Ocular ischemic syndrome as initial manifestation of bilateral internal carotid artery occlusion

Background: Ocular ischemic syndrome (OIS) is characterized by ocular symptoms and signs secondary to severe carotid artery stenosis or occlusion. Methods and results: The authors describe a case of a 66-year-old man, a smoker with hyperlipidemia, who presented with a three-day history of pain over his left eye associated with redness. Visual acuity (VA) of the left eye was 6/18, with marked anterior chamber flare, unreactive dilated pupil, rubeosis of the angle and intraocular pressure of 30 mmHg. Fundus examination showed marked venous stasis with cotton-wool spots. VA of the right eye was 6/6, with mild venous stasis. No bruits were heard on carotid auscultation. Carotid Doppler ultrasonography revealed complete occlusion of both internal carotid arteries (ICA's) which was confirmed by CT-angiography. Endarterectomy of ICA's could not be performed. Three months later panretinal argon laser photocoagulation in the left eye was performed. One year later the left eye VA was perception of light with progression of neovascular glaucoma and development of cataract. No deterioration was noted and VA remained stable 6/6 in the right eye. Conclusions: OIS has a poor visual prognosis, and treatment is primarily aimed at management of the underlying carotid occlusive disease. Clinicians should be aware of the signs and symptoms of carotid artery disease in order to facilitate prompt diagnosis and appropriate referral.