to photoreceptor function, and the b-wave is associated with the function of the inner retinal layers.
  • Ophthalmodynamometry: If the diagnosis of central retinal vein occlusion cannot be excluded, then consider ophthalmodynamometry. In carotid disease, the ophthalmic artery pressure is low, but it is normal to increased in central retinal vein occlusion.

Procedures

  • Invasive carotid artery evaluation

Histologic Findings

Histopathologic studies have shown loss of endothelial cells and pericytes in the peripheral retinal vessels of eyes with OIS. The posterior pole has a normal 1:1 ratio between endothelial cells and pericytes. As the mid periphery is approached, a greater loss of pericytes occurs than endothelial cells. The loss of cells predisposes to leakage from vessels.

More on Ocular Ischemic Syndrome

Overview: Ocular Ischemic Syndrome
Differential Diagnoses & Workup: Ocular Ischemic Syndrome
Treatment & Medication: Ocular Ischemic Syndrome
Follow-up: Ocular Ischemic Syndrome
References
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References

  1. Brown GC, Magargal LE. The ocular ischemic syndrome. Clinical, fluorescein angiographic and carotid angiographic features. Int Ophthalmol. Feb 1988;11(4):239-51. [Medline].

  2. Brown GC. Ocular ischemic syndrome. In: Retina. 2nd ed. Mosby;1994: 1515-27.

  3. Kahn M, Green WR, Knox DL, et al. Ocular features of carotid occlusive disease. Retina. Winter 1986;6(4):239-52. [Medline].

  4. Kearns TP, Hollenhurst RW. Venous-stasis retinopathy of occlusive disease of the carotid artery. Proc Staff Meet Mayo Clin. Jul 17 1963;38:304-12. [Medline].

  5. Eugene JR, Abdallah M, Miglietta M, et al. Carotid occlusive disease: primary care of patients with or without symptoms. Geriatrics. May 1999;54(5):24-6, 29-30, 33 passim. [Medline].

  6. Mizener JB, Podhajsky P, Hayreh SS. Ocular ischemic syndrome. Ophthalmology. May 1997;104(5):859-64. [Medline].

  7. Chen CS, Miller NR. Ocular ischemic syndrome: review of clinical presentations, etiology, investigation, and management. Compr Ophthalmol Update. Jan-Feb 2007;8(1):17-28. [Medline].

  8. Smith VH. Pressure changes in the ophthalmic artery after carotid occlusion (an experimental study in the rabbit). Br J Ophthalmol. 1961;45:1-26.

  9. Takaki Y, Nagata M, Shinoda K, et al. Severe acute ocular ischemia associated with spontaneous internal carotid artery dissection. Int Ophthalmol. Dec 2008;28(6):447-9. [Medline].

  10. Kubicka-Trzaska A, Romanowska-Dixon B. Non-malignant uveitis masquerade syndromes. Klin Oczna. 2008;110(4-6):203-6. [Medline].

  11. Ho TY, Lin PK, Huang CH. White-centered retinal hemorrhage in ocular ischemic syndrome resolved after carotid artery stenting. J Chin Med Assoc. May 2008;71(5):270-2. [Medline].

  12. Hollenhorst RW, Svien HJ, Benoit CF. Unilateral blindness occurring during anaesthesia for neuro- surgical operations. Arch Ophthalmol. 1954;52:819-30.

  13. Leibovitch I, Casson R, Laforest C, et al. Ischemic orbital compartment syndrome as a complication of spinal surgery in the prone position. Ophthalmology. Jan 2006;113(1):105-8. [Medline].

  14. Casson RJ, Fleming FK, Shaikh A, et al. Bilateral ocular ischemic syndrome secondary to giant cell arteritis. Arch Ophthalmol. Feb 2001;119(2):306-7. [Medline].

  15. Hwang JM, Girkin CA, Perry JD, et al. Bilateral ocular ischemic syndrome secondary to giant cell arteritis progressing despite corticosteroid treatment. Am J Ophthalmol. Jan 1999;127(1):102-4. [Medline].

  16. Bosley TM. The role of carotid noninvasive tests in stroke prevention. Semin Neurol. Jun 1986;6(2):194-203. [Medline].

  17. Ho AC, Lieb WE, Flaharty PM, et al. Color Doppler imaging of the ocular ischemic syndrome. Ophthalmology. Sep 1992;99(9):1453-62. [Medline].

  18. Lee HM, Fu ER. Orbital colour Doppler imaging in chronic ocular ischaemic syndrome. Aust N Z J Ophthalmol. 1997;25:157-63. [Medline].

  19. Sivalingam A, Brown GC, Magargal LE. The ocular ischemic syndrome. III. Visual prognosis and the effect of treatment. Int Ophthalmol. Jan 1991;15(1):15-20. [Medline].

  20. Amselem L, Montero J, Diaz-Llopis M, et al. Intravitreal bevacizumab (Avastin) injection in ocular ischemic syndrome. Am J Ophthalmol. Jul 2007;144(1):122-4. [Medline].

  21. Klais CM, Spaide RF. Intravitreal triamcinolone acetonide injection in ocular ischemic syndrome. Retina. 2004;24:459-61. [Medline].

  22. Wolintz RJ. Carotid endarterectomy for ophthalmic manifestations: Is it ever indicated?. J Neuroophthalmol. 2005;25:299-302. [Medline].

  23. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. Aug 15 1991;325(7):445-53. [Medline].

  24. Ros MA, Magargal LE, Hedges TR Jr, et al. Ocular ischemic syndrome: long-term ocular complications. Ann Ophthalmol. Jul 1987;19(7):270-2. [Medline].

  25. Sivalingam A, Brown GC, Magargal LE, et al. The ocular ischemic syndrome. II. Mortality and systemic morbidity. Int Ophthalmol. May 1989;13(3):187-91. [Medline].

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Further Reading

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Keywords

ocular ischemic syndrome, OIS, venous stasis retinopathy, ischemic ocular inflammation, ischemic oculopathy, carotid occlusive disease

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Contributor Information and Disclosures

Author

Igal Leibovitch, MD, Oculoplastic and Orbital Devision, Department of Ophthalmology, Tel-Aviv Medical Center, Tel-Aviv, Israel
Igal Leibovitch, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Diego Calonje, MD, Consulting Staff, Department of Ophthalmology, Private Practice
Disclosure: Nothing to disclose.

Sherif M El-Harazi, MD, MPH, Consulting Staff, Department of Ophthalmology, Sherif El-Harazi, MD
Sherif M El-Harazi, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

Medical Editor

V Al Pakalnis, MD, PhD, Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center
V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians & Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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